Les incapacités motrices lourdes engendrent des situations de handicap au cours desquelles l’autonomie du corps et du sujet sont bousculées. Les attendus et les évidences du corps valide sont suspendus. Ne pouvant plus agir directement sur elle-même ou sur son environnement, la personne en situation de handicap doit passer par l’intermédiaire d’un dispositif d’aide polymorphe constitué à la fois d’aides humaines et techniques. Au cours de chacune des interactions avec ce dispositif, les limites entre soi et l’autre, entre l’intérieur et l’extérieur, se brouillent.A partir de trois enquêtes ethnographiques réalisées auprès de personnes en situation de handicap vivant à domicile, la recherche doctorale a pour objet l’analyse de cette expérience corporelle. Dans une première partie, la thèse montre que la singularité de cette expérience repose sur le principe d’une distribution du corps, alternant entre déconstruction de soi et renégociations empiriques des frontières à partir de la définition d’une intimité. La recherche distingue ensuite trois formes possibles d’une existence au quotidien avec des incapacités motrices. Chacune d’entre elles se traduit par unedistribution singulière des frontières de l’identité / Severe motor impairments generate disability situations in which the autonomy of body and of the subject are disrupted. Expectations and taken-for-granted attitudes regarding the valid body are challenged. No longer in capacity to act directly on themselves or on their environment, persons with disabilities must interact with polymorphic help devices consisting of both human and technical aids. In these interactions, limitations between self and others or between inside and outside are blurred.Based on three ethnographic studies conducted with persons with disabilities living at home, the doctoral research aims at analyzing their specific corporal experience. The first part of the dissertation analyzes the experience of people with severe motor impairments as an experience of a distributed body, alternating between self-destruction and empirical negotiations of body frontiers with reference to intimacy. The second part distinguishes three forms of the experience of everyday life with severe motor impairments, which result in different distributions of the frontiers of self

The purpose of this study was to provide training to peer tutors in order to teach students with severe intellectual disability to initiate communication to obtain preferred objects. A multiple probe (days) across students was used to evaluate the effectiveness of the peer implementing a naturalistic time delay to teach the communication skill. Two of the four students were able to initiate communications with the peer tutors to use objects they preferred. One student showed increasing in responding prior to the implementation of the intervention. The results showed that the peers were able to maintain the instructional procedures to teach the skill.

Doctor of Philosophy / Department of Diagnostic Medicine/Pathobiology / Raymond R. Rowland / Severe acute respiratory syndrome (SARS) is caused by an enveloped, positive-stranded RNA virus, the SARS coronavirus (SARS-CoV). Coronaviruses along with the arteriviruses are placed in the order, Nidovirales. Even though nidovirus replication is restricted to the cytoplasm, the nucleocapsid protein (N) of several coronaviruses and arteriviruses, localize to the nucleolus during infection. Confocal microscopy of N protein localization in Vero cells infected with the SARS-CoV or transfected with the SARS-CoV N gene failed to show presence of N in the nucleoplasm or nucleolus. Recombinant N remained cytoplasmic after the addition of leptomycin B (LMB), a drug that inhibits nuclear export. SARS-CoV N possesses a unique lysine-rich domain, located between amino acids 369-389, which possesses several nuclear localization signal (NLS) and nucleolar localization signal (NoLS) motifs. A chimeric protein composed of the 369-389 peptide substituted for the NLS of equine infectious anemia virus (EIAV) Rev protein (ERev) showed no nuclear localization activity. Three negatively charged amino acids, located at positions 372, 377 and 379 in SARS-CoV N were hypothesized to play a role in the loss of nuclear targeting. Substitution of aspartic acid-372 with alanine restored nuclear localization to the chimeric protein. A full-length recombinant SARS-N protein with the alanine-372 substitution localized to the nucleus. Therefore, the presence of an aspartic acid at position 372 is sufficient to retain N in the cytoplasm The mechanistic basis for how aspartic acid-372 interrupts nuclear transport is unknown, but may lie in the electrostatic repulsion with negatively charged amino acids located within the NLS binding pocket of importin-alpha.

