Introduction : De nos jours, les femmes atteintes de cancer du sein peuvent espérer une survie prolongée et un grand nombre d’entre elles peuvent même entrevoir la guérison. Alors que le dépistage précoce et les traitements rigoureux donnent espoir à de plus en plus de femmes, les chercheurs et les cliniciens doivent maintenant se pencher sur la qualité de vie de ces femmes à chaque phase clinique de la trajectoire de soins. Les difficultés physiques, fonctionnelles, psychologiques et sociales avec lesquelles les femmes vivent peuvent compromettre leur qualité de vie, d’où l’intérêt d’évaluer celle-ci. Peu de chercheurs se sont intéressés au changement longitudinal de la qualité de vie de ces femmes aux différents moments de la trajectoire de soins en oncologie : diagnostic, traitement et suivi. De plus, peu se sont demandés si la perception que les femmes ont de leur communication avec les professionnels de la santé influence leur qualité de vie le long de la trajectoire de soins. Objectifs principaux : 1) Décrire l’évolution de la qualité de vie liée à la santé des femmes atteintes de cancer du sein pendant le diagnostic, les traitements de radiothérapie et le suivi; 2) Décrire l’évolution de la perception que les femmes ont de leur communication avec les médecins, les infirmières et les technologues en radio-oncologie au cours des mêmes phases cliniques; 3) Examiner l’évolution de la relation entre la perception que les femmes ont de leur communication avec les professionnels de la santé et leur qualité de vie liée à la santé durant les phases citées précédemment. Méthodes : L’échantillon se composait de 120 femmes atteintes d’un cancer du sein précoce (stades I et II) qui parlaient le français, âgées de plus de 18 ans (55 ans ± 9,5) qui ont eu une chirurgie conservatrice. Les femmes ont complété des questionnaires à la période entourant le diagnostic (en moyenne six semaines après le diagnostic), à mi-chemin de la radiothérapie (en moyenne 27 semaines après le diagnostic) et de trois à quatre mois après la fin de la radiothérapie (en moyenne 48 semaines après le diagnostic). À chaque temps de mesure, elles ont complété six questionnaires d’une durée totale de 60 minutes au centre hospitalier ou à domicile : un sur les données sociodémographiques, un sur les renseignements médicaux, le MOS SSS, le EORTC QLQ-C30/BR23 et le MCCS. Résultats : Les analyses GEE montrent que la qualité de vie liée à la santé des femmes atteintes de cancer du sein change dans le temps. Elle diminue pendant la radiothérapie, sauf pour le fonctionnement émotionnel et cognitif. Les analyses démontrent aussi que certains facteurs cliniques, intrapersonnels et interpersonnels influencent leur qualité de vie. Précisément, plus les femmes avancent en âge et plus elles perçoivent qu’elles ont eu du soutien social le long de la trajectoire de soins, plus leur qualité de vie est meilleure pour les dimensions génériques et spécifiques du fonctionnement. De plus, celles qui présentent une tumeur de stade II et celles qui ont eu de la radiothérapie et l’hormonothérapie ont des scores plus élevés pour certaines dimensions de qualité de vie comparativement à celles dont le cancer se situe au stade I et à celles qui ont eu la chimiothérapie, la radiothérapie et l’hormonothérapie. Les résultats font état également d’une interaction entre le facteur « temps » et un facteur intrapersonnel pour le fonctionnement « rôle » et le fonctionnement sexuel des femmes. La perception que les femmes ont de leur communication avec les médecins et les autres professionnels de la santé change très peu avec le temps. Ainsi, les femmes se perçoivent plus compétentes dans la recherche d’information avec les radio-oncologues pendant la radiothérapie qu’avec les chirurgiens-oncologues au moment du diagnostic. Elles perçoivent aussi la vérification et la recherche d’information par les radio-oncologues pendant la radiothérapie plus satisfaisante que celle des chirurgiens-oncologues lors de l’annonce du diagnostic. Globalement, les femmes perçoivent leur communication avec les radio-oncologues et les chirurgiens-oncologues comme étant meilleure pendant la radiothérapie et au suivi qu’au moment du diagnostic avec les chirurgiens-oncologues. Les analyses GEE montrent aussi que certains facteurs cliniques (nature des traitements), intrapersonnels et interpersonnels (âge, niveau de scolarité et soutien social perçu) sont des facteurs susceptibles d’influencer la façon dont elles perçoivent leur communication avec les professionnels de la santé. Enfin, la perception des femmes quant à leurs compétences de communication à l’égard des médecins et des autres professionnels de la santé explique davantage leur qualité de vie liée à la santé que celle des compétences des professionnels de la santé. Donc, les femmes ont un meilleur score pour le fonctionnement « rôle », émotionnel et elles ont moins d’effets secondaires et de symptômes pendant la radiothérapie et au suivi lorsqu’elles se perçoivent compétentes envers les médecins (chirurgiens-oncologues et radio-oncologues) pour la recherche d’information et l’aspect socio-affectif d’un entretien aux temps précédents. De plus, l’âge des femmes, le soutien social perçu, le stade de la maladie et la nature des traitements ont une influence sur le lien entre leur qualité de vie et leur communication avec les professionnels de la santé. Enfin, une interaction est présente entre le facteur « temps » et un facteur clinique ou intrapersonnel pour les dimensions de qualité de vie suivantes : rôle, émotionnel et fonctionnement sexuel. Conclusion et retombées : Les résultats de la présente thèse soulignent l’importance d’évaluer de façon longitudinale la qualité de vie liée à la santé des femmes atteintes de cancer du sein à différents moments de la trajectoire de soins, particulièrement pendant la radiothérapie, et, pour les intervenants psychosociaux, de s’occuper des jeunes femmes diagnostiquées et de celles qui ne perçoivent pas recevoir un soutien social. Ainsi, de meilleures ressources psychosociales pourront être mises sur pied pour aider ces groupes de femmes. Les résultats montrent également qu’il est essentiel d’informer les chirurgiens-oncologues de l’importance d’établir une communication satisfaisante avec les femmes atteintes de cancer du sein lors de l’annonce du diagnostic afin de favoriser une perception positive par les femmes de leur communication