Made available in DSpace on 2015-07-22T20:49:42Z (GMT). No. of bitstreams: 0 Previous issue date: 2012-03-30. Added 1 bitstream(s) on 2015-08-11T03:26:02Z : No. of bitstreams: 1 Publico-12520a.pdf: 1207919 bytes, checksum: 1cbb5eb39525a466eede84c0b592aee7 (MD5). Added 1 bitstream(s) on 2015-08-11T03:26:02Z : No. of bitstreams: 2 Publico-12520a.pdf: 1207919 bytes, checksum: 1cbb5eb39525a466eede84c0b592aee7 (MD5) Publico-12520b.pdf: 1232945 bytes, checksum: dccb3be28a625e6fd226753518045ad3 (MD5) / Infecções causadas pelos rinovírus humanos (HRV) são responsáveis por 25-50% das doenças respiratórias entre indivíduos que apresentam doença semelhante à gripe (Influenza-Like Illness - ILI). Os HRVs podem ser classificados em pelo menos três espécies: HRV A, HRV B e HRV C. O HRV C tem sido frequentemente descrito entre crianças aparentemente levando a doenças mais graves e hospitalizações, no entanto a ocorrência dessa espécie entre adultos não é bem conhecida. O objetivo deste estudo foi avaliar a apresentação clínica e a distribuição das espécies de HRV que causam infecções em diferentes populações durante os anos de 2001 a 2005. Um total de 682 amostras foi coletado. As populações estudadas eram compostos por: 132 adultos da comunidade atendidos em pronto socorro e 198 adultos profissionais de saúde (2001-2003); 242 pacientes transplantados renais (2002-2004); 61 crianças portadoras de cardiopatia congênita (2005) e 49 idosos da cidade de Botucatu, São Paulo, Brasil (2003-2004). A amplificação dos genes do HRV foi realizada através da Reação em Cadeia da Polimerase precedida de Transcrição Reversa (RT-PCR), seguida de sequenciamenteo genético e análise filogenética. O HRV foi detectado em 24.05% das amostras (164/682), 15.2% (20/132) em adultos da comunidade, 29.8% (59/198) em profissionais da área da saúde, 23.6% (57/242) em transplantados renais, 22.9% (14/61) em crianças portadoras de cardiopatia congênita e 28.6% (14/49) em idosos. Um total de 85.5% (137/164) das amostras positivas foi seqüenciado, e 79.9% (131/164) foram analisadas através de filogenia. Foram identificadas 80 (61%) das amostras pertencentes à espécie A, 22 (16.8%) a espécie B e 29 (22.2%) pertencentes à espécie C. Foi encontrada uma alta taxa de ILI (38.9%) em pacientes infectados pelo HRV. A regressão logística mostrou um aumento de ILI de três vezes quando os indivíduos estavam infectados com HRV A em comparação ao HRV C. A infecção pelo HRV causa ILI em paciente adultos não hospitalizados. O HRV A foi associado à infecção mais intensa do que o resfriado comum. A dinâmica da infecção entre as diferentes espécies de HRV merece análise no futuro. / Infections caused by Human Rhinoviruses (HRVs) account for 25%-50% of respiratory illnesses among individuals presenting influenza-like illness (ILI). HRVs could be classified in at least three species: HRV-A, HRV-B, and HRV-C. The HRV-C species has frequently been described among children and apparently has led to severe illness resulting in hospitalization; however, the occurrence among adults is unknown. The aim of this study was to assess the clinical presentation and species distribution of HRV infections in different populations during 2001-2005. A total of 682 samples were collected. Subjects consisted of 132 adults from the general community and 198 health-care workers (2001-2003), 242 renaltransplanted outpatients (2002-2004), 61 children with congenital heart disease (2005) and 49 elderly persons from Botucatu city, Sao Paulo, Brazil (2003-2004). Amplification of HRV genes was performed by Reverse Transcriptase – Polymerase Chain Reaction (RT-PCR) and followed by sequencing and phylogenetic analysis. HRV was detected in 24.05% of samples (164/682), 15.2% (20/132) among adults from general community, 29.8% (59/198) among health-care workers, 23.6% (57/242) among renal-transplanted outpatients, 22.9% (14/61) among children with congenital heart disease and 28.6% (14/49) among elderlies. A total of 85.5% (137/164) previously positive HRV samples were sequenced and 79.9% (131/164) were analyzed. We identified 80 isolates (61.0%) of the HRV A species, 22 (16.8%) of the HRV B species and 29 isolates (22.2%) of the HRV C species. High ILI rate (38.9%) was found among HRV infected patients. Logistic regression showed a three-fold increase in prevalence of ILI in individuals with HRV A infection compared with HRV C infected patients. HRV infections caused ILI among non-hospitalized patients. HRV specie A was associated with a disease more intense than a common cold. The dynamics of infection among different species deserve further analysis. / TEDE / BV UNIFESP: Teses e dissertações

Criminal gang membership is growing, which corresponds to a continued breakdown of the family unit in the United States. Most of the young people who form gangs come from broken families or single-parent-headed households. This study explored the role of family hierarchy on gang membership. A qualitative case study approach was used to gather information on what motivates young people to join criminal gangs. A random sampling technique was used to recruit seven former members of the Mac Baller Brim gang. Ethical concerns were addressed to minimize the risks to the participants. The collected data from interviews were analyzed using an interpretive research philosophy to determine the contribution of family hierarchy on motivating the participants to join gangs. Interpretive research philosophy indicates that reality can only be understood by subjective interpretation and intervention. An action research strategy was also used in an attempt to provide a practical solution for the people studied while adding to existing theories. The findings of the study indicated that there are 5 reasons why young people join gangs: protection, respect, money, fun, and because a friend was in the gang. This study may contribute to social change by identifying factors that lead to gang membership to aid policy and program interventions that lower the likelihood of youth joining gangs.

