L'objectif principal de ce travail est d’étudier en profondeur certaines techniques biostatistiques avancées en recherche évaluative en chirurgie cardiaque adulte. Les études ont été conçues pour intégrer les concepts d'analyse de survie, analyse de régression avec “propensity score”, et analyse de coûts. Le premier manuscrit évalue la survie après la réparation chirurgicale de la dissection aigüe de l’aorte ascendante. Les analyses statistiques utilisées comprennent : analyses de survie avec régression paramétrique des phases de risque et d'autres méthodes paramétriques (exponentielle, Weibull), semi-paramétriques (Cox) ou non-paramétriques (Kaplan-Meier) ; survie comparée à une cohorte appariée pour l’âge, le sexe et la race utilisant des tables de statistiques de survie gouvernementales ; modèles de régression avec “bootstrapping” et “multinomial logit model”. L'étude a démontrée que la survie s'est améliorée sur 25 ans en lien avec des changements dans les techniques chirurgicales et d’imagerie diagnostique. Le second manuscrit est axé sur les résultats des pontages coronariens isolés chez des patients ayant des antécédents d'intervention coronarienne percutanée. Les analyses statistiques utilisées comprennent : modèles de régression avec “propensity score” ; algorithme complexe d'appariement (1:3) ; analyses statistiques appropriées pour les groupes appariés (différences standardisées, “generalized estimating equations”, modèle de Cox stratifié). L'étude a démontrée que l’intervention coronarienne percutanée subie 14 jours ou plus avant la chirurgie de pontages coronariens n'est pas associée à des résultats négatifs à court ou long terme. Le troisième manuscrit évalue les conséquences financières et les changements démographiques survenant pour un centre hospitalier universitaire suite à la mise en place d'un programme de chirurgie cardiaque satellite. Les analyses statistiques utilisées comprennent : modèles de régression multivariée “two-way” ANOVA (logistique, linéaire ou ordinale) ; “propensity score” ; analyses de coûts avec modèles paramétriques Log-Normal. Des modèles d’analyse de « survie » ont également été explorés, utilisant les «coûts» au lieu du « temps » comme variable dépendante, et ont menés à des conclusions similaires. L'étude a démontrée que, après la mise en place du programme satellite, moins de patients de faible complexité étaient référés de la région du programme satellite au centre hospitalier universitaire, avec une augmentation de la charge de travail infirmier et des coûts. / The main objective of this work is to study in depth advanced biostatistical techniques in adult cardiac surgery outcome research. The studies were designed to incorporate the concepts of survival analysis, regression analysis with propensity score, and cost analysis. The first manuscript assessed survival, and cardiovascular specific mortality, following surgical repair of acute ascending aortic dissection. The statistical analyses included survival analyses with multiphase parametric hazard regression and other parametric (exponential, Weibull), semi-parametric (Cox) or non-parametric models (Kaplan Meier), comparison with the survival of a matched cohort for age, gender and race using State lifetables, and modelization with bootstrapping and multinomial logit models. The study showed that the early and late survival following surgical repair has improved progressively over 25 years in association with noticeable changes in surgical techniques and preoperative diagnostic testing. The second manuscript focused on outcomes following isolated coronary artery bypass grafting in patients with a history of percutaneous coronary intervention. The statistical analyses included multivariable regression models with propensity score, complex matching algorithm (1:3) and appropriate statistical analyses for matched groups (standardized differences, generalized estimating equations, and survival analyses with stratified proportional hazards models). The study showed that remote prior percutaneous coronary intervention more than 14 days before coronary artery bypass grafting surgery was not associated with adverse outcomes at short or long-term follow-up. The third manuscript evaluated the financial consequences and the changes in case mix that occurred at an academic medical center subsequent to the implementation of a satellite cardiac surgery program. The statistical analyses included two-way ANOVA multivariable regression models (logistic, linear or ordinal), propensity score, and cost analyses using Log-Normal parametric models. “Survival” analyses models were also explored, using “cost” instead of “time” as the outcome of interest, and led to similar conclusions. The study showed that, after implementation of the satellite cardiac surgery program, fewer patients of lower complexity came to the academic medical center from the satellite program area, with a significant increase in nursing workload and costs.

