Les transfusions de culots érythrocytaires (CE) sont un traitement fréquent en soins intensifs pédiatriques. Des études chez l’adulte suggèrent qu’une durée prolongée d’entreposage des CE est associée à une mauvaise évolution clinique. Aucune étude prospective n’a été conduite en pédiatrie. Notre objectif était d’évaluer l’effet clinique de la durée d’entreposage des CE chez des patients de soins intensifs pédiatriques. Nous avons donc conduit une étude observationnelle prospective dans 30 centres de soins intensifs pédiatriques en Amérique du Nord, chez tous les patients consécutifs de moins de 18 ans, séjournant aux soins intensifs pendant plus de 48 heures. Le critère de jugement primaire était l’incidence de cas de syndrome de défaillance multiviscérale après transfusion. Les critères de jugement secondaire étaient la mortalité à 28 jours et la durée d’hospitalisation aux soins intensifs. En utilisant un modèle de régression logistique, les risques relatifs furent ajustés pour le sexe, l’âge, la sévérité de la maladie à l’admission, le nombre total de transfusions et la dose totale de transfusion. L’étude a montré que les patients recevant des CE entreposés pendant 14 jours ou plus avaient un risque relatif ajusté de 1.87 (IC 95% 1.04 :3.27, p=0.03) de contracter ou de détériorer un syndrome de défaillance multiviscérale après transfusion. Ces mêmes patients avaient une durée d’hospitalisation aux soins intensifs prolongée (+3.7 jours, p<0.001), mais pas de risque augmenté de mortalité. En conclusion, chez les patients de soins intensifs pédiatriques, la transfusion de CE entreposés 14 jours ou plus est associée avec une augmentation de l’incidence de syndrome de défaillance multiviscérale et une durée d’hospitalisation prolongée aux soins intensifs. / Transfusion is a common treatment in pediatric intensive care units. Studies in adults suggest that prolonged storage of red blood cell units is associated with worse clinical outcome. No prospective study has been conducted in children. Our objectives were to assess the clinical impact of the length of storage of red blood cell units on clinical outcome in critically ill children. We conducted a prospective, observational study in 30 North American centers, in consecutive patients aged <18 years with a stay ≥48 hours in a pediatric intensive care unit. The primary outcome measure was the incidence of multiple organ dysfunction syndrome after transfusion. The secondary outcomes were 28-day mortality and pediatric intensive care unit length of stay. Odds ratios were adjusted for gender, age, number of organ dysfunctions at admission, total number of transfusions, and total dose of transfusion, using a multiple logistic regression model. Our study showed that for patients receiving blood stored ≥14 days, the adjusted odds ratio for an increased incidence of multiple organ dysfunction syndrome was 1.87 (95% CI 1.04;3.27, p=0.03). There was also a significant difference in the total pediatric intensive care unit length of stay (adjusted median difference +3.7 days, p<0.001) but no significant change in mortality. In critically ill children, transfusion of red blood cell units stored for ≥14 days is independently associated with an increased occurrence of multiple organ dysfunction syndrome and prolonged PICU stay.

Comme la plupart des villes en Afrique subsaharienne, Ouagadougou, capitale du Burkina Faso, a connu au cours de ces dernières décennies une croissance démographique rapide. Cette situation pose de nombreux problèmes d’ordre sanitaire et environnemental. Pourtant, les liens entre la santé et l’environnement immédiat sont encore faiblement étudiés du fait de la qualité des données qui, lorsqu’elles existent, se révèlent peu appropriées. La présente thèse vise à analyser les liens entre l’environnement immédiat et certains symptômes de maladies, plus spécifiquement la fièvre et la diarrhée ; deux problèmes majeurs de santé liés à l’environnement chez les enfants de moins de 5 ans dans les villes d’Afrique subsaharienne. Cette étude se base sur des données de l’Observatoire de population de Ouagadougou (OPO) recueillies entre 2009 et 2010 dans l’objectif d’étudier les inégalités de santé en milieu urbain (notamment les données de l’enquête santé portant sur 950 enfants de moins de 5 ans recueillies en 2010). La thèse décrit d’abord la santé environnementale en milieu urbain en dépassant l’opposition classique quartiers lotis/quartiers non lotis (zones d’habitation formelles/zones d’habitation informelles). Elle s’intéresse ensuite à l’évaluation plus fine des liens entre l’environnement immédiat et la fièvre en tenant compte des facteurs démographiques et socio-économiques pertinents dans l’estimation. Enfin, la thèse approfondit les analyses sur la co-occurrence de la diarrhée et de la fièvre en mettant en évidence les effets conjoints des facteurs environnementaux et démographiques. À l’aide des analyses spatiales basées sur la distance euclidienne, des analyses factorielles et de classification, cette étude décrit le contexte sanitaire des quartiers formels et informels et analyse la pertinence de la dichotomie entre les quartiers lotis et les quartiers non lotis dans les zones suivies par l’OPO. L’étude effectue également des analyses multivariées en recourant respectivement aux modèles logit simple et ordonné pour estimer les effets propres de l’environnement immédiat sur la fièvre et la co-occurrence de la diarrhée et de la fièvre chez les enfants. Les résultats de l’étude montrent que les risques environnementaux sont variables d’un quartier à l’autre, et que les quartiers lotis bien qu’étant les plus pourvus en services urbains de base sont les