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Aim: Most of the patients with Psoriatic Arthritis (PsA) develop arthritis following the onset of psoriasis. The aim of the project is to identify genetic and environmental risk factors for PsA among psoriasis patients. Methods: PsA and psoriasis patients from two prospective cohorts were analyzed. The incidence of PsA among a prospective cohort of psoriasis patients was assessed. The distribution of Human Leukocyte Antigen (HLA) alleles and Killer Cell Immunoglobulin like Receptors (KIRs) and their combinations was compared between PsA, psoriasis and healthy controls. In addition, the association between a wide range of environmental exposures and PsA was evaluated by comparing the frequencies of exposed individuals among patients with recent onset PsA and psoriasis. The association between smoking and PsA was further investigated. The prevalence of smoking was in PsA, psoriasis and the general population. The interaction between HLA-C*06 and smoking was also tested. Results: The genetic analysis revealed several HLA-B alleles and HLA haplotypes that are associated with PsA compared to psoriasis and can potentially serve as independent markers for PsA. Furthermore, several combinations of KIR genes and their respective HLA ligands were also found to be associated with PsA compared to psoriasis. The incidence of PsA among psoriasis patients was found to be higher than previously reported and its rate was constant over time. HLA-C*06 was associated with increased interval between psoriasis onset and PsA. Several environmental factors including occupational exposures, infections, injuries and smoking were associated with development of PsA. The prevalence of smoking was decreased among PsA patients compared to psoriasis. The interaction between HLA-C*06 and smoking was found to be significant. Conclusions: Genetic and environmental factors are associated with the development of PsA in patients with psoriasis. These factors may serve as specific markers to identify psoriasis patients at increased risk for PsA.

Aim: Most of the patients with Psoriatic Arthritis (PsA) develop arthritis following the onset of psoriasis. The aim of the project is to identify genetic and environmental risk factors for PsA among psoriasis patients. Methods: PsA and psoriasis patients from two prospective cohorts were analyzed. The incidence of PsA among a prospective cohort of psoriasis patients was assessed. The distribution of Human Leukocyte Antigen (HLA) alleles and Killer Cell Immunoglobulin like Receptors (KIRs) and their combinations was compared between PsA, psoriasis and healthy controls. In addition, the association between a wide range of environmental exposures and PsA was evaluated by comparing the frequencies of exposed individuals among patients with recent onset PsA and psoriasis. The association between smoking and PsA was further investigated. The prevalence of smoking was in PsA, psoriasis and the general population. The interaction between HLA-C*06 and smoking was also tested. Results: The genetic analysis revealed several HLA-B alleles and HLA haplotypes that are associated with PsA compared to psoriasis and can potentially serve as independent markers for PsA. Furthermore, several combinations of KIR genes and their respective HLA ligands were also found to be associated with PsA compared to psoriasis. The incidence of PsA among psoriasis patients was found to be higher than previously reported and its rate was constant over time. HLA-C*06 was associated with increased interval between psoriasis onset and PsA. Several environmental factors including occupational exposures, infections, injuries and smoking were associated with development of PsA. The prevalence of smoking was decreased among PsA patients compared to psoriasis. The interaction between HLA-C*06 and smoking was found to be significant. Conclusions: Genetic and environmental factors are associated with the development of PsA in patients with psoriasis. These factors may serve as specific markers to identify psoriasis patients at increased risk for PsA.

