Calf health data and first lactation records for 2556 cows born in a commercial dairy herd between June 1998 and June 2001 were studied to determine the effects of calfhood disease on survival and performance. Operator-treated respiratory disease occurrences within the first year of life and digestive disease occurrences within the first 45 d of life were analyzed to determine their effects on calfhood morbidity, age at first calving, 305-d first lactation production, and mortality in first lactation. Of the 2556 records used, 2083 calves contracted respiratory or digestive disease at least once, 1254 calves had digestive disease only, 771 had respiratory disease only, and 191 calves had both diseases. Occurrence of calfhood digestive disease increased the chance of calfhood respiratory disease 2-fold. Age at first calving increased 0.53 mo with multiple occurrences of respiratory disease versus none. Calves born in the winter calved at 25.4 mo, whereas calves born in spring calved at 24.5 mo. Respiratory disease had the largest effect on calves born in the spring, resulting in 23.9 mo age at first calving for no occurrence and 25.4 mo for multiple occurrences. No significant effect of disease was detected for 305-d milk yield, fat yield, or SCC, but protein yield decreased by 0.05 kg/d with increased calf respiratory disease. Although calfhood disease had no influence on illness as a cow, disease-free calves had a 5% advantage in probability of remaining in the herd through 305-d, and an 8% advantage at 730-d compared with calves with 2 or more disease occurrences. In conclusion, calfhood occurrences of respiratory and digestive disease had a slight impact on age at first calving, depending on season of birth, and minimal impact on production performance through 305-d of first lactation. The occurrence of respiratory or digestive disease caused a decrease in survival rate from calving through 305-d in first lactation and 730 d after calving. / Master of Science

Hip fractures are common injuries with devastating consequences, including high rates of morbidity and mortality. The purpose of my thesis was to lay the foundation for further research which can fully explore: i) the epidemiology of morbidity and mortality following hip fracture; ii) risk factors for poor outcomes following hip fracture; iii) causes and pathways to mortality following hip fracture; iv) secondary prevention of morbidity and mortality following hip fracture; and v) potential interventions to improve outcomes following hip fracture. To this end, I will first detail the design, execution, results, and ‘lessons learned’ of a prospective observational pilot cohort study that recruited 100 consecutive patients aged ≥18 years presenting with a hip fracture to the Juravinski Hospital and Cancer Centre of the Hamilton Health Sciences. The primary aim of this pilot study was to assess the feasibility of a larger prospective international cohort study. Second, I will present a systematic review and meta-analysis of a promising intervention that consisted of multi-disciplinary (specifically geriatrician-led) co-management of hip fracture patients. This intervention has previously been shown to reduce mortality and length of stay following hip fracture. The meta-analysis presented will determine the effectiveness of this intervention in reducing the incidence, duration, and severity of delirium—a common condition following hip fracture. / Thesis / Master of Science (MSc)

BACKGROUND. Frailty is a syndrome characterized by a decreased resistance to stressors, leading to increased vulnerability to adverse outcomes, including mortality. Multi-morbidity refers to the presence of two or more chronic diseases, and is associated with increased risk of adverse health outcomes. Most of the literature in frailty is based on older people (65+ years) living in high income countries. OBJECTIVE. To compare the predictive ability of three frailty indices for all-cause and one-year mortality among high- (HIC), middle- (MIC), and low- income country (LIC) participants; and to assess the mortality risk associated with multi-morbidity. METHODS. Using data from the Prospective Urban and Rural Epidemiological (PURE) study, we developed three indices using different definitions of frailty (one phenotypic frailty index; two cumulative deficit indices). All indices were tested for predictive ability for mortality both individually and with multi-morbidity. RESULTS. Prevalence of phenotypic frailty was greatest in LIC (8%), intermediate in MIC (7%), and lowest in HIC (4%). Multi-morbidity was most prevalent in HIC (20%), intermediate in MIC (15%), and lowest in LIC (13%). Increased frailty was associated with greater mortality risk using all frailty indices (e.g. HR (95% CI) of 2.63 (2.35-2.95) for the phenotypically frail relative to the robust). At each frailty level, mortality risk was higher within one year of baseline measurement than afterwards, and increased if it was accompanied by concurrent multi-morbidity (e.g. HR of phenotypic frailty increases from 2.27 (1.96-2.62) to 5.08 (4.34-5.95) if accompanied by multi-morbidity). CONCLUSION. All frailty indices predicted mortality. This study is unique in evaluating the prognostic ability of frailty indices in middle-aged adults across HIC, MIC, and LICs. / Thesis / Master of Science (MSc)

