We assessed the relationship between several therapist variables and treatment outcome by examining the predictive power of therapist training/demographic characteristics, therapist competence and treatment integrity, and therapist style, to child outcome in a sample of 279 youth who participated in the Child and Adolescent Anxiety Multimodal Study (CAMS). All youth participated in 14 sessions of CBT (randomly assigned either with medication or without) delivered by trained therapists. Youth across both treatment conditions experienced significant treatment gains with youth in the CBT+MED and CBT only conditions showing greater gains than those in the placebo group. Therapist (a) prior clinical experience and (b) prior anxiety-specific clinical experience were significant predictors of treatment outcome across both parent- and diagnostician- rated measures. Higher levels of prior clinical experience predicted better outcome; higher levels of anxiety-specific experience were less favorable. Therapist treatment integrity, competence, and a collaborative style were also predictive of outcome. Therapists who were more collaborative and empathic, followed the treatment manual, and implemented it in a developmentally appropriate way, had youth with better treatment outcomes. Clinical implications and recommendations for future research are discussed. / Psychology

This study was conducted to analyze various objective measures of treatment outcome among patients that participated in a multidisciplinary chronic pain treatment program and to compare these measures to the absence or presence of antidepressant medication, the level of depression, and the quality of pain and depression reported. In addition, this study examined whether there are certain patient characteristics that are related to treatment outcome measures. Data was collected from the medical records of 232 patients who were admitted to and treated for various chronic pain syndromes at the Lewis-Gale Hospital Pain Center in Salem, Virginia. Results of the study indicate that when chronic pain patients are subdivided into groups based on antidepressant drug use, depression level, reported quality of pain, and depressive symptomatology, there are distinct and significant differences before treatment when between-group comparisons are made. Within-group comparisons revealed significant differences between pre and post test measures for most groups studied, however, those with the most significant changes in scores included those patients on antidepressant medication, those patients with greater cognitive symptoms of depression, and those patients who were non-depressed. Patient characteristics that were significantly related to outcome included age, gender, duration of pain, employment, workers compensation, and litigation status. / Ph. D.

Using 12-month post treatment Timeline Followback drinking reports, data extrapolated from shorter time windows (e.g., 1 month, 6 months) were used to estimate total annual drinking. The objective was to determine whether data from a shorter time window would provide an estimate of annual drinking sufficiently consistent with the full year report such that it can be used in place of the full report. Data for this study were obtained from problem drinkers who voluntarily participated in a randomized controlled trial of a mail-based intervention. Complete follow-up data were obtained for 467 of the 825 participants who completed a 12-month Timeline Followback of their post intervention drinking. The results of this study suggest that 3 months is the necessary minimum time window to best represent annual posttreatment drinking with alcohol abusers. The major implication of this finding is that alcohol treatment outcome studies can use a shorter posttreatment time window, which is more time and resource efficient, over which to obtain follow-up data with little to no loss in the representativeness of that data.

Motivational Interviewing (MI) is an evidence-based, directive, client-centered therapy designed to develop discrepancy and resolve ambivalence by eliciting and reinforcing client Change Talk. However, the exact link between the process engaged in during MI and outcome is only starting to be uncovered. The present thesis has replicated and expanded on the current knowledge of the relationship between Therapist and Client Behaviours during a MI-based intervention (Motivational Enhancement Therapy; MET) and outcome, and has provided support for the emergent theory of the inner workings of MI. This was achieved by coding 106 audiotaped MET sessions primarily by the methods outlined in the Motivational Interviewing Skill Code Version 2.0. Data was drawn from 28 participants who received 3-4 sessions of MET within the context of a randomised controlled trial for mild-moderate alcohol dependence at the Community Alcohol and Drug Service of Christchurch. Therapist and Client Behaviours were analysed within sessions (categorised into Early, Mid, or End Intervals) and across sessions, and compared with whether the client had drank within national drinking guidelines during the 6-months after MET (Controlled Drinkers). In terms of Client Behaviours during MET it was found that Uncontrolled Drinkers (compared with Controlled Drinkers) uttered a significantly higher frequency of Sustain Talk, lower Ability Language strength (over all MET and during End Intervals), and lower Commitment Language strength (during Session 2 and 4, and change over MET). Giving Information was the only Therapist Behaviour where significant differences were observed over all MET, with a higher frequency given to the Uncontrolled Drinkers. However, during End Intervals within MET Sessions, Controlled Drinkers received a significantly higher frequency of Advise without Permission and a lower frequency of Emphasise Control statements. In most instances MI-Consistent Therapist Behaviours were associated with higher strength of Ability and Commitment Language, and a lower frequency of Sustain Talk. MI-Inconsistent Therapist Behaviour, Direct, was associated with lower Client Language strength. Limitations to these results include small sample, limited ability to make inferences about causality, coder biases, and uneven reliability. However, this exploratory study was unique in investigating the relationship between Therapist Behaviours and the strength of Client Language, and in examining these factors within and across multiple sessions, and has produced a number of potentially valuable findings that warrant further investigation.

