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Aim: To describe and analyse the epidemiology and management of asthma, atopy and related morbidity in a Scottish Primary Care population by exploiting the Continuous Morbidity Recording database. Methods: The patient information used in this thesis was extracted from the computerised data of general practices contributing to the Continuous Morbidity Recording project. Results: A significant increase in the prescribing of short-acting beta2 (p<0.005) and adjunct therapy prescribing (p<0.001) occurred over the four study years. There was a significant shift to treatment steps 3 and 4 of the British Asthma Guidelines (p<0.002) in asthma patients followed up over the four study years. Significant declines in the incidence of asthma were observed in children (p<0.001), with no apparent compensatory diagnostic shift. There was a significant increase in the risk of presenting with a Th1 mediated autoimmune condition in patients with a history of allergic disease. There was a particularly strong association between current psoriasis and current eczema. Conclusions: The concurrence of morbidity and prescribing epidemiology with external sources of data such as surveys suggest high quality of data stored by the Continuous Morbidity Recording database. General practitioners prescribed higher doses of inhaled corticosteroids and more new adjunct therapies during the study period, possibly due to the impact of new British Asthma Guidelines completed in 1995 and published in 1997. The decrease in asthma prevalence suggests that the burden of this disease on general practitioner workload is in decline. The decrease of the incidence of asthma gives the first indication of either a permanent or temporary decline of this disease in Scotland after reported increasing prevalences over several decades. The new finding that Th1 and Th2 mediated diseases are significantly associated in a large general practice population supports the proposal that these diseases share risk factors that increase the propensity of the immune system to generate both Th1 and Th2-mediated inappropriate responses to non-pathological antigens.

Orientadores: Marilisa Berti de Azevedo Barros, Priscila Maria Stoless Bergamo Francisco / Dissertação (mestrado) - Universidade Estadual de Campinas. Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-15T23:33:51Z (GMT). No. of bitstreams: 1 Costa_KarenSarmento_M.pdf: 5997477 bytes, checksum: 6d2ec607090eb98273bd84354bf2baba (MD5) Previous issue date: 2010 / Resumo: Os medicamentos tem sido considerados instrumentos terapêuticos fundamentais que produzem curas, prolongam a vida e retardam o surgimento de complicações associadas a doenças, sendo responsáveis por parte significativa da melhoria da qualidade e expectativa de vida da população. São vários os fatores que influenciam o uso de medicamentos, entre eles se destacam os aspectos demográficos, sócio-econômicos e culturais da população e as políticas governamentais para o setor e o mercado farmacêutico. Analisar o padrão de utilização e os fatores associados a esse uso justifica-se devido ao crescente consumo dos medicamentos e o alto investimento do Estado com a Política de Assistência Farmacêutica no país. Os inquéritos de saúde são instrumentos importantes para obter informações relativas a utilização de medicamentos pelos diferentes segmentos sociais da população. O objetivo do presente estudo e analisar a prevalência da utilização de medicamentos segundo variáveis demográficas, sócio-econômicas e de comportamentos relacionadas a saúde da população, identificando os fatores associados ao uso. Trata-se de um estudo transversal, cujos dados foram obtidos do inquérito ISA-SP. A população de estudo e residente da área urbana de Campinas, com idade igual ou superior a 18 anos. A amostragem foi realizada em múltiplos estágios, estratificada e por conglomerados. O período recordatorio do uso de medicamentos foi os 3 dias anteriores a realização da entrevista. Utilizou-se a classificação ATC para a codificação dos medicamentos. As estimativas de prevalência e as analises de regressão consideraram as ponderações relativas ao desenho amostral, utilizando o software STATA 8.0. Utilizou-se o teste qui-quadrado para verificar a associação estatística entre a variável dependente e as variáveis independentes. Foram estimadas razoes de prevalência ajustadas por sexo e idade e respectivos IC 95% utilizando regressão múltipla de Poisson. Foi desenvolvido um modelo hierárquico de regressão múltipla de Poisson para ajuste de variáveis de confundimento. A prevalência global do uso de medicamentos foi de 48,5%. Observou-se que mulheres referiram maior consumo de medicamentos que os homens e que a media de medicamentos aumentou com a idade em ambos os sexos. Apos ajuste por idade e sexo, observa-se que as variáveis religião, renda, numero de doenças crônicas, presença de morbidade nos últimos 15 dias e transtorno mental comum permaneceram significativamente associadas ao uso de medicamentos. No modelo hierarquizado final verificou-se consumo significativamente maior de medicamentos nas pessoas no sexo feminino, nas idades de 40 anos ou mais, renda familiar superior a 4 salários mínimos, religião evangélica, morbidade referida nos últimos 15 dias e apresentando doenças crônicas (uma a duas, três ou mais). Os medicamentos mais consumidos foram os que atuam no sistema