Teikiant socialinę pagalbą šeimai ir vaikui, skatinamas tarpžinybinis bendradarbiavimas, pasitelkiant įvairių sričių specialistų komandos. darbo tikslas - išnadrinėti vaikų dienos centrų ir įvairių institucijų, įstaigų tarpžinybinę sąveiką, įvertinti bendradarbiavimo galimybes, pateikti rekomendacijas šiai veiklai tobulinti. / On providing a social support to a family and children growing in it, an interdepartmental co-operation is encouraged and teams of experts from various spheres are engaged. The goal of the research work: to discuss upon the interdepartmental interaction of children day-time centers and various institutions, to assess the opportunities of co-operation, to provide recommendations for improvin these activities.

Šio magistrantūros studijų baigiamojo darbo tyrimo tikslas yra išanalizuoti socialinio darbuotojo pagalbą rizikos grupės šeimoms. Tyrimo objektas – tai rizikos grupės šeimų problemos ir socialinio darbuotojo pagalba joms. Tyrimui atlikti buvo panaudotos anketos, kurios buvo skirtos dviem tiriamom grupėm, t. y. socialinės rizikos šeimoms bei socialiniams darbuotojams. Tyrimo metu buvo apklaustos 63 rizikos grupės šeimos, gyvenančios Lazdijų rajono savivaldybėje ir 31 socialinis darbuotojas, dirbantis su tomis šeimomis. Gauti rezultatai buvo apdoroti SPSS 15.0 programa. Tyrimo metu paaiškėjo, kad socialinės rizikos grupės šeimos dažniausiai susiduria su tokiomis problemomis, kaip alkoholizmas, bedarbystė, vaikų elgesio problemomis. Tai patvirtina ir atlikta socialinių darbuotojų apklausa. Be to, didžioji dalis rizikos grupės šeimų, kreipiasi pagalbos į socialinius darbuotojus ir priima jų teikiamą pagalbą, tikėdamiesi surasti savo problemų sprendimą. Socialinių darbuotojų pagalba yra svarbi šioms šeimoms. Pasak jų, dirbdami su rizikos grupės šeimomis, dažniausiai naudoja individualų darbo metodą bei teikia kompleksinę pagalbą ir įgyvendina specialias programas, skirtas šioms šeimoms. Be to, tyrimo metu paaiškėjo, kad minėtieji specialistai turi laikytis konfidencialumo principo, taip pat dalyvauja seminaruose, kurių temos yra siejamos su socialinės rizikos grupės šeimomis ir jų problemomis. Tačiau kaip paaiškėjo, kad ne visi gautas žinias pritaiko praktinėje veikloje. ... [toliau žr. visą tekstą] / The aim of this master's thesis is to analyse the help of social worker to risk group families. The subject of research – problems of risk group families and help of social worker to them. The were used questionnaires to fulfill this research, which were appointed to two researched groups, i.e. social risk families and socoal workers. During the research there were surveyed 63 risk group families, living in Lazdijai region municipality and 31 social worker, who work with these families. Final results were worked up by program SPSS 15.0. During the research there was foud out that the families of social risk group most often cope with these problems: alcoholism, unemployment, children behaviour problems. It is also approved by the fulfilled survey of social workers. Moreover, the biggest part of risk group families resort to the help od social workers and receive aid in hope to find the solution to their problems. The help of social workers is important to these families. According them, during working with these families they often use individual working method and provide complex help and implement special programs which are appointed to these families. Besides, during the research it turned out that these specialists have to follow the confidentiality principle; they also participate in seminars which themes are related with social risk group families. But as it turned out, not all of them adapt acquired knowledge. Key words: social worker, family of social risk... [to full text]

The submitted thesis examines the issue of unemployment on the labor market by the age structure during the period of 1999-2009. Special attention is devoted to the unemployment of youth and older labor force. The thesis is focused on characterizing chosen age groups and inequalities between youth and older labor force in the labor market. The development of unemployment in selected age groups between 1999-2009 and the influencing factors (such as demographic structure, extending the retirement age, stage of the economic cycle) are also included. The aim of the thesis is to analyze the status development of selected age groups, particularly the status of youth and older labor force in the labor market and factors that influence the development. The main task is to evaluate the employment of youth and older labor force within the economic cycle.

