Submitted by isabela.moljf@hotmail.com (isabela.moljf@hotmail.com) on 2017-08-22T14:36:13Z No. of bitstreams: 1 danielacristinabelchiormota.pdf: 2344762 bytes, checksum: e860e25865fa9932beb5c64637b5388f (MD5) / Rejected by Adriana Oliveira (adriana.oliveira@ufjf.edu.br), reason: on 2017-08-24T11:33:53Z (GMT) / Submitted by isabela.moljf@hotmail.com (isabela.moljf@hotmail.com) on 2017-08-24T14:04:25Z No. of bitstreams: 0 / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-08-30T12:38:39Z (GMT) No. of bitstreams: 0 / Made available in DSpace on 2017-08-30T12:38:39Z (GMT). No. of bitstreams: 0 Previous issue date: 2016-11-30 / FAPEMIG - Fundação de Amparo à Pesquisa do Estado de Minas Gerais / Embora sejam escassos na literatura e ainda não desenvolvidos no contexto brasileiro, modelos de planejamento baseados nas necessidades da população são fundamentais para a implementação de serviços para usuários de álcool e outras drogas. A presente tese teve como objetivo construir um modelo de planejamento baseado em necessidades para a rede assistencial para usuários de álcool e outras drogas na população geral no Brasil. Os objetivos específicos foram: (1) Identificar, entre atores-chave de São Paulo, quais serviços deveriam ofertar suporte para desintoxicação, suporte ambulatorial e suporte residencial; (2) Compreender a racionalidade da argumentação dos atores-chave durante o processo de identificação dos serviços, elucidando os principais temas de consenso; (3) Obter estimativas de Necessidades de Serviços em decorrência dos riscos e danos associados ao uso de álcool e outras drogas para a população geral da Região Metropolitana de São Paulo (RMSP); (4) Obter estimativas de Demanda Potencial para Uso de Serviços para a população que possuiu Necessidades de Serviços em decorrência dos riscos e danos associados ao uso de tais substâncias na RMSP; (5) Desenvolver o modelo de planejamento baseado em necessidades no município de Osasco, a fim de estimar a capacidade ideal de usuários de álcool e outras drogas, a serem atendidos anualmente, em cada um dos pontos da Rede de Atenção Psicossocial. Estes objetivos foram desenvolvidos em três estudos, com materiais e métodos específicos. No primeiro estudo, que visou a atender aos objetivos (1) e (2), foi realizada uma oficina entre 33 profissionais e pesquisadores de São Paulo, os quais foram subdivididos em três grupos, sendo utilizada a Técnica de Grupo Nominal (TGN). Foi realizada análise de conteúdo, do tipo estrutural e temática, para avaliar o debate nos grupos de TGN. Na comparação dos resultados obtidos entre os três grupos, os Centros de Atenção Psicossocial para Usuários de Álcool e outras Drogas (CAPS AD) de tipo III foram designados como unidades-síntese, que englobam todas as modalidades de cuidado. No componente de suporte residencial, foram também indicadas as Unidades de Acolhimento e dispositivos da assistência social. Nas modalidades de desintoxicação e suporte ambulatorial, uma diversidade de serviços foi indicada para a oferta de cuidado aos usuários de substâncias. A caracterização de um modelo assistencial norteado pela integralidade e intersetorialidade contribuiu para a identificação desta heterogeneidade de serviços nas modalidades de suporte para desintoxicação e de suporte ambulatorial, sendo que a superação do modelo manicomial influenciou a indicação de serviços na modalidade de suporte residencial. Considerando a ampla gama de serviços elencados, é importante fortalecer o papel dos serviços brasileiros com relação aos cuidados e às especificidades de práticas que podem ser ofertadas aos usuários de álcool e outras drogas. No segundo estudo, voltado para atingir os objetivos específicos (3) e (4), foram utilizados dados da subamostra de 2.942 respondentes do Estudo São Paulo Megacity, levantamento que avaliou transtornos mentais na RMSP. A referida subamostra foi hierarquizada em cinco categorias de gravidade quanto aos riscos e danos associados ao uso de álcool e outras drogas, possibilitando obter estimativas de Necessidades de Serviços, as quais combinaram critérios de avaliação do uso de substâncias, condições crônicas de saúde e co-ocorrência de transtornos mentais, nos últimos 12 meses. Para a parcela populacional que apresentou riscos e danos, foram geradas estimativas de Demanda Potencial para Uso de Serviços no último ano. Quanto às Necessidades de Serviços, os resultados apontaram que 86,5% da população (categoria 1) não possuiu problemas com o uso de álcool ou outras drogas; 8,9% (categoria 2) necessita de estratégias de prevenção secundária; 3,49% (categorias 3, 4 e 5) teve transtorno devido ao uso de tais substâncias, dentre os quais 1,29% (categorias 4 e 5) necessita de suporte mais intenso e especializado. Com relação à Demanda Potencial, encontramos estimativas de 7,2% (categoria 