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Made available in DSpace on 2011-05-04T12:36:24Z (GMT). No. of bitstreams: 0 Previous issue date: 2010 / Analisar as vantagens e limitações da definição de caso de episódio hipotônico-hiporresponsivo (EHH) baseada na revisão da literatura, e as implicações para o Sistema de Informação de Eventos Adversos Pós-Vacinação do Programa Nacional de Imunizações. Materias e métodos: Este trabalho é baseado em dados obtidos por um estudo de vigilância ativade eventos adversos pós-imunização com a vacina combinada contra difteria, tétano, coqueluche e Haemophilus influenzae tipo b (DTP/Hib), realizado no município do Rio de Janeiro, no ano de 2004 (VIGAT), cujo objetivo primário era determinar em crianças com menos de 1 ano de idade a incidência do episódio hipotônico-hiporresponsivo (EHH) que se inicia nas primeiras 48 horas após a aplicação da vacina DTP/Hib utilizada pelo Programa Nacional de Imunização. Foram analisados o desempenho das perguntas de triagem para potenciais casos de EHH aplicadas no VIGAT, a reprodutibilidade da sua definição de caso de EHH quando aplicada em diferentes níveis de avaliação, o seu valor preditivo positivo, assim como, o seu desempenho em relação a outras definições de caso presentes na literatura, considerando-se o grau em que esse desempenho afeta a vigilância de eventos adversos associados à vacina DTP/Hib. Foi realizada também uma análise demográfica e dos antecedentes pessoais dos casos de EHH, e da sua possível associação com fatores relacionados à vacina, sua aplicação e outros eventos adversos pós-vacinais (EAPV). Resultados: A freqüência de EHH encontrado no VIGAT foi de 8,1 por 10.000 vacinados (IC95 por cento 4,7 - 13,0 por 10.000). Não houve significância estatística para a associação entre o EHH e o sexo do lactente, baixo peso de nascimento, índice de Apgar abaixo do normal, dose da vacina aplicada e lotes dos componentes vacinais. A febre maior ou igual a 39°C foi considerada como fator de risco para a ocorrência de EHH, encontrando-se associação entre eles com risco relativo de 8,2 (IC 95 por cento = 2,6; 25,7). O valor preditivo positivo da definição de caso do EHH adotada no VIGAT (2004) para o diagnóstico de EHH, quando utilizada pelo coordenador local do estudo foi 0,68 (17/25). Houve 100 por cento de concordância no diagnóstico de EHH entre o Grupo de Revisão de Diagnóstico (GRD) e o Comitê de Monitoramento Externo (CME). O Valor Preditivo Positivo (VPP) das duas perguntas de triagem combinadas foi de 17/47 (36,2 por cento). A concordância entre a definição de caso de EHH do VIGAT e a de Braun et al (1998) foi de 0,84 (kappa = 0,68); de 0,8 (kappa = 0,61) em relação a Brighton (2004); de 0,84 (kappa = 0,66) para Vermeer et al (2006); e de 0,92 (kappa = 0,82) para Brighton (2007). Conclusões: A definição de caso de EHH do VIGAT, norteada por perguntas de triagem de elevada sensibilidade e aplicada por uma equipe capacitada, apresentou bom desempenho na vigilância ativa desse EAPV. Entretanto, observou-se uma dificuldade no processo de diagnóstico de EHH, em função das características inerentes a esse evento, chamando atenção para a necessidade de criterios a avaliação dos dados obtidos por vigilância passiva, principalmente, na comparabilidade entre eles. / Objectives: To analyze the advantages and limitations of the case definition for hypotonichyporesponsive episode (HHE) based on the literature review, and the implications for the Postvaccination Adverse Events (VAE) Information System of the National Immunizations Program. Materials and methods: This work is based on data obtained by an active surveillance study of post-vaccination adverse events with the combined diphtheria-tetanus-whole cell pertussis- Haemophilus influenzae type b vaccine performed in the Rio de Janeiro municipality in 2004 (VIGAT), whose primary objective was to determine the incidence of hypotonic-hyporesponsive episode (HHE) that began in the first 48 hours after the application of the DTP/Hib vaccine used by the National Immunization Program in children under the age of 1 year. The performance of the screening questions for potentials HHE cases performed in VIGAT were analyzed, the reproducibility of its definition for HHE cases when performed in different evaluation levels, its positive predictive value, as well as its performance in relation to other case definitions present in the literature, considering in what degree this performance affects adverse events surveillance associated to the DTP/Hib vaccine. A demographic analysis and of the personal antecedents of HHE cases was also accomplished, and of its possible association with vaccine-related factors, its application and other vaccine adverse events (VAE). Results: The frequency of HHE found in VIGAT was 8.1 for 10,000 vaccinated subjects (CI 95% 4.7 –13.0 for 10,000). There was no statistical significance for the