Objetivos: Identificar e comparar grupos de pacientes potencialmente de risco para tuberculose zoonótica (TBz), investigando a existência de fatores associados. Apresentar a distribuição espacial dos casos de tuberculose (TB) em bovinos e dos casos humanos. Método: Trata-se de estudo descritivo de casos confirmados de TB por todas as formas clínicas, residentes no estado de São Paulo, do período de 2006 a 2015. Definiram-se seis grupos potenciais de risco para TBz conforme critérios estabelecidos pela literatura. A análise descritiva foi realizada separadamente para pacientes menores de 15 anos e pacientes com 15 anos ou mais de idade, comparando os grupos identificados com a população de estudo por meio do teste do Qui-quadrado/Exato de Fisher. A existência de associação entre TB intestinal e/ou ganglionar (aceita como proxy de caso suspeito de TBz) e as exposições de interesse foi investigada pelas estimativas da odds ratio bruta e ajustada, com os respectivos intervalos de 95% de confiança, usando regressão logística. . A distribuição dos casos suspeitos foram apresentados em mapas temáticos. Resultados: Aplicados os critérios estabelecidos para o estudo, foram incluídos 190.368 casos de TB por todas as formas clínicas. Dentre estes: 134 tinham menos de 15 anos e residiam em municípios com até 20.000 habitantes (grupo A); os demais tinham 15 anos ou mais, sendo 1.238 trabalhadores rurais (grupo B); 201 magarefes (grupo C); 1.012 residiam em municípios com até 20.000 habitantes e com rebanhos infectados pela TB (grupo D); 2.776 imigrantes sul americanos (grupo E); e 160 imigrantes africanos (grupo F). Os grupos B e F foram os que mais apresentaram características semelhantes à TBz descrita na literatura, destacando-se no grupo B as maiores proporções de casos de residentes em municípios com caso de TB em bovinos e das formas intestinal e ganglionar periférica. Enquanto que no grupo F verificou-se maior proporção de casos com a forma clínica ganglionar periférica e de coinfecção HIV/TB. Os grupos A, C e D também apresentaram características distintas em relação ao total de casos de TB e associadas à TBz segundo a literatura, porém de maneira menos nítida. O grupo E não apresentou características relacionadas aos casos típicos da TBz. Dentre os pacientes menores de 15 anos de idade, após ajustes, destacaram-se como fatores associados à TB ganglionar e/ou intestinal, residir em município com menores índices de urbanização e com casos de TB em bovino conforme registro oficial. Entte os pacientes com 15 anos ou mais de idade, destacaram-se as associações com a ocupação de trabalhador rural e com a de magarefe. A distribuição dos tipos de rebanhos bovinos foi ampla sendo registrados casos da doença em animais em praticamente todas as regiões do estado. Conclusões: Os dados de vigilância da TB humana e animal, permitiram identificar grupos de pacientes com características associadas à TBz, salietando a importância da aplicação da proposta de Saúde Única, além de oferecerem subsídios para o desenvolvimento de um componente para TBz na vigilância da TB no estado de São Paulo, assim como, para pesquisas sobre o tema. / Objectives: To identify and compare groups of patients potentially at risk for zoonotic tuberculosis (zTB), investigating the existence of associated factors. To present the spatial distribution of cases of tuberculosis (TB) in cattle and human cases. Method: This is a descriptive study of confirmed cases of TB by all clinical forms, residents in the state of São Paulo, from 2006 to 2015. Six potential risk groups for zTB were defined according to literature. The descriptive analysis was performed separately for patients younger than 15 years and patients 15 years of age or older, comparing the groups identified with the study population using the Chi-square / Fisher\'s Exact test. The existence of an association between intestinal and/or ganglion TB (accepted as a proxy for a suspected zTB case) and the exposures of interest was investigated by the estimates of the crude and adjusted odds ratio, with the respective 95% confidence intervals, using logistic regression. The distribution of suspected cases was presented in thematic maps. Results: After applying the criteria established for the study, 190,368 TB cases were included in all clinical forms. Among them: 134 were less than 15 years old and lived in municipalities with up to 20,000 inhabitants (group A); the others were 15 years old or over, with 1,238 rural workers (group B); 201 magarefes (group C); 1,012 resided in municipalities with up to 20,000 inhabitants and with herds infected by TB (group D); 2,776 South American immigrants (group E); and 160 African immigrants (group F). Groups B and F were the ones that presented the most similar characteristics to the zTB described in the literature. In group B, the highest proportions of cases of residents in municipalities with cases of TB in cattle and of the intestinal and peripheral ganglion forms were highlighted. While in the F group there was a higher proportion of cases with peripheral ganglionic form and HIV / TB co-infection. Groups A, C and D also presented distinct characteristics in relation to total TB cases and associated with TB, according to the literature, but less clearly. Group E did not present characteristics related to typical zTB cases. Among patients younger than 15 years of age, after adjustments, they