2), de 25,5% (categoria 3) e de 51,1% (categoria 4), apontando que há um grande contingente de indivíduos que possui transtorno pelo uso de substâncias, mas não percebe a necessidade de ajuda profissional e/ou os cuidados são negligenciados pela rede assistencial. O terceiro estudo, que visou a atender ao quinto objetivo desta tese, foi realizado no município de Osasco, onde dez profissionais atuantes no CAPS AD participaram de um painel Delphi respondendo ao instrumento elaborado para a presente pesquisa, denominado Questionário de Construção de Estimativas para a Alocação de Usuários de Álcool e outras Drogas na Rede de Atenção Psicossocial. A Atenção Básica foi estimada para atender a 100% dos usuários, a Atenção Psicossocial Especializada a 54%, sendo que 19% dos usuários necessitariam de acolhimento noturno nos CAPS AD III, a Atenção de Urgência e Emergência a 37%, a Reabilitação Psicossocial a 35%, Atenção Hospitalar a 20% e a Atenção Residencial de Caráter Transitório a 4%. Os achados apontam para o fortalecimento dos CAPS AD e dos demais pontos da Rede de Atenção psicossocial, e não para uma priorização do componente de atenção residencial. / Although they are scarce in the literature and still have not been developed in the Brazilian context, planning-models based on a population’s needs are fundamental in the implementation of services for users of alcohol and drugs. The objective of this present thesis was to construct a needs-based planning-model for a support network for alcohol and other drugs users among the general population in Brazil. The specific aims were: (1) To identify among the key components in São Paulo, which services should offer support for detoxification, outpatient support and residential support; (2) To understand the rationality of the argumentation of these key components throughout the process of identifying the services, clarifying the main topics of consensus; (3) To obtain estimates of the Needs of Services based on the risk and harm associated with the abuse of alcohol and other drugs among the general population of the São Paulo Metropolitan Area (SPMA); (4) To obtain estimates of the Potential Demand for the use of services for the population in need of these services due to the risks and harm associated with the abuse of the substance in the SPMA; (5) To develop a planning model based on the needs of the municipality of Osasco, aiming to estimate the ideal capacity required for the users of alcohol and other drugs to be attended annually in a network of services. These objectives were developed in three studies, with specific materials and methods. In the first study, which aimed to focus on objectives (1) and (2), was carried out in a workshop among 33 professionals and researchers in São Paulo, who were sub-divided into three groups, using the Nominal Group Technique (NGT). A content analysis, both structural and thematic was carried out, to evaluate the debate in the NGT groups. In the comparison of the results obtained among the three groups, the Centres for Psycho-Social Attention for Alcohol and other Drugs-Users (CAPS AD) of type III, were designated as synthesis-units, which cover all the various care possibilities. In the residential care component, shelter-units and social-welfare assistance were also indicated. In the detox and outpatient support units, a variety of services was indicated to offer care for substance-users. The characteristics of a support-model designed to be integrated and interdepartmental contributed to the identification of the heterogeneous natures of the services provided by the support-units for detoxing and outpatient support, which the discontinued use of asylums influencing the need for residential support. Considering the wide range of services involved, it is important to strengthen the role of Brazilian services regarding the care and specific practices that can be offered to users of alcohol and other drugs. In the second study, aimed at objectives (3) and (4), data from the sub-sample of 2,942 respondents from the São Paulo Megacity study was used, which evaluated mental-health issues in the SPMA. This sub-sample was organised in five hierarchical categories of severity regarding the risks and harms associated with alcohol and drug abuse, making it possible to obtain estimates for the Needs for Services, which brought together criteria for the evaluation of substance abuse, chronic health issues and the comorbidity of mental-health issues over the last 12 months. For the percentage of the population at risk and harmed, estimates for the Potential Demand for service-use over the last year were obtained. Regarding the needs of services, the results demonstrated that 86.5% of the population (category 1) have no problems with alcohol or drugs abuse; 8.9% (category 2) require