plus exposés aux dangers environnementaux. Néanmoins, ce constat ne suffit pas pour rendre compte de la vulnérabilité des enfants dans les quartiers lotis que dans les quartiers non lotis, puisque l’accès à l’eau, l’assainissement, la nature du sol, et le niveau d’éducation de la mère sont des facteurs clés dans l’occurrence des symptômes liés à l’environnement immédiat. On note également une hétérogénéité concernant la santé environnementale, notamment dans les zones non loties. En considérant les effets de l’environnement immédiat sur la fièvre chez les enfants, les résultats montrent que ces effets baissent après la prise en compte des variables démographiques, socio-économiques et du quartier de résidence. Les facteurs de l’environnement tels que la gestion des ordures ménagères et celle des eaux usées discriminent significativement la fièvre. Les enfants à Nioko 2 (quartier non loti), par exemple, ont deux fois plus de risque d’avoir eu de la fièvre par rapport à Kilwin (quartier loti). Les effets conjoints des facteurs environnementaux et démographiques sont également mis en exergue dans la co-occurrence de la diarrhée et de la fièvre, même si ces effets diminuent régulièrement avec le nombre des symptômes chez les enfants. Le fait d’être dans un ménage insalubre ou d’avoir le sol extérieur en terre augmente la propension de co-occurrence de la diarrhée et de la fièvre. En revanche, cette co-occurrence chez les enfants diminue significativement avec l’âge. Les effets de l’environnement sur l’occurrence ou la co-occurrence des symptômes existent, quand bien même ces effets diminuent avec la prise en compte des facteurs démographiques et socio-économiques et du quartier de résidence. Les résultats de la thèse plaident pour un effort méthodologique, afin d’affiner la définition des variables de l’environnement en milieu urbain. / Like most cities in sub-Saharan Africa, Ouagadougou, the capital of Burkina Faso, has experienced skyrocketing demographic growth. This situation causes numerous problems from a sanitary and environmental standpoint. However, the ties between health and the immediate environment have still not been extensively studied, due to the poor quality of data which, when they exist, appear to be relatively ill-suited for such an analysis. This thesis aims to analyze the links between the environment and diseases symptoms, more specifically fever and diarrhea, two major environmentally-related health problems among children under 5 in cities in sub-Saharan Africa. This study is based on the data from the Ouagadougou Health and Demographic Surveillance System (Ouaga HDSS), collected between 2009 and 2010 with the goal of studying health inequalities in urban environments (including health survey data on 950 children under 5 years collected in 2010). The thesis first describes environmental health in urban environments going beyond the classic opposition between formal and informal neighbourhoods. It then examines the links between the environment and fever, taking into account relevant demographic and socio-economic factors in the analysis. Lastly, the thesis expands on studies on the co-occurrence of diarrhea and fever by underscoring the joint effects of environmental and demographic factors. Using spatial and factorial analysis followed by classifications, this study describes the health context of formal and informal neighbourhoods and analyzes the relevance of the dichotomy formal/informal neighbourhoods from the Ouaga HDSS. The study also performed multivariate analysis (simple and ordered logit models) to estimate the effects of the immediate environment of fever and the co-occurrence of diarrhea and fever in children. The results of our study show that environmental risks vary depending on the neighbourhood and the formal neighbourhoods, while better equipped in basic urban services, are the most exposed to environmental dangers. However, this finding is insufficient to explain the difference in vulnerability in child health across formal and informal neighbourhoods, as access to clean water, sanitation, the nature of the soil, and the mother's level of education are key factors in the occurrence of symptoms related to the environment. There is also heterogeneity in environmental health particularly in the informal areas. Considering the effects of the environment on children’s fever, the results suggest that the estimated size of these effects decline after taking into account demographic and socio-economic variables and the neighbourhood of residence. Environmental factors such as household waste and wastewater management have significant effects on the occurrence of childhood fever. For example, the risk of having had a fever for the children living in Nioko 2 (an informal and the poorest neighbourhood) is twice as high as for those in Kilwin (a formal and richer neighbourhood). The study of joint effects of environmental and demographic factors is also underscored in the co-occurrence of diarrhea and fever, even though these effects regularly diminish with the number of symptoms among children. Being in an insalubrious household or having a dirt floor increase the chance of co-occurrence of diarrhea and fever. Conversely, this co-occurrence declines substantially as children grow older. Environmental effects on the occurrence or co-occurrence of symptoms are found to exist, although their estimated importance are reduced when demographic and socio-economic factors and the neighbourhood of residence are taken into account. The results of this thesis underline the need for a methodological effort to refine the definition of environmental variables in cities in sub-Saharan Africa.