were identified as factors associated with lymph node and/or intestinal TB, living in a municipality with lower rates of urbanization and with cases of TB in cattle according to official records. Among the patients aged 15 years and over, the associations with the occupation of rural workers and magarefe stood out. The distribution of bovine herd types was extensive and cases of the disease were recorded in animals in practically all regions of the state. Conclusions: Human and animal TB surveillance data allowed the identification of groups of patients with characteristics associated with zTB, stressing the importance of applying the One Health proposal, as well as providing subsidies for the development of a component for zTB in TB surveillance in the state of São Paulo, as well as for research on the subject.

This study aims at analyzing the content of high school textbooks in social sciences, more specifically the field of law and order, and comparing this with the current research situation in the field. Another purpose is to investigate whether the new type of serious gang crime, which in particular has grown in various immigrant suburbs, adjacent to our largest cities, as reported in the media in recent years, has also looked into the textbooks. The essay uses a constructivist theory formation. The constructivist theory considers that different actors, based on their ideological positions, create different descriptions of current social phenomena, descriptions aimed at influencing the recipient to incorporate specific perceptions of reality and values. In this context, the teaching materials become a political product that is not so much about describing a social phenomenon as complex and objective as possible a complex, but, above all, it will be understood as the attempt of the various parties to convey their specific interpretations and interests of the phenomenon. The survey shows that all analyzing textbooks directly or indirectly highlight the men and adolescents group, and to some extent also people in an exposed psychosocial position that overrepresented in a criminal context. In cases where textbooks address statements about people committing crimes, socio-economic and psychosocial vulnerabilities are mentioned, as well as explanations of the social plane in terms of control and casualty structures. In this regard, textbooks fail to report a broad and current research on the mechanisms of crime. None of the textbooks deal with the new crime that has emerged in different socially vulnerable areas to our metropolitan areas, believing that this has gained a lot of space in the media and that the syllabuses in social sciences emphasize that the subject will highlight current social phenomena. All books consistently choose to not treat people it with a foreign background's overrepresentation in a criminal context. Nor should it be noted that some people have a biological vulnerability in committing crimes, for example, that individuals with ADHD diagnosis are heavily overrepresented in crime statistics. / <p>Godkännane datum: 2018-05-31</p>

The objective of this graduation thesis was making a review of the most occurrenced ectoparasitic diseases and note the efectivity of medical preparation in the most risk groups. From February 2005 to December 2007 there was an observation of individuals apperance specialized in ectoparasitic diseases of miscellaneous origin in the Veterinary Clinic Vltava, which is interested in illnesses of small animals. This observation comprehended usually home breeded animals only. Total of checkuped animals was 6468 individuals. From that in category of race dogs acknowledged by FCI was on record 54 what counted 4702 individuals. Other animals numbering 1756 we have included in category of cats with acknowledged origin and European kind of cats without any origin. There was marginally treated with attendance of ectoparasits 5 rabbits and 5 guinea pigs. Between the most frequently medicaly groups the Yorkshire terriers 603 times belonged, hybrids untill the 10 kg of weight 525 times and Retrievers 512 times. Their age interface was different, what responding to their social popularity. At other individuals was the most recorded counts of parasitosis of European cats without any acknowledged origin 1402 times, mostly wild. Thanks to observation it we were able to analyze risky groups and their scalable treatment. The most frequently ectoparasits belouged for cats european kind Otodectes cynotis , numering about 869 pcs, for yorkshire terriers fleas numering about 295pcs and hubrid dogs up to 10kg fleas numering about. The next freguency occurrence of fleas and ticks we notea by the golden retriever. In spite of the komplex attitude in struggle with ectoparasits has beed prefered, by far not the owners proceeded by the advises of the veterinary. So that all precuation can be successfull in the long term, the owners would have to start to solve the problem with wild cats in their surroundings. This cats forms the most usually treated individuals and continually they contaminate their vicinage with ectoparasits with their contact way of life. In 10 disobedience cases the disease expanded not only to the other individuals in animal breeding but to the owner himself. So the necessity of prevention and through medication had been confirmed so that posibility of dangerous disease transmision would be eliminated.