secondary prevention strategies; 3.49% (categories 3, 4 and 5) had substance abuse related issues, among whom 1.29% (categories 4 and 5) require more intense, specialised support. Regarding Potential Demand, estimates of 7.2% (category 2), 25.5% (category 3) and 51.1% (category 4) were found, demonstrating the existence of large numbers of individuals who have substance-abuse issues, who do not realise that they need professional help and/or are neglected by the network of services. The third study, which aimed to focus on the fifth objective in this thesis, was carried out in the municipality of Osasco, where ten professionals who work at CAPS AD, took part in a Delphi panel answering the questionnaire which was elaborated for this present research, called Questionnaire for the Construction of Estimates for the Allocation of Users of Alcohol and other Drugs in the Psycho-social Care Network. Basic attention was estimated to be offered to 100% of the users, specialised psycho-social attention to 54%, with 19% of users requiring shelter at night in the CAPS AD III, emergency and immediate attention to 37%, psycho-social rehabilitation to 35%, hospital care to 20% and temporary residential to 4%. The findings favour the strengthening of the CAPS AD as well as the other units in the psycho-social care network, and do not favour the prioritization of the residential component.

La survie des lymphomes non hodgkiniens (LNH) en population générale s'est améliorée durant la dernière décennie. Pourtant, des disparités persistent, suggérant le rôle de certains facteurs comme les facteurs socio-économiques et des inégalités dans l’accès ou la qualité des soins.Entre 2002 et 2008, 1798 LNH diffus à grandes cellules B et folliculaire ont été diagnostiqués dans 3 registres spécialisés en hématologie (Basse Normandie, Côte d’Or et Gironde). De fortes inégalités territoriales entre les 3 zones registres sont observées concernant le lieu de leur prise en charge, les délais d'initiation au traitement ou la survie, mais aucune association entre le score de défavorisation (EDI) et ces trois critères n'a été mise en évidence.La survie s'est améliorée durant la période d'étude. Cette tendance positive peut être expliquée par l’usage de l'immunothérapie en 1ère ligne. La zone géographique de diagnostic,la spécialité médicale (onco-hématologie vs autres) sont indépendamment associées à une meilleure survie à 5 ans quel que soit l’âge. Enfin, l'amélioration de la survie chez les patients âgés (75-84 ans en particulier) peut s'expliquer par un bilan initial plus complet (TEP scan entrainant un « upstaging ») suivi de traitements plus agressifs.Le temps de déplacement était associé au lieu de prise en charge et à la survie, avec un pronostic défavorable des patients résidant à plus de 15 minutes du centre de référence le plus proche.Malgré les avancées thérapeutiques, de nombreux facteurs non biologiques peuvent affecter le pronostic des patients atteints de LNH. L'expertise des équipes prenant en charge ces maladies semble primordiale pour obtenir une prise en charge optimale. / Due to the addition of innovative treatment, survival of non-Hodgkin lymphoma (NHL) increased during the last decade. Nevertheless, disparities persist, suggesting the role of certain factors as socio-economic factors and disparities in the access or the quality of healthcare.Between 2002 and 2008, 1798 Diffuse Large B-cell (DLBCL) and follicular lymphomas werediagnosed in 3 hematological malignancies specialized registries (Basse-Normandie, Côted'Or and Gironde). Important territorial disparities between the 3 registries areas were observed regarding the place of care, the delay of treatment initiation or the survival whatever the age while there was no association with the deprivation score (EDI).The survival improved during the study period. This positive trend could be explained by the use of immunotherapy as 1st line therapy. The geographical area where the patient was diagnosed, the medical specialization (onco-hematology vs others departments) are independently associated with a better 5-years survival whatever the age.Finally, the improvement of the survival in elderly (especially 75-84 years) could be explained by better work up (higher TEP scan use leading to "upstaging") and thus to use more aggressive therapies. Also, the travel time was associated with the place of care and the survival, with a poorer prognosis for patients living more than 15 min from the closest reference center. Despite therapeutic advances, various non biological factors can affect the prognosis ofpatients with lymphomas. The notion of lymphoma-specific expertise seems to be essential to achieve optimal DLBCL care management and reopen the debate of centralization of NHLpatients care in hematology/oncology departments.