Contexte : Un accès adéquat aux aliments sains dans les environnements résidentiels peut contribuer aux saines habitudes alimentaires. Un tel accès est d’autant plus important pour les personnes âgées, où les changements associés au vieillissement peuvent accentuer leur dépendance aux ressources disponibles dans le voisinage. Cependant, cette relation n’a pas encore été établie chez les aînés. Objectifs : La présente thèse vise à quantifier les associations entre l’environnement alimentaire local et les habitudes alimentaires de personnes âgées vivant à domicile en milieu urbain. La thèse s’est insérée dans un projet plus large qui a apparié les données provenant d’une cohorte d’aînés québécois vivant dans la région métropolitaine montréalaise avec des données provenant d’un système d’information géographique. Trois études répondent aux objectifs spécifiques suivants : (1) développer des indices relatifs de mixité alimentaire pour qualifier l’offre d’aliments sains dans les magasins d’alimentation et l’offre de restaurants situés dans les quartiers faisant partie du territoire à l’étude et en examiner la validité; (2) quantifier les associations entre la disponibilité relative de magasins d’alimentation et de restaurants près du domicile et les habitudes alimentaires des aînés; (3) examiner l’influence des connaissances subjectives en nutrition dans la relation entre l’environnement alimentaire près du domicile et les habitudes alimentaires chez les hommes et les femmes âgés. Méthodes : Le devis consiste en une analyse secondaire de données transversales provenant de trois sources : les données du cycle 1 pour 848 participants de l’Étude longitudinale québécoise « La nutrition comme déterminant d’un vieillissement réussi » (2003-2008), le Recensement de 2001 de Statistique Canada et un registre privé de commerces et services (2005), ces derniers regroupés dans un système d’information géographique nommé Mégaphone. Des analyses bivariées non paramétriques ont été appliquées pour répondre à l’objectif 1. Les associations entre l’exposition aux commerces alimentaires dans le voisinage et les habitudes alimentaires (objectif 2), ainsi que l’influence des connaissances subjectives en nutrition dans cette relation (objectif 3), ont été vérifiées au moyen d’analyses de régression linéaires. Résultats : Les analyses ont révélé trois résultats importants. Premièrement, l’utilisation d’indices relatifs pour caractériser l’offre alimentaire s’avère pertinente pour l’étude des habitudes alimentaires, plus particulièrement pour l’offre de restaurants-minute. Deuxièmement, l’omniprésence d’aspects défavorables dans l’environnement, caractérisé par une offre relativement plus élevée de restaurants-minute, semble nuire davantage aux saines habitudes alimentaires que la présence d’opportunités d’achats d’aliments sains dans les magasins d’alimentation. Troisièmement, un environnement alimentaire plus favorable aux saines habitudes pourrait réduire les écarts quant à la qualité de l’alimentation chez les femmes ayant de plus faibles connaissances subjectives en nutrition par rapport aux femmes mieux informées. Conclusion : Ces résultats mettent en relief la complexité des liens entre l’environnement local et l’alimentation. Dans l’éventualité où ces résultats seraient reproduits dans des recherches futures, des stratégies populationnelles visant à résoudre un déséquilibre entre l’accès aux sources d’aliments sains par rapport aux aliments peu nutritifs semblent prometteuses. / Context: Adequate access to healthful foods in residential environments may contribute to healthful dietary practices. Such access is important for older adults where changes associated with aging may accentuate their dependence on resources available in their residential neighborhood. However, this relationship has not been established for seniors. Objectives: This thesis aims to quantify associations between the local food environment and dietary patterns of independent urban-dwelling older adults. The thesis is part of a larger project involving the linkage of data from a cohort of Québec seniors living in the Montréal metropolitan area and data from a geographic information system. Three studies addressed the following specific objectives: (1) to develop relative indices of local-area food sources outlets to qualify stores potentially selling healthful foods and supply of restaurants in neighborhoods that were part of the study area, (2) to quantify associations between the relative availability of food stores and restaurants in residential area and dietary patterns of members of the cohort, (3) to examine the influence of subjective nutrition knowledge in the relationship between the residential food environment and dietary patterns among older men and women. Methods: Cross-sectional analysis of data from three different sources was performed: (1) person-level data on 848 participants from cycle 1 of the Québec Longitudinal Study on Nutrition and Successful Aging , (2) 2001 Census data from Statistics Canada and (3) data from private businesses and services registry (2005), these two gathered in a geographic information system called Megaphone. Nonparametric bivariate analyses were applied to address objective 1. Associations between exposure to residential-area food sources and dietary patterns (objective 2), as well as moderating effect of nutrition knowledge (objective 3), were tested using linear regression analyses. Results: Analyses revealed three important results. First, the use of relative indices to characterize availability of local-area food sources is relevant to the study of dietary patterns, particularly regarding the supply of fast food restaurants. Second, the ubiquity of unfavorable aspects in the food environment, characterized by relatively higher fast food restaurants offer seem more detrimental to healthful eating habits that the presence of opportunities to buy healthful foods in food stores. Third, a residential food environment more favorable to healthful dietary patterns could reduce disparities in diet quality between women with low nutrition knowledge compared to women more knowledgeable. Conclusion: These results highlight the complex links between local environment and diet. If findings can be replicated in future research, population-based strategies to address an imbalance between accessibility to healthful food sources relative to unhealthful food sources, would be promising.

