The potential that telemedicine interventions may have in effectively delivering remote specialized cardiovascular care to large numbers of patients with heart diseases has recently come under question. In the first phase of this thesis, a systematic review and meta-analysis was conducted to compare the impact of a basic form of telemedicine that is regular patient follow-up by telephone, with usual care for individuals with coronary artery disease following their discharge. In the second phase of this thesis, a network meta-analysis, using Bayesian methods for multiple treatment comparisons, was conducted to compare the more complex forms of telemedicine for patients with heart failure. In the third and final phase of this thesis, a randomized controlled trial was designed to compare the impact of two forms of telemedicine, identified in the earlier two phases as being the most promising, on clinical outcomes, cardiac risk factors and patient reported outcomes.

Introduction: Neck pain is a common problem in society and is more prevalent among women. The consequences of neck pain for the individual often include activity and participation limitations, thus affecting many dimensions of life. There is still a lack of understanding of the underlying mechanisms of the disorder and likewise of efficient rehabilitation for people with neck pain. However, coordination exercises have shown promising short-term effects. To carry this line of research forward, there is a need to improve methods for objective characterization of impairments and to investigate novel methods of rehabilitation. Aims: To characterize impairments of active cervical range of motion of the upper and lower cervical levels in women with chronic neck pain with a novel method (Study I and II) and identify the influence of head posture and movement strategies (Study II). Further, to investigate the effects of a novel method for neck coordination exercise on sensorimotor function and neck pain (study III) and the consistencies of motor variability metrics in a goal directed arm movement task to aid the design of future clinical research (Study IV). Methods: All studies were laboratory based with kinematic assessments of neck movements (Study I-III), balance (Study III) and goal directed arm movements (Study III, IV). The studies had designs that were: cross-sectional (I and II), randomized controlled trial (III) or test-retest reliability study (IV). Participants in Study I (n=135) and II (n=160) were women with chronic non-specific neck pain and healthy controls. In Study III, women with chronic non-specific neck pain (n=108) were randomized into three different individually supervised 11 week interventions. Study IV included healthy women (n=14). Results: It was found that cervical range of motion impairments in women with non-specific neck pain were direction- and level-specific; impairments were greater in extension in the upper and flexion in the lower levels of the cervical spine. The magnitude of impairments in range of motion was associated to self-ratings of functioning and health. Possible group differences in natural head posture were rejected as a cause for the direction specific effects. Neither could the effects be explained by a strategy to minimize torque in the cervical spine during movement execution. The neck coordination training was not superior to strength training (best-available) and massage treatment (sham) in improving sensorimotor functions or pain according to short-term and 6 months follow ups. The results from the study of the goal directed movement task showed that between and within-subject sizes of most motor variability metrics were too large to make the test suitable for application in clinical research. Conclusions: Women with chronic non-specific neck pain have direction- and level-specific impairments in cervical sagittal range of motion. The underlying causes of these specific impairments remains unresolved, but the direction specific impairments are not related to natural head posture. The clinical validity of the method of characterization of cervical range of motion was supported and it can be useful in future clinical research. The novel method of neck coordination exercise showed no advantages on sensorimotor functions or pain compared with best-available treatment in women with chronic non-specific neck pain. / Långvarig smärta i nacken är vanligt förekommande och orsakar både personligt lidande och stora kostnader för samhället. Långvariga nackbesvär är vanligare hos kvinnor än hos män. Det saknas kunskap om effektiva rehabiliteringsmetoder, men forskning har indikerat att träning som förbättrar nackens koordination kan vara effektivt. För att uppnå bättre rehabiliteringsresultat är det viktigt att utveckla metoder för att objektivt mäta funktionsnedsättningar och att utveckla samt utvärdera nya rehabiliteringsmetoder. Syftet med avhandlingen kan sammanfattas i tre delar: Att detaljerat mäta nedsättningar i nackens rörelseomfång hos kvinnor med långvarig nacksmärta; att utvärdera effekten av en ny metod för nackkoordinationsträning på rörelsefunktion och smärta hos kvinnor med långvarig nacksmärta; samt att utvärdera ett nytt test för att mäta precision och koordination vid målriktade armrörelser och ämnat för framtida klinisk forskning. Resultaten visade att kvinnor med långvarig nacksmärta hade specifika nedsättningar i nacken rörelseomfång; i övre nackregionen var bakåtböjning mer begränsad medan i nedre nackregionen var framåtböjning mer begränsad. Vi kunde utesluta att resultaten berodde på skillnader i huvudets normala hållning. Graden av rörelsebegränsning i nacken uppvisade samband med personernas självskattade funktion, symtom och hälsa. Nackkoordinationsträningen var inte var bättre än styrketräning eller massage för att förbättra rörelsefunktion eller för att minska smärta. Det nya testet för armrörelser var inte lämpat för kliniska studier av rörelseprecision. Slutsatserna från avhandlingsarbetet är att kvinnor med långvarig nacksmärta har begränsningar i nackens rörelseomfång vid framåt- och bakåtböjning av huvudet som är specifika vad gäller nivå i halsryggen och riktning. Att graden av rörelsebegränsning uppvisade samband med självskattad funktion, symtom och hälsa styrker testets kliniska validitet. Ytterligare forskning behövs för att förstå orsakerna bakom de specifika nedsättningarna. Nackkoordinationsträningen som utvärderades kan inte rekommenderas för kvinnor med långvarig nacksmärta eftersom korttidsuppföljning och 6-månadersuppföljning visade att träningsformen inte var bättre än styrketräning eller massage, vare sig när det gällde att förbättra sensomotorisk funktion eller att minska smärta.