Background: Co-morbidity of eating disorders and alcohol use among women is a topical theme. Eating disorders can be seen as a disease of modern women and alcohol use as very frequent and tolerated by society. Co-morbidity of these disorders is not given enough attention. Aim: The theoretical part defines basic terms of eating disorders, alcohol abuse and their co-morbidity. In the practical part my goal was to identify the risk and protective factors, personal characteristics that were common for women suffering with co-morbidity and to outline the subjective perception of respondents regarding this issue. Methods and sample: Data were obtained by the method of a semistructured interview with five respondents - clients of the aftercare group for alcohol addicts. Two methods were used for the purpose of data analysis: qualitative type of an approach and a pattern (gestalt) recognition method. Results: The thesis described risk factors on the individual, familial and social level. It also described personal characteristics of respondents that overlapped with the risk factors. They can therefore be taken as risk factors on the individual level. Protective factors are mainly positive influence of peers, hobbies and awareness of one's value. Respondents and their subjective view on this issue point out...

En Afrique tropicale, là où le paludisme est fortement endémique, la plupart des individus sont semi-immuns et les infections asymptomatiques sont très répandues. Ainsi la détection de parasites dans le sang de malades fébriles n'est pas un critère suffisant pour distinguer le paludisme des autres causes de fièvre. A Dielmo, un village du Sénégal d'environ 500 habitants en 2010, un suivi épidémiologique continu très étroit du paludisme a débuté en 1990. Dans ce village où la transmission est pérenne, la mise en place de moyens de lutte et de prévention contre le paludisme de plus en plus efficaces a profondément transformé l'épidémiologie du paludisme. Dans ce travail, nous analysons l'impact de ces interventions sur les prévalences parasitaires, les densités parasitaires et les critères diagnostiques du paludisme et nous mesurons l'évolution du paludisme clinique à Plasmodium falciparum, P. malariae et P. ovale de juin 1990 à décembre 2010. Les données parasitologiques et cliniques ont été analysées par régression logistique à effet aléatoire pour étudier la relation entre les densités parasitaires et le risque de fièvre. Les prévalences parasitaires des trois espèces plasmodiales ont considérablement diminué lors de l'abandon de la chloroquine en traitement de première ligne et de son remplacement par des combinaisons thérapeutiques, puis sont devenues presque nulles après la mise en place de moustiquaires imprégnées d'insecticides à longue durée d'action. Les seuils pyrogéniques calculés nous ont permis de mesurer la densité d'incidence des accès palustres et d'étudier l'impact des mesures de lutte sur la morbidité palustre dans la population. / In tropical Africa, where malaria is highly endemic, most people are semi-immune and asymptomatic infections are widespread. Thus, the detection of malaria parasites in the blood of febrile patients is not a sufficient criterion for distinguishing malaria from other causes of fever. In Dielmo, a Senegalese village of about 500 inhabitants in 2010, a very closely continuous epidemiological monitoring of malaria began in 1990. In this village where the transmission is perennial, the establishment of more effective means of control and prevention against malaria have profoundly changed the epidemiology of malaria. In this work, we analyze the impact of these interventions on the parasite prevalences, the parasite densities and the malaria diagnostic criteria and we measure the evolution of Plasmodium falciparum, P. malariae and P. ovale clinical malaria from June 1990 to December 2010 in Dielmo. Parasitological and clinical data are analyzed in a random effect logistic regression to investigate the relationship between parasite density and fever risk. The prevalence of the three Plasmodium species decreased dramatically with the abandonment of chloroquine as first line treatment and his replacing with the combination therapies and became almost zero after the introduction of long lasting insecticidal nets. Pyrogenic thresholds calculated enabled us to measure the incidence density of malaria and to study the impact of intervention methods on malaria morbidity in the population.