OBJECTIVE To determine the prevalence of patients with diabetes mellitus (DM2) in Valencia. Moreover, the analysis of population characteristics, disease profile, multimorbidity, pharmaceutical costs, resource consumption and complications We want to establish a prediction model resource consumption of patients with type II diabetes mellitus (DM 2). STUDY DESIGN Methodology Observational, descriptive, retrospective and cross-sectional study. First of all, a database is prepared with patients diagnosed with DM2 in Valencia in 2012. They are rank by their state health system using the Clinical Risk Groups (CRG). From this database, comorbidities and specific complications associated with the disease and pharmaceutical expenditure are analyzed. This is analyzed from different perspectives: comorbidities, CRG health conditions and drugs used to treat the disease. As a result, a multivariate regression models arises to predict pharmaceutical expenditure depending on the different available variables in which the dependent variable is the total pharmaceutical expenditure per patient per year and the explanatory variables will be selected from among those available in the data base developed. Finally, a factorial analysis and principal component analysis is presented to study differences among diabetic patients analyzed in terms of pharmaceutical expenditure, comorbidities not related to DM2, DM2-related comorbidities and complications. Study Population Population diagnosed with type II diabetes of Valencia in the year 2012. Of the 491,854 patients diagnosed with diabetes. We excluded all patients with juvenile diabetes, gestational diabetes and those who received no drug treatment, reducing the group to 350,015 patients. Sources of information and study variables: The basic sources for obtaining data was: - The electronic medical record, ABUCASIS. - The module pharmaceutical services, GAIA. - The Minimum Data Set, CMBD. - The catalog of corporate resources, CRC. - Population Information System, SIP. - Clinical Risk Groups (Clinical Risk Groups, CRGs). Limitations of the study 1. State of coding diagnoses, both in quantitative and qualitative terms. 2. Imbalance in the use of corporate systems outpatient, which enables errors in classification information (SIA-GAIA) RESULTS The estimated gross rate of diabetes was 7.72%, with an average consumption per patient per year was approximately € 1,330. Considering health states, about 48% of patients are classified in health status 6. As for comorbidities of patients with DM2, 68% also suffer from hypertension and 53% of dyslipidemia. The prevalence of comorbid increases with CRG health status and the severity of the patient; and older ages. As expected, also it increases with the number of comorbidity (from 592 € per patient per year with one comorbidity to 3,825 € to six and more comorbidity). By type of pharmaceutical treatment, consumption is lower in biguanides and sulfonylureas, with annual amounts lower to 50 € and achieves amounts over 600 €. Finally models predictive for diabetic patients are raised, with the proposed model considering multivariate linear regression health status and severity of the patient according to the CRG system model. Moreover, the proposed analysis identifies six factors explaining 49.3% of the variance in the pharmaceutical annual consumption of diabetic patients. CONCLUSIONS DM2 shows a high prevalence and is characterized by the coexistence of other diseases, which leads to significant increases in the cost of treatment and complicates the management of the disease. Per patient consumption increases with worsening state of health of the patient and older age, and is also determined by the type of pharmaceutical treatment following by patients. Linear regression and factor analysis allow to establish models to predict and control the pharmaceutical consumption of diabetic patients. / OBJETIVO Determinación de la prevalencia y análisis de las características de la población, perfil de morbilidad, multimorbilidad, costes farmacéuticos, consumo de recursos y complicaciones de los pacientes con Diabetes mellitus (DM2) en la Comunidad Valenciana. Con ello, se pretende establecer un modelo de predicción del consumo de recursos de los pacientes con Diabetes mellitus tipo 2 (DM 2). DISEÑO DEL ESTUDIO Metodología Estudio observacional, descriptivo, retrospectivo y de corte transversal. Se elabora una base de datos con los pacientes diagnosticados de DM2 en la Comunidad Valenciana en el año 2012 y se clasifica a los mismos por estados de salud, utilizando el sistema Clinical