O câncer de mama é a neoplasia mundialmente mais incidente em mulheres, representando a causa mais frequente de morte feminina por câncer, excetuando-se os tumores de pele não melanoma. O conhecimento da dinâmica de óbitos ao logo do tempo em pacientes com tal neoplasia é de grande importância para auxílio na definição de tratamentos e de políticas de prevenção. Modelos de risco que contemplem parâmetros com referência a situações de longa duração e diferentes funções de risco podem ser úteis nesse contexto. O objetivo desta dissertação é investigar as propriedades de um particular modelo, o modelo Weibull Modificado Exponenciado de Longa Duração (WMELD), para aplicação na avaliação de risco e sobrevida de mulheres diagnosticadas com câncer de mama atendidas no Hospital das Clínicas de Ribeirão Preto, São Paulo. As propriedades avaliadas neste estudo consideraram métodos de estimação pontual de Máxima Verossimilhança e estimação intervalar via teoria assintótica, reamostragem bootstrap e verossimilhança perlada. Critérios de seleção de modelos foram considerados: Teste de Razão de Verossimilhanças (TRV), critério de Akaike (AIC) e critério de Informação de Bayes (BIC), bem como métodos gráficos para avaliar a qualidade do ajuste do modelo: gráfico TTT na presença de censuras com intervalo de confiança bootstrap paramétrico. Foram realizados estudos de simulação de Monte Carlo em diferentes cenários do modelo WMELD, considerando Vício, Erro Quadrático Médio (EQM) e Custo dos estimadores pontuais, Probabilidade de Cobertura e Amplitude Média dos intervalos de confiança. Em relação ao estudo das propriedades do modelo, as estimativas pontuais de máxima verossimilhança apresentaram vício e EQM baixos e mais próximos de zero quanto maior o tamanho amostral e menor a proporção de pacientes imunes. Os intervalos construídos com base em reamostragem bootstrap mostraram-se mais adequados em relação à probabilidade de cobertura e amplitude média, com vantagem para o bootstrap paramétrico. AIC e TRV alcançaram poder discriminativo superior ao BIC, porém os três métodos apresentam-se defasados para pequenos tamanhos amostrais e valores dos parâmetros próximos do valor de nulidade. Os métodos de inferência com melhor desempenho nesse estudo foram considerados para avaliar os fatores associados ao risco e sobrevida de pacientes com câncer de mama atendidas no HCFMRP. Com o ajuste do modelo WMELD, mostraram-se associados à sobrevida os fatores: Estadiamento, Faixa Etária e Quantidade de tratamentos. A sobrevida em oito anos ou mais foi maior quanto menor o estadiamento e os óbitos ocorreram de forma mais acelerada ao longo do tempo em estadiamentos avançados. Pacientes com menos de 35 anos de idade nos estadiamentos II e III e com mais de 75 anos no estadiamento III têm menor sobrevida do que as pacientes com 35 a 75 anos. Pacientes que realizaram menos tratamentos nos estadiamentos III ou IV vão a óbito mais rapidamente do que pacientes que zeram mais tratamentos, porém a sobrevida após oito ou mais anos é igual nos dois grupos. Adicionalmente, e fundamental no contexto da clínica médica, o modelo WMELD apresenta interpretações relevantes em relação a seus parâmetros na dinâmica do processo de ocorrência de óbitos ao longo do tempo. Verificamos que os parâmetros , e p levam informações sobre o tempo de vida, já os parâmetros, e descrevem o comportamento do risco de óbito. / Breast cancer is the world\'s most common cancer in women, representing the most frequent cause of female death from cancer, except for non-melanoma skin tumors. Knowledge of the death dynamics over time in patients with such cancer is very important to support definition of treatments and prevention policies. Hazard models that include parameters with reference to long-term situations and dierent hazard functions can be useful in this context. This paper aims to investigate the properties of a particular model, Exponentiated Modified Weibull Model for long-term survivors (EMWLT), for use in risk of death and survival assessment of women diagnosed with breast cancer and treated at Hospital das Clínicas de Ribeirão Preto (HCFMRP), São Paulo. The properties evaluated in this study considered point estimation methods of Maximum Likelihood and interval estimation through asymptotic theory, bootstrap resampling and profile likelihood. Model selection criteria were considered: Likelihood Ratio Test (LRT), Akaike Criterion (AIC) and Bayesian Information Criterion (BIC), as well graphical methods to assess the quality of the model fit: TTT plot in the presence of censorship with an parametric bootstrap confidence interval. Monte Carlo simulation studies were performed in diferent model\'s scenarios considering Bias, Mean Square Error (MSE) and Cost of point estimators, Coverage Probability and Average Size of confidence intervals. Regarding the study of model properties, the point estimates of maximum likelihood showed lower and closer to zero bias and MSE the larger the sample size and the lower the proportion of immune patients. The intervals constructed based on bootstrap resampling seemed more appropriated in relation to the coverage probability and average size, advantageously the parametric bootstrap. AIC and LRT reached a higher discriminative power than BIC; however, all of these three methods seemed lagged for small sample sizes and close to null values of parameters. The inference methods with better performance in this study were considered to evaluate the factors associated with risk of death and survival in patients with breast cancer treated at HCFMRP. By adjusting the EMWLT model, the following were associated to survival: Staging, Age Group and Number of treatments. The survival of eight years or more was higher as the lower the staging was; and the deaths occurred more rapidly over time in advanced staging. Patients under 35 years old in stages II and III and older than 75 years in staging III had lower survival than patients aged 35 to 75 years. Patients who underwent fewer treatments in staging III or IV die earlier than patients who underwent more treatments, but survival after eight years or more is equal in both groups. In addition, the EMWLT model showed to be fundamental in clinical medicine presenting relevant interpretations regarding its parameters in the dynamics of the process of occurrence of deaths over time. We verified that the parameters , and p have information about the lifetime, on the other hand the parameters, and describe the risk of death behavior.