avec les chirurgiens-oncologues. Enfin, les résultats obtenus soulignent les avantages pour les femmes atteintes de cancer du sein d’être proactives et de se sentir compétentes pour la recherche d’information et l’aspect socio-affectif d’une relation avec les chirurgiens-oncologues et les radio-oncologues dans le maintien d’une bonne qualité de vie liée à la santé. / Introduction: Nowadays, women with breast cancer can have a longer survival and many of these women can even foresee a cure. While early screening and aggressive medical treatment offer hope to more women, researchers and clinicians must now look into the quality of life of these women at each clinical phase of the disease’s trajectory. The physical, functional, psychological and social difficulties that women treated for cancer experience can compromise their quality of life, hence the importance to evaluate it. Few researchers were interested in examining the longitudinal change of the quality of life of these women at the various phases of the disease’s trajectory in oncology: diagnosis, treatment and follow-up. Also, few researchers wondered if the perception women have of their communication with healthcare providers influence their quality of life throughout the trajectory of the disease. Main objectives: 1) Describe the evolution of the health-related quality of life of women suffering from breast cancer during diagnosis, radiation therapy and follow-up; 2) Describe the evolution of the women’s perception of their communication with the doctors, nurses and the technicians in radio-oncology during the same clinical phases; 3) Examine the evolution of the association between the perceived communication the women have with healthcare providers and their health-related quality of life during the three phases described above. Methods: The sample consisted of 120 French-speaking women with early breast cancer (stage I or II), aged 18 years and over (55 years ± 9,5) who underwent a lumpectomy. The women have filled out questionnaires around the diagnosis period ( on average six weeks from diagnostic), during half-way of radiation therapy (on average 27 weeks from diagnostic), and between three and four months after the end of radiation therapy (on average 48 weeks after diagnostic). At each measurement time, they completed five questionnaires of 60 minutes of total length at the hospital or at home : One pertaining to demographic data, one on medical data, the MOS SSS, the EORTC QLQ-C30/BR23 and the MCCS. Results: The GEE analyses indicate that the health-related quality of life of breast cancer women changes with time. It diminishes during radiotherapy, except for the emotional and the cognitive functioning. The analyses also show that certain clinical, intrapersonal and interpersonal factors influence their quality of life. Precisely, with age and with a better perceived social support along the disease’s trajectory, better is the women’s quality of life for the generic and specific dimensions of functioning. Moreover, those with stage II cancer and those who received radiotherapy and hormonotherapy have better scores for some quality of life dimensions compared to those who had a stage I cancer and those who were treated with chimiotherapy, radiotherapy and hormonotherapy. The results also revealed an interaction between the factor “time” and one interpersonal factor for the role functioning and the sexual functioning of these women. The perception the women have of their communication with doctors and other healthcare providers changed a little with time. Hence, the women perceived themselves more competent regarding the seeking of information with radio-oncologists during radiotherapy than with surgeons at diagnosis. They also perceived the verification and the seeking of information provided by the radio-oncologists during radiotherapy more satisfying compared to those of surgeons during diagnosis. The women perceived better their overall communication with the radio-oncologists and the surgeons during radiotherapy and at follow-up than during diagnosis with the surgeons. The GEE analyses indicate as well that some clinical (type of treatment), intrapersonal and interpersonal factors (age, education, and perceived social support) are factors that seems to influence the way they perceive their communication with healthcare providers. Finally, women’s perceptions of their competence with regards to their communication skills towards doctors and other healthcare providers explain more their health-related quality of life than their perception of the competence of healthcare providers. Therefore, women have better role and emotional functioning as well as fewer side effects and symptoms during radiotherapy and at follow-up when they perceive themselves as competent communicators for the seeking of information and the socio-emotional aspect of a relation at preceding phases towards doctors (surgeons and radio-oncologists). Moreover, women’s age, their perceived social support, the stage of their cancer and the type of treatments received influence the association between their quality of life and their communication with healthcare providers. Finally, an interaction exists between the factor “time” and one interpersonal or intrapersonal factor for the following quality of life dimensions : role, emotional, and sexual functioning. Conclusion and repercussions: The results of the present thesis underscore the importance to assess longitudinally the health-related quality of life of women with breast cancer at various times along the disease’s trajectory, especially during radiotherapy and for psychosocial specialists to take care of younger women diagnosed with breast cancer and those who do not perceive receiving social support. Thus, better psychosocial ressources can be developed to help those groups of women. The results illustrate as well that it is important to inform surgeons the importance of establishing a satisfactory communication with breast cancer women during diagnosis in order for them to have a positive perception of their communication with surgeons. Finally, the results obtained underscore the benefits for breast cancer women to be proactive and feel competent with regards to seeking information and the socio-emotional aspect of the relation between them and the surgeons and radio-oncologists in order to maintain a good health-related quality of life.