Campylobacter is currently the most common cause of acute bacterial diarrhoea in Australia among all the notified enteric pathogens with more than 15,000 cases each year. The incidence of notified campylobacteriosis has steadily increased during the past 15 years from 67.0/100,000 population in 1991 to 121.4/100,000 in 2005, though the factors contributing to this increase had not been studied. Adjusting for under-reporting there are, at this point in time, an estimated 225,000 infections occurring each year in Australia, most of which are sporadic in nature. Much of our knowledge in Australia about risk factors for sporadic disease has been based on overseas literature. Prior to the studies undertaken in this thesis, the epidemiology of Campylobacter infection had not been thoroughly studied in Australia, nor had there been any national studies examining risk factors for locally-acquired infection. The broad aim of this thesis was to examine in depth the descriptive epidemiology of Campylobacter infection in Australia, explore the reasons for the sustained increase in incidence of infection and to identify the major risk factors for locally acquired infection using a multi-centre case-control study design. The descriptive study of the epidemiology of campylobacteriosis in Australia was based on Australian notifiable disease surveillance data collected over a 15-year period between 1991 and 2005. This study described the key epidemiological characteristics of this disease in Australia and identified some significant differences in incidence trends across states and territories and among different age groups which had not been previously reported. The study identified gaps in our knowledge of this disease in Australia and made recommendations for future research including the investigation of factors associated with the decline in incidence of infection among children aged  4 years and further studies to identify age and sex-specific risk factors for infection. The issue of seasonality, transmission routes and infection was addressed and areas for further research were specified including longitudinal studies at a regional level that incorporate a comparison of human, animal and environmental genotypes. This study also provided strong compelling evidence to support the hypothesis that the increase in notification rates in Australia during this period represented a real increase in the incidence of infection and that the main driving force behind this rise has been the ongoing increase in chicken consumption among the Australian public. The multi-centre case-control study, involving 1,714 participants  5 years of age, identified the major foodborne and non-foodborne risk factors for Campylobacter infection among the general population in Australia. This study confirmed that chicken meat is a major source of sporadic infection in this country and is responsible for almost one-third of all cases that occur in the Australian community each year. Other independent risk factors for sporadic infection in Australia included consumption of offal and ownership of domestic dogs or chickens aged  6 months. The Nagelkerke R² value of 16% for the final multivariable model indicated a considerable proportion of our case-patients had unexplained risk factors. The combined population attributable risk (PAR) estimate for the independent foodborne risk factors in this study was 31%, which is considerably less than the 75% to 80% of cases in the general population which are thought to be caused through foodborne transmission. Possible explanations for these results include the likelihood that a proportion of foodborne transmission in Australia occurs through food vehicles other than chicken due to cross-contamination from raw products, and the likelihood that much of the population attributable risk that is unaccountered for, may in fact be due to inherent limitations of study design resulting in systematic errors (information bias) and possibly reduced estimates of effect. The burden of illness among the general population in Australia attributable to different independent risk factors was estimated using a novel method developed specifically for this study. Briefly, community incidence data was coupled with PAR data from the case-control study and simulation techniques were used to: (i) estimate the number of infections attributable to specific risk factors, and (ii) derive credible intervals for these estimates by modeling the uncertainty in each variable component. This model of using case-control data in conjunction with pre-existing surveillance data provides researchers with a simple but robust tool for conducting source attribution studies on enteric pathogens. In conclusion, the studies undertaken in this thesis have made important contributions to our understanding of the epidemiology of sporadic Campylobacter infection in Australia.