association between HHE and the sex of the infant, low birth weight, below normal Apgar index, dosage of vaccine and lots of vaccinal components. Fever equal to or higher than 39°C was considered as risk factor for the occurrence of HHE, having found an association among them with the relative risk of 8.2 (CI 95% = 2.6; 25.7). The predictive positive value for the HHE case definition adopted in VIGAT (2004) for the HHE diagnosis, when used by the local study coordinator was 0.68 (17/25). There was a 100% agreement in the HHE diagnosis between the Diagnosis Review Group (DRG) and the External Monitoring Committee (EMC). The Predictive Positive Value (PPV) of the two combined screening questions was 17/47 (36.2%). The agreement between the HHE case definition of VIGAT and of Braun et al (1998) was of 0.84 (kappa = 0.68); 0,8 (kappa = 0.61) in relation to Brighton (2004); 0.84 (kappa = 0.66) for Vermeer et al (2006); and 0.92 (kappa = 0.82) for Brighton (2007). Conclusions: The case definition for HHE of VIGAT, orientated by screening questions of high sensibility and applied by a qualified team, presented good performance in the active surveillance of that VAE. However, a difficulty was observed in the HHE diagnosis process, due to the inherent characteristics to that event, highlighting the need for a criterial data evaluation obtained by passive surveillance, mainly, in the comparability among them.

Introduction : Quoique plus de 90 minutes/semaine d’activité physique (AP) soient recommandées, peu d'individus présentant un premier épisode psychotique (PEP) en pratiquent, malgré la présence de complications métaboliques fréquentes. La littérature suggère qu'une intervention d'AP incluant leurs préférences d’AP et des conseils motivationnels faciliterait leur adhésion. Objectifs: Vérifier la faisabilité, l’acceptabilité et l’impact d’une intervention d’AP sur la motivation à l’AP, le niveau d’AP, de sédentarité et la participation sociale. Méthodes: Essai clinique ouvert (étude pilote) conduit auprès de PEP. L’intervention de 24 séances d’AP supervisées est basée sur les « préférences-patient » et inclut des conseils motivationnels utilisant le modèle transthéorique. La faisabilité et l’acceptabilité étaient mesurées grâce au taux d’abandon, de présence et à la satisfaction. La motivation à l’AP, la participation sociale, le niveau d’AP et de sédentarité ont été mesurés. Résultats: Des 40 PEP (25,63±4,22 ans, 52,5% de femmes) recrutés, 40% ont abandonné; le taux de présence était 67,5%. Les PEP (94%) étaient beaucoup (4/5) à énormément (5/5) satisfaits. Le niveau d’AP est passé de 52,71 à 91,79 minutes/semaine (recommandations atteints) et la sédentarité de 90,85 à 33,75 ± 49,16 minutes. Aucun impact observé sur la motivation d’AP et la participation sociale. Conclusion: Les résultats préliminaires suggèrent qu'une intervention basée sur les préférences-patients est faisable et acceptable chez les PEP. De futures études contrôlées randomisées permettraient de déterminer si la diminution de la sédentarité et l’augmentation d’AP sont réellement attribuables à cette intervention et si elle peut contribuer à réduire les complications métaboliques chez les PEP. / Introduction: Although 90 minutes or more/week of physical activity (PA) is recommended, few individuals with early psychosis (IEP) practice it despite the frequent presence of metabolic complications. The literature suggests that a PA intervention including their preferred PA and motivational counseling would facilitate their adherence. Objectives: To determine the feasibility, acceptability and impact of a PA intervention on PA motivation, PA level, sedentary time and social participation. Methods: Open clinical trial (pilot study) conducted with IEP. The PA intervention of 24 supervised PA sessions is based on “patients-preferences” and includes motivational counseling using the transtheoretical model. Feasibility and acceptability were measured by drop-out rates and attendance and satisfaction level. PA motivation, PA level, level of physical inactivity and social participation were measured pre and post intervention. Results: Of the 40 IEP (age: 25.63 ± 4.22 years, 52.5% of women) recruited, 40% dropped out and the attendance rate was 67.5%. The satisfaction was rated (94%) “very satisfied” to “very much”. The PA level increased from 52,71 to 91.79 minutes/week (reaching recommendations) and physical inactivity decreased from 90,85 to 33.75 ± 49.16 minutes. The intervention had no impact on PA motivation and social participation. Conclusion: Our preliminary results suggest that an intervention based on patient preferences is feasible and acceptable in IEP. Future randomised controlled trials would allow to determine if the decreased physical inactivity and increased PA levels are due to this intervention and if it may contribute to reduce the frequent metabolic complications in IEP.