Introdução: A carga da tuberculose (TB) no Brasil ainda é expressiva e a proporção de desfechos de tratamento desfavoráveis é elevada. Para tornar mais efetivas as atividades de controle da TB, implantou-se, em 2010, o esquema terapêutico de dose fixa combinada (RHZE). Contrastando com bons indicadores socioeconômicos, o município de Santos (SP) ainda apresenta elevadas taxas de incidência de TB e de abandono de tratamento. Objetivos: Descrever a tuberculose pulmonar (TBP), os principais desfechos de tratamento em período prévio e posterior a introdução do esquema terapêutico de dose fixa combinada (RHZE), no município de Santos. Métodos: Estudo descritivo, abrangendo pacientes com TBP diagnosticados por critérios clínico-radiológicos ou bacteriológicos, com 15 anos ou mais, residentes, e cujo primeiro tratamento com esquema RHZ ou RHZE ocorreu no município de Santos entre 01/01/2008 a 31/12/2014. As definições de caso são as adotadas pelo Programa Nacional de Controle da Tuberculose (PNCT). As variáveis estudadas foram características sociodemográficas, aspectos relativos ao diagnóstico e tratamento, comorbidades e características do serviço de saúde. A análise descritiva se fez por coortes de pacientes definidas segundo o ano do primeiro tratamento. Para as análises comparativas de proporções aplicaram-se os testes qui-quadrado de Pearson, Exato de Fisher e qui-quadrado de tendência e para variáveis contínuas o de Kruskal - Wallis. Resultados: Dos 1603 pacientes estudados, 67,2 % eram do sexo masculino, a mediana de idade foi de 39 anos, 44,4% com escolaridade entre 8 e 11 anos de estudo, 53,6% de etnia branca, 11,5% coinfectados TB/HIV; 55,0% descoberto por demanda ambulatorial, 60,9% submetidos ao tratamento supervisionado e 17,8% hospitalizados durante o tratamento. Comparando a coorte de pacientes com início de tratamento em 2008 com a de 2014, verificamos a elevação da escolaridade com 12 anos ou mais de estudo (11,3% versus 22,0%; p=0,059, X2 tendência), de privados de liberdade (0,9% versus 2,1%; p=0,026, X2 tendência), de doentes mentais (0,4% versus 3,0%; p=0,027, X2 tendência), de casos descobertos por elucidação diagnóstica (7,4% versus 12,6%; p=0.049, X2 tendência), de atendidos na Unidade Básica de Saúde (79,3% versus 90,1%; p < 0,0001, X2 tendência), de contatos investigados (1,3% versus 4,8%; p=0,040, X2 tendência). Por sua vez, houve declínio na proporção de coinfecção TB/HIV (13,2% versus 8,6%; p=0,018, X2 tendência), e hospitalizações durante o tratamento (21,6% versus 12,9%; p < 0,0001, X2 tendência). Foram tratados inicialmente com esquema RHZ 29,8% (477/1603) e 70,2% (1126/1603) com esquema RHZE. A taxa de cura manteve-se em torno de 80,0%. Por outro lado, houve declínio da proporção de retratamento pós-cura (4,7% versus zero; p < 0,0001, X2 de tendência); de óbitos por TB (3,4% versus 0,9%; p=0,090, X2 tendência), e óbitos por outras causas (3,4% versus 2,1%; p=0,028, X2 tendência). O abandono de tratamento manteve-se em torno de 13,7%, sendo que 70,0% (154/220) deles, não retornaram para retratamento. Conclusão: Após a introdução do RHZE, verificou-se a diminuição da gravidade da TB, mas as taxas de cura e de abandono não se alteraram significativamente, além disso, elevada proporção dos que abandonaram o tratamento não retornaram aos serviços. Tais resultados sugerem a necessidade de estratégias adicionais com vistas a elevar a adesão ao tratamento da TB com foco em grupos de maior risco para abandono de tratamento / Background: The burden of tuberculosis (TB) in Brazil is still expressive and the proportion of unfavorable treatment outcomes is high. In order to make TB control activities more effective, the four-drug fixed-dose combination (RHZE) was implemented in 2010. Despite good socioeconomic indicators, the city of Santos (Sao Paulo, Brazil) still presents high rates of TB incidence and treatment abandonment. Objectives: To describe both pulmonary tuberculosis (PTB) and the main treatment outcomes in the period before and after the introduction of the four-drug fixed-dose combination regimen (RHZE) in the city of Santos. Methods: Descriptive study covering patients living in Santos, 15 years of age or older, with PTB diagnosed by bacteriological or clinical and radiological criteria whose first treatment with either regimen (RHZ) or RHZE occurred in the city of Santos between 01/01/2008 and 12/31/2014. Case definitions are those adopted by Brazil\'s National TB Control Program (NTP). The variables of interest were sociodemographic characteristics, aspects related to diagnosis and treatment, comorbidity and health service characteristics. The descriptive analysis was done by cohorts of patients defined according to the year of their first treatment. We used Pearson\'s chi-square test, Fisher\'s exact test and chi-square test for trend for comparative proportions analyzes and the Kruskal-Wallis test for the continuous variables. Results: Of the 1603 cases studied, 67.2% were male, 39 years old on average, 44.4% had 8 to 11 years of schooling, 53.6% were white, 11.5% had TB/HIV coinfection; 55.0% were discovered by outpatient lab testing, 60.9%were under supervised treatment and 17.8%were hospitalized during treatment. When we compared the 2008 and 2014 cohorts, we found an increase of 12 years of schooling or more (11.3% versus 22.0%; p=0.059, X2 trend), prisoners (0.9% versus 2.1%; p =0.026, X2 trend), mentally ill (0.4% versus 3.0%; p=0.027, X2 trend),cases detected by diagnostic elucidation (7.4% versus 12.6%; p=0.049, X2 trend), patients seen at a Local Health Care Center (79.3% versus 90.1%; p < 0.0001, X2 trend) and investigated household contacts (1.3% versus 4.8%; p=0.040, X2 trend). However, there was decline in the proportion of TB/HIV coinfection (13.2% versus 8.6%; p=0.018, X2 trend) and hospitalizations during treatment (21.6% versus 12.9%; p < 0.0001, X2 trend). 