While tobacco use remains a leading preventable risk factor for mortality and morbidity in Canada (Patra, Rehm, Baliunas & Popova, 2007), the overall smoking prevalence rate of Canadians has decreased substantially from close to 50% of the population in 1965 to 16.1% of the population in 2012 (Canadian Tobacco Use Monitoring Survey (CTUMS) 2012; Reid, Hammond, Rynard & Burkhalter, 2014). However, up to 85% of individuals with a mental illness continue to use tobacco products (Harris, Parle & Gagne, 2007), contributing to an inequitable distribution of negative health outcomes for this population. Individuals with severe mental illness die an estimated twenty-five years earlier than the general population, with sixty per cent of these deaths due to cardiovascular, pulmonary and infectious disease (Parks, Svendsen, Singer, & Foti, 2006). A recent study that examined specific tobacco-attributable deaths in these populations found that tobacco accounted for 53% of deaths in individuals with schizophrenia, 50% of all deaths for those diagnosed with a depressive disorder, and 48% of all deaths for those with a diagnosis of bipolar disorder (Callaghan et al., 2014). This research project is intended to increase our understanding of what constitutes an effective intervention for smoking cessation and smoking reduction in a population of individuals with severe mental illness who are homeless or vulnerably housed, living in a large urban setting. Two areas of inquiry were proposed. The first inquiry examined data collected as part of a needs assessment to determine the overall prevalence rate of smoking and related behaviours for a population of individuals with severe mental illness receiving services from a community mental health agency. We found that the tobacco use prevalence was 72%, and 62% of smokers had high or very high levels of nicotine dependence; however almost half of respondents (47%) were interested in quitting or reducing tobacco within the next 6 months. Smokers were found to be over 9 times more likely to have a co-occurring substance use disorder (OR=9.44, 95%CI[6.33,14.08]). The second inquiry was a pilot study conducting a randomized controlled trial design to evaluate smoking cessation and smoking reduction outcomes for two groups of individuals (n=61) with severe mental illness receiving different smoking cessation interventions. Clients randomly assigned to the routine Smoking Cessation group (SC-R) received up to 24 weeks of no-cost Nicotine Replacement Therapy (NRT) and clients assigned to the Smoking Cessation Plus group (SC+) received up to 24 weeks of no-cost Nicotine Replacement Therapy (NRT) plus two initial individual sessions of motivational interviewing followed by weekly psychosocial group interventions for up to 24 weeks. Primary outcomes were levels of tobacco use at the 3-month and 6-month follow-up. The 7-day point prevalence abstinence rate measured at 3 months was 21.9% (n=7) for the SC+ group and 13.8% (n=4) for the SC-R group (OR=1.75,95%CI[.46,6.74]). At 6 months, the 7-day point prevalence abstinence rate was 12.5% (n=4) for the SC+ group and 6.9% (n=2) for the SC-R group (OR=1.93, 95%CI[.33,11.41]). Secondary outcomes included change in reported quality of life, physical health and mental health status functioning over the course of the study. We found that there were no statistically significant differences in the smoking quit or smoking reduction rates between the two treatment groups. At the 3-month time point the overall quit rate for both groups combined was 18% (n=11) and at the 6-month time point the quit rate was 10% (n=6). Reduction in the number of daily cigarettes smoked was statistically significant over time (F [1.68, 98.90] = 55.13, p < .001, η p 2 = 0.48) for both groups, as was the overall reduction of the FTND score (F [2, 94] = 17.98, p < .001, η p 2 = 0.28). This research demonstrates that collecting vital tobacco prevalence and dependency information is a straightforward and important task for community mental health agencies. Individuals with mental illness have both the interest and ability to quit or reduce their use of tobacco. Practitioners need to be aware of alternative smoking practices that may contribute to understanding tobacco use patterns and dependence in this population. Other factors such as co-morbid substance use disorder and level of community functioning may influence smoking status and, consequently, how treatment is provided. The findings of the pilot trial demonstrate the feasibility of conducting smoking cessation research with the population. Findings also suggest that a larger definitive trial is warranted to examine the effectiveness of the SC+ intervention. This research adds to the limited but growing knowledge base of how to address tobacco use and provide treatment to this vulnerable group, and will contribute to advances in population health by informing effective interventions with the attendant implications for program and policy development.