Background: Liver cirrhosis is a global health problem and a national health problem in Egypt. There is a lack of literature on Health-Related Quality of Life (HRQOL) and symptoms experience of liver disease and cirrhotic patients in Middle East, particularly in Egypt. Aims: This PhD had three major aims: First aim: To describe HRQOL of Egyptian liver cirrhotic patients and to identify and evaluate the factors associated with (HRQOL) physical and mental health domains. Second aim: To explore and describe experienced symptoms (prevalence, severity and hindrance) in Egyptian cirrhotic patients and to identify and evaluate factors associated with symptoms severity and symptoms hindrance (distress). Third aim: To explore and describe how cirrhotic patients in Egypt perceive social support from spouse, family and friends and to identify and evaluate factors associated with general perceived social support. Method: A cross-sectional study with a convenience sample of 401 patients from three hospitals in Cairo, Egypt, was conducted between June and August 2011. Patients were interviewed to complete a background data sheet, Short Form-36v2 (SF-36), the Liver Disease Symptom Index (LDSI)-2.0 and the Multidimensional Scale of Perceived Social Support (MSPSS). Results: Findings for first aim: The findings showed that all domains and component summary scores [Physical component summary score (PCS) and mental component summary score (MCS)] of the generic SF-36 were below the norm (cut-off score 50), suggesting that patients with liver cirrhosis in Egypt have poor HRQOL. About 87.2% of the patients rated their general health as poor or fair, which means the majority of these patients have low perceived general health. Many socio-demographic and medial factors were shown to be significantly associated with perceived HRQOL. Women, illiterate and unemployed people, and patients with frequent hospitalisation had poor PCS and MCS, while patients with advanced disease stage, increasing number of comorbidities and complications and those admitted to inpatients had significantly poorer PCS only. Perceived social support from a spouse had a statistically significant positive association with PCS and MCS, while perceived social support from family and friends had a statistically significant positive association with MCS only. Also, severity and hindrance of symptoms significantly correlated with PCS and MCS. Using stepwise multiple linear regression analysis, two models were developed to identify factors associated with PCS (Model 1) and MCS (Model 2) health. Model 1 could significantly explain 19% of the variation in PCS (R2 = 0.190, R2adj = 0.180, p = 0.0005), and four factors (symptoms severity, disease stage, comorbidities and employment status) were significantly (p ≤ 0.02) associated with PCS. Model 2 could significantly explain 31.7% of the variation in MCS (R2 = 0.317, R2adj = 0.308, p = 0.0005), and four factors (symptoms severity, employment status, perceived spouse support and perceived family support) were associated (p ≤ 0.04) with MCS. The key findings of this study were that severity of symptoms and social support from spouse and family were associated with HRQOL. Where patients with high symptoms severity were likely to report poor PCS and MCS; and patients with low perceived social support were likely to report poor MCS. Symptoms severity contributed significantly in explaining 28.7% of the variation in PCS and 43.6% of the variation in MCS. Findings for second aim: This study found that the majority of patients had one or more of a wide range of symptoms and social problems. Two-thirds of patients reported joint pain (78.3%), decreased appetite (75.6%) and memory problems (77.3%). Joint pain and depression were reported to have the biggest impact on daily life. Symptoms severity and distress were significantly higher among patients who were: female, illiterate, unemployed, and who had advanced cirrhosis with more complications and comorbidities (p ≤ 0.006). Symptoms severity (r=-0.206) and symptoms distress (r=-0.205) were negatively associated with perceived social support (p=0.005). Stepwise regression analysis showed that the regression model could significantly explain 19.6% of the variation in symptoms severity (R2 = 0.196, R2adj = 0.180, p = 0.0005), and 14% of the variation in hindrance of symptoms (R2 = 0.140, R2adj = 0.132, p = 0.0005). Being female, having an increasing number of liver disease complications, and having low perceived support from spouse were significantly associated with high-perceived symptoms severity and hindrance (p≤0.01). Findings for third aim: This study found that social support score was relatively high among patients with cirrhosis in Egypt (total score mean of MSPSS was 2.02± standard deviation (0.537), while perceived support from spouse was the highest source of support. 67.5% of the patients felt their spouse is around when they need him/her and 71.7% of them share their joys and sorrows with their spouse. Likewise, 64.9% of married people feel their spouse cares about their feelings. In relation to the perception of adequacy of family support, it was observed that 52.6% felt that their families do not really try to help them. At the same time, 52.1% reported that they got the emotional help and support that they needed from their families. Regarding perceived support from friends, more than half of the patients reported that their friends do not really try to help them (57.9%), they cannot count on their friends when things go wrong (65.6%) and they cannot talk about their problems with their friends (56.4%). There was a significantly positive association between the perception of social support and general health perception (GHP), suggesting that when social support decreases GHP also decreases or and vice versa (r= 0.208, p = 0.0005). Stepwise regression analysis showed that the regression model could significantly explain 10.9% of the variation in perceived social support (R2 = 0.109, R2adj = 0.100, p = 0.0005). Marital status, gender, age and employment status were significantly associated with general perceived social support (p ≤ 0.01), while unmarried, females, unemployed and elderly cirrhotic patients were vulnerable groups that were likely to perceive low social support. Overall discussion and conclusion: This is the first study to investigate HRQOL, symptoms experience and perceived social support in patients with liver cirrhosis in Egypt. All aspects of HRQOL of Egyptian cirrhotic patients were poor, and they were experiencing various symptoms that can affect their daily life. However, social support was found to be related to perceived symptoms severity and perceived poor mental health. Hence, social support may alleviate suffering for certain cirrhotic patients. Nurses have a responsibility to assess and treat symptoms that cirrhotic patients experience, particularly such treatable symptoms as depression, pain and decreased appetite. Also, nurses should involve the patient’s family in any plan of care. Future intervention studies that aim to develop programs to relieve treatable symptoms and enhance social support are also recommended.

Purpose: The purpose of this study was to study the association between Silver Diamine Fluoride (SDF) and Oral Health-Related Quality of Life as assessed by “The Early Childhood Oral Health Impact Scale” questionnaire. Methods: Parents of healthy children (ASA I and II) ages 1-5 with early childhood caries with reversible pulpitis who had application of SDF filled out a questionnaire at baseline and again after one month. The questionnaire was designed to evaluate the child’s behavior, physical abilities, pain, temperament, and how well the child gets along with others. Results: Wilcoxon Signed Rank Test was used to determine if responses to various ECOHIS items and the total scores were different between the two time points. Conclusion: Children with dental caries who had application of SDF reported less dental pain, less eating problems, higher quality of sleep and overall higher quality of life at one-month follow up compared with the baseline.