Risk Groups (CRG). Se analizan las comorbilidades y complicaciones específicas asociadas a la enfermedad así como el gasto farmacéutico. Este se analiza desde diferentes puntos de vista: comorbilidades, estados de salud CRG y fármacos utilizados para el tratamiento de la enfermedad. Con todo ello, se plantea modelos de regresión multivariante para predecir el gasto farmacéutico en función de las diferentes variables disponibles en los que la variable dependiente es el gasto farmacéutico total por paciente y año y las variables explicativas se seleccionarán, de entre las disponibles en la base de datos elaborada. Finalmente, se presenta un análisis factorial y de componentes principales para estudiar diferencias entre los pacientes diabéticos analizados, en cuanto a gasto farmacéutico. Población de estudio Población con diagnóstico de diabetes tipo 2 de la Comunidad Valenciana en el 2012. De los 491.854 pacientes con diagnóstico de diabetes, se excluyen todos aquellos pacientes con diabetes juvenil, diabetes gestacional y los que no recibieron tratamiento farmacológico, reduciendo el grupo a 350.015 pacientes. Fuentes de información y variables de estudio Las fuentes fundamentales para la obtención de los datos: -La historia clínica electrónica, ABUCASIS. -El módulo de prestación farmacéutica, GAIA. -El Conjunto Mínimo Básico de Datos, CMBD. -El catálogo de recursos corporativos, CRC. -Sistema de Información Poblacional, SIP. -Los Grupos de Riesgo Clínico (Clinical Risk Groups, CRGs). Limitaciones del estudio 1.Estado de la codificación de los diagnósticos, tanto en términos cuantitativos como cualitativos. 2. Desequilibrio en la utilización de los sistemas de información ambulatorios corporativos con posibilidad de clasificaciones erróneas (SIA-GAIA). RESULTADOS La prevalencia bruta estimada de la diabetes fue del 7,72%, con un consumo medio por paciente y año de cerca de 1.330€. Por estados de salud, cerca de 48% de los pacientes se clasifican en el estado de salud 6. En cuanto a las comorbilidades de los pacientes con DM2, el 68% sufren además hipertensión y un 53% dislipemia. El gasto farmacéutico aumenta con la presencia de comorbilidades (de 592€ a 3.825€ anuales por paciente, con una comorbilidad a seis y más, respectivamente)., el estado de salud CRG y la severidad del paciente; y con edades más avanzadas. Por tipo de fármaco, el consumo varía entre importes anuales inferiores a 50€ hasta cifras que superan los 600€. Un modelo de regresión lineal multivariante que considera el estado de salud y severidad del paciente alcanza un coeficiente de determinación corregido¿R2 de un 39,3% de la variabilidad. Finalmente, el análisis factorial identifica 6 factores que explican el 49,3% de la varianza en el consumo anual farmacéutico de los pacientes diabéticos. CONCLUSIONES La diabetes presenta una elevada prevalencia y se caracteriza por la coexistencia de otras enfermedades, lo cual conlleva incrementos considerables en el coste del tratamiento. El consumo por paciente aumenta con el empeoramiento del estado de salud del paciente y la edad más avanzada, así como por el tipo de tratamiento farmacológico del paciente. La r / OBJECTIU Determinació de la prevalença i anàlisi de les característiques de la població, perfil de morbiditat, multimorbilitat, costos farmacèutics, consum de recursos i complicacions dels pacients amb Diabetis Mellitus (DM2) a la Comunitat Valenciana (CV). Es pretén establir un model de predicció del Consum de recursos dels Pacients amb Diabetis Mellitus tipus II (DM 2). DISSENY DE L'ESTUDI Metodologia Estudi observacional, descriptiu, retrospectiu i de tall transversal. En primer s'elabora una base de dades amb els pacients amb diagnòstic de DM2 a la Comunitat Valenciana en l'any 2012 i es classifica als pacients per estats de salut, utilitzant del sistema de Grups de Risc Clínic (CRG). S'analitzen les comorbiditats i complicacions associades a la infermetat, així com la despesa farmacèutica des de diferents perspectives: comorbiditats, estats de salut i fàrmacs utilitzats per al tractament de la malaltia. Es plantegen models de regressió multivariant per predir la despesa farmacèutica en funció de les diferents variables disponibles. La variable dependent es la despesa farmacèutica total per pacient i any, i les variables explicatives es seleccionaran, d'entre les disponibles a la base de dades elaborada. Finalment, a la tesi, es presenta l'anàlisi factorial i de components principals que ens permet estudiar les diferències entre els pacients diabètics analitzats, des del punt de vista de la despesa