“Cartas al editor” / Revisión por pares

Racional: Aproximadamente um de cada cinco pacientes hospitalizados por pneumonia adquirida na comunidade (PAC) apresenta uma resposta clínica inadequada, sendo a mortalidade nestes pacientes de 40%. Os objetivos do estudo foram: determinar a incidência e as variáveis de associação independente com fracasso terapêutico da PAC, e os fatores prognósticos da PAC tratada em ambiente hospitalar. Métodos: Estudo de coorte, prospectivo, multicêntrico, com 425 pacientes hospitalizados por PAC. Os pacientes foram acompanhados de forma sistemática para identificação do fracasso terapêutico e seguidos até a alta hospitalar. Resultados: A incidência de fracasso terapêutico foi de 14,6% (62/425). Os preditores independentes de risco para o fracasso foram: insuficiência renal aguda à admissão (OR 2,9; IC 95% 1,2-7,2; p=0,017), progressão radiológica (OR 29,8; IC 95 8,1-109,7%; p<0,001), derrame pleural (OR 3,4; IC 95% 1,3-8,6; p=0,010), relação PaO2/FiO2 inferior a 250 à admissão (OR 2,7; IC 95% 1,1-6,7; p=0,017) e PSI classe V (OR 2,7; IC 95% 1,1-7,0; p=0,042). A mortalidade geral foi de 7,5%, e de 40,3% nos pacientes com fracasso. O fracasso terapêutico foi o principal fator independente de mortalidade na PAC (OR 85,3, IC 95% 18,8-387,4, p<0,0001). Conclusão: O fracasso terapêutico da PAC é freqüente, está associado a marcadores clínicos, radiológicos e laboratoriais identificáveis desde a admissão hospitalar (ou nos primeiros dias de acompanhamento), sendo o principal preditor independente de mortalidade. / Rational: One out of five patients hospitalized for community-acquired pneumonia (CAP) might have an inadequate response to empirical antimicrobial treatment, and the mortality among these patients may reach rates of up to 40%. The aims of the study were to: quantify the incidence of empirical treatment failure in CAP, identify risk factors for therapeutic failure and prognostic factors in CAP. Methods: Prospective, multicenter cohort study of 425 hospitalized patients for CAP. The systematic identification of treatment failure required a daily follow-up until hospital discharge. Results: The incidence of treatment failure was 14.6% (62/425). The independent risk factors associated with therapeutic failure in a logistic analysis were: acute renal failure (OR 2.9; 95% CI 1.2-7.2; p=0.017), radiological progression (OR 29.8; IC 95 8.1-109.7%; p<0.001), pleural effusion (OR 3.4; 95% CI 1.3-8.6; p=0.010), PaO2/FiO2 ratio < 250 (OR 2.7; 95% CI 1.1-6.7; p=0.017) e pneumonia severity index Class V (OR 2.7; 95% CI 1.1-7.0; p=0.042). Mortality was significantly higher in patients with therapeutic failure (40.3% vs. 7.5%). Treatment failure was the main prognostic factor associated with CAP (OR 85.3; 95% CI 18.8-387.4, p<0.0001). Conclusion: The treatment failure is frequently found and it is associated with clinical, radiological and laboratorial markers. It is also an important independent predictor of mortality in CAP.

A obesidade e a perda dental são importantes problemas de saúde pública mundial e ambas as condições ocasionam desfechos adversos à saúde. Em estudos prévios, a existência de associação entre essas condições tem sido observada; no entanto, evidências ainda são inconclusivas, embora muitos estudos indicam que fatores de risco comuns estão relacionados com ambos os problemas. O objetivo principal foi avaliar a associação entre o índice de massa corporal e a perda dental em uma população adulta. O método utilizado baseou-se em dados transversais que foram coletados através de questionários autopreenchíveis e medidas antropométricas foram aferidas em 3.930 funcionários tecnicoadministrativos de uma universidade no Rio de Janeiro, participantes da Fase 1 (1999) do Estudo Pró-Saúde. Perda dental autorreferida (4 categorias) foi o desfecho de interesse e obesidade foi a variável de exposição principal. Os dados sobre os aspectos da dieta, acesso e utilização dos serviços de saúde, fatores socioeconômicos, hábitos e comportamentos de saúde e dados demográficos foram utilizados como covariáveis. Em comparação com aqueles com IMC< 25 kg/m², as pessoas com sobrepeso (IMC≥ 25 e <30 Kg/m²) e obesidade (IMC≥ 30 Kg/m²) apresentaram uma maior chance de perda dental, OR = 1,6 (IC 95% 1,4-1,9) e OR = 2,1 (IC 95% 1,8-2,5), respectivamente. Ajustando por potenciais fatores de