29.8% (477/1603) were initially treated with the RHZ regimen and 70.2% (1126/1603) with the RHZE regimen. The cure rates remained at around 80.0%. However, there was a decline in the proportion of post-cure retreatment (4.7% versus zero; p < 0.0001, X2 trend); deaths from TB (3.4 % versus 0.9%; p=0.090, X2 trend) and deaths from other causes (3.4% versus 2.1 %; p=0.028, X2 trend). Treatment abandonment remained at around 13.7% while (154/220) cases, (70.0%), did not return for retreatment. Conclusion: After the introduction of the RHZE regimen, there was a decrease in TB severity. Nevertheless, treatment abandonment and cure rates showed no significant change. Moreover, a high proportion of patients who abandoned treatment did not return for retreatment. Such results suggest the necessity of additional strategies to improve patient adherence to TB treatment focusing on patients at high risk of abandoning the treatment

O objetivo do estudo foi comparar as características cefalométricas iniciais da má oclusão da Classe II completa entre dois grupos divididos pelo tipo de protocolo de tratamento: sem extrações e extrações de dois pré-molares superiores e verificar a influência das características cefalométricas iniciais dos grupos na proporção de sucesso dos resultados oclusais ao final do tratamento. A amostra constituiu de 84 pacientes com má oclusão de Classe II completa e os grupos foram divididos com as seguintes características: grupo 1 consistiu de 31 pacientes tratados sem extrações com idade média de 12.95 anos e o grupo 2 consistiu de 53 pacientes tratados com extrações de dois pré-molares superiores, com idade média de 13.3 anos. As condições oclusais inicial e final foram avaliadas nos modelos de gesso utilizando o Índice de Prioridade de Tratamento de Grainger (IPT) e as características cefalométricas iniciais foram obtidas em telerradiografias ao início do tratamento. As características cefalométricas iniciais dos grupos foram comparadas pelo test t. A análise de regressão linear múltipla foi utilizada para avaliar a influência de todas as variáveis cefalométricas iniciais e do tipo de protocolo de tratamento na proporção de sucesso oclusal (porcentagem de redução do IPT). O protocolo de extrações de dois pré-molares superiores demonstrou uma porcentagem de alteração oclusal significantemente maior que o protocolo sem extrações. O grupo com extrações de dois pré-molares superiores apresentou crescimento ligeiramente mais vertical, protrusão dos incisivos superiores e inferiores, maior altura dentoalveolar dos incisivos e molares superiores ao início do tratamento e lábios superiores e inferiores mais protruídos em relação ao grupo sem extrações. Contudo, a análise de regressão linear múltipla demonstrou que somente o protocolo de extrações apresentou influência na proporção de sucesso dos resultados oclusais entre os dois grupos. Portanto, as características cefalométricas iniciais dos dois grupos não influenciam na proporção de sucesso oclusal dos dois tipos de protocolos de tratamento da má oclusão de Classe II completa. / The objective of this investigation was to compare the initial cephalometric characteristics of complete Class II, treated without extractions or 2 premolar extractions and to verify their influence in the occlusal success rate of these two treatment protocols. A sample of 84 records from patients with complete Class II division 1 malocclusion was divided into two groups with the following characteristics: Group 1 consisted of 31 patients treated without extractions at an initial mean age of 12.95 years; and Group 2 included 53 patients treated with 2 premolar extractions, with an initial mean age of 13.3 years. Initial and final occlusal status were evaluated on dental casts with Grainger?s treatment priority index (TPI) and the initial cephalometric characteristics were obtained on the pretreatment cephalograms. The initial cephalometric characteristics of the groups were compared by t test. A multiple linear regression analysis was used to evaluate the influence of all variables in the percentage of TPI reduction. The two maxillary premolar extraction cases presented a slight vertical growth pattern, maxillary and mandibulr incisior protrusion, greater maxillary incisor and molar dentoalveolar heights and greater upper and lower lip protrusion than the nonextraction group. However, the multiple linear regression analysis demonstrated that only the extraction protocol was significantly associated with the final occlusal status of the groups. It was concluded that the initial cephalometric characteristics of the groups did not influence the occlusal success rate of the two treatment protocols investigated.