Acute lymphoblastic leukemia (ALL) has poor prognosis in older/elderly adults and in high-risk/relapsed disease. Recommended treatment of ALL was evaluated (study I-IV). Data was obtained from the Swedish Acute Leukemia registries and from patient records. I. We assessed ALL relapse treatment and outcome in 76 patients aged 15-65 years (y). Complete remission (CR) was achieved in 50/71 patients (70%). Of them, 29 underwent allogeneic hematopoietic stem cell transplantation (hSCT). Five year overall survival (OS) was 15%, but close to 50% in 19 patients <35y after hSCT. II. We studied outcome of treatment with the Hyper-CVAD protocol in 19 of 24 patients with T-ALL aged 18-72y. CR was reached in 89%, but 5y leukemia-free survival was only 29%, and 20% in 15 patients not transplanted in CR1. Six patients received hSCT in CR2. Finally, 5y OS in all 19 patients was 47%. The only negative prognostic factor found was age ≥35y. III. We evaluated minimal residual disease (MRD) monitoring in 35 patients with Philadelphia (Ph) negative B-ALL aged 46-79y and treated with the ABCDV protocol. The CR rate was 91%. MRD was measured by flow cytometry in 73% in CR1 (MRD1) and omitted in those >70y or with high-risk ALL. Five patients received hSCT (only one due to MRD). Five year OS in the whole cohort was 47%. Continuous CR but not OS was improved in patients with MRD1 <0.1 %. IV. We studied 155 patients with ALL (Ph+ in 35%) aged 55-85y and treated with remission induction/palliation (124/31). Both, intensive, and palliative treatment resulted in the CR rates of 70/83/16% and 3y OS of 26/32/3%. OS was negatively influenced by age and platelet count ≤35×109/L (but not Ph+). OS was not enhanced by introduction of an age-adapted protocol. We concluded that intensive treatment with subsequent allogeneic hSCT is the most reasonable option in younger patients with ALL recurrence (I). Hyper-CVAD has low relapse-preventing efficacy (II). MRD guided intensification is probably feasible in only a minority of older patients (III). Prognosis in elderly ALL is poor, but no longer impaired by Ph+ (IV).

Background Nutritional status is an important health outcome influenced by both intake and utilization of nutrients. Factors associated with child nutritional status in low-and middle-income countries are many and interlinked yet not fully understood. Child malnutrition is a major problem in Ethiopia whose influence by socio-economic determinants is less studied. The aim of this study was to investigate the association between socio-economic determinants and undernutrition among children under the age of five years in Wolayita zone, Southern Ethiopia. Methods A population based cross-sectional survey was conducted from August 2011 to January 2012 that included a total of 4,197 children. Purposive sampling was used to select study participants and data were collected using a validated questionnaire and standard anthropometric measurements. Multivariable logistic regression was used to model the association between socio-economic determinants and child undernutrition (stunting and wasting). Results  Children from the richest households had significantly lower odds (ORadj= 0.64; 95% CI: 0.55, 0.75) of stunting compared with children from the poorest households. Food secure households had children with significantly lower odds (ORadj 0.83; 95% CI: 0.71, 0.96) of stunting compared food insecure ones. Children of women who always had money were significantly associated with 24% (CI: 0.60, 0.96) decrease in the odds of stunting compared with children of women who never had money. Time availability was not associated with stunting nor wasting. Conclusion Household asset score, food security and women economic status were significantly associated with stunting among children aged 0-59 months. Mitigation measures should be community-based and more studies on maternal time availability and its association with undernutrition are recommended.