Made available in DSpace on 2015-07-22T20:50:00Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-10-27. Added 1 bitstream(s) on 2015-08-11T03:26:32Z : No. of bitstreams: 1 Publico-478a.pdf: 1748555 bytes, checksum: b181ae22edf209a657904d2ffd598714 (MD5). Added 1 bitstream(s) on 2015-08-11T03:26:32Z : No. of bitstreams: 2 Publico-478a.pdf: 1748555 bytes, checksum: b181ae22edf209a657904d2ffd598714 (MD5) Publico-478b.pdf: 1641358 bytes, checksum: 0e86ce5d9ab1f861e041d1c439ae3929 (MD5). Added 1 bitstream(s) on 2015-08-11T03:26:32Z : No. of bitstreams: 3 Publico-478a.pdf: 1748555 bytes, checksum: b181ae22edf209a657904d2ffd598714 (MD5) Publico-478b.pdf: 1641358 bytes, checksum: 0e86ce5d9ab1f861e041d1c439ae3929 (MD5) Publico-478c.pdf: 865894 bytes, checksum: 6c26a1bd60d04ccd988686846c01b9cf (MD5) / O presente estudo avaliou a eficácia e a tolerabilidade do topiramato nos pacientes com Transtorno de Estresse Pós-Traumático (TEPT). Foi realizado estudo clínico randomizado, duplo-cego e controlado comparando topiramato com placebo. Homens e mulheres entre 18 e 62 anos com diagnóstico de TEPT segundo os critérios do DSM-IV foram selecionados do ambulatório do Programa de Violência da Universidade Federal de São Paulo (Prove- UNIFESP) entre abril de 2006 e dezembro de 2009. Os participantes foram avaliados através da escala de TEPT administrada por clínicos (CAPS), escala de Impressão Clínica Global (CGI) e Inventário de Depressão de Beck (BDI). Após 1 semana de wash-out, trinta e cinco pacientes com TEPT foram randomizados para tratamento com topiramato ou placebo e acompanhados por 12 semanas. Foi observado que 82,35% dos pacientes que receberam topiramato apresentaram melhora dos sintomas do TEPT. Na análise de eficácia, os pacientes do grupo topiramato demonstrou demonstraram redução significativa dos sintomas de revivescência: memórias intrusivas, flashbacks e pesadelos (CAPS B; p=0,004) e sintomas de evitação e entorpecimento emocional (CAPS C; p = 0,0001). Além disso, encontramos melhora significativa do escore do CAPS total (topiramato –57,78; placebo –32,41; p = 0,0076) nos pacientes do grupo experimental. Topiramato foi bem tolerado e efetivo principalmente nos sintomas de revivescência e anestesia e evitação do TEPT. Este estudo dá suporte para o uso de anticonvulsivantes na melhora dos sintomas do TEPT. / The aim of this study was to evaluate the efficacy and tolerability of topiramate in patients with posttraumatic stress disorder (PTSD). We conducted a 12-week double-blind, randomized, placebo-controlled study comparing topiramate to placebo. Men and women aged 18 to 62 years with diagnosis of PTSD according to DSM-IV were recruited from the outpatient clinic of the violence program of Federal University of São Paulo Hospital (Prove- UNIFESP), São Paulo City, between April 2006 and December 2009. Subjects were assessed for the Clinician-Administered Posttraumatic Stress Scale (CAPS), Clinical Global Impression (CGI), and Beck Depression Inventory (BDI). After 1-week period of washout, 35 patients were randomized to either group. The primary outcome measure was the CAPS total score changes from baseline to the endpoint. In all 82.35% of patients in the topiramate group exhibited improvements in PTSD symptoms. The efficacy analysis demonstrated that patients in the topiramate group exhibited significant improvements in reexperiencing symptoms: flashbacks, intrusive memories, and nightmares of the trauma (CAPS-B; p = 0.04) and in avoidance/numbing symptoms associated with the trauma, social isolation, and emotional numbing (CAPS-C; p = 0.0001). Furthermore, the experimental group demonstrated a significant difference in decrease in CAPS total score (topiramate –57.78; placebo –32.41; p = 0.0076). Topiramate was generally well tolerated. Topiramate was effective in improving reexperiencing and avoidance/numbing symptom clusters in patients with PTSD. This study supports the use of anticonvulsants for the improvement of symptoms of PTSD. / TEDE / BV UNIFESP: Teses e dissertações

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Esta tese é composta por dois artigos que buscaram avaliar a relação entre pressão arterial e consumo alimentar em adolescentes, no ensaio comunitário randomizado denominado PAPPAS (Pais, Alunos e Professores Pela Alimentação Saudável), conduzido com alunos do 5 ano de vinte escolas públicas do município de Duque de Caxias, Rio de Janeiro. Este ensaio teve como objetivo principal reduzir o ganho de peso excessivo dos adolescentes, por meio de intervenções que estimularam o consumo de frutas e feijão e desencorajaram o consumo de bebidas adoçadas e biscoitos. A pesquisa foi conduzida durante o ano letivo de 2010. A coleta de dados de consumo alimentar e medidas antropométricas ocorreu em três fases: (1) início do ano letivo, (2) metade do ano letivo e (3) fim do ano letivo. A pressão arterial foi mensurada nas fases 2 e 3. Nove sessões de educação nutricional foram realizadas. Pais/responsáveis