Introdução: O envelhecimento populacional, decorrente do aumento da expectativa de vida, foi, sem dúvida, uma importante conquista em nível global. Contudo, discute-se atualmente a necessidade premente de agregar qualidade aos anos de vida ganhos. Objetivo: Identificar fatores associados à Qualidade de Vida Relacionada à Saúde (QVRS) de idosos não institucionalizados do Município de São Paulo, em 2006. Método: Este estudo faz parte do Estudo Longitudinal SABE Saúde, Bem-Estar e Envelhecimento. Os dados foram coletados em 2006, de uma amostra representativa composta por 1.160 idosos (idade 60 anos) que responderam ao Short-Form 12 (SF-12), questionário genérico que avalia QVRS. As variáveis dependentes foram os Componentes Físico (PCS) e Mental (MCS) do SF-12 e as análises foram conduzidas separadamente segundo sexo. Buscou-se a associação com variáveis demográficas, socioeconômicas, estado de saúde, incapacidade funcional, estilo de vida e relacionamento social, utilizando o método de regressão logística múltipla. Resultados: Entre as idosas, estiveram associados a baixos escores no PCS: idade 80 anos, multimorbidade, internação, ter incontinência urinária, ter depressão, ter dificuldades para executar atividades instrumentais e básicas da vida diária (AIVD e ABVD) e não praticar atividades físicas. Baixos escores no PCS dos homens associaram-se a idade 80 anos, renda insuficiente, multimorbidade, tomar dois ou mais medicamentos, ter dificuldades para ABVD e não praticar atividades físicas. Baixos escores no MCS das mulheres estiveram associados a ser fumante, auto-percepção negativa de saúde geral e saúde bucal, ocorrência de queda no último ano e ter depressão. Baixos escores no MCS entre os homens idosos associaram-se à auto-percepção negativa de saúde, ter incontinência urinária e ter depressão. Homens mais velhos (idade 70 anos) apresentaram melhores escores no MCS em relação aos mais jovens (60-69 anos). Discussão: No PCS, as únicas variáveis coincidentes entre homens e mulheres foram idade, prática de atividades físicas, multimorbidade e dificuldade para ABVD; enquanto no MCS foram auto-percepção de saúde e depressão. A análise separada por sexo possibilitou a identificação de modelos distintos de determinantes da QVRS de idosos. Conclusão: Os fatores que se associaram significativamente ao PCS-SF12 de idosos de ambos os sexos foram: auto-percepção de saúde, multimorbidade, dificuldades para desempenhar ABVD e prática de atividades físicas. Enquanto suficiência de renda e número de medicamentos associaram-se apenas para o sexo masculino e internação, incontinência urinária, depressão e dificuldades para desempenhar AIVD, apenas para o sexo feminino. Ao MCS-SF12 de ambos os sexos associaram-se apenas auto-percepção de saúde e depressão; enquanto para o sexo masculino associaram-se também faixa etária e incontinência urinária. Já para as mulheres também apresentaram associação significativa o tabagismo, a auto-percepção de saúde bucal e quedas / Background: The world had experienced a high increased in life expectancy during the last decades, which has been undoubtedly considered as a major achievement. Because the increase of elderly population, that presents highest prevalence of chronic conditions, besides other single characteristics, several researches have been developed due to determine ways to add quality to the gained years of life. The aim of this study was to identify factors associated with elderly health-related Quality of Life (HRQoL), in São Paulo. Methods: This study is part of the Longitudinal Study SABE - Health, Welfare and Ageing (from Portuguese: Saúde, Bem-Estar e Envelhecimento). Data were collected in 2006. The sample consisted of 1,160 elderly (age 60 years) who answered the Short-Form 12 (SF-12), a generic HRQoL questionnaire. Dependent variables were Physical (PCS) and Mental Components (MCS) of SF-12. All analysis were separated by sex and the independent variables approached demographic, socioeconomic, health status, functional disability, lifestyle and social networking conditions, using the multiple logistic regression. Results: Among old women, lower PCS scores were associated with age 80 years, multimorbidity, hospitalization, urinary incontinence, depression, difficulty to perform basic and instrumental activities of daily living (BADL and IADL) and lack of physical activities. Among old men, lower PCS scores were associated with age 80 years, insufficient income, multimorbidity, taking two or more medications, difficulty to perform BADL and the lack of physical activities. Among the women, lower MCS scores were associated with being a smoker, negative self-perception of general health and oral health, occurrence of falls in the last year and depression. Among the men, lower MCS scores were associated with negative self-perception of health, urinary incontinence and depression. Older men ( 70 years) had better MCS scores than younger (60-69 years). Conclusion: Significantly associated factors with the PCS-SF12 for both male and female elderly were: self-perceived health status, multimorbidity, incapacity for BADL and physical activity; while income and number of drugs were associated only for males. Hospitalization, urinary incontinence, depression and incapacity for IADL were associated only for females. To the MCS-SF12 of both sexes were associated only self-perceived health and depression, while age and urinary incontinence were associated for males. Females MCS-SF12 also had significant association with tobacco, self-perception of oral health and falls

L’arrêt cardiaque extra-hospitalier (ACREH) touche environ 30 à 40,000 personnes en France chaque année. Dans près de la moitié des cas, la cause de l’ACREH est une occlusion coronaire aiguë provoquant un trouble du rythme ventriculaire létal. Malgré les progrès réalisés ces dernières années en terme de prise en charge pré et intra-hospitalière, le pronostic de ces patients reste sombre, de par les lésions neurologiques se produisant très rapidement après l’arrêt circulatoire. Alors que le pronostic à court terme est relativement bien décrit, les données sur le devenir à long terme, en termes de survie, mais aussi de devenir fonctionnel, neurologique, et de qualité de vie, restent rares. Objectifs : L’objectif de ce travail est de décrire le devenir à long terme des patients victimes d’un ACREH et admis vivants à l’hôpital (qualité de vie liée à l’état de santé, devenir neurologique et fonctionnel) et d’évaluer les facteurs associés à ce devenir (biomarqueurs, revascularisation coronaire précoce). Patients et méthodes : Ce travail a consisté en l’analyse des données de la cohorte des patients victimes d’un ACREH et admis vivants en réanimation mé- dicale à l’hôpital Cochin. Cette cohorte a été constituée rétrospectivement entre 2000 et 2006 sur dossiers archivés puis prospectivement selon les recommandations internationales d’Utstein depuis 2007. Les données de survie ont été collectées. Le devenir neurologique et fonctionnel et les données de qualité de vie ont été collectées lors d’entretiens téléphoniques réalisés auprès des survivants sortis vivants de l’hôpital. Résultats principaux : La mortalité globale à J30 était de 68,2%. La revascu- larisation coronaire (ATL) immédiate était associée à une mortalité à J30 plus faible (ORcoro sans ATL vs. pas coro 0,79 [0,57;1,08], p=0,14 et ORcoro avec ATL vs. pas coro 0,61 [0,43;0,85], p<0,01). Les 466 patients vivants à J30 ont été suivis pendant une durée médiane de 3,2 ans [IQR : 0,7 ;6,7], avec une durée maximale de suivi de 13,5 ans. En analyse multivariée, la revascularisation coronaire immédiate restait inversement associée à la mortalité à long terme (HRcoro sans ATL vs. pas coro 0,78 [0,45 ;1,33], p=0,35 et HRcoro avec ATL vs. pas coro 0,40 [0,23 ;0,70], p<0,01).