cardiovascular, sistema nervoso e fitoterápicos. O perfil de utilização de medicamentos em Campinas encontra-se dentro dos parâmetros observados em outros estudos. Os resultados podem subsidiar ações da Política de Assistência Farmacêutica, visando a ampliação do acesso e a promoção do uso racional de medicamentos. / Abstract: The drugs have been considered key therapeutic tools that produce healing, prolong life and delay the onset of complications associated with diseases, accounting for a significant part of improving the quality and life expectancy of the population. There are several factors influencing the use of drugs, among them stand out the demographic, socioeconomic and cultural population and government policies for the sector and the pharmaceutical market. To analyze the pattern of use and factors associated with such use is justified due to the increasing consumption of drugs and the high investment from the State Pharmaceutical Assistance Policy in the country. Health surveys are important tools for information concerning the use of drugs by different social segments of the population. The aim of this study is to analyze the prevalence of use of medicines according to demographic, socioeconomic and health-related behaviors of the population, identifying the factors associated with use. This is a cross-sectional study with data obtained from the survey ISA-SP. The study population is resident in the urban area of Campinas, aged over 18 years. Sampling was performed in multiple stages, stratified by conglomerates. The recall period of drug use was the three days prior to the interview. We used the ATC classification for the coding of medicines. The prevalence estimates and regression analysis considered the weights from the sample design, using STATA 8.0. We used the chi-square test to verify the statistical association between the dependent and independent variables. We estimated adjusted prevalence ratios by sex and age and their respective 95% using Poisson multiple regression. We developed a hierarchical model of Poisson multiple regression to adjust for confounders. The overall prevalence of drug use was 48.5%. It was observed that women reported higher consumption of drugs than men and that the mean number of medications increased with age in both sexes. After adjusting for age and sex, it is observed that the variables of religion, income, number of chronic diseases, presence of morbidity in the last 15 days and common mental disorder remained significantly associated with drug use. In the final hierarchical model was found significantly higher consumption of medicines in people in females, ages 40 years or more family income than 4 minimum wages, evangelical religion, reported morbidity in the last 15 days and presenting chronic diseases (one two, three or more). Most frequently consumed drugs were acting on the cardiovascular system, nervous system and herbal medicines. The profile of drug utilization in Campinas is within the parameters observed in other studies. The results can support the actions of Pharmaceutical Policy, aimed at expanding access and promoting rational drug use. / Mestrado / Epidemiologia / Mestre em Saude Coletiva

Introduction: Breast cancer is the most frequently diagnosed cancer and leading cause of cancer death among women and represents a considerable public health burden in South Africa and other low-middle income countries. Breast cancer management comprises single or combination treatment including surgery, radiotherapy and chemotherapy. Short and long-term complications of these treatments include shoulder morbidities such as pain, decreased range of motion, tightness, weakness, pain, numbness and lymphoedema, and may be present for up to 6 years post-surgery. An understanding of baseline demographic and clinical risk factors can guide rehabilitation and management strategies for high risk patients. Materials and Methods: This study was a cross-sectional analysis of the prevalence of shoulder pain and dysfunction in women attending their post-treatment annual follow up visit for unilateral breast carcinoma. The aim of this study was to quantify the burden of shoulder pain and disability in a tertiary academic hospital in Cape Town, South Africa, and identify potential risk factors for the development of shoulder morbidity. The primary objective of this study was to determine the prevalence of shoulder morbidity and the secondary objective was to evaluate associations between shoulder morbidity and risk factors such as treatment protocol or baseline demographics. Results: The majority of patients were of mixed ancestry, had their left side affected, received ALND and had undergone Modified Radical Mastectomy. The mean age was 60 years with a mean follow-up since surgery of 6 years. Three-quarters of patients reported a presence of pain or disability; 9% experienced severe pain and disability. Multivariable ordinal logistic regression analysis identified race, side, axillary surgery, chemotherapy and age as significant predictors of pain, and chemotherapy a significant predictor of disability. Discussion: The substantial burden of shoulder morbidity in this population represents a significant public health burden. The use of identified clinical and demographic characteristics may guide in the development of survivorship programmes incorporating surveillance and management of these high risk patients.