e professores receberam informação e material de divulgação sobre os mesmos temas abordados em sala de aula. As análises estatísticas consideraram os dados faltantes e o efeito de conglomerado. No primeiro artigo é apresentado o efeito da intervenção na pressão arterial dos adolescentes. Os hábitos alimentares dos adolescentes são inadequados e redução do consumo de biscoitos e refrigerantes, bem como aumento do consumo de frutas, podem contribuir para redução da pressão arterial. Os achados nessa população de adolescentes com baixa prevalência de pressão arterial elevada sugerem que a qualidade da dieta pode contribuir para redução da pressão arterial, independente de possíveis modificações no IMC. Os resultados reforçam a importância da promoção de hábitos alimentares saudáveis para prevenir doenças cardiovasculares na vida adulta. No segundo artigo, em análise transversal, verificou-se a associação entre pressão arterial e consumo de refrigerante. O consumo de refrigerantes é comum entre adolescentes. Consumidores de refrigerante diet/light, seguido por consumidores de refrigerantes adoçados com açúcar, apresentaram pressão arterial mais alta indicando que a redução do consumo de refrigerantes é importante, bem como a prevenção da substituição de bebidas adoçadas com açúcar por bebidas diet/light. Os resultados sugerem que escolhas alimentares inadequadas podem estar associadas ao aumento da pressão arterial. / This thesis consists of two articles that evaluated the relationship between blood pressure and dietary intake in adolescents, as the secondary aim of the randomized community trial named PAPPAS (Parents, Students and Teachers Through Healthy Eating), conducted with students in the 5th grade of twenty public schools in the municipality of Duque de Caxias, Rio de Janeiro. The main aim of the study was to reduce excessive weight gain in adolescents using interventions encouraging the consumption of fruits and beans and discouraging the consumption of sweetened beverages and cookies. The project was conducted during the school year of 2010. Data about dietary intake and anthropometric measures were collected in three phases: (1) beginning of the school year, (2) middle of the school year and (3) end of the school year. Blood pressure was measured in phases 2 and 3. Nine sessions of intervention about nutritional education were performed. Parents/guardians and teachers received information and materials on the same topics covered in the classroom. Statistical analyses considered missing data and the cluster effect. In the first article, the effect of the intervention on blood pressure of students is presented. The dietary habits among adolescents are inadequate and reduction of cookies and soft drinks consumption, as well as increase of fruits consumption may reduce blood pressure. The findings in this population of adolescents with very low prevalence of hypertension, suggest that changes in the quality of diet may change BP independent of possible changes in BMI. These results highlight the importance of promoting healthy eating behaviors to prevent cardiovascular diseases later in life. In the second article, in a cross-sectional analysis, it was investigate the association between blood pressure and soft drink consumption. The consumption of soft drinks is common in Brazilian adolescents. Diet/light soft drinks consumers, followed by sugar-sweetened consumers, presented higher blood pressure indicating that reduction of soft drink frequency of consumption is important, as well as the prevention of substitution of sugar-sweetened beverages by diet/light beverages. The present results suggest that inadequate food choices and dietary habits among adolescents may be associated with higher blood pressure.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Esta tese é composta por três artigos que veiculam os resultados da realização e análise de uma intervenção de base escolar com o objetivo de reduzir o ganho de peso excessivo em adolescentes. O ensaio, denominado PAPPAS (Pais, Alunos e Professores Pela Alimentação Saudável), foi conduzido com alunos do 5 ano de vinte escolas públicas do município de Duque de Caxias, Rio de Janeiro. As atividades desenvolvidas durante o ano letivo de 2010 desencorajaram o consumo de bebidas adoçadas e biscoitos e estimularam o consumo de feijão e frutas. Pais/ responsáveis e professores receberam informação e material de divulgação sobre os mesmos temas abordados em sala de aula. O consumo de alimentos foi avaliado por meio de um questionário de frequência alimentar aplicado ao início e ao final do estudo. A aferição do peso e da estatura se deu em três momentos: na linha de base, na metade do ano letivo e ao fim do estudo. Para as análises longitudinais, empregou-se modelos generalizados lineares mistos, que levam em conta tanto os dados faltantes quanto o efeito de conglomerado. No primeiro artigo é apresentado o efeito da intervenção no Índice de Massa Corporal (IMC) dos