O objetivo do estudo foi comparar as características cefalométricas iniciais da má oclusão da Classe II completa entre dois grupos divididos pelo tipo de protocolo de tratamento: sem extrações e extrações de dois pré-molares superiores e verificar a influência das características cefalométricas iniciais dos grupos na proporção de sucesso dos resultados oclusais ao final do tratamento. A amostra constituiu de 84 pacientes com má oclusão de Classe II completa e os grupos foram divididos com as seguintes características: grupo 1 consistiu de 31 pacientes tratados sem extrações com idade média de 12.95 anos e o grupo 2 consistiu de 53 pacientes tratados com extrações de dois pré-molares superiores, com idade média de 13.3 anos. As condições oclusais inicial e final foram avaliadas nos modelos de gesso utilizando o Índice de Prioridade de Tratamento de Grainger (IPT) e as características cefalométricas iniciais foram obtidas em telerradiografias ao início do tratamento. As características cefalométricas iniciais dos grupos foram comparadas pelo test t. A análise de regressão linear múltipla foi utilizada para avaliar a influência de todas as variáveis cefalométricas iniciais e do tipo de protocolo de tratamento na proporção de sucesso oclusal (porcentagem de redução do IPT). O protocolo de extrações de dois pré-molares superiores demonstrou uma porcentagem de alteração oclusal significantemente maior que o protocolo sem extrações. O grupo com extrações de dois pré-molares superiores apresentou crescimento ligeiramente mais vertical, protrusão dos incisivos superiores e inferiores, maior altura dentoalveolar dos incisivos e molares superiores ao início do tratamento e lábios superiores e inferiores mais protruídos em relação ao grupo sem extrações. Contudo, a análise de regressão linear múltipla demonstrou que somente o protocolo de extrações apresentou influência na proporção de sucesso dos resultados oclusais entre os dois grupos. Portanto, as características cefalométricas iniciais dos dois grupos não influenciam na proporção de sucesso oclusal dos dois tipos de protocolos de tratamento da má oclusão de Classe II completa. / The objective of this investigation was to compare the initial cephalometric characteristics of complete Class II, treated without extractions or 2 premolar extractions and to verify their influence in the occlusal success rate of these two treatment protocols. A sample of 84 records from patients with complete Class II division 1 malocclusion was divided into two groups with the following characteristics: Group 1 consisted of 31 patients treated without extractions at an initial mean age of 12.95 years; and Group 2 included 53 patients treated with 2 premolar extractions, with an initial mean age of 13.3 years. Initial and final occlusal status were evaluated on dental casts with Grainger?s treatment priority index (TPI) and the initial cephalometric characteristics were obtained on the pretreatment cephalograms. The initial cephalometric characteristics of the groups were compared by t test. A multiple linear regression analysis was used to evaluate the influence of all variables in the percentage of TPI reduction. The two maxillary premolar extraction cases presented a slight vertical growth pattern, maxillary and mandibulr incisior protrusion, greater maxillary incisor and molar dentoalveolar heights and greater upper and lower lip protrusion than the nonextraction group. However, the multiple linear regression analysis demonstrated that only the extraction protocol was significantly associated with the final occlusal status of the groups. It was concluded that the initial cephalometric characteristics of the groups did not influence the occlusal success rate of the two treatment protocols investigated.