La copeptine a été dosée chez 298/510 patients à l’admission et chez 224 patients à J3. Le taux médian à l’admission était de 261,3 [125,2 ;478,6] pmol/L. Le taux de survie à 1 an était inversement proportionnel au quintile de copeptine à l’admission (38,2, 32,6, 27,7, 31 et 13,6%, respectivement; p<0,01). En analyse multivariée, seul le cinquième quintile de copeptine à l’admission était associé à la mortalité à 1 an (HR5ème vs. 1er 1,64 [1,06;2,58], p=0,03). Après ajustement mutuel des taux de copeptine à l’admission et à J3, le taux de copeptine à l’admission n’était plus associé à la mortalité à 1 an mais le taux de copeptine à J3 restait asso- cié à la mortalité à 1 an par une relation concentration-dépendante (HR2ème vs. 1er 1,60 [0,90-3,17], p=0,10 ; HR3ème vs. 1er 1,94 [1,01 ;3,71], p=0,05 ; HR 4ème vs. 1er 2,01 [1,04 ;3,89], p=0,04 et HR5ème vs. er 2,38 [1,19 ;4,74], p=0,01 ; p de tendance =0,02). Au cours du suivi, 255 patients ont pu être recontactés. Le délai médian de recon- tact après la survenue de l’ACREH était de 50 [22-93] mois. 66% des patients sortis de réanimation avec un score CPC coté à 1 gardaient une performance neurolo- gique préservée au moment de l’interview (n=150/231). Les dimensions physiques et mentales agrégées du SF-36 étaient similaires chez les survivants d’ACREH en comparaison avec les individus de la population générale (47,0 vs. 47,1, p=0,88 et 46,4 vs. 46,9, p=0,45, respectivement). Les patients présentaient une altération plus marquée des dimensions physiques que des dimensions mentales du score SF- 36 en comparaison avec la population générale. L’activité physique (74,1 vs. 78,4, p=0,02) et la vitalité (50,7 vs. 56,2, p<0,01) étaient les dimensions les plus altérées. (...) / Out-of-hospital cardiac arrest (OHCA) occurs in about 30-40,000 people in France each year and is related to a culprit coronary occlusion in half cases. Although pre and in-hospital management of such patients dramatically improved last years, outcome remains poor because of the neurological damage related to brain anoxia. Short-term outcome is well-described but data are lacking on long-term outcome, functionnal and neurological outcome and health-related quality of life (HRQOL). Objectives : The main purpose of this work was to describe the long-term outcome of successfully resuscitated OHCA patients admitted alive at ICU. We aimed at picking up factors associated with HRQOL as well. Patients and methods : Data from the Paris registry were used. Consecutive sucessfully resuscitated OHCA patients admitted alive at Medical ICU of Cochin hospital, Paris, France are included in the database since 2000, January 1st, accor-ding to Utstein style. We also collected survival data. Neurological and functionnal outcome, as well as HRQOL (SF-36 questionnaire) were recorded during phone in- terviews in OHCA patients discharged alive from hospital. Main results : Overall mortality at day-30 was 68.2%. Immediate percutaneous coronary intervention (PCI) was associated with day-30 mortality (ORcoro w/o PCI vs. no coro 0.79 [0.57,1.08], p=0.14 et ORcoro w/ PCI vs. no coro 0.61 [0.43,0.85], p<0.01). The 466 patients alive at day-30 were followed-up for 3.2 years [IQR : 0.7-6.7]. After adjus- tement for cofounders, immediate PCI remained associated with long-term mor-
tality (HRcoro w/o PCI vs. no coro 0.78 [0.45,1.33], p=0.35 et HRcoro w/ PCI vs. no coro 0.40 [0.23,0.70], p<0.01). Copeptin was assessed in 298/510 patients at ICU admission and in 224 patients at day-3. Median admission copeptin level was 261.3 [125.2,478.6] pmol/L. Survival rates were 38.2, 32.6, 27.7, 31 and 13.6% through admission copeptin quintiles (p<0,01). In multivariate analysis, only the fifth quin-
tile was associated with one-year mortality (HR5ème vs. 1st 1.64 [1.06-2.58], p=0.03). After mutual adjustement of admission and day-3 copeptin levels, admission co- peptin level was not associated anymore with one-year mortality whereas day-3 copeptin level remained associated with one-year mortality in a concentration- dependent manner (HR2nd vs. 1st 1.60 [0.90-3.17], p=0.10; HR3th vs. 1st 1.94 [1.01- 3.71], p=0.05; HR 4th vs. 1st 2.01 [1.04-3.89], p=0.04 et HR5th vs. st 2.38 [1.19-4.74], p=0.01 ; p for trend =0.02). During follow-up, 255 OHCA patients dicharged alive from hospital were phone in- terviewed, after a median duration from cardiac arrest of 50 [22-93] months. 66% of patients kept a good cerebral performance after hospital discharge (n=150/231). Overall physical and mental SF-36 dimensions were similar between OHCA pa- tients and age- and gender-matched individuals from French general population (47.0 vs. 47.1,p=0.88 and 46.4 vs. 46.9, p=0.45, respectively). Physical dimensions were more significantly altered in OHCA patients, especially physical functionning (74.1 vs. 78.4, p=0.02) and vitality (50.7 vs. 56.2, p<0.01). In multivariate analysis, age, male gender, initial shockable rhythm were associated with an improvement in most of the SF-36 dimensions. Immediate PCI was associated with a gain in physical functionning (+7.0, p=0.06), general health (+7.3, p=0.02) and vitality (+4.4, p=0.08). Conclusion : Overall survival in this large cohort of successfully resuscitated OHCA patients was about 20%. Immediate PCI was associated with a decrea- sed short and long-term mortality. HRQOL was similar between OHCA patients and age and gender matched individuals from general population but physical di- mensions appeared significantly altered. Age, male gender and initial shockable rhythm were associated with a better HRQOL. (...)