estudantes. Análise por intenção de tratamento revelou que a alteração no IMC dos adolescentes ao longo do tempo não foi estatisticamente diferente entre os grupos intervenção e controle. Observou-se redução estatisticamente significativa no consumo de bebidas adoçadas e biscoitos e aumento no consumo de frutas nos participantes do grupo intervenção quando comparados aos do grupo controle. Pôde-se concluir que estratégias baseadas exclusivamente na qualidade da dieta podem não levar à alterações no peso corporal de adolescentes. No segundo artigo verificou-se a influência do estágio de prontidão para modificação dos hábitos alimentares dos adolescentes na alteração do consumo de refrigerantes, biscoitos e frutas. Observou-se maior alteração no consumo dentre os participantes do grupo intervenção que se encontravam nos estágios de ação na linha de base (relataram já ter alterado seus hábitos alimentares), sugerindo que essa estratégia pode auxiliar em estudos de intervenção visando à alteração do comportamento. O terceiro artigo revisou evidências do ajuste inadequado para características da linha de base, em análises de ensaios randomizados de base escolar que objetivaram alteração no estado nutricional de adolescentes. Foram avaliados 37 estudos e 35% apresentaram desbalanceamento estatisticamente significativo para o IMC na linha de base. Concluiu-se que o ajuste para o IMC na linha de base é frequente em ensaios comunitários randomizados, porém, esta prática força um balanço, que pode levar à resultados espúrios sobre o efeito do tratamento. Os resultados dos artigos 2 e 3 permitem explicar, ao menos em parte, as inconsistências nos resultados de estudos de intervenções voltadas para alteração de hábitos alimentares em escolares. / This thesis consists of three articles that convey the results of the achievement and analysis of a school-based intervention aimed to reduce excessive weight gain in adolescents. The project, named PAPPAS (Parents, Students and Teachers Through Healthy Eating), was conducted with students in the 5th year of twenty public schools in the municipality of Duque de Caxias, Rio de Janeiro. The activities conducted during the school year of 2010 discouraged the consumption of sweetened beverages and cookies and stimulated the consumption of beans and fruits. Parents / guardians and teachers received information and promotional material on the same topics covered in the classroom. The dietary intake was assessed using a food frequency questionnaire applied at the beginning and end of the study. The measurement of weight and height occurred on three occasions: at baseline, halfway through the school year and the end of the study. For the longitudinal analyzes, we used generalized linear mixed models, which take into account both the missing data as the conglomerate effect. In the first article, the effect of the intervention on body mass index (BMI) of students is presented. Intention to treat analysis showed that change in BMI among adolescents over time was not statistically different between the intervention and control groups. We observed a statistically significant reduction in the consumption of sweetened beverages and cookies and an increase in the consumption of fruits in participants in the intervention group compared to the control group. It was concluded that strategies based only on diet quality may not lead to changes in body weight in adolescents. In the second article we verified the influence of stage of readiness to change dietary habits of adolescents in the consumption of soft drinks, cookies and fruit. There was a greater change in consumption among participants in the intervention group who were in the action stage at baseline (reported having changed their eating habits), suggesting that this strategy may assist in intervention studies aimed at behavior change. The third paper reviews evidence of inadequate adjustment for baseline characteristics in analyzes of school-based randomized trials that aimed to change the nutritional status of adolescents. Thirteen (35%) of the reviewed studies had statistically significant unbalanced measures of BMI at baseline. It was concluded that the adjustment for BMI at baseline is common in randomized trials community, however, this approach may lead to spurious results on the effect of the treatment. The results of Articles 2 and 3 allow explain, at least in part, the inconsistencies in the results of studies of interventions aimed at changing eating habits in students.