confusão, os indivíduos com sobrepeso e obesidade tiveram um OR estatisticamente não significativo para perda dental, respectivamente OR=0,8 e OR=0,9. Os resultados são consistentes com a hipótese de que a associação entre obesidade e perda dental resulte de fatores de risco comuns. / Obesity and tooth loss are important public health problems worldwide, and both conditions cause adverse health outcomes. In previous studies, an association between these conditions has been observed; however, evidence is still inconclusive, although many studies indicate that common risk factors are related to both problems. The main objective of this study was to evaluate the association between overweight/obesity and tooth loss in adults. Cross-sectional data was collected through and self-administered questionnaires and anthropometric measurements in 3,930 civil servants at a university in Rio de Janeiro, participants in Phase 1 (1999) of the Pró-Saúde Study. Self-reported tooth loss (4 categories) was the outcome of interest, and obesity was the main independent variable. Data on aspects of diet, access and utilization of health services, socioeconomic factors, health habits and behaviors as well as demographic data were used as covariates. Compared with those with BMI< 25 kg/m², overweight people (BMI≥ 25 and <30 kg/m²) and obesity (BMI≥ 30 kg/m²) had a greater chance of tooth loss, OR=1.6 (95% CI 1.4-1.9) and OR=2.1 (95% CI 1.8-2.5), respectively. Adjusting for potential confounding factors, overweight and obese participants showed no statistically significant higher odds for tooth loss, respectively, OR=0.8 and OR=0.9.The results are consistent with the hypothesis that the association between obesity and tooth loss is the result of common risk factors.

Made available in DSpace on 2014-06-11T19:33:28Z (GMT). No. of bitstreams: 0 Previous issue date: 2001-11-28Bitstream added on 2014-06-13T19:44:17Z : No. of bitstreams: 1 rossel_fl_dr_arafo.pdf: 218723 bytes, checksum: 597100c28484b7a6aeb83d1d399d438f (MD5) / O objetivo deste estudo foi avaliar a prevalência dos fatores clínicos de risco de cárie (frequência de cárie, mancha branca, dentisteria, dieta, índice de placa, frequência diária da escovação e uso de fio dental) em gestantes que frequentaram a Clínica de Prevenção da Faculdade de Odontologia de Araraquara - UNESP no período de 1997 a 2000. Realizou-se um levantamento de prontuários clínicos de gestantes, totalizando 120 prontuários. As gestantes tinham idades de 16 a 41 anos e encontravam-se do 2º ao 9º mês gestacional. Os dados foram armazenados e analisados através do programa Epi Info versão 6.04 - CDC - USA. 26,7% das gestantes tinham de 16-20 anos, 36,7% de 21-25 anos, 20,0% de 26-30 anos, 10,8% de 31-35 anos e 5,8% de 36-41 anos; 52,5% das gestantes procuraram atendimento no 2º trimestre gestacional, 27,5% no 3º trimestre e 20,0% no 1º trimestre; a prevalência foi de 79,2% para dieta cariogênica e 20,8% não cariogênica; em relação à frequência de cárie prevalência foi de 38,3% das gestantes com baixa, 28,3% moderada, 24,2% alta 9,2% livres de cárie; 46,7% das gestantes apresentavam dentisteria deficiente, 27,5% boa, 25,0% regular e 0,8% não apresentavam restaurações; em relação as manchas brancas, 58,3% das gestantes não a apresentavam, 26,7% tinham manchas brancas ativas e 15,0% inativas; 61,7% das gestantes escovavam três vezes ao dia, 35,0% duas vezes e 3,3% uma vez ao dia; o fio dental era utilizado três vezes ao dia por 24,2% das gestantes, quatro vezes por 17,5% e 58,3% não o utilizavam; 72,5% das gestantes apresentavam maior ou igual que 50,0% das superfícies dentárias com placa corada e 27,5% menor que 50,0% das superfícies dentárias. Os fatores clínicos de risco de cárie mais prevalentes foram: dieta cariogênica (79,2%), dentisteria deficiente (46,7%) e superfícies dentárias com placa corada (72,5%)... . / The object of this study was to evaluate the prevalence of clinical risk factors of tooth decay ( tooth decay frequency, white mark, dentistery, diet, plaque rate, daily frequency of tooth brushing and the use of dental floss) in pregnant women who attended the Prevention Clinic of the Dentristry Faculty in Araraquara - UNESP from 1997 to 2000. A survey with 120 dentists' notes was made. The pregnant women had ages between 16 and 41 and were in the 2nd to the 9thmonth of pregnancy. The data was stored and analised by the Epi Info. Program. 