L’artésunate est désormais le traitement de référence du paludisme grave au plan mondial. Cependant, des cas d’anémie hémolytique différée ont été décrits chez 20% à 25% des voyageurs traités. L’épisode hémolytique survient 2 à 3 semaines après traitement. Environ la moitié des patients vont nécessiter une transfusion sanguine. L’artésunate induit un phénomène original en physiologie humaine : le “pitting” ou épépinage splénique des érythrocytes parasités. Il consiste en l’expulsion du parasite mort de l’érythrocyte hôte lorsque celui-ci traverse une structure microcirculatoire splénique appelée « fente interendothéliale ». Ces érythrocytes pittés retournent sans destruction immédiate dans la circulation générale. Nous avons étudié l’efficacité et la tolérance de l’artésunate intraveineux chez 123 voyageurs atteints de paludisme grave. Cent dix-sept patients ont survécu (95%). Parmi 78 patients suivis plus de 8 jours, 76 (97%) ont eu une anémie au cours du suivi et 21 une hémolyse différée typique (27%). Dans ce sous groupe de patients la chute médiane en hémoglobine a été de 1,3g/dl avec un nadir <7g/dl dans 15% des cas. Un seul patient a été transfusé. Le marquage de la protéine parasitaire Resa, véritable empreinte de l’infection érythrocytaire par Plasmodium falciparum, permet la visualisation des érythrocytes pittés. Chez 21 patients non transfusés le pic de concentration en érythrocytes pittés est survenu durant la première semaine. Chez 9 patients évoluant vers une hémolyse différée le pic de pittés était significativement plus élevé que chez 12 patients présentant d’autres profils évolutifs d’anémie (0,30 vs. 0,07 ; P = 0,0001). Une concentration d’érythrocytes pittés au pic supérieure à 180 millions/l aurait prédit le risque d’hémolyse différée avec une sensibilité de 89% et une spécificité de 83%. Utilisant la technologie ImageStream* l’étude morphologique érythrocytaire chez 4 patients a montré que l’infection plasmodiale suivi de pitting entraine une réduction de surface projetée de 8,9%. Cette altération pourrait contribuer à la réduction de la durée de vie des érythrocytes pittés. La destruction différée des érythrocytes infectés et épargnés par le pitting durant le traitement par artésunate est un mécanisme original d’anémie hémolytique. Ce travail a permis de structurer l’espace nosologique de l’anémie post-thérapeutique au cours du paludisme, de clarifier la physiopathologie de l’hémolyse différée et d’identifier certains de ses mécanismes. Malgré l’incidence élevée de l’hémolyse différée, l’anémie résultante n’est préoccupante que dans 15% des cas et ne remet pas en cause le bénéfice de l’artésunate par rapport à la quinine dans le traitement du paludisme grave. La concentration précoce des érythrocytes pittés pourrait être un marqueur prédictif intéressant de la survenue d’une hémolyse différée post-artésunate. / Worldwide, artesunate is now the recommended treatment for severe malaria. However cases of delayed hemolytic anemia have been described in 20% to 25% travelers treated with artesunate. The episode usually occurs 2 to 3 weeks after the end of the treatment. About half on the inpatients need blood transfusion. Artesunate induces an original phenomenon called splenic “pitting” of parasitized erythrocyte. The dead parasite is expelled from the host erythrocyte when it comes through a microcirculatory structure called inter-endothelial slit. These pitted red blood cells go back to the general blood circulation without destruction. We have studied efficacy and tolerance of intravenous artesunate in 123 patients with imported severe malaria, of whom 117 have survived (95%). Among 78 patients followed more than 8 days, 76 (97%) suffered from anemia during follow-up and 21 had a typical delayed hemolysis pattern (27%). In this sub group the median loss of hemoglobin was 1.3g/dl with a nadir below 7g/dl in 15% of them. Only one patient was transfused. The labelling of Resa protein, a plasmodium protein included in the bilayer membrane of the red blood cell, allowed the visualization of pitted cells. In 21 patients non transfused, the pitted cells peak occured during the first week post treatment. In 9 patients with typical delayed hemolysis pattern, the pitted cells peak was higher than in the 12 patients with other kind of anemia patterns (0.30 vs. 0.07 ; P = 0.0001). A pitted cells concentration above 180 millions/l would have predicted the risk of late hemolysis with 89% sensitivity and 83% specificity. Red blood cell morphology was studied using ImageStream* technology in 4 patients. It has shown that infection and pitting process induces a membrane projected area loss of 8.9%. This loss could explain the reduced life span of the pitted red blood cells. Differed destruction of the erythrocytes first infected and then spared by pitting process during the treatment with artesunate is a new pattern of hemolytic anemia during malaria. This work has provided a nosological framework of post therapy hemolysis during malaria, a clarified pathophysiology of delayed hemolysis and has identified potential explanatory mechanisms. Notwithstanding the high incidence of hemolysis, the resulting anemia is severe in 15% of the patients and does not jeopardize the advantage of artesunate compared to quinine in the treatment of severe malaria. Early pitted cells concentration could be a surrogate marker to determine the risk of delayed hemolysis and anemia after artesunate treatment.