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Esta tese é composta por dois artigos que buscaram avaliar a relação entre pressão arterial e consumo alimentar em adolescentes, no ensaio comunitário randomizado denominado PAPPAS (Pais, Alunos e Professores Pela Alimentação Saudável), conduzido com alunos do 5 ano de vinte escolas públicas do município de Duque de Caxias, Rio de Janeiro. Este ensaio teve como objetivo principal reduzir o ganho de peso excessivo dos adolescentes, por meio de intervenções que estimularam o consumo de frutas e feijão e desencorajaram o consumo de bebidas adoçadas e biscoitos. A pesquisa foi conduzida durante o ano letivo de 2010. A coleta de dados de consumo alimentar e medidas antropométricas ocorreu em três fases: (1) início do ano letivo, (2) metade do ano letivo e (3) fim do ano letivo. A pressão arterial foi mensurada nas fases 2 e 3. Nove sessões de educação nutricional foram realizadas. Pais/responsáveis e professores receberam informação e material de divulgação sobre os mesmos temas abordados em sala de aula. As análises estatísticas consideraram os dados faltantes e o efeito de conglomerado. No primeiro artigo é apresentado o efeito da intervenção na pressão arterial dos adolescentes. Os hábitos alimentares dos adolescentes são inadequados e redução do consumo de biscoitos e refrigerantes, bem como aumento do consumo de frutas, podem contribuir para redução da pressão arterial. Os achados nessa população de adolescentes com baixa prevalência de pressão arterial elevada sugerem que a qualidade da dieta pode contribuir para redução da pressão arterial, independente de possíveis modificações no IMC. Os resultados reforçam a importância da promoção de hábitos alimentares saudáveis para prevenir doenças cardiovasculares na vida adulta. No segundo artigo, em análise transversal, verificou-se a associação entre pressão arterial e consumo de refrigerante. O consumo de refrigerantes é comum entre adolescentes. Consumidores de refrigerante diet/light, seguido por consumidores de refrigerantes adoçados com açúcar, apresentaram pressão arterial mais alta indicando que a redução do consumo de refrigerantes é importante, bem como a prevenção da substituição de bebidas adoçadas com açúcar por bebidas diet/light. Os resultados sugerem que escolhas alimentares inadequadas podem estar associadas ao aumento da pressão arterial. / This thesis consists of two articles that evaluated the relationship between blood pressure and dietary intake in adolescents, as the secondary aim of the randomized community trial named PAPPAS (Parents, Students and Teachers Through Healthy Eating), conducted with students in the 5th grade of twenty public schools in the municipality of Duque de Caxias, Rio de Janeiro. The main aim of the study was to reduce excessive weight gain in adolescents using interventions encouraging the consumption of fruits and beans and discouraging the consumption of sweetened beverages and cookies. The project was conducted during the school year of 2010. Data about dietary intake and anthropometric measures were collected in three phases: (1) beginning of the school year, (2) middle of the school year and (3) end of the school year. Blood pressure was measured in phases 2 and 3. Nine sessions of intervention about nutritional education were performed. Parents/guardians and teachers received information and materials on the same topics covered in the classroom. Statistical analyses considered missing data and the cluster effect. In the first article, the effect of the intervention on blood pressure of students is presented. The dietary habits among adolescents are inadequate and reduction of cookies and soft drinks consumption, as well as increase of fruits consumption may reduce blood pressure. The findings in this population of adolescents with very low prevalence of hypertension, suggest that changes in the quality of diet may change BP independent of possible changes in BMI. These results highlight the importance of promoting healthy eating behaviors to prevent cardiovascular diseases later in life. In the second article, in a cross-sectional analysis, it was investigate the association between blood pressure and soft drink consumption. The consumption of soft drinks is common in Brazilian adolescents. Diet/light soft drinks consumers, followed by sugar-sweetened consumers, presented higher blood pressure indicating that reduction of soft drink frequency of consumption is important, as well as the prevention of substitution of sugar-sweetened beverages by diet/light beverages. The present results suggest that inadequate food choices and dietary habits among adolescents may be associated with higher blood pressure.