26,7% of the pregnant women were between 16 and 20 years old, 36,7% between 21 and 25 years old, 20,0% between 26 and 30 years old, 10,8% between 31 and 35 years old, and 5,8% between 36 and 41 years old; 52,5% of the pregnant women looked for consultation during the 2nd quarter of pregnancy, 27,5% during the 3rd quarter, and 20,0% during the 1st quarter; the prevalence was of 79,2% for a tooth decay diet and 20,8% for a non-tooth decay diet; in relation to the tooth decay frequency, the prevalence was of 38,3% of the pregnant women with low frequency,28,3% with moderate frequency, 24,2% with high frequency, and 9,2% free of tooth decay; 46,7% of the pregnant women presented deficient dentistery, 27,5% presented a good one, 25,0% a regular one and 0,8% didn't present any fillings; in relation to the white marks, 58,3% of the pregnant women didn't present any, 26,7% had active white marks, and l5,0% had inactive ones; 6l,7% of the pregnant women brushed their teeth three times a day, 35,0% two times a day, and 3,3% once a day; the dental floss was used three times a day by 24,2% of the pregnant women, four times a day by 17,5% of them, and 58,2% of the women didn't use it at all; 72,5% of the pregnant women presented 50% or more of the dental surfaces with colored plaque and 27,5% of the... (Complete abstract, click electronic address below).

Racional: Aproximadamente um de cada cinco pacientes hospitalizados por pneumonia adquirida na comunidade (PAC) apresenta uma resposta clínica inadequada, sendo a mortalidade nestes pacientes de 40%. Os objetivos do estudo foram: determinar a incidência e as variáveis de associação independente com fracasso terapêutico da PAC, e os fatores prognósticos da PAC tratada em ambiente hospitalar. Métodos: Estudo de coorte, prospectivo, multicêntrico, com 425 pacientes hospitalizados por PAC. Os pacientes foram acompanhados de forma sistemática para identificação do fracasso terapêutico e seguidos até a alta hospitalar. Resultados: A incidência de fracasso terapêutico foi de 14,6% (62/425). Os preditores independentes de risco para o fracasso foram: insuficiência renal aguda à admissão (OR 2,9; IC 95% 1,2-7,2; p=0,017), progressão radiológica (OR 29,8; IC 95 8,1-109,7%; p<0,001), derrame pleural (OR 3,4; IC 95% 1,3-8,6; p=0,010), relação PaO2/FiO2 inferior a 250 à admissão (OR 2,7; IC 95% 1,1-6,7; p=0,017) e PSI classe V (OR 2,7; IC 95% 1,1-7,0; p=0,042). A mortalidade geral foi de 7,5%, e de 40,3% nos pacientes com fracasso. O fracasso terapêutico foi o principal fator independente de mortalidade na PAC (OR 85,3, IC 95% 18,8-387,4, p<0,0001). Conclusão: O fracasso terapêutico da PAC é freqüente, está associado a marcadores clínicos, radiológicos e laboratoriais identificáveis desde a admissão hospitalar (ou nos primeiros dias de acompanhamento), sendo o principal preditor independente de mortalidade. / Rational: One out of five patients hospitalized for community-acquired pneumonia (CAP) might have an inadequate response to empirical antimicrobial treatment, and the mortality among these patients may reach rates of up to 40%. The aims of the study were to: quantify the incidence of empirical treatment failure in CAP, identify risk factors for therapeutic failure and prognostic factors in CAP. Methods: Prospective, multicenter cohort study of 425 hospitalized patients for CAP. The systematic identification of treatment failure required a daily follow-up until hospital discharge. Results: The incidence of treatment failure was 14.6% (62/425). The independent risk factors associated with therapeutic failure in a logistic analysis were: acute renal failure (OR 2.9; 95% CI 1.2-7.2; p=0.017), radiological progression (OR 29.8; IC 95 8.1-109.7%; p<0.001), pleural effusion (OR 3.4; 95% CI 1.3-8.6; p=0.010), PaO2/FiO2 ratio < 250 (OR 2.7; 95% CI 1.1-6.7; p=0.017) e pneumonia severity index Class V (OR 2.7; 95% CI 1.1-7.0; p=0.042). Mortality was significantly higher in patients with therapeutic failure (40.3% vs. 7.5%). Treatment failure was the main prognostic factor associated with CAP (OR 85.3; 95% CI 18.8-387.4, p<0.0001). Conclusion: The treatment failure is frequently found and it is associated with clinical, radiological and laboratorial markers. It is also an important independent predictor of mortality in CAP.