INTRODUÇÃO: A pesquisa de fatores que possam reconhecer precocemente quais serão os pacientes portadores de HAI com boa evolução ou aqueles que serão resistentes ao tratamento, levaria a um melhor planejamento da terapia. OBJETIVOS: Determinar se fatores laboratoriais pré-tratamento, e o tempo necessário para atingir remissão clínico-laboratorial são preditivos de remissão histológica ou melhora do grau arquitetural na HAI tipo1 em crianças. MÉTODOS: Estudo retrospectivo com 50 crianças portadoras de hepatite autoimune tipo 1 acompanhadas na Unidade de Hepatologia Pediátrica do Instituto da Crianças HC- FMUSP, no período de 1992 a 2012. Realizado revisão de 93 biópsias hepáticas às cegas por um único patologista. RESULTADOS: Foram selecionadas 40 crianças segundo critérios de inclusão. Na biópsia inicial a atividade inflamatória grau 4 e cirrose eram predominantes (31 pacientes-77,5%), sendo que na biópsia de controle, 17 crianças atingiram remissão histológica e 11 melhora do grau arquitetural. Não encontramos valores estatísticos dos fatores laboratoriais ao diagnóstico em relação à remissão histológica. Já em relação à arquitetura, os exames bilirrubina total (p=0,02) e direta (p=0,04) e o tempo de Protrombina (p=0,07) foram relacionados à melhora do grau arquitetural quando apresentavam valores com menor alteração. O tempo necessário para atingir remissão clínico-laboratorial não apresentou correlação com a melhora do padrão inflamatório ou arquitetural. O tratamento foi suspenso em 14 crianças, com taxa de recaída de 50%, em que a maioria ainda apresentava atividade inflamatória na histologia. O tempo de tratamento foi maior nas crianças que evoluíram com remissão sustentada depois de retirada da medicação. CONCLUSÕES: Observou-se em nosso estudo que os fatores laboratoriais ao diagnóstico, independente de seu grau de alteração, não podem predizer quais as crianças que evoluirão para remissão histológica. As crianças com menor grau de alteração de bilirrubina total e direta e tempo de Protrombina, são as que evoluíram com reversão da fibrose hepática. O tempo necessário para atingir a remissão clínico-laboratorial não foi fator preditivo de melhora histológica. Recaída depois da suspensão do tratamento foi associada a presença de atividade inflamatória, e os pacientes em remissão sustentada são os com maior tempo de tratamento / INTRODUCTION: The study of factors that can recognize, earlier, which patients will be carrying autoimmune hepatitis presenting good outcome or those who will be resistant to treatment, would lead to a much better therapy planning. This study aims to: determine whether pretreatment laboratory factors and the time required for achieving clinical and laboratory remission are predictors of histological remission or improvement of the architectural degree in AIH type 1 in children. METHODS: A retrospective study of 50 children with autoimmune hepatitis type 1 accompanied by the Pediatric Hepatology Unit of the Institute of Children HC- FMUSP between 1992 and 2012. A review of 93 liver biopsies was randomly conducted by a single pathologist. RESULTS: Forty children were selected according to criteria of inclusion. In the initial biopsy the inflammatory activity level 4 and cirrhosis were predominant (31 patients-77, 5%), in the control biopsy 17 patients achieved histological remission and 11 presented improvement in the architectural degree. We found no statistical values of the diagnostic laboratory factors in relation to histological remission. Regarding the architecture, the exams total bilirubin (p = 0.02) and direct bilirubin (p = 0.04) and prothrombin time (p = 0.07) were related with the improvement of the architectural level when presented the values with lower changes. The time required for achieving clinical and laboratory remission presented no correlation with the improvement of the inflammatory or architectural pattern. The treatment was suspended in 14 children with relapse rate of 50%, in most of them the inflammatory activity still present on histology. The length of treatment was longer in children who developed sustained remission after the withdrawal of medication. CONCLUSIONS: We observed in our study that the laboratory factors for the diagnosis, regardless their degree of alteration, can not predict which children will progress to histological remission. The children who presented lower degrees of change in total and direct bilirubin and prothrombin time are those who have progressed to reversal of liver fibrosis. The time required for achieving clinical and laboratory remission was not a predictive factor for histological improvement. Relapse after discontinuation of treatment was associated to the presence of inflammatory activity, and patients with sustained remission are the ones who had longer period of treatment