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L’étude de la qualité de vie relative à la santé est un objectif prioritaire des essais cliniques en cancérologie pour évaluer l’efficacité d’une prise en charge ; elle est mesurée par le biais d’auto-questionnaire. Dans ce travail, nous proposons différentes modélisations statistiques pour l’analyse longitudinale de ce critère, ainsi que leur application sur des données issues de plusieurs essais cliniques. Une première partie présente les modèles issus de la théorie de réponse à l’item (IRT) pour réaliser une analyse longitudinale directement sur les données brutes (multi-réponses ordinales) et ce par dimension. Une fois replacés dans le contexte des modèles linéaires généralisés mixtes, une sélection conceptuelle de modèles IRT a conclu que le Graded response model semble le mieux adapté. Dans une seconde partie, nous proposons un modèle à équation structurelle permettant de prendre en compte conjointement l’aspect multidimensionnel et longitudinal de la qualité de vie. À l’aide de facteurs reflétés par des ensembles de variables observées, il permet de lier à chaque temps de mesure toutes les observations issues du questionnaire, tout en considérant également des variables explicatives. L’analyse longitudinale est réalisée sur le statut global de santé et les facteurs réduisant ainsi le nombre de tests. Enfin, une approche par mélanges de modèles mixtes est proposée pour obtenir des classes latentes à partir de trajectoires de qualité de vie. Cette approche a permis de caractériser des sous-populations homogènes et d’associer différente évolution de la qualité de vie suivant des profils particuliers de patients. / The health-related quality of life is a major objective in oncology clinical trials to improve patients’ care and better evaluate the impact of the treatments on their everyday life. Auto-questionnaires are usually used to measure this endpoint. In this work, different statistical models for the longitudinal analysis of health-related quality of life in oncology are proposed and applied to clinical trial data. First, we present different models derived from the item response theory (IRT) to achieve a longitudinal analysis directly on raw data (multi-response outcomes) for each dimension. Within the generalized linear mixed model background, a conceptual selection of the IRT models concluded that the graded response model seems to be the most suitable. Then, we propose a structural equation model which allows taking into account the multidimensional nature of data at each time and the longitudinal aspect induced by the repeated measurements. At each measurement time, the model allows to link all the observed variables issued from the questionnaire given explanatory variables. Two factors are estimated, each summarizing a set of observed variables. The longitudinal analysis is performed on the global health status and on the factors, thus reducing the number of tests. Finally, an approach based on a mixture of mixed models is used to obtain latent classes from quality of life trajectories. The approach has resulted in the identification of homogeneous subpopulations and their latent trajectory according to specific patient profiles.

Aims: Coronary Revascularization (CR) has increased patients' survival rate globally. However, the lack of a consensus definition of Health Related Quality of Life (HRQoL) and the different methodological and conceptual approaches adopted by researchers in the cardio-revascularization field create an incomplete picture of the influence of CR on individuals' HRQoL. By using mixed methodology, the current research aimed to explore Greek CHD patients' perspectives of their HRQoL after CR (Coronary Artery Bypass Grafting (CABG) or Percutaneous Coronary Interventions (PCI)), as well as detect and explain individual disparities. Method: Two studies were conducted with a total sample of 487 individuals: (1) The translation and validation of the Coronary Revascularization Outcome Questionnaire (CROQ) into Greek and (2) The longitudinal mixed methods study, the main study of the thesis, following a sequential explanatory design with two research components: a) the longitudinal quantitative component aimed to detect changes in patients' HRQoL (both overall and its subdomains) following CR over a 12-month period based on individuals' subjective evaluation as captured by the CROQ, detect the influence of CR type on the outcome and to explore potential predictors (individuals' demographic, clinical and behavioural features). Data were analysed using multilevel modelling; b) the qualitative component aimed to capture individuals' lived experience, their view and understanding of themselves and their life approximately 12 months after treatment using Interpretive Phenomenological Analysis (IPA). Results/findings: Based on participants' subjective evaluations as captured by the validated Greek version of the CROQ, one year after CR Greek Coronary Heart Disease (CHD) patients experience an increase in their HRQoL level compared to prior to CR. The pattern of change though is not constant; initially HRQoL increases with time, and then decreases again, however, remaining much greater compared to prior to CR one year after CR. Regarding the influence of the CR type of treatment on patients' HRQoL level, a year after CR mixed findings are revealed. In the symptoms and physical functioning subdomain, patients treated with CABG demonstrate a greater increase compared to patients treated with PCI. In the psychosocial functioning subdomain no difference is found. In the cognitive functioning subdomain, patients treated with CABG demonstrate a decline compared to their cognitive functioning prior to the CR. Various demographic, clinical and behavioural features are demonstrated to be predictors of the outcome though not consistent for all subdomains. The main predictors associated with larger positive changes following CR seem to be sex, BMI and smoking; females with low BMI that do not smoke tend to demonstrate a greater increase in HRQoL after CR. According to individuals' lived experience, participants, reflecting on their experience one year after treatment, perceive CR as a simple process and their negative experience is mostly related to medical care. Many participants with no symptoms or adverse effects tend to misperceive CHD, viewing their health condition as an acute disease treated with CR. Trying to understand disease causality they tend to adopt medical discourse especially in relation to stress as a factor that can be controlled by themselves and reflect on their own responsibility as a causal factor. Feeling grateful for being alive, sensing a different body, a 'revitalized body' as many participants suggest, as well as a fear of re-occurrence or disease progression motivate individuals to work on aspects of the self related to the CHD development in an effort to regain control over their life which has been reduced after the CHD diagnosis. In effect a dramatic change in how the self and life are viewed is reported, highlighting a positive growth; a greater appreciation of life, a personal growth and effort to build more meaningful relationships. Challenges that participants face in modification of their lifestyle are attributed to both external and internal factors. Concerning smoking participants' accounts point to a lack of knowledge regarding the relationship between smoking and CHD, a lack of support (by experts or family members) and conscious denial as a way to cope with every day anxiety and stress, but also a pleasure in everyday life. The findings provide a complementary insight into perceptions of individuals with CHD about their quality of life one year after CR, suggesting that other factors beyond CR may influence their perspectives. Conclusions/implications: This study highlights the benefits of using a mixed methods longitudinal design in exploring HRQoL. Both the quantitative and qualitative findings support the notion that HRQoL is a multidimensional, continuously changing concept, providing support for the Wold Health Organization's definition. Also, the findings suggest that CR has a positive influence on individuals' HRQoL. The effect of the CR type needs further investigation as mixed findings are observed in the present thesis. Moreover, it seems difficult to investigate the pure effect of CR on individuals' HRQoL without taking into consideration individuals' adjustment processes and positive growth triggered by the CR. The self regulation model (SRM) might be considered a useful theoretical framework for developing theory-based interventions aiming to alter patients' false beliefs since individuals' making-meaning process seems to be aligned with it. Finally, the complementary insights concerning smoking may help health care providers to develop smoking cessation interventions tailored to cardiac patients.