Thesis (Ph. D.)--Uniformed Services University of the Health Sciences, 2005. / Typescript (photocopy).

INTRODUÇÃO: Em 1999 e 2000, a ocorrência de surtos de rubéola, com maior acometimento entre adultos jovens, refletiu no aumento da síndrome da rubéola congênita. Como estratégia de controle da doença, foram realizadas campanhas de vacinação contra a rubéola em mulheres em idade fértil em vários Estados do País. Em razão das controvérsias existentes na literatura geradas quanto ao emprego da vacina de vírus vivos atenuados em gestantes, não se recomendou sua utilização durante a gravidez e até um mês após a aplicação da vacina. No entanto, 6.473 mulheres foram inadvertidamente vacinadas no Estado de São Paulo, sendo encaminhadas a serviços de referência para acompanhamento dessas gestações, dentre eles, o HCFMUSP. OBJETIVO: Este estudo buscou descrever as características clínicas e epidemiológicas das gestantes atendidas no HCFMUSP e obter os resultados dessas gestações. MÉTODO: Foi realizado um estudo epidemiológico descritivo, utilizando-se como fonte de dados as notificações das gestantes inadvertidamente vacinadas contra a rubéola e atendidas no HCFMUSP entre novembro de 2001 a dezembro de 2002. Para obter o desfecho das gestações, utilizou-se a base de dados dos nascidos vivos do Município de São Paulo (SINASC). RESULTADOS: No HCMFUSP, foram atendidas e notificadas 409 gestantes. Destas, 49,1% foram vacinadas no primeiro mês de gravidez e 26,2% engravidaram até um mês após a vacinação. Em relação a condição sorológica durante o pré-natal, 16,9% das gestantes apresentaram sorologia reagente para rubéola. Do relacionamento com a base de dados do SINASC, foram localizados os dados do parto de 63,3% das gestantes, sendo detectadas duas malformações congênitas no SINASC e um abortamento, porém, não se pode atribuir estes resultados à vacina, pois, as sorologias das mães não permitem determinar se estas mulheres eram realmente suscetíveis. CONSIDERAÇÕES FINAIS: O estudo apresentou o fluxo de informação estabelecido frente a um evento inusitado. Além disso, o uso de bases de dados secundárias contribuiu para o aprimoramento dos dados coletados, resultando na melhora da qualidade das informações. Os Núcleos de Epidemiologia Hospitalar são fundamentais na articulação entre a equipe assistencial e o Sistema de Vigilância e colaboram para discussão na padronização de Sistemas de Informação para permitir melhor integração entre as informações geradas pelos Serviços de Saúde. / INTRODUCTION: In the years 1999 and 2000, rubella outbreaks reaching mostly young adults resulted in an increased number of cases of Congenital Rubella Syndrome in Brazil. State Vaccination Campaigns aiming at women at childbearing age were promoted around the country to control the disease, recommending that vaccination of pregnant women should be avoided and pregnancy should be postponed for at least a month after vaccination. Despite the recommendations, 6.473 pregnant women were accidentally vaccinated in the State of São Paulo and therefore sent to reference obstetrical services for prenatal care. A study was conducted to describe the cases assisted at the University of São Paulo, School of Medicine, General Hospital and notified to Public Health and also to obtain information on the pregnancy outcomes. METHODS: This descriptive epidemiological study used notification by the Hospital Epidemiology Service as source of information on pregnant women accidentally vaccinated against rubella that received care from November 2001 to December 2002 at the School of Medicine, General Hospital. The City of São Paulo Newborn Database was searched for pregnancy outcomes. RESULTS: Among the 409 notified cases, 49,1% were women accidentally vaccinated during fist trimester of pregnancy and 26,2% women that became pregnant within less than a month after vaccination. Positive serological tests were found in 16,9% of women during prenatal care. Newborn data base search yielded pregnancy outcome for 63,3%. The findings of 2 cases of Congenital Rubella Syndrome and 1miscarriage cannot be surely attributed to vaccination because immediate previous immunization status was unknown. CONCLUSIONS: The study described the information flow established for an unexpected adverse event and the use of secondary data to improve quality of information. Hospital Epidemiology Services have a fundamental role in connecting health assisting professionals to Public Surveillance Systems and in setting standards for information generated by Health Assistance.