A vertigem de posicionamento paroxística benigna (VPPB) é a síndrome mais freqüente em ambulatório especializado. Caracteriza-se por ataques de vertigem de curta duração e é diagnosticada através de nistagmo típico desencadeado pela manobra de Dix-Hallpike. Do ponto de vista fisiopatológico a VPPB é explicada pela teoria da canalolitíase, um processo no qual partículas flutuam livremente pela endolinfa do canal semicircular. Em 1980 Brandt e Daroff foram os primeiros a sugerir que a VPPB pudesse ser tratada com exercícios por ser um problema mecânico do labirinto. Posteriormente Semont e col., em 1988 e Epley em 1992 propuseram outras manobras com boa eficácia após duas sessões de tratamento. Recentemente foi proposta a manobra de Epley modificada para tratamento domiciliar. Os objetivos deste estudo foram: (1) avaliar a viabilidade do tratamento domiciliar da VPPB; (2) comparar a eficácia da manobra de Semont, de Epley modificada e de Brandt- Daroff; (3) avaliar a eficácia destas manobras após duas e quatro semanas de tratamento domiciliar; (4) analisar o efeito de uma segunda manobra no caso de falha da primeira; (5) avaliar se ajuda de familiares e acurácia na realização das manobras interfere nos resultados; e (6) determinar possíveis fatores prognósticos da VPPB. Sessenta pacientes (38 mulheres) com idade de 26 a 87 anos (média 63.5) foram distribuídos aleatoriamente em três opções terapêuticas - manobra de Brandt-Daroff, de Semont e de Epley modificada. Todos os pacientes apresentavam nistagmo típico de VPPB do canal posterior no teste de posicionamento. Dez pacientes não compareceram aos retornos. Os 50 pacientes restantes ficaram distribuídos da seguinte maneira: manobra de Brandt-Daroff, n=17, manobra de Semont, n=18; manobra de Epley modificada, n=15. Cada exercício deveria ser realizada em três sessões diárias, que consistiam de 10 repetições para a manobra de Brandt-Daroff , e três para a de Semont e Epley modificada. Na primeira consulta a manobra selecionada era realizada com o auxílio do examinador e em seguida o paciente executava o exercício sem sua ajuda. As reavaliações foram feitas com intervalos de uma ou duas semanas. Foi considerada resolução total apenas naqueles pacientes sem vertigem e sem nistagmo no teste de posicionamento. Nos retornos o paciente demonstrava a manobra para determinar a acurácia na sua realização. Após sete dias os pacientes com resolução total eram instruídos a interromper a manobra, enquanto aqueles sem remissão mantinham o tratamento por mais sete dias. Após 14 dias de tratamento domiciliar houve resolução total em 29% dos pacientes realizaram a manobra de Brandt-Daroff, em 72% dos que fizeram a de Semont e em 80% daqueles que fizeram a de Epley modificada (p=0,019, log rank test). Vinte pacientes permaneceram sintomáticos após 14 dias. Destes, 11 foram instruídos a manter o tratamento inicial por mais duas semanas (grupo 1), oito receberam a orientação de realizar uma segunda manobra pelo mesmo período (grupo 2), e uma paciente não compareceu aos retornos. Cinco pacientes (45%) do grupo 1 e cinco (62%) do grupo 2 tiveram resolução total após 14 dias. As conclusões deste estudo foram as seguintes: (1) o tratamento domiciliar da VPPB é possível e leva a bons resultados; (2) as manobras de Semont e de Epley modificada são semelhantes entre si e melhores que a de Brandt-Daroff; (3) metade dos pacientes que permaneceram sintomáticos após duas semanas se beneficiaram de um período adicional de duas semanas de tratamento; (4) o efeito obtido com a manutenção da manobra inicial por mais duas semanas foi semelhante àquele obtido com a realização de uma segunda manobra pelo mesmo período; (5) pequenos erros e ajuda de familiares não interferiram nos resultados e (6) idade, gênero, etiologia e duração dos sintomas antes do inicio do tratamento não modificaram o prognóstico da VPPB / Benign paroxysmal positioning vertigo (BPPV) is the most common syndrome in a dizziness unit. It is characterized by brief attacks of vertigo and can be easily diagnosed with the Dix-Hallpike test on the basis of its typical nystagmus. Canalolithiasis, a process in which free particles float freely within the endolymph of the semicircular canal, is the underlying mechanism of BPPV. In 1980 Brandt and Daroff, were the first to suggest that BPPV could be treated by simple exercises because of its mechanical pathogenesis. Later Semont and colleages in 1988 and Epley in 1992 proposed different maneuvers, which reportedly yielded good results after two treatment sessions. Recently a modified Epley maneuver was proposed for use as self-treatment of BPPV. The aims of our study were: (1) to analyze the efficacy