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This study investigates how the book of Acts addresses certain local problems in Luke's community through a linguistic stylistic analysis that utilizes models of verbal art and intertextuality within a systemic-functional linguistic framework. This methodology is suited to demonstrate how Luke symbolically articulates a message to his audience through his stylistic patternings of language of the Jerusalem Council in Acts 15 and the texts with which it shares thematic content. The scheme of the study begins with the analysis of the Cornelius episode in Acts 10:1-11:18, continues with the Jerusalem Council in Acts 15:1- 29, and concludes with Paul's return to Jerusalem where he stands accused of forsaking the Law of Moses in Acts 21:17-26. Each of these episodes, sharing patterns of repetition, plays a role in the symbolic articulation of a message in the book of Acts. First, the Cornelius story establishes the legitimacy of table fellowship among Jewish and Gentile believers against opposing Jewish value positions regarding moral purity. Next, the Jerusalem Council in Acts 15 recapitulates the Cornelius episode but then further develops value orientations concerning social relations among Jewish and Gentile believers in the church, principally by means of the Apostolic Decree. Then, the repetition of the Apostolic Decree in Acts 21 clarifies its meaning according to different situational variables. The thesis of this study is that these patterns reveal contextual elements of a particular conflict the early church faced over the communal integration of Jewish and Gentile believers - namely, that Jews were susceptible to splitting off from multi-ethnic churches due to the pressures of a Jewish separationist ideology. The book of Acts subverts this ideology by means of the foregrounded patternings identified in this study. These patternings, which serve to identify foregrounded thematic formations, orient the reader to the proper heterglossic backdrop and reveal that Luke engages a particular Noahic tradition associated with the discursive practice of rewriting sacred scripture in Second Temple Jewish literature, not to align with its value orientations but to subvert it and thereby convince Jewish believers not to withdraw from the community of God.

Increasing time trends in the recorded incidence of childhood cancer have been reported in many different settings. The extent to which these trends reflect real changes in incidence, rather than improvements in methods for diagnosis and registration, is controversial. Using data from the National Registry of Childhood Tumours (NRCT), this thesis investigates time trends in cancer diagnosed under age 15 in residents of Britain during 1966-2005 (54650 cases), and considers potential sources of artefact in detail. Several different methods are used to estimate completeness of NRCT registration. The history of methods for diagnosis and registration of childhood cancers in Britain is described, and predictions are made for effects on recorded incidence. For each of the 12 main diagnostic groups, Poisson regression is used to fit continuous time trends and ‘step’ models to the annual age-sex-standardised rates by year of birth and year of diagnosis. Age-specific rates by period, and quinquennial standardised rates for diagnostic subgroups, are shown graphically. For three broad groups (leukaemia, CNS tumours and other cancer), geographical variation is compared by period of diagnosis. The results of these analyses are discussed in relation to the predicted artefacts. The evidence for a positive association between affluence and recorded incidence of childhood leukaemia is briefly reviewed. A special form of diagnostic artefact, the ‘fatal infection’ hypothesis, is proposed as an explanation of both this association and the leukaemia time trend. This hypothesis is examined in a novel test based on clinical data. The recorded incidence of childhood cancer in Britain increased in each of 12 diagnostic groups during 1966-2005 (from 0.5% per year for bone cancer to 2.5% for hepatic cancer, with 0.7% for leukaemia). Evidence presented here suggests that these increases are probably artefacts of diagnosis and registration. The potential implications for epidemiological studies of childhood cancer should be considered.