O câncer de mama é a neoplasia mundialmente mais incidente em mulheres, representando a causa mais frequente de morte feminina por câncer, excetuando-se os tumores de pele não melanoma. O conhecimento da dinâmica de óbitos ao logo do tempo em pacientes com tal neoplasia é de grande importância para auxílio na definição de tratamentos e de políticas de prevenção. Modelos de risco que contemplem parâmetros com referência a situações de longa duração e diferentes funções de risco podem ser úteis nesse contexto. O objetivo desta dissertação é investigar as propriedades de um particular modelo, o modelo Weibull Modificado Exponenciado de Longa Duração (WMELD), para aplicação na avaliação de risco e sobrevida de mulheres diagnosticadas com câncer de mama atendidas no Hospital das Clínicas de Ribeirão Preto, São Paulo. As propriedades avaliadas neste estudo consideraram métodos de estimação pontual de Máxima Verossimilhança e estimação intervalar via teoria assintótica, reamostragem bootstrap e verossimilhança perlada. Critérios de seleção de modelos foram considerados: Teste de Razão de Verossimilhanças (TRV), critério de Akaike (AIC) e critério de Informação de Bayes (BIC), bem como métodos gráficos para avaliar a qualidade do ajuste do modelo: gráfico TTT na presença de censuras com intervalo de confiança bootstrap paramétrico. Foram realizados estudos de simulação de Monte Carlo em diferentes cenários do modelo WMELD, considerando Vício, Erro Quadrático Médio (EQM) e Custo dos estimadores pontuais, Probabilidade de Cobertura e Amplitude Média dos intervalos de confiança. Em relação ao estudo das propriedades do modelo, as estimativas pontuais de máxima verossimilhança apresentaram vício e EQM baixos e mais próximos de zero quanto maior o tamanho amostral e menor a proporção de pacientes imunes. Os intervalos construídos com base em reamostragem bootstrap mostraram-se mais adequados em relação à probabilidade de cobertura e amplitude média, com vantagem para o bootstrap paramétrico. AIC e TRV alcançaram poder discriminativo superior ao BIC, porém os três métodos apresentam-se defasados para pequenos tamanhos amostrais e valores dos parâmetros próximos do valor de nulidade. Os métodos de inferência com melhor desempenho nesse estudo foram considerados para avaliar os fatores associados ao risco e sobrevida de pacientes com câncer de mama atendidas no HCFMRP. Com o ajuste do modelo WMELD, mostraram-se associados à sobrevida os fatores: Estadiamento, Faixa Etária e Quantidade de tratamentos. A sobrevida em oito anos ou mais foi maior quanto menor o estadiamento e os óbitos ocorreram de forma mais acelerada ao longo do tempo em estadiamentos avançados. Pacientes com menos de 35 anos de idade nos estadiamentos II e III e com mais de 75 anos no estadiamento III têm menor sobrevida do que as pacientes com 35 a 75 anos. Pacientes que realizaram menos tratamentos nos estadiamentos III ou IV vão a óbito mais rapidamente do que pacientes que zeram mais tratamentos, porém a sobrevida após oito ou mais anos é igual nos dois grupos. Adicionalmente, e fundamental no contexto da clínica médica, o modelo WMELD apresenta interpretações relevantes em relação a seus parâmetros na dinâmica do processo de ocorrência de óbitos ao longo do tempo. Verificamos que os parâmetros , e p levam informações sobre o tempo de vida, já os parâmetros, e descrevem o comportamento do risco de óbito. / Breast cancer is the world\'s most common cancer in women, representing the most frequent cause of female death from cancer, except for non-melanoma skin tumors. Knowledge of the death dynamics over time in patients with such cancer is very important to support definition of treatments and prevention policies. Hazard models that include parameters with reference to long-term situations and dierent hazard functions can be useful in this context. This paper aims to investigate the properties