Estudo descritivo, correlacional e longitudinal que teve como objetivos estudar a validade e a confiabilidade da Burns Specific Pain Anxiety Scale-BSPAS que avalia ansiedade frente a procedimentos dolorosos e a Impact of Event Scale-IES que avalia o estresse pós-traumático. Participaram do estudo 91 indivíduos maiores de 15 anos de idade, internados na Unidade de Queimados do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto. Seguiramse as seguintes etapas: 1ª etapa: coleta de dados relacionados à internação e ao tratamento. 2ª etapa: seguimento de manifestações dolorosas, durante sete dias, com a aplicação da Escala Visual Analógica para Dor, em três momentos diferentes do dia: a) imediatamente antes do banho e curativo (DIABC); b) imediatamente depois do banho e curativo (DIDBC); e c) dor no período de descanso, por volta das 20 horas (DDPD). 3ª etapa: no oitavo dia, aplicação da BSPAS - Versão Português, da IES - Versão Português e do Inventário de Ansiedade-Estado de Spielberger (IDATE). 4ª etapa (composta por fases A e B): entre o 4º e o 6º meses (fase A) e entre o 9º e o 12º meses, após o acontecimento da queimadura (fase B), aplicação da IES-VP, da Escala de Autoestima de Rosenberg (EAER), do Inventário de Depressão de Beck (IDB) e do SF-36. Nas três primeiras etapas, participaram do estudo 91 pacientes (64 homens e 27 mulheres). A superfície corporal queimada (SCQ) média foi de 18% (1-60%), sendo os locais anatômicos mais atingidos membros superiores (66; 72,5%), tórax (61; 67%) e cabeça/face (43; 47,3%). Os agentes causadores de queimaduras mais comuns foram os líquidos quentes (15,4%) e os agentes inflamáveis, principalmente o álcool, (38,5%). Na 4ª etapa, participaram 77 pacientes, na fase A, e 76, na fase B. Na avaliação da validade de construto convergente, a BSPAS-VP apresentou correlações fortes e positivas com a IES-VP (0,52; p<0,01), fortes e moderadas com as subescalas que avaliam pensamentos intrusivos (0,54; p<0,01) e reações de evitação (0,37; p<0,01) e correlações moderadas com as avaliações de dor: DIABC (0,32; p<0,01), DIDBC (0,31; p<0,01) e DDPD (0,31; <0,01). A IES-VP total apresentou correlações moderadas e positivas com o IDB (0,63; p<0,01), moderadas e negativas com a EAER (-0,58; p<0,01) e moderadas a baixas e negativas com os domínios Dor (r=-0,24; p<0,05), Aspectos Sociais (r=-0,34;p<0,01) e Saúde Mental (r=-0,27; p<0,05), entre o 4º e o 6º meses e baixa e de pouca aplicabilidade para a prática com o domínio Estado Geral de Saúde (r=-0,24; p<0,05), entre o 9º e o 12º meses, do SF-36. Na aplicação da BSPAS-VP e da IES-VP, observaram-se valores médios mais altos para o sexo feminino (55,15 e 63,96, respectivamente), entre os indivíduos com SCQ maior que 20% (54,90 e 62,98, respectivamente) e para os indivíduos que referiam as cicatrizes visíveis (52,53 e 61,40, respectivamente), porém, quando testadas as diferenças por meio do Teste t de Student para amostras independentes, essas não foram estatisticamente significantes. Na análise dos componentes principais por meio da Matrix de Rotação Varimax, a IES-VP apresentou-se como uma escala bidimensional e a BSPAS-VP, unidimensional, conforme a proposta original de cada escala. O Alfa de Cronbach de ambas as escalas foi alto, 0,90 para a BSPAS-VP e 0,87 para a IES-VP, mostrando forte consistência interna entre seus itens. Quando aplicado o Teste t para amostras dependentes, a IES-VP apresentou-se sensível para detectar mudanças no tempo. Conclui-se que a BSPAS-VP e a IES-VP são instrumentos confiáveis e válidos para a avaliação de ansiedade-estado relacionada à dor no paciente queimado e para a avaliação do impacto do evento, respectivamente. / This descriptive, correlation and longitudinal study aimed to study the validity and reliability of the Burns Specific Pain Anxiety Scale-BSPAS, which assesses anxiety about painful procedures, and the Impact of Event Scale-IES, which assesses post-traumatic stress. Study participants were 91 individuals over 15 years of age, hospitalized at the Burns Unity of the Ribeirão Preto Medical School Hospital das Clínicas. The following steps were followed: 1st step: data collection about hospitalization and treatment. 2nd step: follow-up of painful manifestations for seven days, applying the Visual Analogue Scale for Pain at three different times each day: a) immediately before bathing and wound dressing (DIABC); b) immediately after bathing and wound dressing (DIDBC); and c) pain in the rest period, around 20:00h (DDPD). 3rd step: on the eighth day, application of the BSPAS Portuguese Version, IES Portuguese Version and Spielbergers State Anxiety Inventory (SAI). 4th step (including phases A and B): between the 4th and 6th month (phase A) and between the 9th and 12th month after the burn event (phase B), application of the IES-VP, Rosenbergs Self-Esteem Scale (RSES), the Beck Depression Inventory (BDI) and the SF-36. In the first three steps, study participants were 91 patients (64 men and 27 women). The mean burned body surface (BBS) was 18% (1-60%), with upper limbs (66; 72.5%), thorax (61; 67%) and head/face (43; 47.3%) as the most affected anatomical sites. The most common causal agents of the burns were hot fluids (15.4%) and inflammable agents, mainly alcohol (38.5%). In the 4th step, 77 patients participated in phase A and 76 in phase B. In convergent construct validity, the BSPAS-VP presented strong and positive correlations with the IES-VP (0.52; p<0.01), strong and moderate with the subscales that assess intrusive thoughts (0.54; p<0.01) and reactions of avoidance (0.37; p<0.01) and moderate correlations with the pain assessments: DIABC (0.32; p<0.01), DIDBC (0.31; p<0.01) and DDPD (0.31; <0.01). Total IES-VP presented moderate and positive correlations with the BDI (0.63; p<0.01), moderate and negative with the RSES (-0.58; p<0.01) and moderate to low and negative with the Pain (r=-0.24; p<0.05), Social Aspects (r=-0.34;p<0.01) and Mental Health (r=-0.27; p<0.05) domains between the 4th and 6th month, besides low correlation and little applicability to practice with the General Health State (r=-0.24; p<0.05) domain of the SF-36 between the 9th and 12th month. When applying the BSPAS-VP and IES-VP, higher mean scores were observed for women (55.15 and 63.96, respectively), among individuals with a BBS of more than 20% (54.90 and 62.98, respectively) and for people who mentioned visible scars (52.53 and 61.40, respectively). When differences were tested through Students t-test for independent samples, however, these were not statistically significant. In the main components analysis through the Varimax Rotation Matrix, IES-VP appeared as a bidimensional scale and BSPAS-VP as a unidimensional scale, in accordance with each scales original proposal. Both scales obtained a high Cronbachs Alpha, 0.90 for BSPAS-VP and 0.87 for IES-VP, showing strong internal consistency of its items. When the t-test for independent samples was applied, the IES-VP showed sensitivity to detect changes over time. It is concluded that the BSPAS-VP and the IES-VP are reliable and valid instrument to assess state-anxiety related to pain in burned patients and to assess the impact of the event, respectively.