Bakgrund: Att som barn ha ett svårt sjukt syskon eller förälder är en traumatisk händelse som kan leda till en kris. Då barn uppfattar döden och förluster på olika sätt beroende på person och ålder, bearbetar de även en kris på olika sätt. Det är enligt lag sjuksköterskans ansvar att ta hänsyn till barns behov av stöd i dessa situationer, varpå det är viktigt att ha kunskap om lämpligt tillvägagångssätt. Syfte: Att beskriva hur sjuksköterskan kan ge stöd till barn med ett svårt sjukt syskon eller förälder samt vilka konsekvenser obearbetad sorg kan leda till. Metod: En litteraturstudie som baserades på 11 vetenskapliga artiklar, varav 6 kvalitativa och 5 kvantitativa. Resultatet bearbetades och delades in i två områden baserade på syfte och frågeställningar, därefter identifierades totalt fem kategorier. Resultat: De fem kategorier som identifierades var ge information, inkludera och uppmärksamma, erbjuda samtalsstöd, ångest och depression samt självskadebeteende och substansbruk. Slutsats: För att som sjuksköterska kunna ge stöd till ett barn som har en svårt sjuk förälder eller syskon är det viktigt att informera och inkludera barnet samt erbjuda samtalsstöd. Obearbetad sorg kan leda till ångest och depression samt självskadebeteende och substansbruk. / Background: To have a sibling or parent with a severe illness is a traumatic experience, which can lead to a crisis. Children perceive death and losses in a different way depending on person and age, which makes them cope with a crisis in different ways. Purpose: To describe how the nurse can provide support to children who have a sibling or parent with a severe illness, and the consequences that can occur following unresolved grief. Method: A literature review based on a total of 11 scientific articles, of which six had a qualitative approach and five of quantitative approach. The result was analysed and divided into two areas based on purpose and formulated questions, followed by identifying a total of five categories. Result: The five categories identified were: Give information, include and acknowledge, offer counsellor support, anxiety and depression, self-injury and use of substances. Conclusion: For nurses giving support to children having a sibling or parent with a severe illness it is important to provide the children with information, include them and to offer counsellor support. Unresolved grief can result in anxiety and depression, self-injury and use of substances.

Severe traumatic brain injury (sTBI) is a cause of death and disability worldwide and requires treatment at specialized neuro-intensive care units (NICU) with a multimodal monitoring approach. The CT scan imaging supports the monitoring and diagnostics. The level of S100B and neuron specific enolase (NSE) reflects the severity of the injury. The therapy resistant intracranial hypertension requires decompressive craniectomy (DC). After DC, the cranium must be reconstructed to recreate the normal intracranial physiology as well as to address cosmetic issues. The evolution of the pathological intracranial changes was analyzed in accordance with the three CT classifications: Marshall, Rotterdam and Morris-Marshall. The Rotterdam scale was best in describing the dynamics of the pathological evolution. Both the Rotterdam score and Morris- Marshall classification showed strong correlation with the clinical outcome, a finding that suggests that they could be used for prognostication. We demonstrated a clear correlation between the CT classifications and concentrations of S100B and NSE. The results revealed a concomitant correlation between NSE and S100B and clinical outcome. We found that the interaction between the ICP, Rotterdam CT classification, and concentrations of biochemical biomarkers are all associated with DC. We found a high percentage of complications following cranioplasty. Our results call into question whether custom-made allograft should be considered the best material for cranioplasty. It is concluded that both the Rotterdam and Morris-Marshall classification contribute to clinical evaluation of intracranial dynamics after sTBI, and might be used in combination with biochemical biomarkers for better assessment. The decision to perform DC should include a re-assesment of ICP evolution, CT scan images and concentration of the biochemical biomarkers. Furthermore, when determining whether DC treatment should be used, surgeon should also consider the risks of the following cranioplasty.