La Communauté française décide en concertation avec la Région bruxelloise et la Région wallonne, de financer un Centre d’Epidémiologie Périnatale (CEpiP). Les Communautés et Régions chargent le CEpiP de les assister dans la vérification, le remplissage et la correction des certificats concernant les naissances à partir du 1er janvier 2008. Le CEpiP est également chargé d’encoder les certificats bruxellois, les certificats wallons étant toujours encodés par un sous-traitant.<p>Un problème souvent rencontré dans l’analyse des certificats de naissance est la présence de données manquantes. Des informations manquaient sur 64.0% des certificats bruxellois de janvier 2008 (situation de base). Le renforcement de l’enregistrement par le CEpiP durant l’année 2008 est lié à une diminution des informations manquantes sur les certificats initiaux (à la sortie des maternités et services d’état civil) après la première et la deuxième année d’enregistrement :20,8% et 19,5% des naissances en décembre 2008 et 2009 respectivement. Le taux résiduel de données manquantes après correction grâce aux listes envoyées aux maternités et services d’Etat civil est faible. En particulier, la nationalité d’origine des parents était souvent manquante, jusqu’à 35% à Bruxelles (données non publiées), et ce taux est passé à 2.6% en 2008 et 0.1% en 2009. Certaines données manquantes ne sont pas distribuées de façon équivalente selon la nationalité de la mère, même après correction. Les mères d’origine sub-saharienne ont les taux de remplissage les moins élevés. Enfin, le taux de mort-nés a augmenté par rapport aux données de 2007, au profit des mort-nés avant l’âge de 28 semaines, et suggère une amélioration de l’enregistrement suite au renforcement de l’information.<p>Les données concernant l’indice de masse corporelle des patientes sont donc relevées depuis 2009 pour l’ensemble des mères qui accouchent en Belgique. L’obésité maternelle et l’immigration sont en augmentation en Belgique, et ont été rarement étudiées au travers d’études de population sur les certificats de naissance. Des études ont pourtant montré que ces mères étaient à risque de complications périnatales, comme la césarienne ou la mortalité périnatale. L’obésité et l’immigration ont en commun le fait qu’elles recouvrent des réalités médicales, sociales et relationnelles face au personnel soignant, qui les mettent à risque de complications périnatales.<p>Des différences en termes de complications obstétricales et néonatales entre populations immigrantes et autochtones ont été observées en Belgique et dans d’autres pays, mais elles sont encore mal comprises. <p>Dans un premier travail d’analyse, nous avons évalué les taux de mortalité périnatale chez les mères immigrantes, en fonction du fait qu’elles étaient naturalisées ou non.<p>Le taux de mortalité périnatale est globalement plus élevé chez les mères immigrantes (8.6‰) que non-immigrantes (6.4‰).<p>Le taux de mortalité périnatale est globalement plus élevé chez les mères non naturalisées (10.3‰) que chez les mères naturalisées (6.1‰).<p>Le taux de mortalité périnatale varie selon l’origine des mères, mais dans chaque sous-groupe étudié, les mères non naturalisées ont un taux plus élevé de mortalité périnatale.<p><p>Des études ont successivement montré davantage, ou moins de césariennes chez les mères immigrantes. Peu de facteurs confondants étaient généralement pris en compte. Dans un second travail d’analyse, nous avons comparé les taux de césarienne dans plusieurs sous-groupes de nationalités.<p>Les taux de césarienne varient selon les sous-groupes de nationalités. Les mères originaires d’Afrique sub-saharienne ont un odds ratio ajusté pour la césarienne de 2.06 (1.62-2.63) en comparaison aux mères belges. L’odds ratio ajusté n’est plus statistiquement significatif après introduction des variables anthropométriques dans le modèle multivariable pour les mères d’Europe de l’Est, et après introduction des interventions médicales pour les mères du Maghreb.<p><p>Peu d’études ont analysé la relation entre l’obésité maternelle et les complications néonatales, et la plupart de ces études n’ont pas ajusté leurs résultats pour plusieurs variables confondantes. Nous avons eu pour but dans un troisième travail d’analyse d’étudier la relation entre l’obésité maternelle et les paramètres néonatals, en tenant compte du type de travail (induit ou spontané) et du type d’accouchement (césarienne ou voie basse). Les enfants de mères obèses ont un excès de 38% d’admission en centre néonatal après ajustement pour toutes les caractéristiques du modèle multivariable (intervalle de confiance à 95% :1.22-1.56) ;les enfants de mères obèses en travail spontané et induit ont également un excès de risque de 45% (1.21-1.73) et 34% (1.10-1.63) respectivement, alors qu’après une césarienne programmée l’excès de risque est de 18% (0.86-1.63) et non statistiquement significatif.