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Magister Public Health - MPH / Background: Malnutrition is a complex condition profoundly impacting child mortality and morbidity, especially in sub-Saharan Africa. Severe acute malnutrition is of growing concern locally where unacceptable mortality rates persist, despite reasonable standards of clinical care. Aim: To determine factors associated with morbidity and mortality in children under-five years admitted with severe acute malnutrition to a regional paediatric hospital in KwaZulu-Natal. Methodology: This was a quantitative study. A retrospective observational study design was used. Medical records of all children with severe acute malnutrition, under the age of five years, admitted between April 2015 and December 2016 to the regional paediatric hospital in KwaZulu-Natal were included. Data was obtained from medical records and admission books. A trained research assistant was used to extract and record data with a piloted data extraction tool. Data was entered and cleaned using Microsoft Excel and analysed using SPSS (v 20) and STATA (v 14). Descriptive summary statistics were used to describe the characteristics of the study population and bivariate analysis using t-tests and Chi-square tests to determine significance. Kaplan Meier and Multivariate Cox regression was used to assess the association of variables with morbidity and mortality. Results: Of the 276 eligible case records included in the study, 54% were male and 90% of all cases were younger than 2 years. Even though associations did not reach significance, teenage pregnancy and unemployment was high amongst the caregivers of the study population. Most of the malnourished children admitted (74%) presented with multiple comorbidities. Diarrhoea (43%), HIV- infection (30%) and respiratory tract infections (30%) were the top three comorbidities found, followed by tuberculosis (27%). The overall mortality rate was 8.7%. Survival probability was significantly reduced in children with pneumonia and those who presented with hypoglycaemia, dehydration, dermatosis, severe pallor, altered consciousness or shock on admission (p < 0.05). There was a significantly increased risk of death in males (HR = 0.174, 95%CI = 0.05 - 0.665), and in those who presented with dehydration (HR = 4.1, 95%CI = 1.25 - 13.59), evidence of lethargy or coma (HR = 4.2, 95%CI = 1.04 - 17.12) or multiple clinical signs (HR = 4.4, 95% CI =2.56 - 7.59) on admission (p < 0.05). The comorbidities HIV-infection (HR = 9.9, 95%CI = 1.39 - 70.68) and pneumonia (HR = 3.4, 95%CI = 1.56 - 7.43) showed a significantly increased mortality risk (p < 0.05). Conclusion: This study supports the body of evidence that despite reasonable standards of hospital care, it is difficult to obtain the target for severe acute malnutrition mortality (< 5%), likely due to the presence of contextually specific factors. Local interventions at hospital, primary health care and community level is needed, as well as further research to facilitate comprehensive policy-making.

Chapter 2 evaluates the effectiveness of two simple and widely applied self-report psychometric questionnaires: the 12-item General Health Questionnaire (GHQ-12) and Beck Depression Inventory (BDI) in detecting psychological morbidity after miscarriage. Both GHQ-12 and BDI demonstrated satisfactory psychometric properties and both questionnaires were found to be effective in detecting general psychiatric disorders and depression respectively. / Chapter 3 reports the application of GHQ-12 and BDI in assessing the psychological well-being of 280 miscarrying women over a one-year longitudinal course after the loss. The psychometric outcomes were also compared with a community cohort unexposed to pregnancy loss. The study confirmed that although psychological distress reduces over time, the psychological impact following miscarriage is significant and could be enduring. Patients who were more distressed immediately after miscarriage continued to be at a higher risk of psychological morbidity at a later stage. / Chapter 4 assesses the possible underlying risk factors associated with psychological morbidity following miscarriage over a one-year longitudinal course. It has demonstrated that while a poor marital dyad and psychological distress experienced immediately after miscarriage are consistent predisposing factors, some obstetric variables such as the type of medical management, a history of abortion and prior ultrasound evidence of fetal viability contribute to the development of psychological morbidity at various time points along its evolutionary course. / Chapter 5 reports a randomised controlled trial involving 280 miscarrying women in assessing the effectiveness of a psychological counselling programme in reduction of psychological morbidity. A 30% reduction in the proportion of patients with psychological morbidity was found three months after miscarriage in the counselling group, suggesting a potential clinical beneficial effect, albeit not statistically significant. This potential effect was more profound for selected patients who were initially more distressed after miscarriage. / Chapter 6 reports our exploratory findings of the psychological reaction of 83 male partners after miscarriage and it reports the gender differences over a one-year longitudinal course. A significant proportion of men were found to report psychological distress and depressive