of a particular model, Exponentiated Modified Weibull Model for long-term survivors (EMWLT), for use in risk of death and survival assessment of women diagnosed with breast cancer and treated at Hospital das Clínicas de Ribeirão Preto (HCFMRP), São Paulo. The properties evaluated in this study considered point estimation methods of Maximum Likelihood and interval estimation through asymptotic theory, bootstrap resampling and profile likelihood. Model selection criteria were considered: Likelihood Ratio Test (LRT), Akaike Criterion (AIC) and Bayesian Information Criterion (BIC), as well graphical methods to assess the quality of the model fit: TTT plot in the presence of censorship with an parametric bootstrap confidence interval. Monte Carlo simulation studies were performed in diferent model\'s scenarios considering Bias, Mean Square Error (MSE) and Cost of point estimators, Coverage Probability and Average Size of confidence intervals. Regarding the study of model properties, the point estimates of maximum likelihood showed lower and closer to zero bias and MSE the larger the sample size and the lower the proportion of immune patients. The intervals constructed based on bootstrap resampling seemed more appropriated in relation to the coverage probability and average size, advantageously the parametric bootstrap. AIC and LRT reached a higher discriminative power than BIC; however, all of these three methods seemed lagged for small sample sizes and close to null values of parameters. The inference methods with better performance in this study were considered to evaluate the factors associated with risk of death and survival in patients with breast cancer treated at HCFMRP. By adjusting the EMWLT model, the following were associated to survival: Staging, Age Group and Number of treatments. The survival of eight years or more was higher as the lower the staging was; and the deaths occurred more rapidly over time in advanced staging. Patients under 35 years old in stages II and III and older than 75 years in staging III had lower survival than patients aged 35 to 75 years. Patients who underwent fewer treatments in staging III or IV die earlier than patients who underwent more treatments, but survival after eight years or more is equal in both groups. In addition, the EMWLT model showed to be fundamental in clinical medicine presenting relevant interpretations regarding its parameters in the dynamics of the process of occurrence of deaths over time. We verified that the parameters , and p have information about the lifetime, on the other hand the parameters, and describe the risk of death behavior.

The thesis gives the analysis of the life insurance market in Ukraine. The first part is dedicated to the main characteristics of the Ukrainian insurance market with detailed specification of its participants, regulatory and theoretical basement of life insurance. The second part introduces deep analysis of the main insurance indexes of the market and also the analysis of particular insurance companies with reference to their market shares and product supplies. The last part compares evolution of the Ukrainian insurance market with other nations. Finally, the thesis points out the main problems of the life insurance market in Ukraine and their probable solutions.

This thesis deals with actual questions about life insurance on the Czech insurance market. At the beginning of the work, life insurance is described from a theoretical point of view - main characteristic, forms of traditional and new products, kinds of available insurances. It also deals with Czech insurance market, price of insurance and insurance premium in case of insured event. The last part contains actual problems with life insurance - one-shot insurance payment, universal life insurance, equality of rights of men and women, distributional channels and general insurance conditions.