Orientadores: Jose Guilherme Cecatti, Mary Angela Parpinelli / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-04T02:12:51Z (GMT). No. of bitstreams: 1 Souza_JoaoPauloDiasde_M.pdf: 201299 bytes, checksum: c4c09ce932de896dc48b404ffe7eba4a (MD5) Previous issue date: 2004 / Resumo: Objetivos: Fazer uma ampla revisão da literatura internacional e nacional, compilando dados publicados sobre a ocorrência de morbidade materna grave (near miss) em diferentes contextos; analisar a ocorrência de near miss em uma maternidade brasileira de nível terciário, utilizando diferentes conjuntos de critérios; e caracterizar os determinantes primários da morbidade grave, sua demanda assistencial e o desfecho materno-fetal. Sujeitos e métodos: a revisão foi realizada a partir da busca eletrônica de artigos publicados e indexados nas bases bibliográficas MedLine e SciELO, além da busca manual em periódico brasileiro e na lista de referências bibliográficas dos artigos identificados pelos unitermos ¿maternal near miss¿. Os artigos foram qualitativamente avaliados pelo tipo de desenho de estudo, procedência, disponibilidade de dados originais e tipo de critério utilizado para a definição de near miss. Foi ainda realizado um estudo descritivo em um centro terciário de referência à saúde da mulher, entre 01 de julho de 2003 e 30 de junho de 2004. De 2.929 mulheres que tiveram parto na instituição, foram identificados os casos de morbidade grave segundo critérios propostos por Mantel e Waterstone, através de visita diária às instalações da maternidade. A revisão dos prontuários e a coleta dos dados de interesse foram realizadas no momento da alta hospitalar. As principais medidas de efeito estudadas foram: a ocorrência de near miss e seus fatores determinantes primários, critério de identificação como near miss, tempo total de permanência hospitalar, tempo de permanência em UTI e número e tipos de procedimentos especiais realizados. Resultados: Foram incluídos na revisão 33 estudos da literatura, com uma razão média de near miss de 7,5/1000 partos. No centro de referência foram identificados 124 casos de near miss, correspondente a uma razão de 42/1000 partos, e ocorreram dois óbitos maternos. Foram realizados 126 procedimentos especiais, 102 deles realizados em mulheres admitidas na UTI para suporte intensivo (80,9%). O número médio de procedimentos especiais por mulher foi de 1,04 (±1,91) e os mais freqüentes foram a instalação de acesso venoso central, a realização de ecocardiografia e a ventilação artificial invasiva. A média de permanência hospitalar foi de 10,3 dias (±13,24). O tempo de permanência hospitalar e o número de procedimentos especiais foram significativamente maiores quando utilizados os critérios de Mantel. Conclusões: A incidência de near miss tende a ser maior nos países em desenvolvimento e quando utilizada a definição de disfunção orgânica. A incidência de near miss foi elevada e os critérios propostos por Mantel permitiram a identificação de um subgrupo de mulheres com manejo clínico mais complexo, considerando-se o tempo de permanência hospitalar e a demanda por procedimentos especiais. Os determinantes primários de morbidade materna grave foram coincidentes com as principais causa básicas conhecidas de morte materna / Abstract: Objectives: to perform a wide review of the international and national literature and to combine reported data on the occurrence of severe maternal morbidity (near miss) in several contexts; to evaluate the occurrence of near-miss in a tertiary Brazilian maternity, using different sets of criteria, to identify their primary determinants, their demand for care and the maternal and fetal outcomes. Methods: the review was performed through an electronic search of the published articles indexed in the bibliographic databases of MedLine and SciELO, besides a manual search in Brazilian journal and in the list of references of the articles identified through the uniterms ¿maternal near miss¿. The articles were qualitatively evaluated according to their study design, local, availability of original data and kind of criteria used for the definition of near miss. A descriptive study was also performed at a tertiary referral center for the women¿s health, between 1st. July 2003 to 30th. June 2004. From the total of 2929 women who delivered at the institution during the period, the