Abstract Maternal thyroid dysfunction and/or antibodies are present in 5–10% of pregnancies and may be associated with increased risks of adverse pregnancy and perinatal outcomes. In the present study maternal thyroid function and antibody status in the Northern Finland Birth Cohort 1986 was analyzed using early pregnancy serum samples. The impact of long-term storage on the stability of thyroid hormones and antibodies was studied and while TSH and thyroid hormone levels were not affected by storage time the concentrations of thyroid antibodies appeared to be significantly increased after 10 years of storage. Normal maternal thyroid function was evaluated by calculating thyroid hormone reference intervals in the thyroid antibody-negative population using a biobank of stored serum samples. Thyrotropin, free thyroxine and triiodothyronine reference intervals in the first and second trimester were 0.07–3.1 mU/L and 0.10–3.5 mU/L, 11.4–22.4 pmol/L and 11–18.9 pmol/L; and 3.4–7.0 pmol/L and 3.5–7.3 pmol/L, respectively, in this population (Abbott Architect method). Compared with thyroid antibody-negative mothers, antibody-positive mothers had significantly higher TSH and lower fT4 concentrations and an increased risk of experiencing death of an infant in the perinatal period with odds ratios (ORs) of 3.1 (95% confidence interval 1.4–7.1) for thyroid-peroxidase and OR 2.6 (1.1–6.2) for thyroglobulin antibody positivity. These infants were more often born very preterm, which could possibly explain these increased risks. Positive thyroid antibody status was not associated with preterm birth in this study. No other major pregnancy or perinatal complications were observed among mothers or newborns of mothers with thyroid dysfunction/antibodies. Mothers, who had hypothyroidism or thyroid antibodies during pregnancy, had a very high risk of subsequent thyroid disease: hazard ratio (HR) 17.7 (7.8–40.6) for overt hypothyroidism, 4.2 (2.3–7.4) for thyroid-peroxidase and 3.3 (1.9–6.0) for thyroglobulin antibody positivity. Mothers with hypothyroidism during pregnancy had increased risk of subsequent diabetes, (HR 6.0 [2.2–16.4]). Women at risk of thyroid dysfunction should be recognized and their prepregnancy counseling, blood sampling and treatment is probably beneficial. Whether universal screening of all pregnant women is justified is still under debate. / Tiivistelmä Kilpirauhasen toimintahäiriö tai ainoastaan kilpirauhasvasta-aineita (tyreoideaperoksidaasi- tai tyreoglobuliinivasta-aineita) esiintyy 5–10 % raskaana olevista naisista ja ne mahdollisesti lisäävät riskiä raskausajan ja vastasyntyneisyyskauden ongelmiin. Tässä väitöskirjatyössä tutkittiin Pohjois-Suomen syntymäkohorttia vuodelta 1985–1986. Äitien kilpirauhasen toimintaa tutkittiin alkuraskauden verinäytteiden avulla. Selvitimme pitkäaikaisen (20 vuotta) pakkassäilytyksen vaikutusta kilpirauhaslaboratoriokokeisiin. Tutkimuksessamme pakkassäilytyksellä ei ollut vaikutusta kilpirauhashormonien pitoisuuksiin, mutta kilpirauhasvasta-aineiden pitoisuudet olivat merkittävästi lähtötasoa korkeampia 10 säilytysvuoden jälkeen. Äitien normaali kilpirauhasen toiminta arvioitiin laskemalla aineistosta kilpirauhashormonien viitevälit kilpirauhasvasta-ainenegatiivisille naisille raskauden ensimmäiselle ja toiselle kolmannekselle käyttäen Abbott Architect metodia. Viitearvot olivat: tyreotropiinille 0.07–3.1 mU/l ja 0.10–3.5 mU/l, vapaalle tyroksiinille 11.4–22.4 ja 11–18.9 pmol/l sekä vapaalle trijodotyroniinille 3.4–7.0 ja 3.5–7.3 pmol/l. Äidin kilpirauhasen toimintahäiriöt eivät liittyneet vaikeisiin raskausajan tai vastasyntyneisyyskauden ongelmien, kuten ennenaikaisuuden ja kohtukuolemien esiintymiseen. Äidin kilpirauhasvasta-aineiden esiintyminen, mikä osoittaa kroonista autoimmuunityreoidiittia, lisäsi riskiä lapsen kohtukuolemaan ja ensimmäisen elinviikon kuolemaan; riski oli jopa kolminkertainen tyreoideaperoksidaasivasta-ainepositiivisten äitien vastasyntyneillä. Nämä vastasyntyneet olivat usein syntyneet hyvin ennenaikaisina (ennen 28. raskausviikkoa), mikä voi selittää tätä riskiä. Äidin kilpirauhasvasta-aineet eivät kuitenkaan lisänneet ennenaikaisten synnytysten riskiä tässä tutkimuksessa. Äideillä, joilla oli todettu kilpirauhasen vajaatoiminta tai kilpirauhasvasta-aineita, itsellään oli korkea, jopa 17-kertainen, riski sairastua myöhempiin kilpirauhasen sairauksiin, ja kilpirauhasen vajaatoiminta kuusinkertaisti sokeritautiin sairastumisriskin. Olisi tärkeää tunnistaa jo ennen raskautta ne naiset, joilla on riski sairastua kilpirauhasen vajaatoimintaan. Raskauden aikaisesta yleisestä seulonnasta ei vielä ole yksimielisyyttä.