Abstract A model of intensive care nursing of patients and their significant others compatible with a data system was developed and evaluated by using an action research approach in 1997-2001. The study was carried out in Oulu University Hospital's ICUs for emergency and postoperative care and internal medicine. At stage I of the study, the model of intensive care nursing was developed and pilot-tested by collecting questionnaire data from the nurses who participated in the action research group (N = 14), from the texts produced by small groups made out of the action research group and the whole group (N = 33), by audio-recording oral report sessions (N = 57) and by using the researcher's written notes. The data for pilot testing were collected on a form from nursing documents (N = 17) and on a questionnaire from nurses (N = 11). The research data were analysed with methods of inductive and deductive content analysis. At stage II, the model was made compatible with the ICU data system. At stage III, the validity of the model was evaluated by analysing patient data drawn from the emergency and postoperative ICU's data system (N = 1464) and patient records filed by the researcher (N = 30). The patients' needs for nursing and the quantitative needs for staff were compared between the model of intensive care nursing and the Therapeutic Intervention Scoring System (TISS) based on the patient data drawn from the data systems of the emergency (N = 253) and postoperative (N = 579) ICU. The data were analysed using statistical methods and methods of content analysis. The model of intensive care nursing includes nursing diagnoses of the changes in the patient's vital functions, the restrictions and experiences caused by the disease and its treatment and the significant others' distress, the nursing to meet the severity of the health problems, the nursing interventions and the outcomes of nursing as well as the nursing workload. Based on the validity assessment, the model differentiated between the nursing interventions needed by the patients in different admission types and with different severity scores (p < 0.001). The model also provided a good prediction of the patients' risk of death (ROC 0.86-0.91). Contrary to TISS, the model gave higher nursing workload scores and a greater need for staff for the patients who were more ill on admission, and whose hospital stay was longer and mortality higher. The model can be used as a starting-point in developing evidence-based middle-range theory, which will provide a basis for demonstrating the efficacy of nursing in patients' overall care. / Tiivistelmä Tutkimuksessa kehitetään ja arvioidaan tietojärjestelmään soveltuva potilaan ja hänen läheistensä hoitotyötä kuvaava tehohoitotyön malli toimintatutkimuksen lähestymistapaa noudattaen vuosina 1997-2001. Tutkimusyhteisöinä toimivat Oulun yliopistollisen sairaalan päivystysalueen, postoperatiivinen ja sisätautien teho-osastot. Tutkimuksen I-vaiheessa kehitettiin ja esitestattiin tehohoitotyön malli keräämällä tutkimusaineisto kyselylomakkeen avulla toimintatutkimusryhmään osallistuneilta hoitajilta (N = 14), toimintatutkimusryhmästä muodostettujen pienryhmien ja toimintatutkimusryhmän tuottamista kirjallisista aineistoista (N = 33), äänittämällä raporttitilanteita (N = 57) ja tutkijan kirjallisista muistiinpanoista. Esitestausaineisto kerättiin lomakkeella hoitotyön dokumenteista (N = 17) ja kyselylomakkeella hoitajilta (N = 11). Tutkimusaineistot analysoitiin induktiivisella ja deduktiivisella sisällönanalyysillä. II-vaiheessa yhteensovitettiin malli tehotietojärjestelmään. III-vaiheessa arvioitiin mallin luotettavuutta päivystysalueen ja postoperatiivisen osaston tietojärjestelmästä kerätyn potilasaineiston (N = 1464) ja tutkijan arkistoitujen potilasasiakirjojen (N = 30) analyysien avulla. Potilaiden hoitoisuutta ja hoitohenkilökunnan määrällistä tarvetta verrattiin tehohoitotyön mallin ja Therapeutic Intervention Scoring System-luokituksen (TISS) kesken tietojärjestelmästä kerätyn päivystysalueen (N = 253) ja postoperatiivisen (N = 579) teho-osaston potilasaineiston perusteella. Tutkimusaineisto analysoitiin tilastollisin menetelmin ja sisällönanalyysin avulla. Tehohoitotyön malli kuvaa potilaan elintoimintojen muutoksiin, sairauden ja sen hoidon tuomiin rajoituksiin ja kokemuksiin sekä läheisten hätään liittyviä hoitotyön diagnooseja, terveysongelmien vaikeusasteita vastaavaa hoitotyötä, hoitotyön toimintoja ja hoitotyön tuloksia sekä hoitoisuutta. Luotettavuustutkimuksen mukaan malli erotteli tulotyypiltään ja sairauden vaikeusasteiltaan erilaisten potilaiden hoitotyötä (p < 0.001). Mallin avulla voitiin kuvata hyvin potilaiden kuoleman riskiä (ROC 0.86-0.91). Malli antoi suuremmat hoitoisuuspisteet ja henkilökunnan määrällisen tarpeen päinvastoin kuin TISS potilaille, jotka olivat tulovaiheessa sairaampia ja joiden hoitoaika oli pitkä ja kuolleisuus suuri. Mallia voidaan käyttää lähtökohtana näyttöön perustuvan keskitason teorian kehittämiseen, jolla voidaan antaa perusteet osoittaa tehohoitotyön vaikuttavuutta potilaan kokonaishoidossa.