cases of maternal near miss morbidity were identified through a daily visit in the wards of the maternity according to the criteria proposed by Mantel and by Waterstone. At the moment of hospital discharge a review of the clinical records and data collection were performed. The main outcome measures studied were the occurrence of near miss and their primary determinant factors, criteria for identification as a near miss case, total time of hospital stay, time of stay in ICU and number and kind of special procedures performed. Results: thirty three studies were identified and evaluated as adequate for inclusion in the review and the mean near miss ratio was 7.5/1000 deliveries. A total of 124 cases of near-miss were identified in the referral center, corresponding to a ratio of 42/1000 deliveries, and there were two maternal deaths. For these cases, 126 special procedures were performed, 102 of them among women admitted in ICU for intensive care (80.9%). The mean number of special procedures by each woman was 1.04 (±1.91) and the most frequent were central venous access, echocardiography and invasive mechanical ventilation. The mean total time of hospital stay was 10.3 days (±13.24). The total time of hospital stay and the number of special procedures were significantly higher when the criteria of Mantel were used. Conclusions: there is a trend of higher incidence of near miss in developing countries and when using the definition of organ dysfunction. The incidence of near miss was high and the criteria proposed by Mantel allowed the identification of a sub-group of women with a more complex clinical management, considering the total time of hospital stay and the demand for special procedures. The primary determinants of severe maternal morbidity were coincident with the main known basic causes of maternal death / Mestrado / Tocoginecologia / Mestre em Tocoginecologia

Orientador: José Guilherme Cecatti / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-26T18:48:20Z (GMT). No. of bitstreams: 1 Souza_RenatoTeixeira_M.pdf: 10640708 bytes, checksum: 93bc984ddc636a415fed23ea6ca3a333 (MD5) Previous issue date: 2015 / Resumo: Introdução: Mais de 15 milhões de bebês nascem prematuros anualmente no mundo, sendo a prematuridade a maior causa de óbitos no período neonatal. A prematuridade terapêutica tem papel importante nesse contexto, pois se estima que 20 a 40% dos partos prematuros ocorrem por indicação dos provedores de assistência obstétrica. Dessa forma, a redução dos partos prematuros terapêuticos adquire cada vez mais importância para o controle da taxa de prematuridade e da morbimortalidade neonatais. O conhecimento dos fatores relacionados ao parto prematuro terapêutico é ponto fundamental para atingir essa redução. Objetivos: Avaliar a ocorrência do parto prematuro terapêutico e seus fatores associados na população do Estudo Multicêntrico de Investigação em Prematuridade (EMIP). Métodos: Análise secundária do EMIP, um estudo brasileiro de caso-controle aninhado a um corte transversal multicêntrico. O estudo ocorreu em 20 hospitais de referência em 3 regiões do Brasil de abril de 2011 a julho de 2012 e realizou a vigilância de 33.740 partos nesse período. O principal desfecho a ser avaliado é a ocorrência de parto prematuro terapêutico, definido como o parto que ocorreu antes de 37 semanas e que foi indicado pela equipe de assistência devido uma condição materna ou fetal. O grupo controle foi composto pelas mulheres com parto a termo. Os partos prematuros foram categorizados, conforme recomendações da Organização Mundial da Saúde, em prematuro extremo, muito prematuros e pretermo moderado Uma quarta categoria de idade gestacional, contemplando apenas os prematuros tardios, também foi analisada. Variáveis relacionadas a características sociodemográficas, pôndero-estaturais e de estilo de vida maternos, características da assistência ao pré-natal e ao parto e sobre a presença de morbidade ou complicação durante a gravidez, parto ou puerpério foram avaliadas na análise de risco para parto prematuro terapêutico. Foi realizada uma análise bivariada para estimar o risco de parto prematuro terapêutico para cada e uma análise multivariada com regressão logística não condicional para obter os fatores independentemente associados ao desfecho. Resultados: O parto prematuro terapêutico foi responsável por 