Abstract The present study surveyed medical problems and mental health in an unselected population-based series of people with Down syndrome (DS). All people with DS identified in the Intellectual Disability Service Register in the Kainuu region (n=138) were included, and their health and disability case records in the public services were analysed. The severity of intellectual disability was related to age, gender, and recorded medical problems. Adaptive behaviour changes were assessed among adults repeatedly during ten years using the Adaptive Behaviour Scale - Residential and Community, Part I. The study evaluated health surveillance and practices were compared to the national Current Care guidelines. Numerous medical problems and behavioural symptoms were recorded in this population. Surgical treatments were used extensively. The number of medical problems varied to a great degree among participants. Health problems were extensive from birth to old age. Many health concerns were age-related. The degree of intellectual disability related to visual and neurological impairments. Depression, and among participants in their forties and older, Alzheimer’s disease were the most common underlying reasons for changes in adaptive behaviour. A gradual functional decline and dementia affected many participants at a relatively early age. Visual acuity and hearing should be regularly monitored in all individuals with DS because of a high prevalence of visual impairment and hearing loss in this population. There was a general lack of evidence that the health care guidelines initiated five years ago were being followed. This suggests that possibilities to enhance health have not been optimally implemented. Therefore, further efforts are needed to diagnose and treat medical problems in people with DS. / Tiivistelmä Tutkimuksessa kuvattiin todettujen terveysongelmien yleisyyttä ja terveysseurannasta annettujen suositusten toteutumista Downin oireyhtymässä. Nykyisin Kainuussa elävien Down -henkilöiden tietojen lisäksi alueella aiemmin asuneiden saatavissa olevat sairaus- ja huoltokertomustiedot analysoitiin (n=138). Kehitysvammaisuuden vaikeusasteen, iän, sukupuolen ja todettujen sairauksien yhteyksiä selvitettiin. Aikuisten ja ikääntyvien Down -henkilöiden toimintakykyä seurattiin kymmenen vuoden ajan käyttäen Adaptiivisen käyttäytymisen asteikkoa. Käypä hoito -suosituksen toteutumista terveysseurannan osalta arvioitiin. Down -henkilöillä oli todettu lukuisia terveysongelmia ja käytösoireita kaikissa ikäryhmissä. Kirurgisia hoitoja oli tehty paljon. Yksilölliset erot sairastavuudessa ja toimintakyvyssä olivat erittäin huomattavat. Monet terveysongelmista liittyivät tiettyyn ikään. Vaikeasti kehitysvammaisilla todettiin enemmän silmäsairauksia ja näön ongelmia sekä neurologisia sairauksia kuin lievästi tai keskivaikeasti kehitysvammaisilla. Masennus ja yli 40 vuoden ikäisillä Alzheimerin tauti olivat yleisimmät toimintakyvyn heikentymisen syyt. Toimintakykvyn heikentyminen alkoi usein 40 ikävuoden jälkeen ja moni sairastui suhteellisen nuorena dementiaan. Kaikkien Down -henkilöiden kuuloa ja näköä tulisi seurata säännöllisesti, koska kuulon alentuminen ja näön ongelmat ovat yleisiä ja jäävät usein toteamatta. Hoitosuositukset eivät toteutuneet ainakaan säännöllisen kuulon ja kilpirauhasen toiminnan seurannan osalta viiden vuoden kuluessa suositusten antamisesta. Terveysseurannan parempi toimeenpano terveyden edistämiseksi on mahdollista. Down henkilöiden sairauksien toteamisen ja hoidon kehittäminen vaatii edelleen työtä.