<p>Les enfants de mères obèses ont un excès de 31% de taux d’Apgar à 1 minute inférieur à 7, après ajustement pour toutes les caractéristiques du modèle mutivariable (1.15-1.49) ;les enfants de mères obèses en travail spontané et induit ont également un excès de risque de 26% (1.04-1.52) et 38% (1.12-1.69) respectivement, alors qu’après une césarienne programmée l’excès de risque est de 50% (0.96-2.36) et non statistiquement significatif.<p><p>In 2008, a Centre for Perinatal Epidemiology was created inter alia to assist the Health Departments of Brussels-Capital City Region and the French Community to check birth certificates. A problem repeatedly reported in birth certificate data is the presence of missing data. The purpose of this study is to assess the changes brought by the Centre in terms of completeness of data registration for the entire population and according to immigration status. Reinforcement of data collection was associated with a decrease of missing information. The residual missing data rate was very low. Education level and employment status were missing more often in immigrant mothers compared to Belgian natives both in 2008 and 2009. Mothers from Sub-Saharan Africa had the highest missing rate of socio-economic data. The stillbirth rate increased from 4.6‰ in 2007 to 8.2‰ in 2009. All twin pairs were identified, but early loss of a co-twin before 22 weeks was rarely reported.<p>Differences in neonatal mortality among immigrants have been documented in Belgium and elsewhere, and these disparities are poorly understood. Our objective was to compare perinatal mortality rates in immigrant mothers according to citizenship status. Perinatal mortality rate varied according to the origin of the mother and her naturalization status: among immigrants, non-naturalized immigrants had a higher incidence of perinatal mortality (10.3‰) than their naturalized counterparts (6.1‰). In a country with a high frequency of naturalization, and universal access to health care, naturalized immigrant mothers experience less perinatal mortality than their not naturalized counterparts. <p>Our second objective was to provide insight into the differential effect of immigration on cesarean section rates, using Robson classification. Cesarean section rates currently vary between Robson categories in immigrant subgroups. Immigrant mothers from Sub-Saharan Africa with a term, singleton infant in cephalic position, without previous cesarean section, appear to carry the highest burden.<p>If it is well known that obesity increases morbidity for both mother and fetus and is associated with a variety of adverse reproductive outcomes, few studies have assessed the relation between obesity and neonatal outcomes. This is the aim of the last study, after taking into account type of labor and delivery, as well as social, medical and hospital characteristics in a population-based analysis. Neonatal admission to intensive care and low Apgar scores were more likely to occur in infants from obese mothers, both after spontaneous and <p> / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

Indiana University-Purdue University Indianapolis (IUPUI) / Epidemiological studies suggest that depression may be an independent risk factor for cardiovascular disease (CVD). Although several possible mediators of this association have been proposed, the precise mechanisms are yet unknown. Accordingly, we examined periodontal disease as a novel mediator of the depression-CVD association, given its separate links with both depression and CVD. Data from the National Health and Nutrition Examination Survey (NHANES) I and its Epidemiologic Follow-up Study (NHEFS) were analyzed. Participants were 3,346 individuals aged 25-74 years free of CVD at baseline (53% female, 16% non-white). Depression was assessed by the, depressed mood subscale of the General Well-Being Schedule Based on the Russell Periodontal Index, periodontal disease (43%) was defined as the presence of four or more periodontal pockets identified by a licensed dentist during an examination. The primary outcome was incident CVD (n=727, 22%), defined as nonfatal or