Due to the increasingly documented prevalence of diarrhoeal diseases in Malaysia, a number of water-related programmes have been implemented in an attempt to improve health status through the reduction of incidence of waterborne communicable diseases associated with poor public water supplies. The implicit assumption underlying these projects is that the enhancement of the physical infrastructure, and subsequent improvements in the quality of the water supply, will substantially reduce waterrelated disease. This thesis questions the veracity of this hypothesis, and therefore the justifiability of an emphasis upon engineering and urban infrastructural interventions. Research centred upon Port Dickson, a district which typifies existing water and sanitation conditions in much of semi-rural Malaysia. The specific objectives of the thesis were: to determine the measured burden of illness of waterborne disease within the district and to estimate levels of underreporting; to determine morbidity-related factors influencing the decision to seek medical treatment; to provide a demographic profile of the population experiencing diarrhoeal episodes; and to identify risk markers or predictors of morbidity. Burden of illness was measured by health services utilization, while values for underreporting and risk markers were derived from a 268 household diarrhoeal morbidity survey. Diarrhoeal incidence was estimated to be 12-16% annually, much higher than Malaysia's official average. This incorporated a rate of non-reporting of 19~, which was influenced by chronicity, duration and severity of episodes. Individuals found to be most at risk were young children and adults in their child-bearing years, minority racial groups, and those with poor water supply and sanitation infrastructure and inappropriate hygiene habits. While water quality was found to influence diarrhoeal rates, factors in addition to infrastructure - partially hygiene - were shown to play a greater role. Thus, it is suggested that the impact of water and sanitation improvement projects would likely be minimal, unless accompanied by complementary behavioural education programmes. The spatial bias of the aforementioned risk factors suggests a need to refocus intervention initiatives upon rural areas. / Thesis / Master of Arts (MA)

Yes / Objectives: Longitudinal evidence documenting health conditions in spousal caregivers of people with dementia and whether these influence caregivers’ outcomes is scarce. This study explores type and number of health conditions over two years in caregivers of people with dementia and subgroups based on age, sex, education, hours of care, informant-rated functional ability, neuropsychiatric symptoms, cognition of the person with dementia, and length of diagnosis in the person with dementia. It also explores whether over time the number of health conditions is associated with caregivers’ stress, positive experiences of caregiving, and social networks Methods: Longitudinal data from the IDEAL (Improving the experience of Dementia and Enhancing Active Life) cohort were used. Participants comprised spousal caregivers (n = 977) of people with dementia. Self-reported health conditions using the Charlson Comorbidity Index, stress, positive experiences of caregiving, and social network were assessed over two years. Mixed effect models were used Results: On average participants had 1.5 health conditions at baseline; increasing to 2.1 conditions over two years. More health conditions were reported by caregivers who were older, had no formal education, provided 10 + hours of care per day, and/or cared for a person with more neuropsychiatric symptoms at baseline. More baseline health conditions were associated with greater stress at baseline but not with stress over time. Over two years, when caregivers’ health conditions increased, their stress increased whereas their social network diminished Discussion: Findings highlight that most caregivers have their own health problems which require management to avoid increased stress and shrinking of social networks / Economic and Social Research Council (ESRC) and the National Institute for Health and Care Research (NIHR) - grant ES/L001853/2. Alzheimer’s Society, grant number 348, AS-PR2-16-001. Sabatini was supported by an ESRC Postdoctoral fellowship (ES/X007766/1).