A obesidade e a perda dental são importantes problemas de saúde pública mundial e ambas as condições ocasionam desfechos adversos à saúde. Em estudos prévios, a existência de associação entre essas condições tem sido observada; no entanto, evidências ainda são inconclusivas, embora muitos estudos indicam que fatores de risco comuns estão relacionados com ambos os problemas. O objetivo principal foi avaliar a associação entre o índice de massa corporal e a perda dental em uma população adulta. O método utilizado baseou-se em dados transversais que foram coletados através de questionários autopreenchíveis e medidas antropométricas foram aferidas em 3.930 funcionários tecnicoadministrativos de uma universidade no Rio de Janeiro, participantes da Fase 1 (1999) do Estudo Pró-Saúde. Perda dental autorreferida (4 categorias) foi o desfecho de interesse e obesidade foi a variável de exposição principal. Os dados sobre os aspectos da dieta, acesso e utilização dos serviços de saúde, fatores socioeconômicos, hábitos e comportamentos de saúde e dados demográficos foram utilizados como covariáveis. Em comparação com aqueles com IMC< 25 kg/m², as pessoas com sobrepeso (IMC≥ 25 e <30 Kg/m²) e obesidade (IMC≥ 30 Kg/m²) apresentaram uma maior chance de perda dental, OR = 1,6 (IC 95% 1,4-1,9) e OR = 2,1 (IC 95% 1,8-2,5), respectivamente. Ajustando por potenciais fatores de confusão, os indivíduos com sobrepeso e obesidade tiveram um OR estatisticamente não significativo para perda dental, respectivamente OR=0,8 e OR=0,9. Os resultados são consistentes com a hipótese de que a associação entre obesidade e perda dental resulte de fatores de risco comuns. / Obesity and tooth loss are important public health problems worldwide, and both conditions cause adverse health outcomes. In previous studies, an association between these conditions has been observed; however, evidence is still inconclusive, although many studies indicate that common risk factors are related to both problems. The main objective of this study was to evaluate the association between overweight/obesity and tooth loss in adults. Cross-sectional data was collected through and self-administered questionnaires and anthropometric measurements in 3,930 civil servants at a university in Rio de Janeiro, participants in Phase 1 (1999) of the Pró-Saúde Study. Self-reported tooth loss (4 categories) was the outcome of interest, and obesity was the main independent variable. Data on aspects of diet, access and utilization of health services, socioeconomic factors, health habits and behaviors as well as demographic data were used as covariates. Compared with those with BMI< 25 kg/m², overweight people (BMI≥ 25 and <30 kg/m²) and obesity (BMI≥ 30 kg/m²) had a greater chance of tooth loss, OR=1.6 (95% CI 1.4-1.9) and OR=2.1 (95% CI 1.8-2.5), respectively. Adjusting for potential confounding factors, overweight and obese participants showed no statistically significant higher odds for tooth loss, respectively, OR=0.8 and OR=0.9.The results are consistent with the hypothesis that the association between obesity and tooth loss is the result of common risk factors.