of self treatment (2) to compare the efficacy of Semont maneuver, modified Epley maneuver, and Brandt-Daroff exercises during self-treatment of posterior BPPV; (3) to evaluate the efficacy of these maneuvers after two and four weeks of self-treatment; (4) to analyze the effect of a second maneuver if the first one failed; (5) to evaluate if assistance of relatives or inaccuracies in performing the maneuvers may interfere in the results; and (6) to determine possible prognostic factors of BPPV . Sixty patients (38 women) aged 26 to 87 years (mean 63.5) were randomly assigned for one of the three treatment options: Semont maneuver, modified Epley maneuver, and Brandt- Daroff exercises. All patients showed a typical nystagmus of posterior canal-BPPV during the positional test. Ten patients were lost to follow-up and therefore not included in the analysis. The remaining 50 patients were distributed among the treatment options as follows: Brandt-Daroff exercises, n=17; Semont maneuver, n=18; modified Epley maneuver, n=15. Each treatment option had to be performed in three daily sessions consisting of 10 repetitions for Brandt-Daroff exercises and 3 repetitions for Semont maneuver and modified Epley maneuver. On the first visit the assigned maneuver was done with the examiner assistance and afterwards it was performed by the patient alone. Clinical revaluation occurred on weekly intervals. BPPV was considered resolved only in those patients who had neither vertigo nor nystagmus on the positional testing. Patients were asked to demonstrate the maneuver, so that their accuracy could be determined. After 7 days those patients in whom BPPV had resolved were instructed to interrupt the maneuver, whereas those without remission were required to perform the same initial maneuver for another 7 days. After 14 days of self-treatment the remission rates were 29% for those performing BDE, 72% for SM and 80% for MEM (p=0,019, log rank test). Twenty patients were still symptomatic after 14 days, 11 of these patients were instructed to perform the same initial procedure (group 1), 8 were instructed to execute another maneuver (group 2), and 1 was missed to follow-up (Table 1). Five (45%) patients in group 1 and five (62%) in group 2 were asymptomatic after another 14 days of treatment (p=0,93, log rank test;). We conclude from our data that (1) self-treatment of BPPV has a good efficacy ; (2) SM and MEM are both equally efficient and better than BDE; (3) half of all patients who remain symptomatic after a 2-week treatment, may benefit from a 4-week self-treatment; (4) equivalent results are achieved by performing one or two maneuvers during a 4-week self-treatment; (5) accurate performance and assistance of relatives did not improve the outcome; and (6) age, gender, etiology, duration of symptoms before treatment were not predictive of outcome

Ho Man Choi. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2006. / Includes bibliographical references (leaves 178-215). / Abstracts and appendices in English and Chinese. / ACKNOWLEDGEMENT --- p.ii / ABSTRACT --- p.iii / 研究摘要 --- p.vi / Chapter CHAPTER 1 --- INTRODUCTION / Chapter 1.1. --- Heroin --- p.1 / Chapter 1.1.1. --- Manufacture --- p.1 / Chapter 1.1.2. --- Administration --- p.2 / Chapter 1.1.3. --- Physical and Psychological Effects --- p.4 / Chapter 1.1.4. --- Heroin Metabolism --- p.5 / Chapter 1.1.5. --- Treatments for Heroin Dependence --- p.6 / Chapter 1.2. --- Opioids and Analgesia --- p.8 / Chapter 1.2.1. --- Pain Transmission --- p.8 / Chapter 1.2.2. --- Pain Modulation and Endogenous Opioid System --- p.9 / Chapter 1.2.3. --- Clinical Application of Opiates in Pain Management --- p.11 / Chapter 1.2.4. --- Narcotics and Pain --- p.11 / Chapter 1.3. --- Biological Basis of Drug Addiction --- p.12 / Chapter 1.3.1. --- Mesocorticolimbic Reward System --- p.13 / Chapter 1.3.2. --- Molecular Neurobiology of Drug Addiction --- p.16 / Chapter 1.3.2.1. --- "Cyclic Adenosine-3',5'-Monophosphate and Protein Kinase A" --- p.16 / Chapter 1.3.2.2. --- Transcription Factors: cAMP-Response Element Binding Protein and Delta-Fos B --- p.18 / Chapter 1.3.2.3. --- Neurotrophic Factors --- p.23 / Chapter 1.4. --- Biological Basis of Relapse --- p.25 / Chapter 1.4.1. --- Environmental Stimuli --- p.26 / Chapter 1.4.2. --- Drug Re-exposure/Priming --- p.26 / Chapter 1.4.3. --- Acute Stress Exposure --- p.27 / Chapter 1.5. --- Gene Polymorphisms and Opioid Dependence --- p.30 / Chapter 1.5.1. --- Opioidergic System --- p.31 / Chapter 1.5.2. --- Dopaminergic System --- p.36 / Chapter 1.5.3. --- Serotoninergic System --- p.41 / Chapter 1.5.4. --- Noradrenergic System --- p.43 / Chapter 1.5.5. --- GABAergic System --- p.44 / Chapter 1.6. --- Aim of Research --- p.45 / Chapter