Faculty of Sicence, Charles University Aleš Urban, Praha 2012 Effects of temperature extremes on hospital admissions for cardiovascular diseases The thesis compares differences in the impacts of warm and cold days on both excess mortality and hospitalizations for individual cardiovascular diseases (CVDs) in Prague and a selected rural region (southern Bohemia - JČ) consisting of the Jihočeský kraj and Vysočina districts in the period 1994- 2009. Population size and age structure are similar in the two regions. The differences are compared between selected population groups (men and women; < 65 and 65+ years). Value of the 90% (10%) percentile of daily mean air temperature in summer (winter) during the period were used for the definition of warm (cold) days for each region separately. The excess mortality and hospitalizations were determined as the difference from standardized daily counts of death and hospital admissions, adjusted for epidemics of influenza/acute respiratory infections, long-term changes, and for annual and weekly cycles of mortality and hospitalizations. Generally higher relative excess CVD mortality on warm days was identified in Prague, while for cold days we found higher excess mortality in south Bohemia. In contrast to mortality, weak excess CVD hospitalizations were observed for both...

L’accès aux interventions de la prévention de la transmission mère-enfant (PTME) est limité en Afrique de l’Ouest et les mères infectées continuent de transmettre le virus à leurs enfants. D’importantes questions sur le diagnostic et traitement antirétroviral (TAR) précoce pour les enfants dans les pays à ressources-limitées restent sans réponses. La simulation est un outil utile qui permet d’intégrer toutes les données disponibles et de projeter à long terme les retombées cliniques et économiques de l’infection à VIH pédiatrique et informer les politiques de santé. Bien que les modèles de simulation soient mathématiquement sophistiqués, l’utilité des études basées sur la simulation dépend de la qualité des données de départ. L’objectif principal de ce travail était de fournir des données originales et récentes sur la mortalité, morbidité sévère et recours aux soins chez les enfants infectés par le VIH suivis dans des programmes de soins, avant et après initiation du TAR, dans le contexte du passage à l’échelle du TAR depuis 2004 en Afrique de l’Ouest. Nos résultats font ressortir un taux de mortalité comparable à d’autres études, atteignant 5.5% après 18 mois de suivi dans une cohorte d’enfants non traités par TAR, inclus à un âge médian de 5 ans. Les taux de morbidité sévère étaient élevés chez les enfants non traités mais aussi traités. Nous avons rapportés qu’une hospitalisation sur trois était provoquée par une morbidité infectieuse, évitable par une prophylaxie par cotrimoxazole, une intervention simple et efficace qui n’est toujours pas accessible à tous en Afrique de l’Ouest. Nous avons également observé un recours aux soins importants associé à la morbidité sévère. Cependant, parmi les enfants non traités, comme les traités, le recours aux soins était plus faible parmi les enfants les plus immunodéprimés. Le principal obstacle aux recours aux soins était le coût associé pour les familles. Enfin, les enfants qui initiaient un TAR l’initiaient trop tard, à un stade trop avancée de la maladie pour une restitution immunitaire pour âge ; la probabilité de rattraper une immunité normale était encore plus faible chez les enfants âgés > 5 ans comparé aux plus jeunes. Globalement, ce travail met en avant la nécessité de la mise en place de stratégies de diagnostic et traitement précoce. Optimiser le parcours de soins ainsi implique des interventions à de nombreux niveaux du système de soins et aucune approche unique ne pourra être efficace. De plus, les coûts liés à une prise en charge à vie devront être estimés dans un contexte où le VIH devient une maladie chronique engendrant un plus gros recours aux soins. Intégrer ces données dans un modèle de simulation permettra d’informer les politiques de santé et les soignants afin d’identifier les stratégies les plus efficaces et coût-efficaces pour le diagnostic, le traitement et le suivi à long terme de l’enfant infecté par le VIH dans les pays à ressources limitées. / Access to prevention of mother-to-child transmission (PMTCT) interventions is limited in West Africa and mothers continue to transmit HIV disease to their children. Important questions on early HIV diagnosis and early antiretroviral therapy (ART) for children in resource-limited settings remain unanswered. Computer simulation models can provide helpful information to project long-term patient outcomes and inform health policy. Although simulation models are computationally sophisticated, the usefulness of the results of modelling studies depends on the quality and accuracy of the data on which they are based. The main objective of the following work was to provide accurate and up-to-date data on mortality, severe morbidity and healthcare resource utilisation in HIV-infected children enrolled in care, before and after ART initiation in the context of the access to ART roll-out since 2004 in West Africa. Our findings suggest mortality rates comparable to those of other studies, reaching 5.5% by 18 months of follow-up in children enrolled in cohorts at a median age of 5 years who had not yet initiated ART. Severe morbidity rates were high, in both ART-treated and untreated children. We found that one hospitalisation in three was caused by an infectious disease, avoidable by cotrimoxazole prophylaxis, a simple and efficient intervention that is still not accessible to all in West Africa. We also reported substantial rates of healthcare resource utilisations associated with this severe morbidity. However, in both untreated and ART-treated children, healthcare resource utilisation was lower in the sickest, most immunodeficient children. Access to healthcare remains limited and one of the explanations we put forward are the costs borne by the families. Finally, children on ART remain initiated at a too late stage to be able to restore normal immunity for age; this is even less likely in those who initiated ART after 5 years compared to younger children. Overall, this work underlines the need for an effective early HIV diagnosis and treatment. Optimising this requires interventions at multiple levels of the healthcare system and no single approach is likely to be effective. Furthermore, lifetime treatment costs will need to be assessed as HIV becomes a chronic disease leading to greater healthcare resource utilisation. Integrating these data in computer simulation models will assist healthcare providers and policy-makers to identify the most effective and cost-effective strategies for diagnosis, treatment and monitoring of paediatric HIV in low income countries.