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Esta tese é composta por três artigos que veiculam os resultados da realização e análise de uma intervenção de base escolar com o objetivo de reduzir o ganho de peso excessivo em adolescentes. O ensaio, denominado PAPPAS (Pais, Alunos e Professores Pela Alimentação Saudável), foi conduzido com alunos do 5 ano de vinte escolas públicas do município de Duque de Caxias, Rio de Janeiro. As atividades desenvolvidas durante o ano letivo de 2010 desencorajaram o consumo de bebidas adoçadas e biscoitos e estimularam o consumo de feijão e frutas. Pais/ responsáveis e professores receberam informação e material de divulgação sobre os mesmos temas abordados em sala de aula. O consumo de alimentos foi avaliado por meio de um questionário de frequência alimentar aplicado ao início e ao final do estudo. A aferição do peso e da estatura se deu em três momentos: na linha de base, na metade do ano letivo e ao fim do estudo. Para as análises longitudinais, empregou-se modelos generalizados lineares mistos, que levam em conta tanto os dados faltantes quanto o efeito de conglomerado. No primeiro artigo é apresentado o efeito da intervenção no Índice de Massa Corporal (IMC) dos estudantes. Análise por intenção de tratamento revelou que a alteração no IMC dos adolescentes ao longo do tempo não foi estatisticamente diferente entre os grupos intervenção e controle. Observou-se redução estatisticamente significativa no consumo de bebidas adoçadas e biscoitos e aumento no consumo de frutas nos participantes do grupo intervenção quando comparados aos do grupo controle. Pôde-se concluir que estratégias baseadas exclusivamente na qualidade da dieta podem não levar à alterações no peso corporal de adolescentes. No segundo artigo verificou-se a influência do estágio de prontidão para modificação dos hábitos alimentares dos adolescentes na alteração do consumo de refrigerantes, biscoitos e frutas. Observou-se maior alteração no consumo dentre os participantes do grupo intervenção que se encontravam nos estágios de ação na linha de base (relataram já ter alterado seus hábitos alimentares), sugerindo que essa estratégia pode auxiliar em estudos de intervenção visando à alteração do comportamento. O terceiro artigo revisou evidências do ajuste inadequado para características da linha de base, em análises de ensaios randomizados de base escolar que objetivaram alteração no estado nutricional de adolescentes. Foram avaliados 37 estudos e 35% apresentaram desbalanceamento estatisticamente significativo para o IMC na linha de base. Concluiu-se que o ajuste para o IMC na linha de base é frequente em ensaios comunitários randomizados, porém, esta prática força um balanço, que pode levar à resultados espúrios sobre o efeito do tratamento. Os resultados dos artigos 2 e 3 permitem explicar, ao menos em parte, as inconsistências nos resultados de estudos de intervenções voltadas para alteração de hábitos alimentares em escolares. / This thesis consists of three articles that convey the results of the achievement and analysis of a school-based intervention aimed to reduce excessive weight gain in adolescents. The project, named PAPPAS (Parents, Students and Teachers Through Healthy Eating), was conducted with students in the 5th year of twenty public schools in the municipality of Duque de Caxias, Rio de Janeiro. The activities conducted during the school year of 2010 discouraged the consumption of sweetened beverages and cookies and stimulated the consumption of beans and fruits. Parents / guardians and teachers received information and promotional material on the same topics covered in the classroom. The dietary intake was assessed using a food frequency questionnaire applied at the beginning and end of the study. The measurement of weight and height occurred on three occasions: at baseline, halfway through the school year and the end of the study. For the longitudinal analyzes, we used generalized linear mixed models, which take into account both the missing data as the conglomerate effect. In the first article, the effect of the intervention on body mass index (BMI) of students is presented. Intention to treat analysis showed that change in BMI among adolescents over time was not statistically different between the intervention and control groups. We observed a statistically significant reduction in the consumption of sweetened beverages and cookies and an increase in the consumption of fruits in participants in the intervention group compared to the control group. It was concluded that strategies based only on diet quality may not lead to changes in body weight in adolescents. In the second article we verified the influence of stage of readiness to change dietary habits of adolescents in the consumption of soft drinks, cookies and fruit. There was a greater change in consumption among participants in the intervention group who were in the action stage at baseline (reported having changed their eating habits), suggesting that this strategy may assist in intervention studies aimed at behavior change. The third paper reviews evidence of inadequate adjustment for baseline characteristics in analyzes of school-based randomized trials that aimed to change the nutritional status of adolescents. Thirteen (35%) of the reviewed studies had statistically significant unbalanced measures of BMI at baseline. It was concluded that the adjustment for BMI at baseline is common in randomized trials community, however, this approach may lead to spurious results on the effect of the treatment. The results of Articles 2 and 3 allow explain, at least in part, the inconsistencies in the results of studies of interventions aimed at changing eating habits in students.