INTRODUÇÃO: Existem dúvidas e controvérsias em relação à falta de controle clínico dos pacientes portadores de asma grave. Neste estudo avaliamos a proporção de asmáticos graves que atingem o controle com seguimento supervisionado e tratamento padronizado. Comparamos a inflamação das vias aéreas através do escarro induzido e do óxido nítrico exalado em pacientes que atingem o controle da asma em comparação aos não controlados. Avaliamos também o impacto do controle sobre o estado de saúde e comparamos o comportamento psicossocial (ansiedade e depressão) entre os pacientes controlados e não controlados. MÉTODOS: Os pacientes foram selecionados no ambulatório de asma da Pneumologia porque apresentavam asma grave não controlada apesar de tratamento de acordo com as diretrizes de tratamento da asma. Avaliamos as características clínicas, funcionais, inflamatórias, controle da asma, qualidade de vida relacionada à saúde e ansiedade e depressão, na condição basal, após as 2 semanas de corticosteróide oral e ao final do tratamento otimizado por via inalatória. RESULTADOS: Cento e vinte e oito pacientes foram elegíveis, 74 incluídos e 54 completaram o protocolo. Destes, 36 (66,7%) pacientes foram classificados em grupo não controlado e 18 (33,3%) controlados. Na inclusão, o grupo que não se controlou apresentou mais mulheres, maior porcentagem de ex-tabagistas, menor porcentagem de dias livres de sintomas e maior porcentagem de mulheres com piora da asma no período menstrual. Os pacientes dos dois grupos apresentavam alta utilização do sistema de saúde e várias comorbidades. Após o tratamento padronizado, não se observou diferença nos parâmetros de função pulmonar, escarro induzido e óxido nítrico exalado entre os grupos. No grupo não controlado, o curso de corticosteróide oral promoveu redução significativa dos eosinófilos no escarro induzido, mas com aumento destes após a retirada da medicação oral, embora sem significância estatística. O óxido nítrico exalado não se alterou com o tratamento, mantendo-se normal nos dois grupos durante todo o acompanhamento. Os pacientes apresentavam baixa qualidade de vida relacionada à saúde, com melhora significativa nos dois grupos. Observamos alta porcentagem de pacientes com ansiedade moderada, que não se alterou com o tratamento da asma. CONCLUSÕES: Pacientes com asma grave não controlada podem atingir o controle clínico quando submetidos à intervenção proposta. Mas 2/3 dos nossos pacientes não atingiram o controle. Apresentaram características semelhantes aos de outras coortes internacionais, grande utilização dos recursos da saúde e baixa qualidade de vida relacionada à saúde. A inflamação eosinofílica responde ao uso de corticosteróide oral. O óxido nítrico exalado pode estar normal em pacientes com asma grave e inflamação eosinofílica persistente. A intervenção proposta melhorou a qualidade de vida relacionada à saúde nestes pacientes, mas não apresentou impacto na ansiedade / INTRODUCTION: There are doubts and open questions about low achieve control in severe asthma patients. In this study we evaluated the proportion of severe asthmatics who achieve control status after a systematic follow-up protocol and standardized treatment. We compared airway inflammation according to induced sputum and exhaled nitric oxide in controlled and non-controlled patients. We also evaluated the impact of control status on health related quality of life and compared the psychosocial behavior (anxiety and depression) between groups. METHODS: Patients were selected on outpatient asthma clinic of Pulmonary Division. They had severe asthma and underwent a systematic follow-up protocol with standardized treatment. We evaluated clinical, functional and inflammatory characteristics, asthma control, health related quality of life and anxiety and depression symptoms in baseline, after two weeks of oral corticosteroid and at the end of the follow-up, with inhaled corticosteroid plus long acting beta 2 agonist. RESULTS: One hundred and twenty eight patients were eligible, 74 included and 54 completed the follow-up period. Among this, 36 (66.7%) patients were classified as non-controlled and 18 (33.3%) controlled. At the inclusion non-controlled group had significantly higher female and ex-smokers prevalence, less percentage of days free of symptoms and higher frequency of females with menstrual worsening of asthma symptoms. Both groups had high health care use and several comobidities. There was not any significant difference in pulmonary function, induced sputum and exhaled nitric oxide between the two groups after standardized treatment. Induced sputum eosinophils had a significant reduction after oral corticosteroid trial in non-controlled patients but there was impairment after oral steroid withdrawn, but without statistic significance. Exhaled nitric oxide did not change with treatment and was normal in both groups during the follow-up period. Patients had low health related quality of life but with significant improvement on two groups. We observed high prevalence of patients with moderate anxiety which did not change with asthma treatment. CONCLUSION: Non-controlled severe asthma patients can achieve clinical control after proposed standardized protocol. But 2/3 of our patients did not achieve clinical control. Our patients share characteristics with others international cohorts, had high health care utilization and low health related quality of life. Induced sputum eosinophilia showed an improvement after oral corticosteroid trial. Exhaled nitric oxide may be normal in severe asthmatics with persistent eosinophilc inflammation. There was an improvement on health related quality of life with asthma treatment but no change was observed on anxiety