The aim of this dissertation is to provide the readers with as comprehensive view of the issue of sickness and accident rate of workers in relation to work attendance as possible. The dissertation deals with both absenteeism of sick individuals, i.e. the incapacity for work, and presenteeism, that is the performance of gainful employment despite acutely impaired health condition. Due to the different nature and level of knowledge of the examined phenomena, each of them is devoted a different level of attention. The issue of the incapacity for work due to disease or injury is analyzed in more detail. Development of the parametric values is set in the context of administration and legal changes, which have occurred in the Czech Republic since the early 1990s, and conditionality of the occurrence of the incapacity for work due to disease or injury are further investigated based on individual anonymized data. In the part dealing with presenteeism, the dissertation introduces the readers to the basic findings that have been published so far about this type of addressing health incapacitation. Attention is also paid to the mutual comparison of the incapacity for work and presenteeism, both on the basis of theoretical and empirical knowledge. In conclusion of the dissertation, the level of absence and...

OBJETIVOS: Comparar resultados perinatais entre gemelares, com dopplervelocimetria da artéria umbilical (AU) com fluxo diastólico presente (FDP), discordantes (GD) e concordantes (GC) em relação ao peso estimado fetal (PEF) e de acordo com a corionicidade. MÉTODOS: Estudo retrospectivo, caso-controle, desenvolvido na Clínica Obstétrica HCFMUSP entre janeiro 2005 e dezembro 2015. Para cada GD, foram selecionados 2 controles de GC, pareados pela idade gestacional do parto (IG) e corionicidade. Critérios de inclusão: discordância PEF >= 20%, Doppler da artéria umbilical (AU) com fluxo diastólico presente, ausência de malformação ou cromossomopatias, diamniótica, fetos vivos na primeira avaliação, ausência de complicações da monocorionicidade, parto na instituição. Resultados perinatais considerados: peso no nascimento, IG no parto, internação na unidade de terapia intensiva (UTI) neonatal, tempo de internação na UTI, suporte ventilatório (VM), hemorragia periventricular (HIPV), hipoglicemia (HG), icterícia (Ic), enterocolite necrosante (EN), sepse (Sp), óbito perinatal. Foram comparados os resultados perinatais dos fetos maiores e menores entre os grupos GD e GC. O resultado perinatal do feto menore foi comparado de acordo com a presença ou ausência de restrição de crescimento fetal (RCF). RESULTADOS: Selecionados 14 GD e 28 GC monocoriônicos (MC), e 38 GD e 76 GC dicoriônicos (DC). Fetos menores MC GD apresentaram maior TI (30,60 ± 20,19 vs 10,68 ± 11,64 dias, P<0,001), maior frequência de Ic (78,6% vs 28,6%; P=0,003; RC=9,17) e Sp (21,4% vs 0%; P=0,032; RC=23,42) em comparação com fetos menores GC. Nos DC, fetos menores GD apresentaram maior frequência de Sp (10,5% vs 1,3%; P=0,042; RC=8,82), HG (15,8% vs 3,9%; P=0,003; RC=4,56), EN (5,3% vs 0%; P=0,044; RC=20,63) e Ic (57,9% vs 28,9%, P=0,003; RC=3,38) comparado com fetos menores GC. Dentre os fetos menores MC, 10 (71,4%) tem RCF e dentre os DC menores, 21 (55,3%). Os gemelares menores sem RCF apresentaram frequência de morbidade neonatal similar entre os GD e GC, exceto pelo menor peso no nascimento do feto GD DC (2167,35 vs 2339,68g, P=0,026). CONCLUSÃO: Na presença do Doppler AU com FDP, o feto menor GD apresenta maior frequência de morbidades perinatais comparado aos fetos menores GC, independentemente da corionicidade. A presença da RCF, e não apenas a discordância de peso entre os fetos, parece ser responsável pela piora dos parâmetros de morbidade neonatal dentre os fetos GD / OBJECTIVE: The aim of this study was to compare the perinatal outcome between fetal weight discordance (FwD) with fetal weight concordant (FwC) twins, with umbilical artery (UA) Doppler with positive end-diastolic flow, according to chorionicity. METHODS: This was a retrospective case-control study of twin pregnancy over an 11-year period in a tertiary referral center. For each FwD, it was selected 2 controls of FwC matched for gestational age at delivery and chorionicity. The inclusion criteria were: estimated fetal weight (EFW) discordance >= 20%, UA Doppler with positive end-diastolic flow, absence of fetal malformation