Magister Curationis - MCur / Background and Problem Statement: Maternal mortality is a global health issue, which mostly affects the developing countries. The United Nations (UN) member states have made a commitment to reduce maternal mortality by 75% by 2015. However, one of the biggest challenges in monitoring maternal deaths in Sub-Sahara Africa including Ghana, is the lack of adequate information for the accurate estimation of the maternal mortality rate (MMRate), and to identify causes of death. The World Health Organization (WHO) developed strategies and guidelines to assist countries to generate accurate information regarding maternal deaths. Maternal death review is one such strategy that was implemented in Ghana. Midwives are among the health workers who participate in the implementation of this strategy in different health facilities.However, what is not well understood is the role that midwives play in the implementation of Maternal Death Review (MDR).The purpose of the study: To explore and describe the roles that midwives play in the implementation of MDR in selected health facilities in Ghana‟s Ashanti Region.Methodology: A qualitative descriptive design was used to guide the research.Purposive sampling was conducted to select midwives who have been involved in maternal death review from the teaching, regional and district referral hospitals. Data was collected by conducting semi-structured individual interviews. Data saturation was reached after twenty interviews. Thematic Content Analysis was used to manage and analyse data. The Facility-based maternal death review model was used to assist the researcher to identify and organize the emerged themes. Ethical clearance was obtained from the University, as well as approval from the management of the health facilities prior to approaching the informants.Main findings: The results of this study indicate that midwives in Ghana‟s Ashanti Region are undertaking various activities and duties in all the stages of the Facilitybased maternal review model. The type of activities and duties undertaken by midwives varied according to their seniority and the level of the health facilities.Conclusion and recommendation: The findings of this study bring insight into the roles played by midwives in the implementation of the Facility-based maternal death review process in the health facilities in Ghana‟s Ashanti Region. These findings have a direct implication for the training and education of midwives. It is recommended that issues related to maternal death review methods and processes be included in the formal and continuing training and education of midwives. However, further research considering the training and practice development needs of midwives in respect of implementation of maternal death review is required.

Apart from the personal and socioeconomic burdens of dementia, the immense, intangible emotional and psychological suffering endured by dementia patients, their carers and families are difficult to quantify. Alzheimer’s dementia (AD) accounts for over 50% of all dementias and is responsible for a large percentage of morbidity and mortality in older adults. It is also recognised as a disease qualitatively distinct from the normal ageing process. Identified almost 95 years ago by Alois Alzheimer, it poses a seminal problem, which in the twenty-first century is compounded by the predicted extension in human longevity. Caregivers thus bear a considerable financial, social and emotional burden due to the progressive debilitating nature of the disease. It is hypothesised that social support buffers the individual from the negative emotional effects of stressful circumstances associated with the caregiving process; and although the inevitable course of the disease cannot be stopped, improving support to caregivers may decrease feelings of isolation and improve psychological health. Caregivers of AD patients often report experiencing a lack of social support due to the nature and progression of this disease. This study thus aims to investigate the relationship between real and/or perceived social support and psychological health (depression, loneliness, and perceived burden of care) amongst a cohort of Alzheimer’s caregivers. The following standardised measuring instruments were used to elicit data: the Zarit Burden Interview (ZBI), the Beck Depression Inventory (BDI-II), UCLA Loneliness Scale, Personal Resource Questionnaire (PRQ85) and a biographical questionnaire. Data were analysed using correlation and regression statistical techniques. The main findings of this study were that there is a significant positive correlation