Background: It is unclear whether generalized anxiety disorder (GAD) has a specific relationship to pain syndromes, going beyond the established association of pain with anxiety syndromes in general. Methods: Mental disorders were assessed in a community sample (N = 4181; 18–65 years) using the DSM-IV/M-CIDI. Several threshold definitions were used to define GAD and medically unexplained pain. Results: The association between pain and GAD (odds ratio, OR = 5.8 pain symptoms; OR = 16.0 pain disorder) is stronger than the association between pain and other anxiety disorders (OR = 2.4 pain symptoms; OR = 4.0 pain disorder). This association extends to subthreshold level definitions of GAD with some indication for a non-linear dose–response relationship. The GAD-pain link cannot sufficiently be explained by demographic factors, comorbid mental or physical disorders. Conclusions: The association of pain and generalized anxiety is not artifactual. Compared to other anxiety syndromes, it appears to be stronger and more specific suggesting the need to explore clinical and public health implications.

The relationship of social determinants of health, Appalachian residence, and prostate cancer treatment delay among Tennessee adults is relatively unknown. We used multivariate logistic regression on 2005-2015 Tennessee Cancer Registry data of adults aged ≥18 diagnosed with prostate cancer. The outcome of treatment delay was more than 90 days without surgical or nonsurgical intervention from date of diagnosis. Social determinants in the population-based registry were race (White, Black, Other) and marital status (single, married, divorced/separated, widow/widower). Tennessee residence was classified as Appalachian versus non-Appalachian (urban/rural). Covariates include age at diagnosis (18-54, 54-69, ≥70), health insurance type (none, public, private), derived staging of cancer (localized, regional, distant), and treatment type (non-surgical/surgical). We found that Black and divorced/separated patients had 32% (95% confidence interval [CI]: 1.22-1.42) and 15% (95% CI: 1.01-1.31) increased odds to delay prostate cancer treatment. Patients were at decreased odds of treatment delay when living in an Appalachian county, both urban (odds ratio [OR] = 0.89, 95% CI: 0.82-0.95) and rural (OR = 0.83, 95% CI: 0.78-0.89), diagnosed at ≥70 (OR = 0.59, 95% CI: 0.53-0.66), and received surgical intervention (OR = 0.72, 95% CI: 0.68-0.76). Our study was among the first to comprehensively examine prostate cancer treatment delay in Tennessee, and while we do not make clinical recommendations, there is a critical need to further explore the unique factors that may propagate disparities. Prostate cancer treatment delay in Black patients may be indicative of ongoing health and access disparities in Tennessee, which may further affect quality of life and survivorship among this racial group. Divorced/separated patients may need tailored interventions to improve social support.

Objective: To determine whether use of cannabis in adolescence increases the risk for psychotic outcomes by affecting the incidence and persistence of subclinical expression of psychosis in the general population (that is, expression of psychosis below the level required for a clinical diagnosis). Design: Analysis of data from a prospective population based cohort study in Germany (early developmental stages of psychopathology study). Setting: Population based cohort study in Germany. Participants: 1923 individuals from the general population, aged 14-24 at baseline. Main outcome measure: Incidence and persistence of subthreshold psychotic symptoms after use of cannabis in adolescence. Cannabis use and psychotic symptoms were assessed at three time points (baseline, T2 (3.5 years), T3 (8.4 years)) over a 10 year follow-up period with the Munich version of the composite international diagnostic interview (M-CIDI). Results: In individuals who had no reported lifetime psychotic symptoms and no reported lifetime cannabis use at baseline, incident cannabis use over the period from baseline to T2 increased the risk of later incident psychotic symptoms over the period from T2 to T3 (adjusted odds ratio 1.9, 95% confidence interval 1.1 to 3.1; P=0.021). Furthermore, continued use of cannabis increased the risk of persistent psychotic symptoms over the period from T2 to T3 (2.2, 1.2 to 4.2; P=0.016). The incidence rate of psychotic symptoms over the period from baseline to T2 was 31% (152) in exposed individuals versus 20% (284) in non-exposed individuals; over the period from T2 to T3 these rates were 14% (108) and 8% (49), respectively. Conclusion: Cannabis use is a risk factor for the development of incident psychotic symptoms. Continued cannabis use might increase the risk for psychotic disorder by impacting on the persistence of symptoms.