or chromosomal abnormalities, known chorionicity, diamniotic pregnancies, both fetuses alive at the first assessment, absence of monochorionic (MC) complications, delivery in our institution. The perinatal outcomes considered were: birth weigh (BW), length of hospital stay (LOS), admission to the neonatal intensive care unit (NICU), length of NICU stay, need for ventilator support, intraventricular hemorrhage (IVH), hypoglycemia (Hp), jaundice (JD), necrotizing enterocolitis (NE), sepsis (SP), intrauterine and neonatal death. Perinatal outcome of the smaller and larger twin comparisons between FwD with FwC were analyzed according to chorionicity. In addition, perinatal outcome from smaller twin was compared between FwD with FwC with and without fetal growth restriction (FGR). RESULTS: A total of 14 pregnancies with FwD and 28 with FwC of MC twin and 38 pregnancies with FwD and 76 with FwC of dichorionic (DC) twin were selected. According to chorionicity, in MC FwD group, the smaller twin presented presented longer LOS (30.60 ± 20.19 vs 10.68 ± 11.64 days, P < 0.001), higher frequency of SP (21.4% vs 0%; P=0.032; OR=23.42) and JD (78.6% vs 28.6%; P=0.003; OR=9.17) compared to smaller FwC twin; whereas in DC FwD group, smaller twin presented higher frequency of SP (10.5% vs 1.3%; P=0.042; OR=8.82), Hp (15.8% vs 3.9%; P=0.003; OR=4.56), NE (5.3% vs 0%; P=0.044; RC=20.63) and JD (57.9% vs 28.9%, P=0.003; OR=3.38) compared to smaller FwC twin. FGR in the smaller MC twin was observed in 71.4% (n=10) and in the smaller DC twin, 55.3% (n=21). Twin pregnancies without FGR had similar frequency of neonatal morbidity in discordant and concordant groups, excepted for the lower BW in FwD DC twins (2167.35 vs 2339.68g, P=0.026). CONCLUSION: Regardless chorionicity, perinatal morbidity is increased in the smaller discordant twin with UA Doppler with positive end-diastolic flow, compared to concordant smaller twin. Probably the FGR is responsible to complicate the perinatal outcome of smaller discordant twin

INTRODUÇÃO: O aleitamento materno (AM) é a prática com maior impacto na prevenção de morbimortalidade infantil. A Iniciativa Hospital Amigo da Criança (IHAC) é uma estratégia com forte repercussão na promoção da amamentação e seu custo pode justificar uma análise econômica em saúde. OBJETIVOS: Avaliar o custo-efetividade da IHAC na promoção do aleitamento materno exclusivo e na redução da mortalidade infantil no município de São Paulo. METODOLOGIA: Estudo de avaliação econômica com dados de uma coorte prospectiva realizado em seis hospitais públicos em São Paulo/SP. O grupo intervenção foram três Hospitais Amigos da Criança (HAC) e o grupo comparação três Hospitais não Amigos da Criança (NHAC). A efetividade da IHAC foi avaliada mediante os desfechos intermediários: Amamentação na primeira hora de vida (AMPH), AM e Aleitamento materno exclusivo (AME) e pelos desfechos finais: casos evitados de mortes neonatais tardias, mortes em menores de seis meses e internações hospitalares; estes foram estimados mediante a Fração Preventiva (FP) para mortalidade neonatal e internações hospitalares, e pela Proporção de Redução de Risco (PRR) para mortalidade infantil em menores de seis meses. Foram calculados os custos médios de parto, segundo tipo e tempo de internação por microcusteio, considerando os itens: medicamentos, insumos, exames e recursos humanos para a obtenção da Razão Custo/Efetividade (RCE) e da Razão Custo/Efetividade Incremental (RCEI). Foram aplicados testes para comparação de proporções e médias, regressão de Poisson ajustada por idade e escolaridade maternas (nível de significância de 95% (?=5%)) e análise de sensibilidade univariada e determinística para avaliar a robustez dos resultados da RCEI. RESULTADOS: Incluíram-se 969 mães na primeira entrevista, 902 na segunda e 814 na terceira. Entre as crianças nascidas em HAC as prevalências de amamentação foram maiores em todos os indicadores comparadas às nascidas em NHAC: 30,7% maior para AMPH; 1,2% na AME aos 30 dias; 7,2% no AM e 21,9% no AME aos 6 meses de vida, onde o incremento da AMPH apresentou diferença estatisticamente significativa. Após o ajuste das variáveis foram associados negativamente à AMPH: nascer em NHAC (RP1,29 IC1,04-1,59) de cesárea (RP1,90 IC 1,53-2,36) e não fazer o contato pele-a-pele (RP4,13 IC 2,38-7,13); ao AME aos 30 dias associou-se negativamente a mãe ter tido dificuldade