between loneliness and depression; loneliness and personal strain (burden) as well as both role and personal strain (burden) with depression. A significant negative correlation was also found between perceived social support and loneliness. Additional findings were that participants with higher educational qualifications experienced more personal strain and role strain (burden); caregivers with patients in the two younger age groups scored higher on the BDI-II; and the cognitive status of the patient correlated with the burden experienced by the caregiver. A significant negative correlation between summaries of reactions (burden) and duration of caregiving was also reported. / Dissertation (MA)--University of Pretoria, 2008. / Psychology / unrestricted

Entre les actes chirurgicaux et l'état métabolique il existe des nombreuses interactions. D'un côté, la réponse catabolique majeure induite par la chirurgie viscérale peut être contrôlée par une supplémentation nutritionnelle précoce, ce qui diminuerait la morbidité et la mortalité postopératoire et aussi les durées d'hospitalisation. L'albuminémie préopératoire est un bon facteur prédictif de l'état nutritionnel postopératoire, corrélée avec un pronostic postopératoire inférieure. La préalbumine reflète de façon plus sensible l'évolution de l'état nutritionnel. Principale hormone orexigène, la ghréline présente une cinétique perturbée lors des périodes postopératoires avec une augmentation de sa sécrétion au moment de la reprise de la nutrition entérale et des concentrations postopératoires moyennes inférieures à celles normales. Ces observations posent la question de l'utilité d'un traitement par analogues de la ghréline. De l'autre côté, la chirurgie bariatrique peut corriger les perturbations métaboliques corrélées à l'obésité, mais son efficacité n'est pas absolue. Par contre, en utilisant certains critères clinique (âge, IMC, présence d'un diabète sucré) et biologiques (insulino-résistance, taux d'IGF1), cette efficacité devient prédictible pour les interventions d'insertion d'anneau gastrique / Surgical interventions can have several effects on the metabolic status. On one hand, the important catabolic response caused by major digestive surgery can be controlled through an early nutritional support, which could reduce the mortality, morbidity and also the duration of hospitalization. The preoperative albumin level is a reliable predictive factor of the postoperative nutritional status and correlates to a worse postoperative prognosis. The prealbumin reflects in the most sensitive manner the evolution of the nutritional status. As the main orexigen hormone, ghrelin has a disturbed cynetics in the postoperative period with an augmentation of its secretion corresponding to the reintroduction of the enteral nutrition and mean postoperative concentrations that are lower than normal. These observations raise the question of the utility o a ghreline analogues’ treatment. On the other hand, bariatric surgery could correct the metabolic disturbances associated to obesity, but its efficacy is not absolute. However, by using certain clinical (age, BMI, presence of a diabetes mellitus) and biological (insulin-resistance, IGF1 level criteria, this efficac can be redictable in the case of gastric banding

Le but de cette étude est l’estimation du coût direct médical annuel de l’excès de poids corporel chez la population adulte qui a reçu une assistance médicale au sein de l'Institut Mexicain de la Sécurité Sociale (IMSS) pendant l'année 2006. Méthodes. Une analyse épidémiologique, au niveau national, a été effectuée à partir d’une population adulte mexicaine ayant demandé en 2006 une aide médicale à l'Institut Mexicain de la Sécurité Sociale. Nous avons utilisé la base de donnée informatique « DataMart-2006 » fournie par la DTISS (Division Technique d’Information Statistique en Santé) pour estimer la prévalence de l’excès de poids corporel : surpoids 25kgm2 ≤ IMC <30kgm2, obésité IMC ≥ 30 kgm2 et la fraction de la population attribuable (FAP) atteinte d'hypertension artérielle (HTA), de diabète mellites de type 2 (DM2) ou de dyslipidémie. On a utilisé l’analyse de régression logistique pour estimer les risques appelés odds ratio, également désignée comme rapport des chances. Le coût direct médical de l’hypertension artérielle et du diabète mellites de type 2 a été établi pour l’exercice de l’année 2002 et mis à jour pour l’année de l’étude, à savoir l’année 2006. Le coût direct médical annuel attribué à l’excès de poids corporel a été calculé en multipliant le coût de chaque maladie par la FAP [...] Conclusion. Il y a un pourcentage