farmacèutica, comorbiditats relacionades i no relacionades amb la DM2 i complicacions. Població d'estudi Població amb Diagnòstic de diabetis (DM 2) de la Comunitat Valenciana en l'any 2012. Dels 491.854 pacients amb diagnòstic de la diabetis, s'exclouen de els pacients amb diabetis juvenil, diabetis gestacional i els que no van rebre tractament farmacològic, reduint el grup a 350.015. Fonts d'Informació i variables d'estudi - La història clínica electrònica, ABUCASIS. - El mòdul de prestació farmacèutica, GAIA. - El Conjunt Mínim de Dades Bàsiques, CMBD. - El catàleg de recursos corporatius, CRC. - Sistema d'Informació Poblacional, SIP. - Els Grups de Risc Clínic (grups de risc clínics, CRGs). Limitacions de l'estudi 1. Estat de codificació dels diagnòstics, tant en termes quantitatius com qualitatius. 2. Desequilibri en la utilització dels sistemes d'informació corporatius ambulatoris amb possibilitat de classificació. RESULTATS La prevalença bruta estimada de la diabetis va ser del 7,72, i el consum mitjà per pacient i any de uns 1.330€. Per estats de salut, prop de 48% dels pacients es classifiquen en l'estat de salut 6, i al voltant del 29% en el 5. En quant a les comorbiditats dels Pacients amb DM2, el 68% pateixen hipertensió, i un 53% dislipèmia. La despesa augmenta amb la presencia de comorbiditats (de 592 € a 3.825 € per pacient anualment, amb una comorbiditat i amb una sis i més, respectivament), així com amb l'estat de salut del CRG i la severitat del pacient. Per tipus de fàrmac, el consum és més baix en biguanides i sulfonilurees, amb imports anuals inferiors a 50 € fins a més de 600€ en el cas de combinacions. Es plantegen models per predicció del consum farmacèutic ambulatori de pacients diabètics del tipus 2, proposant com a resultat un model de regressió lineal multivariant que considera l'estat de salut i severitat del pacient segons el sistema CRG. D'altra banda, l'anàlisi factorial identifica 6 factors que expliquen de l'49,3% de la variància a el consum anuals farmacèutic dels pacients. CONCLUSIONS La diabetis presenta una elevada prevalença i es caracteritza per la coexistència d'altres malalties, la qual cosa comporta increments considerables en el cost del tractament i complica la gestió de la malaltia. El consum per pacient augmenta amb l'empitjorament de l'estat de salut del pacient i l'edat avançada, i a més també ve determinat pel tipus de tractament farmacològic que segueixen e / Sancho Mestre, C. (2017). MODELO PREDICTIVO DE AJUSTE DE RIESGO Y COSTES EN PACIENTES CON DIABETES MELLITUS EN LA COMUNIDAD VALENCIANA [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/83483

O carcinoma basocelular (CBC) é malignidade de incidência elevada e crescente na população caucasiana, e sua expressiva prevalência nos serviços de saúde remete à necessidade de avaliação dos índices de cura. O presente estudo analisou marcadores clínicos preditivos do comprometimento das margens cirúrgicas do CBC, em conjunto com um painel de marcadores imuno-histoquímicos (IHQ). Analisou-se 1294 laudos histopatológicos de CBC, emitidos durante 2011, e incluídos 674 casos de excisão cirúrgica completa realizada por diferentes especialidades em hospital terciário. Foram selecionados 40 casos dos diferentes subtipos histológicos para realização de IHQ para os marcadores Ber-EP4, MNF116, E-Caderina e VEGF, analisados por sistema digital de captação de imagens e programa de computador. Na amostra, houve predomínio de homens (60,4%) com idade média de 68 anos, da localização cefálica (71%) e do subtipo nodular (61%); da ulceração (p= 0,003) e do diâmetro médio superior dos CBC nos homens (307,41 mm2 x 190,74 mm2; p< 0,001); do subtipo superficial de localização no tronco (p< 0,001) e em mais jovens (<73 anos; p= 0,001); do subtipo nodular (p< 0,001) e ulcerado (p= 0,05) no segmento cefálico. A especialidade Dermatologia foi responsável pela maioria das cirurgias (78%), cuja dimensão média e índice de margens cirúrgicas livres dos CBC excisados foram respectivamente 274 mm2 e 95%, seguida por 279 mm2 e 89% na Cirurgia Plástica, 218 mm2 e 60% na Cirurgia de Cabeça e Pescoço (CCP), 87 mm2 e 49% na Oftalmologia. O risco para desfecho em margens cirúrgicas comprometidas foi determinado para: subtipo micronodular (OR 3,41; IC 95% 1,71 6,80; p= 0,001); localização cefálica (OR 8,33 IC 95% 1,05 50; p= 0,045); excisões realizadas pelas especialidades Oftalmologia (OR 10,12; IC 95% 4,40 23,27; p= 0,001) e CCP (OR 9,67; IC 95% 5,14 18,21; p= 0,001). A imunomarcação pelo Ber-EP4, MNF116 e ECaderina foi homogênea e de intensidade moderada a acentuada nas células