para amamentar (RP1,38 IC 1,03-1,85), não viver com companheiro (RP1,46 IC 1,08-1,96), não ter recebido apoio no AC (RP1,40 IC1,01-1,95) não cumprimento do passo 6 (RP1,86 IC 1,36-2,55), não cumprimento do passo 9 (RP1,95 IC 1,32-2,88) e criança usar chupeta (RP1,84 IC1,39-2,42). Ao AME aos 180 dias foram negativamente associados o uso de chupeta (RP 1,19 IC1,02-1,39) e o trabalho materno remunerado (RP1,27 IC 1,08-1,49). A IHAC foi muito custo-efetiva em promover a amamentação e custo-efetiva ao reduzir 13% das mortes neonatais tardias e 3,8% de internações hospitalares. CONCLUSÃO: No contexto brasileiro, a IHAC foi custo-efetiva em promover a amamentação na primeira hora de vida, em reduzir a mortalidade neonatal e o número de internações hospitalares. Tais benefícios reforçam a importância desta política ao contribuir para a sobrevivência infantil, justificando os investimentos requeridos para sua expansão e fortalecimento. / INTRODUCTION: Breastfeeding practice has the greatest impact on the prevention of infant morbimortality. The Baby-Friendly Hospital Initiative (BFHI) is an important strategy on the promotion of breastfeeding and its costs might justify to study it to evaluate effectiveness for the health system. OBJECTIVES: To evaluate the cost-effectiveness of BFHI in promoting exclusive breastfeeding and reducing infant mortality in the city of São Paulo. METHODOLOGY: This is a study of economic evaluation of public health policy with data from a prospective cohort study conducted in six public hospitals. The intervention group was composed of three Baby-Friendly Hospitals (BFH) and the comparison group by three Not Baby-Friendly Hospitals (NBFH). The effectiveness of BFHI was evaluated by analyzing intermediate outcomes: the increase first-hour breastfeeding, breastfeeding (BF), exclusive breastfeeding (EBF) and final outcomes: avoided cases of late neonatal deaths, at six months and hospitalizations. The outcomes were estimated by calculating the Preventive Fraction (PF) for neonatal mortality and hospital admissions, and the Risk Reduction Ratio for estimating infant mortality in children under six months. The average costs according to type of delivery and length of stay were calculated, by micro-accounting for the cost items: medicines, supplies, exams and human resources to obtain the cost-Effectiveness Ratio (CER) and incremental Cost-Effectiveness Ratio (ICER) for the intermediate and final outcomes. Tests for comparison of proportions and means were applied. The Poisson regression was adjusted according to maternal age and schooling (significance of 95% (? = 5%)) and univariate and deterministic sensitivity analysis to evaluate the robustness of the ICER. RESULTS: 969 mothers were included in the first interview, 902 in the second and 814 in the third. Among children born in BFH, the prevalence of breastfeeding was higher in all indicators compared to those born in NBFH: 30.7% higher for first-hour breastfeeding; 1.2% in EBF at 30 days; 7.2% in BF and 21.9% in EBF at 6 months of life. Only the first-hour breastfeeding increment showed a statistically significant difference between BFH and NBFH. After adjustment of variables first-hour breastfeeding was negatively associated with: born in NBFH (RP1,29 IC1,04-1,59), cesarean delivery (RP1,90 IC 1.53-2,36) and did not make skin-to- skin (RP4,13 CI 2,38-7,13). EBF at 30 days was negatively associated with the mother having had difficulty in breastfeeding (RP1,38 CI 1.03-1.85), not living with a partner (RP1,46 CI 1.08-1.96), not having received support (RP1,40 CI1,01-1,95) non-compliance with step 6 (RP1,86 CI 1.36-2.55), non-compliance with step 9 (RP1,95 IC 1.32-2 , 88) and children use pacifiers (RP1,84 IC1,39-2,42). EBF at 180 days were negatively associated: use of pacifiers (RP 1.19 CI 1.02-1.39) and maternal work (RP1.27 CI 1.08-1.49). The steps fully met by BFH were 6, 7 and 9. The BFHI was cost-effective in promoting breastfeeding and cost-effective in reducing 13% of late neonatal deaths and 3, 8% in hospital admissions. CONCLUSION: In the Brazilian context, the BFHI was cost-effective to promote breastfeeding in the first hour of life and to reduce neonatal mortality and hospital admissions. BFHI policy contribute to child survival, justifying the investments required for its expansion, strengthening and sustainability resulting in saved lives and economic gains.