élevé des patients qui souffrent d’excès de poids corporel, et par conséquent la répartition de patients souffrant de cette maladie par catégorie de personnel de santé, pour s’occuper globalement de la prévention, du traitement et du contrôle, est aussi élevée. Alors, il est nécessaire, d’établir des stratégies afin de diminuer et contrôler ce problème de santé publique au Mexique. Ainsi donc, comme on vient de le voir, le pourcentage élevé de cette maladie affect directement les dépenses au sein de l’IMSS. Finalement les résultats confirment que le coût direct médical annuel par patient, qui souffre d’obésité au sein de l'Institut Mexicain de la Sécurité Sociale, est plus élevé que dans les autres pays. / The aim of this study is the assessment of the yearly direct medical cost due to excess body weight among the adult population who received medical assistance from the Mexican Institute of Social Security (IMSS) in 2006. Methods. An epidemiological analysis on a national scale has been carried out taking into account an adult population who asked the Mexican Institute of Social Security for medical assistance in 2006. We have used a database “DataMart-2006” provided by DTISS (Technical Division of Health Statistical Information) in order to assess the prevalence of excess body weight: excess weight 25kgm2 ≤ BMI (Body Mass Index) < 30kgm2, obesity BMI ≥ 30 kgm2 and the fraction of related population affected by arterial hypertension (HTA), type 2 diabetes mellitus (DM2) or dyslipidemia. We have used logical regression analysis to evaluate risks called odds ratio also dubbed occurrence ratio. The direct medical cost of arterial hypertension and type 2 diabetes mellitus was established for year 2002 and updated for the year of this study, namely 2006. The yearly medical cost ascribed to excess body weight has been calculated by multiplying the cost of each disease by the fraction of related population [...] Conclusion. There is a high percentage of patients suffering from excess body weight and as a result the distribution of patients suffering from this disorder per health personnel category dealing with prevention, treatment and control is also high. Then it is necessary to devise strategies so as to restrain and keep a check on this issue of public health in Mexico. Thus, as we have seen it, the high occurrences of this illness directly impact IMSS expenditures. Finally, for the Mexican Institute of Social Security, results confirm that the direct yearly medical cost per patient affected by obesity is higher compared to estimated yearly expenses in other countries.

This study investigated the impact of a sensory-motor stimulation programme, namely the SEMOSTI Programme, on the gross motor proficiency of four-to-six-year-old children. A field experiment was conducted using a quasi-experimental comparison group pretest-posttest design as three teachers implemented the SEMOSTI Programme over a 30-week period. Data collection took place at two schools’ grade R classes in Gauteng province of South Africa. Due to a limited sample of 73 participants, the results are context-bound and specific to Afrikaans-speaking, white, grade R children and selected gross motor skills. Data was collected using subtests of the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2), a scale and measuring tape as well as several questionnaires. The variables, physical activity, body mass index (BMI), gender, age, and perinatal morbidity could possibly influence the results and were taken into account. Data was statistically analysed using the General Linear Model (GLM) procedure and Dunnett’s t-test analysis. Findings indicated that the SEMOSTI Programme had a significant impact on the dependent variable, gross motor proficiency. The SEMOSTI Programme positively impacted on all five motor skills tested (bilateral coordination, balance, running speed and agility, upper-limb coordination and strength), but only the impact on running speed and agility and strength were statistically significant. Findings from the questionnaires indicated that the teachers who presented the SEMOSTI Programme perceived it as user-friendly, well-structured and effective in choice of equipment and activities. They identified the timeframe for the evaluation of developmental milestones and the structure of the plan-of-action section as weaknesses. Findings suggest that the SEMOSTI Programme is promising in improving gross motor proficiency in four-to-six-year-old children. Through participation in the programme, the experimental group significantly improved total gross motor proficiency, running speed and agility, and strength. This study offers support for the future use of the SEMOSTI Programme as a stimulation programme in grade R after further development and validation. / Dissertation (MOccTher)--University of Pretoria, 2012. / Occupational Therapy / unrestricted