The study and practice of epidemiology and public health benefit from the use of mortality statistics, such as mortality rates, which are frequently used as key health indicators. Furthermore, multiple causes of death (MCOD) data offer important information that could not possibly be gathered from other mortality data. This study aimed to describe the interrelationships between various causes of death in the United States in order to improve the understanding of the coexistence of MCOD and thereby improve public health and enhance longevity. The social support theory was used as a framework, and multivariate linear regression analyses were conducted to examine the coexistence of MCOD in approximately 80 million death cases across the United States from 1959 to 2005. The findings showed that in the United States, there is a statistically significant relationship between the number of coexisting MCOD, race, education, and the state of residence. Furthermore, age, gender, and marital status statistically influence the average number of coexisting MCOD. The results offer insights into how the number of coexisting MCOD vary across the United States, races, education levels, gender, age, and marital status and lay a foundation for further investigation into what people are dying from. The results have the long-term potential of helping public health practitioners identify individuals or communities that are at higher risks of death from a number of coexisting MCOD such that actions could be taken to lower the risks to improve people's wellbeing, enhance longevity, and contribute to positive social change.

Contexte : Les neuroleptiques sont souvent prescrits chez les sujets âgés et les patients souffrant de schizophrénie qui sont des personnes vulnérables. Notre objectif était d’étudier l’impact des NLP en situation réelle de prescription, dans ces deux populations. Etude 1. Consommation de neuroleptiques et décès en période de canicule chez les sujets âgés. A partir de données de l’Assurance Maladie, nous avons comparé les prescriptions de NLP chez des sujets âgés décédés pendant la canicule d’août 2003 (n=11624) aux prescriptions de témoins non décédés. Nous avons mis en évidence une association entre risque de décès et consommation de neuroleptiques, que ce soit juste avant ou pendant le pic de canicule et indépendamment d’autres médicaments, d’une démence ou d’une pathologie cardiaque. Etude 2. Efficacité réelle des NLP chez les patients souffrant de schizophrénie. A partir de données d’une cohorte observationnelle ayant inclus en France entière des schizophrènes adultes, nous avons montré que chez les patients déjà traités par NLP (n=5500), il y avait une association entre traitement par antipsychotique atypique (vs. NLP classique) et une meilleure satisfaction avec les soins et ce, pour tous les AA pris en compte et indépendamment du niveau de symptomatologie. Par ailleurs, chez les patients naïfs vis-à-vis de tout NLP et pour qui un traitement était introduit pour la première fois (n=467), un tiers des patients ne s’améliorait pas. Les facteurs prédictifs d’une meilleure réponse clinique étaient une moindre sévérité initiale globale des symptômes et des symptômes négatifs de schizophrénie. Au total, il existait cinq types de trajectoires d’évolution clinique. / Context : Antipsychotic drugs (AD) are often prescribed to elderly people and patients with schizophrenia and both populations are fragile. The aim of the present thesis was to investigate the impact of AD in these patients, in a real-life setting. Study 1. Antipsychotic drug use during a heatwave and risk of death, in older people. Using data from the French Social Security, prescriptions of older people who died during the heatwave in August 2003 (n=11624) were compared to these of controls who survived. An association was evidenced between a prescription of AD and death, in the periods just preceding and during the heatwave, independently of other psychotropic drugs, dementia or cardiac disease. Study 2. Effectiveness of AD in schizophrenia patients. Using data from a French nationwide observational study, we found that in patients treated for schizophrenia (n=5500), a higher level of satisfaction was independently associated with being on second-generation AD as compared to first-generation AD. Also, in drug-naive patients (n=467) followed up during 6 months after a first AD initiation, one third of the patients did not experience any improvement of symptoms. The factors predictive of a better clinical response were lower levels of baseline negative symptoms and overall severity of symptoms. A total of 5 trajectories of clinical evolution were identified.

INTRODUCTION. Quality of life (QOL) – and individual’s perception of his or her own health – has become the subject of great interest in Lithuania. THE AIM OF THE STUDY. The aim of the study was to assess the determinants of the quality of life and self-rated health and to clarify the importance of perceived health in determining the risk of death among middle-aged Kaunas population. MAIN RESULTS. Quality of life in middle-aged Kaunas women was found to be lower than in men, except for the spirituality domain. Older age showed worse quality of life. Low income and lower educational level, manual work, living alone, unemployment, disability and retirement were associated with worse QOL in middle-aged Kaunas population. Overweight and obese men had lower probability of rating their overall QOL worse as compared to men with normal body mass. Diabetes, coronary heart disease and smoking were associated with worse QOL in men. Moderate-to-heavy alcohol consumption was associated with lower risk of having worse QOL as compared to light alcohol consumption group among men. Obesity for women increased the odds of having worse QOL as compared to women with normal body mass. Moderate-to-heavy alcohol consumption was associated with better QOL in the physical and independence domains and with worse QOL in the social relationships domain among women. Smoking and inadequate physical activity were associated with worse QOL among women. CHD increased women’s probability of scoring lower in... [to full text]