Background Rheumatoid arthritis (RA) is a systemic progressive destructive joint disease with an increased risk for co-morbidity and premature death if untreated. Cardiovascular disease (CVD) is the main cause of death but also other co-morbid conditions contribute to the patient’s shorter life expectancy. Inflammation is important for the development of CVD, but knowledge of its relationship with other co-morbidities is sparse. Early disease modifying anti rheumatic drugs (DMARDs) can suppress disease activity and improve the long-term outcome. The aim of this thesis was to evaluate prospectively aspects of disease activity and severity in a large cohort of patients with early RA. Predictive and prognostic markers, e.g., antibodies against citrullinated proteins/peptides (ACPAs), occurring in early disease and with implications for disease outcome and co-morbidity were evaluated. Methods Patients with early RA (i.e., symptomatic for ≤12 months) have, since December 1995, been consecutively included in a large survey of prospective and observational studies on the progression of RA and the development of co-omorbidity. Autoantibodies, inflammatory, genetic markers and radiographs have been analyzed. In paper I, 210 RA patients and 102 controls were followed regularly for two years. The predictive value of four different ACPAs in relation to disease activity and radiological progression was evaluated. In Paper II (n = 700) and in Papers III-IV (n =950), patients with early RA from the four northern-most counties of Sweden were followed regularly for 5 years. Data on risk factors and co-morbidity was collected, according to the study protocol, from clinical records and self-reported questionnaires from patients at inclusion into the study cohort and after five years. The predictive value of traditional and potential disease related risk factors for new cardiovascular events (CVE) was evaluated (II). In Paper III, the impact of age at the onset RA, stratified as being young onset RA (<58 years; YORA) and late onset RA (≥58 years; LORA) on disease activity, severity and chosen treatment, was evaluated. In Paper IV, the development of new co-morbidities after RA onset and their relation to inflammatory activity was assessed. Results The presence of anti-mutated citrullinated vimentin (MCV ) antibodies was associated with a more severe disease course, estimated by disease activity score, erythrocyte sedimentation rate (ESR) and swollen joint count after 24 months, compared with anti-CCP2, anti-CCP3, and anti CCP3.1 antibodies. In Paper II, the incidence of a new CVE during 5 years was explained by several of the traditional CV risk factors, and potentiated by a high disease activity. Treatment with DMARDs decreased the risk. In Paper III, LORA patients were associated with greater disease activity/severity at disease onset and over time compared with YORA who were more often ACPA positive. YORA patients were treated earlier with DMARDs, whilst LORA patients were more often treated with corticosteroids and less so with DMARDs early in the course of their disease. In Paper IV, 53%of patients already had one or more co-morbidities already at the onset of RA. After 5 years, 41% of the patients had developed at least one new co-morbidity. ESR at baseline and accumulated disease activity were associated with a new co-morbidity after five years. Conclusion Early RA patients sero-positive for anti- MCV antibodies appeared to have a higher disease activity over time. The occurrence of a new CVE in early RA patients was predicted by traditional risk factors for CVD which were potentiated by a high disease activity. Treatment with DMARDs decreased the risk. Patients with young onset of RA were associated with a higher frequency of ACPA. Late onset of RA was associated with higher disease activity/severity at inclusion and over time. However, LORA patients were more often treated with corticosteroids and less so with DMARDs early in the disease course. Development of a new co-morbidity during the five years following diagnosis was related to ESR.

A deductive, descriptive, quanitative study was undertaken at Nyangabgwe Hospital, Francistown, Botswana, situated in the north east of the country. Its focus was on the use of partogram by midwives. The population consisted of 395 obstetric records for the period of one month. A sample of 303 obstetrics records was drawn. Data were collected through auditing the bed letters of delivered mothers and interviews with and observation of midwives using the partogram in practice. The Statistical Package for Social Sciences (SPSS) program was used to analyse the data. The findings indicate that there are problems regarding, and factors that can have a negative influence on the use of the partogram by midwives. It is suggested that a supportive teaching programme for the midwives should be designed, that will support the system of supervision in the labour ward that already exists, in the use of the partogram throughout the labour process. / Health Studies / M.A. (Advanced Nursing Sciences)