A confecção de próteses totais envolve uma série de procedimentos técnicos complexos. No entanto, a simplificação dessa sequência de procedimentos pode ser tão eficazes quanto os convencionais, mas com menor gasto de tempo e recursos. O objetivo deste estudo foi quantificar os custos envolvidos com a confecção de próteses totais com um método simplificado em comparação a um convencional. A amostra foi formada por pacientes desdentados totais solicitando tratamento com próteses totais duplas, que foram divididos aleatoriamente em dois grupos: o Grupo S recebeu próteses totais confeccionadas por um método simplificado, enquanto que o Grupo C recebeu próteses confeccionadas convencionalmente. Os custos diretos e indiretos de cada procedimento foram calculados por participante, incluindo sessões imprevistas. O estudo foi realizado com 19 e 21 participantes nos grupos S e C, respectivamente, e comparações entre os dois grupos foram feitas por meio dos testes de Mann-Whitney e t de Student (&alpha;=0,05). A confecção das próteses demandou do operador um tempo mediano de 173,2 e 284,5 min. para os grupos S e C, respectivamente, enquanto os tempos para o auxiliar foram 46,6 e 61,7 min. (diferenças significantes, P<0,05). Os grupos não diferiram significantemente na fase de ajustes pós-instalação. O grupo S também apresentou valores menores que C durante a fase de confecção, mas não durante os ajustes, para custos com materiais empregados e tempo despendido pelo paciente. No total, o método simplificado reduziu o custo direto do tratamento em 34,9%. Conclui-se que o método simplificado é menos oneroso ao paciente e sistema de saúde, quando comparado a um protocolo convencional para a reabilitação do paciente edentado. / Complete denture fabrication involves a series of complex technical procedures. Nevertheless, simplified methods may be as effective as conventional ones albeit the lower use of time and resources. The aim of this study is to quantify the costs of complete denture fabrication by means of a simplified method compared with a conventional protocol. A sample of edentulous patients needing conventional maxillary and mandibular complete dentures was randomly divided into: group S, which received dentures fabricated by means of a simplified method, and group C, which received conventionally fabricated dentures. We calculated direct and indirect costs for each participant including unscheduled procedures. This study assessed 19 and 20 participants allocated in groups S and C, respectively, and comparisons between groups were conducted by means of the Mann-Whitney and Students t test (&alpha;=0,05). Complete denture fabrication demanded median time periods of 173,2 and 284,5 min from the operator for groups S and C respectively, and 46.6 and 61.7 min from the dental assistant (significant differences, P<0.05). There was no difference between groups regarding postinsertion adjustments. Group S also showed lower values than C during the fabrication stage, but not during adjustments, for costs with materials and time spent by patients. In summary, the simplified method reduced direct treatment costs in 34.9%. It can be concluded that the simplified method is less costly for patients and health system when compared with a conventional protocol for the rehabilitation of edentulous patients.

Orientador: Donizeti Cesar Honorato / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-23T00:41:21Z (GMT). No. of bitstreams: 1 Silva_AdrianaTeresa_M.pdf: 5979152 bytes, checksum: 4f4aa8d6d612af76e9680bc18aff0911 (MD5) Previous issue date: 2013 / Resumo: O Acidente Vascular Cerebral (AVC) é um problema de saúde pública relevante em virtude de sua alta frequência e de grande impacto na população. Classificam-se, como uma das quatro causas mais comuns de morte no mundo, sendo considerada uma doença incapacitante, e que limita a qualidade de vida. Objetivo deste estudo foi investigar o efeito imediato da vibração de corpo inteiro na função motora de pacientes acometidos por AVC. Trata-se de um ensaio clínico randomizado, nos quais foram alocados quarenta e três indivíduos (33 grupo intervenção - GI - e 10 grupo controle - GC) com sequela de hemiparesia decorrente de AVC. Aplicou-se no GI uma sessão de terapia vibratória (frequência - 50 Hz e amplitude - 2 mm) por 4 série de 1 minuto com descanso de 1 minuto entre as séries, em 3 posições: apoio bipodal com joelho fletido a 30º e a 90º, apoio unipodal sobre o membro parético. Os testes aplicados para análise foram: o teste de caminhada de 6 minutos (TC6M), teste de escada (TSE), teste de time get-up-and-go (TGUG) e a avaliação eletromiográfica (EMG). A EMG foi aplicada na contração isométrica voluntária simultaneamente para os músculos tibial anterior e retofemural ambos do lado acometido e não acometido (TAA e TANA; RFA e RFNA) respectivamente. Aplicou-se para análise estatística o teste t independente para comparar as características basais dos grupos, teste t pareado e o teste de ANCOVA para verificar o efeito da intervenção no grupo e no tempo. Os resultados demonstram que não há evidência de efeitos na interação grupo e tempo para as variáveis RFA, RFNA, TAA, TANA e TSE (p?0,05). Há evidências de efeito na interação grupo para as variáveis TC6M e para TGUG (p<0,05). Conclui-se que o efeito imediato da vibração de corpo inteiro não contribuiu para melhora da função motora em pacientes acometidos por Acidente Vascular Cerebral / Abstract: Stroke is a relevant public health problem, due to its high frequency and strong impact on the population. It is classified as one of the four most common causes of death worldwide and is considered to be a disabling disease, which limits the patients' quality of life. The aim of this paper was to investigate the immediate effects of whole body vibration on the motor function of patients affected by stroke. This is a randomized clinical trial, where forty-three hemiparetic subjects, due to stroke sequel, were allocated (33 for the intervention group - IG - and 10 for the control group - CG). For the IG subjects a vibratory therapy (50 Hz frequency and 2 mm amplitude) session was applied consisting of four series of stimulation of 1-minute each with a 1-minute resting interval among all series, in three different positions: bipodal landing position with knees bent at 30º then at 90º and finally, unipodal landing position on the hemiparetic limb. The tests used for the analysis were the 6 minute walking test (6MWT), stair climbing test (SCT), time get-up-and-go test (TGUGT) and electromyographic evaluation (EMG). The latter was applied simultaneously, at isometric voluntary contraction, of tibialis anterior and rectus femorais muscles', both affected and unaffected sides (TAA and TAU ; RFA and RFU) respectively. For statistical analysis, the independent t test was applied to compare the baseline characteristics of the groups and the paired t test as well as ANCOVA to determine the effect of the intervention in both the groups and time. The results show no evidence of effects in group and time interaction for the RFA, RFU, TAA, TAU and SCT variables (p?0.05). There is evidence of effect on the group interaction for the 6MWT and TGUGT variables (p<0.05). It was concluded that, the immediate effects of whole body vibration have not contributed for the improvement of stroke-patients' functional motor / Mestrado / Ciencias Biomedicas / Mestra em Ciências Médicas

Aim: The overall aim of the thesis is to investigate whether a new care-model can be introduced – in which patients with primary care needs and not in need of hospital emergency department care can be referred directly to a healthcare centre – and respond to the patient’s need of trust and patient safety.   Methods: The four sub studies employ different methods: three are quantitative with varying approaches and one is qualitative. Sub study I is a retrospective explorative register study aimed to identify characteristics and frequency. Sub study II is an instrument development study aimed to measure patient trust. Sub study III is a randomized controlled trial, which compared the level of patient trust and patient-safety among low-priority ambulance patients who were randomized into two groups: the experimental group (care at the healthcare centre) and the control group (traditional care at Emergency department). Finally, sub study IV is a hermeneutic lifeworld study based on interviews with patients who participated in the new care model.   Main results: Sixteen percent of the patients to whom an ambulance was allocated could have received care at a healthcare centre instead of an emergency department. They were slightly younger and healthier as regards their histories, but were found at all priority levels and with almost all symptom codes. Patient trust in care did not differ regardless of whether they were cared for at a healthcare centre or at the emergency department. However, 59 patients of 188 overall (31%) fulfilled one or more of the given criteria for potentially reduced patient safety. The phenomenon of trust does not automatically involve medical care. However, attention to the patient’s lifeworld in a professional caring relationship enables the patient to trust the caregiver and the healthcare environment. It is clear that the “voice of lifeworld” enables the patient to feel trust.  Conclusion: One in six patients allotted an ambulance may get taken to primary care instead of the hospital emergency department. These patients are found at all priority levels and in most of the symptom codes.  An instrument has been developed that measures patient trust in the prehospital chain of care (Study I). The instrument has proved to be useful in this patient group and is based on two dimensions: Credibility and Accessibility (Study II). Patients’ trust in the prehospital care chain proved to be high and bore no relation to where they received care. Patient safety, on the other hand, appeared to be limited in view of the fact that an excessive proportion of patients were exposed to potential patient safety risks (Study III). Communication that appeals to a patient's lifeworld increases the opportunities for understanding and participation. In all, lifeworld communication creates trust in care at the right level of care as well as in care relationships and the healthcare environment (Study IV).