Orientadores: Maria Laura Costa do Nascimento, José Guilherme Cecatti / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-28T01:47:22Z (GMT). No. of bitstreams: 1 Pfitscher_LuciaChaves_M.pdf: 6366056 bytes, checksum: 9a70e9992cbec443ea7d924bdc77f7bb (MD5) Previous issue date: 2015 / Resumo: Introdução: A infecção representa importante causa de morbidade e mortalidade materna, sendo uma preocupação crescente no mundo todo. As doenças respiratórias, especialmente as virais, têm se destacado justamente pelo potencial de epidemia com que ameaçam a saúde da população mundial e pela vulnerabilidade identificada durante a gestação. Objetivo: Avaliar o impacto da morbidade materna grave (MMG) atribuível à infecção (sepse, meningite e doença respiratória) e os fatores associados ao pior resultado materno (near miss e óbito), entre mulheres da Rede Brasileira de Vigilância da Morbidade Materna Grave. Métodos: análise secundária de um estudo transversal, multicêntrico, que incluiu 27 centros de referência obstétrica das cinco regiões do Brasil no período de 2009 e 2010. A vigilância prospectiva dos casos de infecção grave foi realizada utilizando os critérios da OMS de condições potencialmente ameaçadoras da vida (CPAV) e near miss materno (NMM). Os principais focos de infecção foram identificados e comparados a outras causas de MMG. Mulheres com complicação devido à doença respiratória também foram avaliadas em dois grupos: com e sem suspeita de A(H1N1)pdm09 e também comparadas a outras causas de MMG. Casos com suspeita de A(H1N1)pdm09 foram revisados e separados em três grupos: não-testados, confirmados e não confirmados para A(H1N1)pdm09 e os seus resultados foram comparados. Complicações devidas à infecção e a doenças respiratórias foram comparadas com complicações devidas a outras causas de MMG. Os fatores associados com desfecho materno grave (DMG) foram avaliados para os casos de infecção e doença respiratória. Resultados: Dentre os 9555 casos de MMG, apenas 502 (5,3%) apresentaram infecção grave, entretanto foram responsáveis por cerca de um quarto dos casos de NMM e quase metade dos casos de morte materna (MM). Os indicadores de saúde avaliados demonstram maior gravidade dos casos complicados por infecção, com índice de mortalidade (IM) superior a 26% em comparação com 11% para as demais causas de MMG. Para doença respiratória, 206 mulheres apresentaram suspeita de A(H1N1)pdm09, cerca de 60% foram testados para a doença e 49 mulheres apresentaram resultado positivo. A gravidade dos desfechos maternos foi pior entre os casos de A(H1N1)pdm09 positivo, com uma taxa de NMM:MM abaixo de 1 (0,9:1), em comparação a 12:1 para outras causas de MMG. O IM para doença respiratória foi superior a 50% (7,4% outras causas de MMG). Demoras no atendimento foram associadas com pior prognóstico materno e estiveram presentes em mais de 50% entre os casos de infecção, aumentando em duas vezes o risco de DMG para doença respiratória. Resultados perinatais foram piores dentre os casos de doença respiratória, com aumento da prematuridade, morte fetal, baixo peso ao nascer e Apgar <7. HIV/AIDS, histerectomia, hospitalização prolongada, admissão em UTI e demoras no atendimento foram alguns fatores independentes associados DMG. Conclusão: complicações por infecção e em especial por influenza A(H1N1)pdm09 geram grande impacto sobre morbidade e mortalidade materna no Brasil e compreender os fatores associados à maior gravidade pode gerar medidas capazes de colaborar para a melhoria do cuidado obstétrico. Investir em intervenções específicas para gravidez, visando diagnóstico precoce e tratamento oportuno são essenciais para melhorar a saúde materna e reduzir o número de mortes maternas evitáveis no país / Abstract: Background: Infection represents the major cause of maternal morbidity and mortality, and a growing concern worldwide. Respiratory diseases, especially viral, have stood out because of their epidemic potential and the identified vulnerability towards infection during pregnancy. Objective: To assess the impact of severe maternal morbidity (SMM) due to infection (sepsis, meningitis and respiratory disease) and the factors associated with worse maternal outcome (near miss and death) among women of the Brazilian Network for the Surveillance of Severe Maternal Morbidity. Methods: secondary analysis of a cross-sectional, multicenter study that included 27 