O Homem é parte integrante do sistema Ambiental. O ambiente cria impactos Nele e por sua vez ele também pode provocar impactos no Ambiente. O objetivo da tese foi identificar qual a intensidade e freqüência do impacto que a poluição atmosférica e a variabilidade das variáveis meteorológicas na saúde da população da Área Metropolitana do Porto (Portugal), através de um estudo epidemiológico ecológico. Escolheu-se o período de 2002 a 2005 para estudar um conjunto de cidades que contam com espaços urbanos, suburbanos e industriais mesclados, perto do litoral Atlântico com clima Mediterrânico. Usando como métodos a análise descritiva e multivariada (ACP), de correlação e regressão múltipla (RM), assim como índices de conforto térmico (ID, H, Te e Tev), trabalharam-se dados de admissões hospitalares (4 hospitais públicos) de doenças cardiovasculares (DCV) (401-405, Hipertensão; 410-414, DCV Isquêmica, 426-428, Insuficiência Cardíaca) e respiratórias (490-496, Asma/Bronquite; 500-507, Pneumoconioses), informações meteorológicas do Instituto de Meteorologia de Portugal (Temperatura, Umidade, Precipitação e Pressão) e valores diários e mensais do índice de Oscilação do Atlântico Norte (OAN), da NOAA, assim como, saídas de normais de pressão e médias de velocidade de vento do modelo NOAA e de 10 estações fixas de qualidade do ar pertencentes à Agencia Portuguesa do Ambiente (O3; NO2, NO, CO, SO2, PM10, PM2,5). Identificaram-se alguns períodos de temperaturas elevadas (38°C) durante o verão e inversões térmicas durante o inverno (2004/05), as quais criaram situações de estresse térmico por calor e muito frio (dos 1461 mais de 930 dias -24°C< TEv tmin Urmáx vmáx < 0°C), por um lado, e aumento da poluição, por outro. Esse aumento da poluição contribuiu para se observar maior número de casos por doenças respiratórias por Asma/bronquite (lag 3 dias durante inverno 2004/05 correlação com PM2,5=0,33), doenças Cardíacas Hipertensivas (regressão multivariada para Primavera, para PM10 com Beta=0,80, R2ajustado=0,076), e Insuficiências Cardíacas (regressão para Outono NO2 Beta = 0,42 com R2ajustado= 0,060). Encontrou-se também relação significativa e forte entre a variabilidade da Oscilação do Atlântico Norte (OAN) e de alguns poluentes durante o inverno (ex: correlação PM10=0,71, em 2003; PM2,5= 0,91, em 2005; SO2=0,45, em 2004). Uma importante conclusão, também sugerida por outros autores, é que as mudanças climáticas podem modificar a intensidade e regularidade da OAN, afetando assim a circulação atmosférica o que terá impacto direto na dispersão dos poluentes em pequena escala e conseqüentemente irá influenciar a saúde publica. / Humans are part of environmental system. Environment impacts on Humans and we so can impact on earth ecosystems. The thesis aims identify the intensity and frequency of air pollution and meteorological impact on Porto Metropolitan Area (PMA) public health, although a ecological epidemiological study. The 2002- 2005 period was select to study climatologically Mediterranean seaside cities with typical urban, suburban and industrial mixed spaces. The statistical methods used were: descriptive and multivariate (ACP) analyze, correlation and multiple regression, as well as, discomfort indices (ID, Te, Tev, H). Data set from 3 different institutions was analyzed: admission from 4 public hospitals referent to heart (401-405, Hypertension; 410-414, Ischemic cardiac, 426-428, Heart Insufficiency) and respiratory diseases (490-496, Asthma/Bronchitis; 500-507, Pneumoconioses), meteorological information from Meteorological Institute of Portugal.(Temperature, Humidity, Precipitation, Wind speed, Pressure) and daily and monthly North Atlantic Oscillation index values, from NOAA, as well as, pressure daily normal and wind velocity daily mean NOAA model output and from 10 fixed air quality stations (Environmental Portuguese Agency) the pollutants (O3; NO2, NO, CO, SO2, PM10, PM2,5) time series. Some high temperature (38°C) periods was identified during summertime and thermal inversions in the wintertime (2004 and 2005), which provoked stress for heat and cold (from 1461 days, 930 days the thermal sensation was -24°C< TEv tmin Urmáx vmáx < 0°C), and pollution increase. The air pollution increased the hospital admissions for respiratory diseases special Asthma/bronquitis (lag 3 days during 2004/05 Winter correlation PM2.5= 0.33), Cardiac Hypertension (Spring multivariate regression Beta= 0.80, R2ajusted= 0.076), and Heart insufficiency (Autumn multivariate regression NO2 Beta = 0.42 with R2ajustaded= 0.060). Significant and strong association was found between North Atlantic Oscillation (NAO) and some pollutants during Wintertime (eg.: correlation PM10=0.71, 2003; PM2.5=0.91, 2005; SO2=0.45, 2004). ). It is important to notice that some studies have already suggested that climate change can modify the intensity and regularity of the NAO, affecting the atmospheric general circulation and it could have a direct impact on pollutants dispersion in small scale and on public health.

A deductive, descriptive, quanitative study was undertaken at Nyangabgwe Hospital, Francistown, Botswana, situated in the north east of the country. Its focus was on the use of partogram by midwives. The population consisted of 395 obstetric records for the period of one month. A sample of 303 obstetrics records was drawn. Data were collected through auditing the bed letters of delivered mothers and interviews with and observation of midwives using the partogram in practice. The Statistical Package for Social Sciences (SPSS) program was used to analyse the data. The findings indicate that there are problems regarding, and factors that can have a negative influence on the use of the partogram by midwives. It is suggested that a supportive teaching programme for the midwives should be designed, that will support the system of supervision in the labour ward that already exists, in the use of the partogram throughout the labour process. / Health Studies / M.A. (Advanced Nursing Sciences)