35,4% dos partos prematuros na amostra estudada. As síndromes hipertensivas, o descolamento prematuro de placenta e a diabetes foram as condições que mais frequentemente motivaram a resolução prematura da gravidez. A idade materna avançada, a hipertensão crônica, a obesidade e a gravidez múltipla foram as principais condições maternas relacionadas à ocorrência de parto prematuro terapêutico. Houve uma tentativa de tratamento da condição materna que motivou a resolução em mais de 50% dos casos e 74,5% das mulheres com parto entre 28 e 31 semanas receberam corticoterapia. A cesariana foi a via de parto mais frequente. A proporção de mortalidade neonatal, do Apgar do quinto minuto menor que sete e da admissão em unidade intensiva neonatal foi muito maior nos prematuros terapêuticos do que no termo, mesmo considerando os prematuros tardios. Conclusões: Os resultados do estudo corroboram com a crescente importância do parto prematuro terapêutico, devido sua prevalência e impacto nos resultados perinatais. A gravidez múltipla, idade materna avançada, a obesidade e a presença de morbidades pré-gestacionais são os fatores que requerem especial atenção nas estratégias de prevenção da prematuridade terapêutica / Abstract: Background: More than 15 million babies are born prematurely each year worldwide and its the leading cause of deaths in the neonatal period. Provider-initiated preterm birth (piPTB) plays an important role in this context because it is estimated that 20-40% of preterm births occur by indication of obstetric care providers. Thus, the reduction in piPTB rate acquires more importance to decrease the rate of prematurity and neonatal morbidity and mortality. Knowledge of the factors related to piPTB is a key factor to achieve this reduction. Objectives: To evaluate the occurrence of provider-initiated preterm birth and the associated factors in the Multicenter Study on Preterm Birth in Brazil (EMIP) population. Methods: Secondary analysis of EMIP, a Brazilian multicenter cross-sectional study plus a nested case-control. The study took place in 20 referral hospitals in 3 regions of Brazil from April 2011 to March 2012 and conducted surveillance of 33,740 deliveries in this period. The primary outcome to be evaluated is the occurrence of provider-initiated preterm birth, defined as birth that occurred before 37 weeks and was medically indicated due to maternal or foetal condition. The control group was composed of women with term delivery. Preterm birth was categorized into extremely premature, very premature and moderate preterm, according to the World Health Organization. Another category that includes only the late preterm was also evaluated. Maternal, socio-demographic, obstetrical, prenatal care, delivery and postnatal characteristics were assessed as factors associated with piPTB. A bivariate analysis to estimate the risk for piPTB and a multivariate analysis using unconditional logistic regression for the factors independently associated with piPTB was performed. Results: The therapeutic preterm labor accounted for 35.4% of premature births in the sample. Hypertensive disorders, placental abruption and diabetes were the main conditions related to pi-PTB indications. Advanced maternal age, chronic hypertension, obesity and multiple pregnancy were the main maternal conditions related to pi-PTB. There was an attempt to treat maternal condition that led to the resolution in over 50% of cases and 74.5% of women with birth between 28 and 31 weeks received corticosteroid therapy. Cesarean section was the most frequent mode of delivery. The proportion of neonatal mortality, Apgar score<7 at 5 minutes and NICU admission were much higher in provider-initiated preterm newborns than in term newborns, even considering the late preterms. Conclusions: The results of our study corroborate the increasing notability of provider-initiated preterm birth, due to its prevalence and impact on perinatal outcomes. Multiple pregnancies, advanced maternal age, obesity and the presence of pre-gestational morbidities are the main factors that require special attention in prematurity prevention strategies / Mestrado / Saúde Materna e Perinatal / Mestre em Ciências da Saúde