neoplásicas em todos os subtipos; os valores de intensidade da marcação, percentual de área e escore para o MNF116 discriminaram os CBC agressivos (esclerodermiforme e micronodular) daqueles não agressivos (nodular e superficial); e foram superiores para ECaderina no subtipo superficial; o percentual de células marcadas pelo VEGF foi superior nos tumores agressivos (p< 0,001). O segmento cefálico e o subtipo micronodular, seguido do esclerodermiforme, implicam em riscos elevados para o comprometimento das margens e merecem atenção quanto ao manuseio cirúrgico. A imunomarcação por Ber-EP4, MNF116 e E-Caderina pode auxiliar na identificação de ninhos tumorais multifocais no subtipo superficial, ou em meio ao processo inflamatório nos subtipos agressivos. A marcação da E-Caderina pode representar o padrão menos agressivo e de crescimento radial do subtipo superficial; e a do VEGF, nos tumores mais agressivos, ser indicativa do papel desta proteína no comportamento mais invasivo. A especialidade Dermatologia tem expressiva participação institucional e níveis de resolubilidade superiores, representada pelas maiores frequências de excisão de CBC e de margens cirúrgicas livres. O reconhecimento de fatores preditivos para desfecho em margens cirúrgicas comprometidas é de fundamental relevância para o planejamento cirúrgico e obtenção das mais elevadas taxas de cura. / Basal cell carcinoma (BCC) is the most common human malignancy and it is increasing its incidence in the Caucasian population. The significant prevalence of cases in specialized health services indicates the need of assessment of cure rates. The present study analyzed clinical predictive markers of compromised surgical margins in BCC in association with a panel of Immunohistochemistry (IHC) markers. We analyzed 1294 BCC histopathological reports during 2011, and 674 cases of complete surgical excision performed by different specialties in a tertiary hospital were included. From the sample, 40 cases of different histological subtypes were selected to perform IHC markers Ber-EP4, MNF116, E-cadherin and VEGF, which were analyzed by digital image capture system and computer program. There was male predominance (60.4%) with mean age of 68 years, location at cephalic segment (71%) and nodular subtype (61%); ulceration (p= 0.003) and higher average size of CBC in men (307.41 mm2 x 190.74 mm2; p< 0.001); superficial subtype was more frequent on trunk (p< 0.001) and in younger than 73 years (p< 0.001); nodular subtype (p< 0.001) and ulceration (p= 0.05) at cephalic segment. The specialty Dermatology performed the majority of surgeries (78%), and the average size and the index of free surgical margins were 274 mm2 and 95% in Dermatology, 279 mm2 and 89% in Plastic Surgery, 218 mm2 and 60% in Head and Neck Surgery (HNS), 87 mm2 and 49% in Ophthalmology. The risk for compromised surgical margins was determined for: micronodular subtype (OR 3.41; 95% CI 1.71 6.80; p= 0.001); location at cephalic segment (OR 8.33; 95% CI 1.05 50; p= 0.045); excisions performed by Ophthalmology (OR 10.12; 95% CI 4.40 23.27; p= 0.001) and HNS (OR 9.67; 95% CI 5.14-18.21; p= 0.001). Immunostaining by Ber-EP4, MNF116 and E-cadherin was homogeneous and moderate to high intensity within the neoplastic cells in all BCC subtypes; values obtained from staining intensity, percentage of area and score for the MNF116 showed difference between aggressive BCC (morpheaform and micronodular) and non-aggressive (superficial nodular); and were higher for E-cadherin in superficial BCC; the percentage of marked cells by VEGF was higher in aggressive tumors (p< 0.001). The cephalic segment and micronodular subtype, followed by the morpheaform, imply high risks for compromised margins and deserve attention during the surgical treatment by trained experts. The immunohistochemistry markers Ber-EP4, MNF116 and E-cadherin may help the identification of multifocal tumor nests in superficial subtype or amid the inflammatory process in the aggressive subtypes. E-cadherin staining may represent the least aggressive and radial pattern of growth of superficial subtype. VEGF staining in peritumoral inflammatory cells of aggressive tumors may be indicative of the role of this protein in more invasive behavior of these subtypes of the BCC. Dermatology has significant institutional participation with highest resolution, represented by higher frequency of BCC excision and less compromised surgical margins. Knowing the predictive factors for compromised surgical margins is important for planning surgical treatment and obtaining the highest cure rates.