fatal coronary artery disease or cerebrovascular disease, identified during the follow-up period by interviews and death certificate records. All analyses were adjusted for demographic and cardiovascular risk factors. Logistic regression analyses revealed no association between the GWBS depressed mood score and periodontal disease (OR=1.05, 95% CI: 0.96-1.14, p=.24). Cox proportional hazard models revealed that both periodontal disease (HR=1.24, 95% CI: 1.06-1.46, p=.009) and depressed mood (HR=1.08, 95% CI: 1.01-1.17, p=.03) were significant predictors of incident CVD. However, Sobel analyses found that periodontal disease was not a partial mediator of the depressed mood-incident CVD association (t=1.01, p=.31). Overall, these mediation results suggest that (a) both periodontal disease and depressed mood are independent predictors of incident CVD and that (b) the effect of depressive symptoms on incident CVD is not mediated by periodontal disease.

Brass musicians are known to experience a performance problem that is sometimes called valsalva maneuver or musical stuttering. This problem is known to cause difficulty starting a first note, tension in the throat, and tightness in the chest. Unfortunately, the research literature lacks sufficient details for evidence-based interventions. Therefore, the purpose of this study is to characterize and define this performance problem as experienced by brass musicians. An online epidemiologic survey was developed and deployed to collect data from brass musicians who have experienced this problem in their own playing. The survey was designed to acquire data in order to characterize and define the phenomenon through a biopsychosocial framework. The survey was also designed to assess whether this problem aligns with Altenmuller's heuristic model of motor control disruptions. A diverse group of brass musicians (n = 252) participated and offered relevant details for characterizing and defining this problem. Analysis of characteristic data suggests this problem is not a form of musical stuttering. Considering these data through Altenmuller's model suggests that this problem is experienced as a spectrum of motor disruptions that can develop into a unique type of musician's dystonia. While additional research is warranted, the results of this study are applicable to brass musicians, brass pedagogues, music educators, and performing arts health clinicians.

O etanol de cana-de-açúcar se consolida como combustível renovável, o que promove nova expansão da cultura da cana-de-açúcar no Brasil e, principalmente, no Estado de São Paulo. Como a queima prévia controlada da palha de cana-de-açúcar ainda é considerada uma prática agrícola necessária para a viabilização econômica da colheita, em mais de 70% dos municípios do Estado de São Paulo a população é obrigada a conviver com essa poluição. Para estudar a distribuição desse fator de risco e sua relação com a saúde, realizei um estudo epidemiológico ecológico nos 645 municípios de São Paulo. Usei um modelo Bayesiano de regressão multivariada relacionando os efeitos na saúde com a exposição à queima prévia da palha de cana-de-açúcar, sendo controlados os efeitos das variações socioeconômicas (saneamento, educação e renda) e climáticas (temperatura máxima, umidade mínima e precipitação), através da inserção das mesmas no modelo. O efeito sobre a saúde foi medido por meio da Razão de Mortalidade e Morbidade Padronizada (RMP) dos desfechos: óbitos por doenças respiratórias nas faixas etárias acima de 65 anos e internações por doença respiratória, nas faixas etárias menores de 5 anos e acima de 65 anos de cada um dos municípios. Usei como medida de exposição à queima prévia dados obtidos no INPE: percentual da área de cana colhida com queima (PMQ), níveis médios de Aerossol e Focos de queima, testadas separadamente. Para resolver a autocorrelação entre os dados, estes foram considerados conforme sua disposição espacial, através da construção de uma matriz de vizinhança dos 645 municípios do Estado. Utilizei o método de simulação de Monte Carlo via Cadeias de Markov (MCMC) para \'suavizar\' as estimativas da RMP. A análise demonstrou que existe associação entre a queima prévia da palha de cana-de-açúcar e a ocorrência de doenças respiratórias, porque o aumento nos focos de queima (Focos) esteve associado significativamente com o aumento das internações por doenças respiratórias, na faixa etária de menores de cinco anos. Os resultados mostraram que a queima prévia da palha da cana-de-açúcar