Orientadores: João Paulo Dias de Souza, José Guilherme Cecatti / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-27T16:41:03Z (GMT). No. of bitstreams: 1 Chaves_SolangedaCruz_M.pdf: 1613021 bytes, checksum: 7d4197dbf48569d759c9b1315425c34b (MD5) Previous issue date: 2015 / Resumo: Objetivos: Avaliar se as características propostas da Transição Obstétrica ¿ um modelo conceitual criado para explicar as mudanças graduais que os países apresentam ao eliminar a mortalidade materna evitável ¿ são observadas em um grande banco de dados multipaíses sobre a saúde materna e perinatal.Métodos: Trata-se de análise secundária de um estudo transversal da OMS que coletou informações de todas as mulheres que deram à luz em 359 unidades de saúde de 29 países da África, Ásia, América Latina e Oriente Médio, durante um período de 2 a 4 meses entre 2010 e 2011. As razões de Condições Potencialmente Ameaçadoras da Vida (CPAV), Resultados Maternos Graves (RMG), Near Miss Materno (NMM), e Mortalidade Materna (MM) foram estimadas e estratificadas por estágio de transição obstétrica. Resultados: Dados de 314.623 mulheres incluídas neste estudo demonstram que a fecundidade das mulheres, indiretamente estimada pela paridade, foi maior nos países que estão em estágio menor da transição obstétrica, variando de uma média de 3,0 crianças por mulher no Estágio II para 1,8 crianças por mulher no Estágio IV. O nível de medicalização do nascimento nas instituições de saúde dos países participantes, avaliada pelas taxas de cesárea e de indução de trabalho de parto, tendeu a aumentar à medida que os estágios de transição obstétrica aumentam. No Estágio IV, as mulheres tiveram 2,4 vezes a taxa de cesáreas (15,3% no Estágio II e 36,7% no Estágio IV) e 2,6 vezes a taxa de indução de trabalho de parto (7,1% no Estágio II e 18,8% no Estágio IV) que as mulheres de países no Estágio II. À medida que os estágios da transição obstétrica aumentaram, a média de idade das primíparas também aumentou. A ocorrência de ruptura uterina apresentou uma tendência decrescente, caindo aproximadamente 5,2 vezes, de 178 para 34 casos para 100 000 nascidos vivos à medida que os países transicionaram do Estágio II para o Estágio IV. Conclusões: Esta análise corroborou o modelo da Transição Obstétrica utilizando um banco de dados de grande porte e multipaíses. O modelo da Transição Obstétrica pode justificar a individualização da estratégia de redução da mortalidade materna de acordo com os estágios da transição obstétrica de cada país / Abstract: Objectives: To test whether the proposed features of the Obstetric Transition Model¿a theoretical framework that may explain gradual changes that countries experience as they eliminate avoidable maternal mortality¿are observed in a large, multicountry, maternal and perinatal health database. Methods: This was a secondary analysis of a WHO cross-sectional study that collected information on all women who delivered in 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East, during a 2¿4-month period in 2010 ¿ 2011. The ratios of Potentially Life-threatening Conditions (PLTC), Severe Maternal Outcomes (SMO), Maternal Near Miss (MNM) and Maternal Death (MD) were estimated and stratified by stages of obstetric transition. Results: Data from 314 623 women showed that female fertility, indirectly estimated by parity, was higher in countries at a lower obstetric transition stage, ranging from a mean of 3 children in Stage II to 1.8 children in Stage IV. The level of medicalization in health facilities in participating countries, defined by the number of caesarean deliveries and number of labor inductions, tended to increase as the stage of obstetric transition increased. In Stage IV, women had 2.4 times the caesarean deliveries (15.3% in Stage II and 36.7% in Stage IV) and 2.6 times the labor inductions (7.1% in Stage II and 18.8% in Stage IV) than women in Stage II. As the stages of obstetric transition increased, the mean age of primiparous women also increased. The occurrence of uterine rupture had a decreasing trend, dropping by 5.2 times, from 178 to 34 cases per 100 000 live births, as a country transitioned from Stage II to IV. Conclusions: This analysis supports the concept of obstetric transition using multicountry data. The obstetric transition model could provide justification for customizing strategies for reducing maternal mortality according to a country¿s stage in the obstetric transition / Mestrado / Saúde Materna e Perinatal / Mestra em Ciências da Saúde