obstetric referral centers in five regions of Brazil between 2009 and 2010. Prospective surveillance of severe infection was performed using WHO criteria of potentially life threatening conditions (PLTC) and maternal near miss (MNM). The main sources of infection were identified and compared to other causes of SMM. Women with complications due to respiratory disease were also assessed in two groups: with and without suspected A(H1N1)pdm09 and also compared to other causes of SMM. Cases of suspected A(H1N1)pdm09 were reviewed and divided into three groups: non-tested, confirmed and unconfirmed for A(H1N1)pdm09 and their results were compared. Complications due to infection and respiratory disease were compared with complications due to other causes of SMM. Factors associated with SMO were assessed for cases of infection and respiratory disease. Results: Among the 9555 cases of SMM, only 502 (5.3%) had severe infection, however they were responsible for about a quarter of cases of MNM and almost half of the cases of maternal mortality (MM). The assessed health indicators demonstrate greater severity of cases complicated by infection, with a mortality index (MI) above 26% compared to 11% for other causes of SMM. For respiratory disease, 206 women had suspected A(H1N1)pdm09, about 60% were tested for the disease and 49 women were positive. The severity of the maternal outcomes was worse between the cases of A(H1N1)pdm09 positive, with a rate of MNM: MM below 1 (0.9: 1), compared to 12: 1 for other SMM causes. The MI among respiratory disease was superior to 50% (7.4% other causes SMM). Delays in care were associated with worse maternal prognosis and were present in over 50% of cases of infection. Perinatal results were worse in cases of respiratory disease, with increased prematurity, stillbirth, low birth weight and Apgar <7. HIV/AIDS, hysterectomy, prolonged hospitalization, ICU admission and delays in care were independent factors associated with severe maternal outcome. Conclusion: infections and especially those caused by A(H1N1)pdm09 presented great impact on maternal morbidity and mortality in Brazil and the identification of factors associated with the increased severity can contribute to the improvement of obstetric care. There is need for specific interventions during pregnancy, seeking early diagnosis and timely treatment of infections, which are essential for improving maternal health and to reducing the number of preventable maternal deaths in the country / Mestrado / Saúde Materna e Perinatal / Mestra em Ciências da Saúde

Método: Trata-se de uma pesquisa qualitativa de cunho documental utilizando o audiovisual como lócus de instalação de depoimentos de lideranças indígenas do Estado do Acre, Brasil. O objetivo é analisar registros de vivências de lideranças indígenas sobre suas condições de vida, como contribuição às políticas públicas do SUS. E apresentar uma proposta interventiva a partir das potencialidades do vídeo documentário. Resultados: A população indígena, por uma série de motivos, certamente é a parcela da população brasileira sobre a qual menos existem dados específicos que permitam o estabelecimento de políticas de saúde pública eficazes. Embora tenham ocorrido avanços significativos no conhecimento das questões indígenas e um crescente empoderamento das lideranças indígenas na luta por seus direitos básicos de cidadania, a situação ainda está aquém do esperado. Temas relevantes abordados: 1. Participação nas instâncias do poder público/ direitos indígenas. 2. Medicina tradicional exterioridade da doença. 3. Dificuldades com o SUS. 4. Cuidados de saúde nas aldeias. 5. Segurança Alimentar e desnutrição. 6. Qualidade da água e saneamento básico. 7. Logística. 8. Cobertura vacinal. 9. Saúde das mulheres indígenas. 10. Ecologia e biodiversidade. 11. Morte de crianças indígenas. Conclusões: 1. A omissão sistemática dos governos em qualificar agentes de saúde indígenas no tocante às intervenções em saúde individual e coletiva e no exercício dos direitos sociais. 2. Falta de empenho do SUS em contratar profissionais com formação especializada para compor as equipes e direções do Sistema de Saúde que atuam nas aldeias e nos postos avançados de saúde no interior do território. 