oferece efetivamente risco à saúde da população e, adicionados aos mapas coropléticos gerados, oferecem subsídios para a vigilância epidemiológica e contribuem para o estabelecimento de políticas públicas para controle da poluição do ar, que contemplem além dos grandes centros urbanos, os pequenos municípios. A eliminação desse fator de risco deve fazer parte das medidas primordiais de prevenção à saúde a serem adotadas no Estado / Ethanol from sugarcane is consolidated as a renewable fuel which promotes further expansion of the culture of sugarcane in Brazil and especially in the State of São Paulo. As the controlled pre-harvest burning of sugarcane straw is still considered an agricultural practice necessary for the economic viability of this crop in more than 70% of municipalities in the State of São Paulo the population is forced to live with this pollution. To study the distribution of this risk factor and its relationship with the health of the population, I conducted an ecological study in the 645 municipalities of São Paulo. I used a Bayesian multivariate regression model relating the health effects and the exposure to previous straw burning of sugarcane, controlling the effects of socioeconomic factors (sanitation, education and income) and climate (maximum temperature, minimum humidity and precipitation) by the insertion of these variables in the model. The effect on health was measured by Standardized Mortality and Morbidity Ratio (SMR) of the outcomes: deaths from respiratory diseases in the age group above 65 years old and admissions for respiratory disease in children less than 5 years old and above 65 years old of each of the municipalities. I used as a measure of exposure to the pre-harvest burning data obtained at INPE: percent of sugarcane area harvest with burning (PMQ), levels of Aerosol and Spotlights of burning, tested separately. To solve the autocorrelation in the data these were considered as their spatial arrangement, by building a neighborhood matrix of the 645 municipalities in the state. I used the Markov Chain-Monte Carlo simulation method (MCMC) to \'soften\' the estimates of the SMR. The analysis showed that there is an association between previous straw burning of sugarcane and respiratory diseases, because the increase in outbreaks of burning (Spotlights) was significantly associated with increased hospital admissions for respiratory diseases in children aged under five years old. The results show that the previous straw burning of sugarcane effectively offers health risk to the population and added to the choropleth maps generated provide valuable information for epidemiological surveillance and contribute to the establishment of public policies for the control of air pollution, which should contemplate beyond the major urban centers, the small towns. The elimination of this risk factor should be part of a primordial prevention measure to be taken in the state

O etanol de cana-de-açúcar se consolida como combustível renovável, o que promove nova expansão da cultura da cana-de-açúcar no Brasil e, principalmente, no Estado de São Paulo. Como a queima prévia controlada da palha de cana-de-açúcar ainda é considerada uma prática agrícola necessária para a viabilização econômica da colheita, em mais de 70% dos municípios do Estado de São Paulo a população é obrigada a conviver com essa poluição. Para estudar a distribuição desse fator de risco e sua relação com a saúde, realizei um estudo epidemiológico ecológico nos 645 municípios de São Paulo. Usei um modelo Bayesiano de regressão multivariada relacionando os efeitos na saúde com a exposição à queima prévia da palha de cana-de-açúcar, sendo controlados os efeitos das variações socioeconômicas (saneamento, educação e renda) e climáticas (temperatura máxima, umidade mínima e precipitação), através da inserção das mesmas no modelo. O efeito sobre a saúde foi medido por meio da Razão de Mortalidade e Morbidade Padronizada (RMP) dos desfechos: óbitos por doenças respiratórias nas faixas etárias acima de 65 anos e internações por doença respiratória, nas faixas etárias menores de 5 anos e acima de 65 anos de cada um dos municípios. Usei como medida de exposição à queima prévia dados obtidos no INPE: percentual da área de cana colhida com queima (PMQ), níveis médios de Aerossol e Focos de queima, testadas separadamente. Para resolver a autocorrelação entre os dados, estes foram considerados conforme sua disposição espacial, através da construção de uma matriz de vizinhança dos 