Background: The interest in obstetrical complications that culminate with maternal death and the urgent need for improvement in these indexes led to the development of the concept of maternal near miss. From a normal situation, the patients are in a continuum that can evolve with the development of moderate and severe situations of health. Severe acute maternal morbidity (SAMM) (situation less severe) and near miss (NM) (situation more severe) are two degrees of situation immediately before maternal death. The main advantage of studying these cases is higher frequency when comparing with maternal deaths cases and that the determining factors are the same. This study aims to determine the ocurrence of SAMM and NM situations in two maternities of reference of the state of Sergipe, determine the prevalence of the event and describe the risk factors associated. Casuistic and methods: A cross sectional study with double controls was conducted in patients who were pregnant sometime and were hospitalized in two reference maternities of Sergipe state. The patients answered a survey about issues relevant to the subject. For categorical variables was used Fisher s exact test. For normal continuous variables was applied the Student t test and for the not normal, the U-Mann-Whitey test. Odds ratio and confidence interval were used whenever possible. Multivariate analysis was performed and p <0,05. Results: There were 16,243 live birth deliveries, and occurred 1102 SAMM, 77 NM and 17 maternal deaths cases. The prevalence of SAMM + NM founded were, respectively, 7.6 cases/1000 LB, the mortality index was 18% (4.5 cases for each death) The main causes of SAMM and NM were respectively: 67.5% by hypertensive causes and 87.1% by necessity of invasive procedures. High age, low income, absence of prenatal, high rates of cesarean section, previous abortion and low weight of the baby at birth with unfavorable perinatal prognosis were statistically significant for the study group. Multivariate analysis showed that the number of eligibility criteria for NM was related with the severity of the situation. Conclusions: The situations of SAMM and NM in the two maternities studied reached significant values. Study NM can be the most efficiently way of conducting internal audits for the improving of the quality of services. Protocols based on adverse situations like these, where the detection can be made on the exact point of failure, can recommend conducts and interventions able to save lives. / Introdução: O interesse por complicações em obstetrícia que culminassem com morte materna e a necessidade urgente da melhora desses índices resultou no desenvolvimento do conceito de near miss materno. A partir de uma situação normal, a paciente insere-se em um continuum que pode evoluir com o desenvolvimento de situações de gravidade moderada e intensa. Morbidade materna grave (MMG) e near miss (NM) são duas denominações dadas às situações imediatamente anteriores ao óbito materno. A grande vantagem em se estudar esses casos é justamente a sua frequência superior em relação aos casos de morte materna (MM) e que os fatores determinantes são os mesmos. Este estudo tem por objetivos: determinar a ocorrência de situações de MMG e NM em duas maternidades de referência do estado de Sergipe, determinar a prevalência do evento nesses locais e descrever os fatores de risco associados. Casuística e métodos: Foi realizado estudo do tipo transversal com duplo controle em pacientes que em algum momento estiveram gestantes e permaneceram internadas em situações de risco nas duas maternidades de referência do Estado de Sergipe no período de um ano. As pacientes responderam a um questionário que continham questões sobre o assunto. Para a análise estatística das variáveis categóricas foi utilizado o teste exato de Fisher. Para as variáveis contínuas normais e para tabelas 2x2 foi aplicado o teste t de Student e para tabelas maiores o teste do qui-quadrado. Para as tabelas não-normais foi aplicado o teste de U-Mann-Whitey. Cálculo do Odds ratio e intervalo de confiança foram utilizados sempre que possível. Neste estudo foi realizada análise multivariada e o valor de p< 0,05 foi considerado. Resultados: Dos 16.243 partos, ocorreram 1102 casos de MMG, 77 casos de NM e 17 MM. A prevalência de MMG + NM foi de 72,6 casos /1000 NV, o índice de mortalidade foi de 18% (4,5 casos para cada morte). As principais causas de MMG e NM foram respectivamente: 67,5% por causas hipertensivas e 87,1% devido à necessidade de realização de procedimentos invasivos. Idade elevada, baixa renda, a não realização de pré natal, maior índice de parto cesáreo, antecedentes obstétricos de aborto anterior e cesárea anterior, baixo peso do RN ao nascer com prognóstico perinatal desfavorável mostraram-se estatisticamente significantes para o grupo estudado. A análise multivariada demonstrou que a quantidade de critérios de elegibilidade de NM esteve relacionada à gravidade do quadro. Conclusões: As situações de NM + MMG nas duas maternidades estudadas atingiram valores expressivos. Estudar NM pode ser o modo mais eficiente de realização de auditorias internas na busca da melhora da qualidade dos serviços. Protocolos baseados em situações adversas como estas, onde pode ser feita a detecção exata do ponto de falha, podem recomendar condutas e intervenções possivelmente capazes de salvar vidas.