Introdução: A principal causa de mortes maternas no Brasil são as Síndromes Hipertensivas na Gravidez (SHG). Estudos têm focado nos fatores de risco para essas síndromes, entretanto são pequenos e localizados. Um estudo de maior abrangência poderia encontrar valores mais precisos e diferenças entre seus estratos. Objetivo: Estimar a frequência das SHG na região sudeste do Brasil. Descrever e analisar os fatores associados às síndromes hipertensivas na gravidez. Método: Este é um estudo transversal, parte integrante do Nascer no Brasil: Inquérito Nacional sobre Parto e Nascimento, cuja coleta de dados ocorreu entre Fevereiro de 2011 e Julho de 2012. A amostra do estudo foi composta por todas as mulheres entrevistadas pelo inquérito em toda a região Sudeste do Brasil, totalizando 10154 pares de mulheres e conceptos. Resultados: As mulheres tinham entre 10 e 54 anos, predominantemente pardas/mulatas/morenas, não possuíam ensino superior, pertenciam à classe econômica C, tiveram seus bebê em hospitais das capitais e possuíam companheiro(a). De todos os nascimentos, 52,1 por cento ocorreram por cesariana, e destas 69,2 por cento sem que a mulher entrasse em trabalho de parto. Quase metade (43,9 por cento) dos nascimentos aconteceram antes que a gestação completasse 39 semanas. 77,7 por cento das mulheres relatam ter um acompanhante ao seu lado em algum momento durante o trabalho de parto/parto. As SHG acometeram 17,6 por cento de todas as mulheres. Destas, 3,4 por cento possuíam hipertensão crônica e a incidência de eclâmpsia foi de 1,6 por cento. Após análise multivariada, permaneceram independentemente associadas às SHG as variáveis cor preta (OR 1,4), histórico pessoal de eclâmpsia (OR 2,8), primiparidade (OR 1,6), diabetes (OR 2,3), mulheres com sobrepeso (OR 1,8), obesidade (OR 4,4) e gestação múltipla (OR 2,9). As mulheres com baixo peso apresentaram associação protetora (OR 0,6) Conclusões: Pode-se concluir que o histórico pessoal de eclâmpsia, diabetes, obesidade e gestação múltipla foram as variáveis que apresentaram maior associação com as SHG / Introduction: The main cause of maternal deaths in Brazil is hypertensive syndromes in pregnancy (HSP). Studies have focused on risk factors for these syndromes, however most are small-scaled and localized. A population-based study on the other hand, could potentially find more accurate results and differences between strata. Objective: To describe and analyze the incidence of HSP and the occurrence of associated factors in the Southeast of Brazil. Method: This is a cross-sectional study, part of \"Birth in Brazil: National Survey into Labor and Birth\" a national epidemiological survey on birthing in Brazil. Data collection took place between February 2011 and July 2012. The study sample consisted of all women interviewed for the survey across the southeastern region of Brazil, totaling 10,154 pairs of women and fetuses. Results: The women were between 10 and 54 years of age, predominantly brown skinned, with no graduation, in economic class C, had their babies in the hospitals placed on the capital cities and had a partner. 52.1 per cent of births occurred by cesarean section, 36 per cent without the woman going into labor. Almost half (43.9 per cent) of births occurred before 39 weeks of completed gestation. 77.7 per cent of women reported having a companion only sometimes during labor/delivery. HSP occurred in 17.6 per cent of all women, 3.4 per cent had chronic hypertension and the incidence of eclampsia was 1.6 per cent. After multivariate analysis, the independent variables associated with HSP is black skin (OR 1.4), personal history of preeclampsia (OR 2.8), primiparity (OR 1.6), diabetes (OR 2.3), underweight (OR 0.6), overweight (OR 1.8), obesity (OR) and multiple gestations (OR 2.9). Conclusion: The population-based data shows that a personal history of eclampsia, diabetes, obesity and multiple pregnancies were the variables with greater association with HSP