645 municípios do Estado. Utilizei o método de simulação de Monte Carlo via Cadeias de Markov (MCMC) para \'suavizar\' as estimativas da RMP. A análise demonstrou que existe associação entre a queima prévia da palha de cana-de-açúcar e a ocorrência de doenças respiratórias, porque o aumento nos focos de queima (Focos) esteve associado significativamente com o aumento das internações por doenças respiratórias, na faixa etária de menores de cinco anos. Os resultados mostraram que a queima prévia da palha da cana-de-açúcar oferece efetivamente risco à saúde da população e, adicionados aos mapas coropléticos gerados, oferecem subsídios para a vigilância epidemiológica e contribuem para o estabelecimento de políticas públicas para controle da poluição do ar, que contemplem além dos grandes centros urbanos, os pequenos municípios. A eliminação desse fator de risco deve fazer parte das medidas primordiais de prevenção à saúde a serem adotadas no Estado / Ethanol from sugarcane is consolidated as a renewable fuel which promotes further expansion of the culture of sugarcane in Brazil and especially in the State of São Paulo. As the controlled pre-harvest burning of sugarcane straw is still considered an agricultural practice necessary for the economic viability of this crop in more than 70% of municipalities in the State of São Paulo the population is forced to live with this pollution. To study the distribution of this risk factor and its relationship with the health of the population, I conducted an ecological study in the 645 municipalities of São Paulo. I used a Bayesian multivariate regression model relating the health effects and the exposure to previous straw burning of sugarcane, controlling the effects of socioeconomic factors (sanitation, education and income) and climate (maximum temperature, minimum humidity and precipitation) by the insertion of these variables in the model. The effect on health was measured by Standardized Mortality and Morbidity Ratio (SMR) of the outcomes: deaths from respiratory diseases in the age group above 65 years old and admissions for respiratory disease in children less than 5 years old and above 65 years old of each of the municipalities. I used as a measure of exposure to the pre-harvest burning data obtained at INPE: percent of sugarcane area harvest with burning (PMQ), levels of Aerosol and Spotlights of burning, tested separately. To solve the autocorrelation in the data these were considered as their spatial arrangement, by building a neighborhood matrix of the 645 municipalities in the state. I used the Markov Chain-Monte Carlo simulation method (MCMC) to \'soften\' the estimates of the SMR. The analysis showed that there is an association between previous straw burning of sugarcane and respiratory diseases, because the increase in outbreaks of burning (Spotlights) was significantly associated with increased hospital admissions for respiratory diseases in children aged under five years old. The results show that the previous straw burning of sugarcane effectively offers health risk to the population and added to the choropleth maps generated provide valuable information for epidemiological surveillance and contribute to the establishment of public policies for the control of air pollution, which should contemplate beyond the major urban centers, the small towns. The elimination of this risk factor should be part of a primordial prevention measure to be taken in the state

The literature directly comparing the epidemiology of MRSA among adult and pediatric hospitalized patients is strikingly minimal. The objective of this thesis was to identify any differences between these two patient groups. The Canadian Nosocomial Infections Surveillance Program MRSA data (1995 to 2007: n=1,262 pediatric and 35,907 adult cases) were used to compare MRSA clinical and molecular characteristics and rates. Hospital characteristics were modeled using repeated measures Poisson regressions. The molecular and epidemiological characteristics of MRSA differed significantly between adults and children. Compared to children, MRSA in adults was more likely to be healthcare-associated, colonization, SCCmec type II, PVL negative, and resistant to most antibiotics. Rates of MRSA in Canada increased in both populations over time but were significantly higher in adults. The hospital characteristics associated with increased MRSA rates differed in adult and pediatric facilities. Implications for infection prevention and control strategies are discussed.