This study proposes age- and sex-specific percentiles for serum cobalamin and folate, and analyzes the effects of sex, age, body mass index (BMI), and socioeconomic status (SES) on cobalamin and folate concentrations in healthy children and adolescents. In total, 4478 serum samples provided by healthy participants (2 months–18.0 years) in the LIFE (Leipzig Research Centre for Civilization Diseases) Child population-based cohort study between 2011 and 2015 were analyzed by electrochemiluminescence immunoassay (ECLIA). Continuous age-and sex-related percentiles (2.5th, 10th, 50th, 90th, 97.5th) were estimated, applying Cole’s LMS method. In both sexes, folate concentrations decreased continuously with age, whereas cobalamin concentration peaked between three and seven years of age and declined thereafter. Female sex was associated with higher concentrations of both vitamins in 13- to 18-year-olds and with higher folate levels in one- to five-year-olds. BMI was inversely correlated with concentrations of both vitamins, whilst SES positively affected folate but not cobalamin concentrations. To conclude, in the assessment of cobalamin and folate status, the age- and sex-dependent dynamic of the respective serum concentrations must be considered. While BMI is a determinant of both vitamin concentrations, SES is only associated with folate concentrations.

Restricting animal-based products from diet may exert beneficial effects on weight status; however, less is known about such a diet and emotional health. Moreover, personality traits, for example high neuroticism, may contribute to restrictive eating habits and potentially confound diet-health associations. We aim to systematically assess if restrictive dietary intake of animal-based products relates to lower weight and higher depressive symptoms, and if differences in personality traits play a significant role. Cross-sectional data from the baseline LIFE-Adult study were collected from 2011–2014 in Leipzig, Germany (n = 8943). Main outcomes of interest were dietary frequency of animal-derived products in the last year measured using a Food Frequency Questionnaire (FFQ), body-mass-index (BMI) (kg/m2), and the Center of Epidemiological Studies Depression Scale (CES-D). Personality traits were assessed in a subsample of n = 7906 using the Five Factor Inventory (NEO-FFI). Higher restriction of animal-based product intake was associated with a lower BMI, but not with depression scores. Personality, i.e., lower extraversion, was related to higher frequency of animal product intake. Moreover, personality traits were significantly associated with depressive symptoms, i.e., higher neuroticism, lower extraversion, lower agreeableness, lower conscientiousness, and with higher BMI. These findings encourage future longitudinal studies to test the efficacy of restricting animal-based products as a preventive and therapeutic strategy for overweight and obesity.

Introduction: Recent years have witnessed a medicalization of obesity, promoting a classification as a disease or disability in order to reduce or protect against weight stigma and discrimination. This study sought to investigate the public understanding of the disability and disease concepts in obesity, their acceptance, and association with weight stigma. Methods: In a representative German population sample (n = 2,524), public views of obesity as a disease or disability were assessed via a self-report questionnaire. For the assessment of weight stigma, the Weight Control/Blame subscale from the Antifat Attitudes Test was used. Results: A significantly greater acceptance of the disease than the disability concept was found (37.1 vs. 15.4%). Both disease and disability were mainly viewed as physical conditions, although onethird also viewed obesity as a mental disease. While agreement with the disease concept – especially of physical and genetic disease – significantly predicted lower weight stigma; agreement with the disability concept – especially of mental or intellectual disability – predicted higher weight stigma. Conclusions: These results suggest a careful use of the disease and disability terms and precise definitions. The disability concept in particular carries notions that are publicly devalued.