CHAPTER 2 --- METHODS OF STUDY / Chapter 2.1. --- Subject Recruitment and Demographic Data Collection --- p.49 / Chapter 2.1.1. --- Heroin-dependent Subjects --- p.49 / Chapter 2.1.1.1. --- Phenotype Assessment --- p.49 / Chapter 2.1.1.2. --- Socio-demographics Data and Substance Use History --- p.50 / Chapter 2.1.1.3. --- Addiction Severity Index (ASI) --- p.51 / Chapter 2.1.1.4. --- History of Detoxifications and Relapse --- p.51 / Chapter 2.1.2. --- Control Subjects --- p.51 / Chapter 2.2. --- Pain Response Assessment using Cold-Pressor Test (CPT) --- p.52 / Chapter 2.3. --- Personality Trait Assessment --- p.53 / Chapter 2.4. --- Genotype Analysis --- p.55 / Chapter 2.4.1. --- DNA Extraction --- p.55 / Chapter 2.4.2. --- Genotyping --- p.56 / Chapter 2.4.2.1. --- MORA118G --- p.56 / Chapter 2.4.2.2. --- DOR T921C --- p.56 / Chapter 2.4.2.3. --- COMTVal108/158Met --- p.57 / Chapter 2.4.2.4. --- Prodynorphin 68bp-VNTR --- p.58 / Chapter 2.4.2.5. --- DRD2 TaqI A --- p.59 / Chapter 2.4.2.6. --- DRD4 -521C/T --- p.59 / Chapter 2.4.2.7. --- 5HT1B G861C --- p.60 / Chapter 2.5. --- Saliva Collection and Salivary Cortisol Measurement --- p.61 / Chapter 2.6. --- Statistical Analysis --- p.62 / Chapter CHAPTER 3 --- RESULTS / Chapter 3.1. --- Demographics --- p.64 / Chapter 3.1.1. --- Age --- p.64 / Chapter 3.1.2. --- Ethnicity --- p.64 / Chapter 3.1.3. --- District of Residence and Type of Housing --- p.64 / Chapter 3.1.4. --- "Education, Employment and Income" --- p.68 / Chapter 3.1.5. --- ASI Scores --- p.71 / Chapter 3.1.5.1. --- Family/Social Relationship --- p.71 / Chapter 3.1.5.2. --- Employment and Support Status --- p.73 / Chapter 3.1.5.3. --- Medical Status --- p.73 / Chapter 3.1.5.4. --- Legal Status --- p.75 / Chapter 3.1.5.5. --- Psychiatric Status --- p.75 / Chapter 3.1.5.6. --- Drug Use Status --- p.76 / Chapter 3.1.5.7. --- Alcohol Use Status --- p.79 / Chapter 3.1.6. --- Tranquillizer Use Status --- p.79 / Chapter 3.1.7. --- Smoking Status --- p.81 / Chapter 3.1.8. --- Detoxification and Relapse --- p.83 / Chapter 3.2. --- Cold-Pressor Test (CPT) --- p.88 / Chapter 3.3. --- Personality Traits --- p.90 / Chapter 3.3.1. --- NEO PI-R --- p.90 / Chapter 3.3.2. --- BIS/BAS --- p.93 / Chapter 3.3.3. --- SSS-V --- p.93 / Chapter 3.4. --- Salivary Cortisol Levels --- p.93 / Chapter 3.5. --- Genotype and Allele Frequencies of Gene Polymorphisms --- p.96 / Chapter 3.5.1. --- MOR A118G Polymorphism --- p.96 / Chapter 3.5.2. --- DOR T921C Polymorphism --- p.96 / Chapter 3.5.3. --- COMT Val108/158Met Polymorphism --- p.99 / Chapter 3.5.4. --- Prodynorphin 68bp-VNTR --- p.99 / Chapter 3.5.5. --- DRD2 TαqI A Polymorphism --- p.102 / Chapter 3.5.6. --- DRD4 -521C/T Polymorphism --- p.102 / Chapter 3.5.7. --- 5HT1B G861C Polymorphism --- p.105 / Chapter 3.6. --- "Association of Gene Polymorphisms, Personality Traits and CPT" --- p.105 / Chapter 3.7. --- Association of Gene Polymorphisms and CPT --- p.108 / Chapter 3.7.1. --- COMT Val108/158Met Polymorphism --- p.108 / Chapter 3.7.2. --- DRD4 -521C/T Polymorphism --- p.108 / Chapter CHAPTER 4 --- DISCUSSIONS AND CONCLUSIONS / Chapter 4.1. --- Demographics and Potential Environmental Factors of Relapse --- p.111 / Chapter 4.1.1. --- Medical and Psychological Status --- p.114 / Chapter 4.1.2. --- Substance Use Status --- p.116 / Chapter 4.1.3. --- Detoxification and Relapse --- p.118 / Chapter 4.2. --- Cold-Pressor Test (CPT) --- p.121 / Chapter 4.3. --- Personality Traits --- p.123 / Chapter 4.4. --- Salivary Cortisol --- p.125 / Chapter 4.5. --- "Association of Gene Polymorphisms, Personality Traits and Cold-Pressor Test" --- p.127 / Chapter 4.5.1. --- MORA118G Polymorphism --- p.127 / Chapter 4.5.2. --- DOR T921C Polymorphism --- p.129 / Chapter 4.5.3. --- COMT Val108/158Met --- p.130 / Chapter 4.5.4. --- Prodynorphin (ProDYN) 68bp-VNTR --- p.133 / Chapter 4.5.5. --- DRD2 A Polymorphism --- p.134 / Chapter 4.5.6. --- DRD4 -521C/T Polymorphism --- p.138 / Chapter 4.5.7. --- 5HTlB G861C Polymorphism --- p.141 / Chapter 4.5.8. --- Personality Traits --- p.142 / Chapter 4.6. --- Limitations --- p.144 / Chapter 4.7. --- Potential Clinical Application --- p.145 / Chapter 4.8. --- Conclusion --- p.146 / APPENDIXES --- p.148 / APPENDIX 1 Addiction Severity Index (ASI) with Additional Questions for Heroin Users / APPENDIX 2 Detoxification and Relapse History Questionnaire / APPENDIX 3A Questionnaire for Control Subjects (Chinese version) / APPENDIX 3B Questionnaire for Control Subjects (English version) / APPENDIX 4A NEO PI-R (Chinese version) / APPENDIX 4B NEO PI-R (English version) / APPENDIX 5A BIS/BAS (Chinese version) / APPENDIX 5B BIS/BAS (English version) / APPENDIX 6A SSS- V (Chinese version) / APPENDIX 6B SSS- V (English version) / REFERENCES --- p.178