3. Dificuldades de comunicação entre as equipes do SUS e os povos indígenas. Há barreiras de idioma, de cultura e de percepção do processo saúde-doença / Method: This is a qualitative research that uses the documentary audio-visual like a place of installation register statements of native indigenous leaders of Acre, Brazil. The objective is to analyze records of indigenous leaders from experiences about their living conditions as a contribution to public SUS policies. And present an interventional proposal from the documentary video potentiality. Results: The indigenous population, for a number of reasons, it is certainly the Brazilian population, on which there is less specific data that allow the establishment of effective public health policies. Although there have been significant advances in knowledge of indigenous issues and a growing empowerment of indigenous leaders in the struggle for their basic rights of citizenship, the situation is still below expectations. Relevant topics approached:1. Participation in public authoritys instances / indigenous rights. 2. Traditional medicine - externality of the disease. 3. Difficulties with SUS. 4. Health care in villages. 5. Food security and malnutrition. 6. Water quality and basic sanitation. 7. Logistics. 8. Vaccination coverage. 9. Indigenous women\'s health. 10. Ecology and biodiversity. 11. Death of indigenous children. Conclusions: 1. the systematic omission of governments in qualify indigenous health workers with regard to the individual and collective health interventions and the exercise of social rights. 2. Lack of commitment of the SUS in hiring professionals with specialized training to compose the teams and directions of the Health System that work in the villages and in the outposts of health in the territory. 3. Difficulties in communication between SUS teams and indigenous peoples. There are barriers to language, culture and perception of the health-disease process

Le ratio de mortalité maternelle en Afrique de l’Ouest est le plus élevé au monde et l’hémorragie du post-partum (HPP) y est la principale cause directe de mortalité maternelle. L’objectif général de ce travail était d’apporter des connaissances pour améliorer la prise en charge des HPP dans les structures hospitalières en Afrique de l’Ouest. Tout d’abord, nous avons montré que les facteurs de risques maternels de morbi-mortalité liée à l’HPP retrouvés dans les pays à ressources élevées étaient généralisables au contexte de l’Afrique de l’Ouest. Par ailleurs, nos analyses suggèrent que la qualification du médecin en charge du service de maternité (médecin généraliste versus gynécologue-obstétricien) a un impact déterminant sur la survie des femmes présentant une HPP dans ce contexte. Ensuite, nous avons montré que l'injection d'ocytocine dans les dix minutes qui suivent le diagnostic d’HPP était un facteur déterminant pour améliorer la santé maternelle au Bénin et au Mali. Le diagnostic rapide de l’HPP et une meilleure surveillance du post-partum immédiat étaient également importants. Enfin, nous avons mis en place une étude pilote pour évaluer la faisabilité d’un essai contrôlé randomisé (ECR) dont l’objectif est de tester l’efficacité du tamponnement utérin par condom catheter dans la prise en charge des hémorragies du post-partum dans cette région. Les résultats ont montré que la mise en place d’un ECR était faisable et ont apporté des connaissances supplémentaires pour optimiser le protocole de recherche. Ainsi, nous avons identifié un certain nombre de facteurs sur lesquels des actions doivent être menées pour améliorer la qualité de la prise en charge de l’HPP. / The maternal mortality ratio in West Africa is the highest in the world and postpartum hemorrhage (PPH) is the leading direct cause of maternal mortality. The general objective of this work was to provide knowledge to improve the management of PPH in hospitals in West Africa. Firstly, we have highlighted that maternal risk factors for morbidity and mortality related to the PPH found in high-resource countries were generalizable to the context of West Africa. Furthermore, our analysis suggests that the qualification of the doctor in charge of the maternity unit (general practitioner versus obstetrician) has a decisive impact on the maternal issue in this context. Then, we showed that injection of oxytocin within ten minutes after the diagnosis of PPH was a key factor for improving maternal health in Benin and Mali. Rapid diagnosis of PPH and better monitoring of the immediate postpartum period were also important. Finally, we set up a pilot study to assess the feasibility of a randomized controlled trial (RCT), which aims to test the effectiveness of uterine tamponade with condom catheter in the postpartum hemorrhage management in this region. The results showed that f a RCT was feasible and provided additional knowledge to optimize the research protocol. Thus, we have identified a number of factors on which action should be taken to improve the quality of PPH management.