symptoms immediately after miscarriage. When compared with their female partners, the psychological impact was less intense and less enduring. / Chapter 7 concludes the thesis and proposes directions for future research. / Miscarriage (spontaneous abortion) is the most common complication of pregnancy with 15-20% of clinically recognised pregnancies aborting spontaneously. It is also one of the commonest gynaecological conditions leading to hospitalisation, accounting for more than 10% of gynaecological admissions in Hong Kong. The common occurrence and the procedural simplicity involved in the medical management, however, may tend to obscure its psychological impact. While emerging evidence has suggested that miscarriage could be associated with significant and possibly enduring psychological consequences, many questions remain unanswered, such as how to detect and screen for psychological morbidity after miscarriage; how long the symptoms last or when do they resolve; what are the underlying risk factors throughout its longitudinal course; what is the psychological impact on the male partner; and whether psychological intervention is helpful. In addition, nearly all studies have been conducted in Caucasian societies with the effect on other ethnic groups remaining largely unexplored. / This thesis specifically addresses the following aspects in assessing and managing psychological morbidity following miscarriage: Chapter 1 firstly introduces the clinical aspects of miscarriage, including the definition, incidence, risk factors, clinical manifestations and the current management options. It then discusses the current evidence available on the psychological aspects of miscarriage and outlines the deficiency in current knowledge. Finally, the hypotheses for this thesis are proposed. / Lok Hung Ingrid. / "May 2006." / Source: Dissertation Abstracts International, Volume: 68-03, Section: B, page: 1567. / Thesis (M.D.)--Chinese University of Hong Kong, 2006. / Includes bibliographical references (p. 248-276). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / School code: 1307.

Background: Diabetes is one of the leading causes of death and disability among chronic diseases in the United States. Type 2 diabetes, which accounts for 90-95% of all diabetes cases, is a preventable form of disease which can be controlled through diet and physical activity. But residents of places such as ‘food deserts’, with no access to fresh food, often bear the burden of chronic diseases such as diabetes. There have been very few studies which have particularly looked at the association between food environment and diabetes prevalence in such deprived areas. Objective: The study investigated the association between living in food desert and developing diabetes or dying from the disease. It considered factors such as access to grocery stores and supermarkets, convenience stores, food joints and owning a personal vehicle that might affect diabetes related morbidity and mortality. It has also looked at factors such as income and race which might influence the association. Methodology: The study emphasizes on the lack of access to food, in low income and deprived neighborhoods and its impact on diabetes mortality and morbidity at the micro level of census tracts in Fulton County, Georgia. Diabetes related data was obtained from OASIS and Fulton County Department of Health and Wellness for the years 1994-2010 for 204 census tracts of Fulton County. Data for food desert distribution was extracted from the ‘Food desert Locator’ tool of the United States Department of Agriculture (USDA). Data on food stores was obtained through ReferenceUSA. Demographic information was acquired from American Fact Finder of the US Census Bureau. SPSS version 21 was used to calculate Pearson’s correlation to find the association between food environment and diabetes as well as to see whether there is an association between income and vehicle ownership with diabetes occurrence. ArcGIS 10.1 was used to represent data as maps showing the geographical distribution of various factors across the County and their association with the occurrence of diabetes. Results: Low income African American dominated census tracts which have been designated as food deserts have a higher occurrence of morbidity and mortality from diabetes. The correlation between number of supermarkets and grocery stores, convenience stores and full service restaurants has no statistically significant relation with diabetes. Similarly, there is no statistically significant relation between car ownership and diabetes. But the relationship between income and diabetes has a statistical significance. Conclusion: This study did not find any significant statistical association between diabetes and living in food desert. But from the GIS maps it can be observed that the number of food markets (supermarkets and grocery stores) is much less in the low income tracts than elsewhere and these are also the tracts which have higher occurrence of diabetes. Similarly, the numbers of convenience stores, which usually do not have a healthy collection of food, are more in the low income neighborhoods. The weak association between the factors studied might be because other factors such as education and access to healthcare have not been considered for this study. More research in this field is required to get a better picture of the diabetes health status in food desert areas.