Submitted by Erika Demachki (erikademachki@gmail.com) on 2015-02-13T20:15:11Z No. of bitstreams: 2 Dissertação - Anna Carolina Galvão Ferreira - 2012.pdf: 1738587 bytes, checksum: b4a75ebc8af8f8a234573009292ed508 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Erika Demachki (erikademachki@gmail.com) on 2015-02-13T20:16:17Z (GMT) No. of bitstreams: 2 Dissertação - Anna Carolina Galvão Ferreira - 2012.pdf: 1738587 bytes, checksum: b4a75ebc8af8f8a234573009292ed508 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-02-13T20:16:17Z (GMT). No. of bitstreams: 2 Dissertação - Anna Carolina Galvão Ferreira - 2012.pdf: 1738587 bytes, checksum: b4a75ebc8af8f8a234573009292ed508 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2012-05-28 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / OBJECTIVE: To describe tuberculosis treatment rates of cure, failure and default of a self administered regimen, with rifampin, isoniazid, pyrazinamide and ethambutol in the first two months of treatment followed by isoniazid and rifampcina in the four last months (2RHZE/4RH) in four-drug fixed-dose combination (FDC), implemented in Brazil since 2010 to replace a regimen of separately administered rifampicin, isoniazid and pyrazinamide in the first two months of treatment followed by isoniazid and rifampcina for four months (2RHZ/4RH). METHODS: Descriptive study using prospectively collected data from medical records of TB cases, older than18 years of age undergoing treatment with 2RHZE/4RH in two units of primary health care in the metropolitan area of Goiânia. RESULTS: The study included 40 cases of TB. The cure rate was 67.5% (27/40), the abandonment was 17.5% (7/40) and there were no cases of failure. There was reports of adverse reactions in 47% (19/40) of the cases. Of these, 87% were mild and 13% were moderate. There was no need for change or suspension of the scheme. CONCLUSIONS: The cure rate in FDC 4RHZE/2RH scheme under self-administered regimen was similar to historical rates of cure with 2RHZ/4RH. The default rate in the sample studied was much higher than the rate recommended as appropriate (up to 5%). / INTRODUÇÃO: O esquema de tratamento da TB tem alta eficácia em torno de 95% e com possibilidade de cura de aproximadamente 100% dos casos e reduz rapidamente a transmissão, e assim pode-se reduzir a incidência da doença. Embora a distribuição da medicação seja gratuita em todo país pelo Sistema Único de Saúde, a efetividade do tratamento da TB varia muito nos diferentes locais. JUSTIFICAVA: Conhecer as taxas de sucesso de tratamento ,falência e abandono além de verificar a segurança do tratamento da TB com 4 medicamentos em apresentação dose fixa combinada. OBJETIVO: Descrever as taxas de cura, falência e abandono do tratamento da tuberculose com o esquema básico com rifampicina, isoniazida, pirazinamida e etambutol nos dois primeiros meses de tratamento seguidos de isoniazida e rifampcina por quatro meses (2RHZE/4RH), sob forma de comprimidos em dose fixa combinada (DFC), em regime auto administrado implementado no Brasil desde 2010, em substituição ao esquema utilizando cápsulas e comprimidos com rifampicina, isoniazida e pirazinamida nos dois primeiros meses de tratamento, seguidos de isoniazida e rifampcina por quatro meses (2RHZ/4RH). MÉTODOS: Estudo descritivo utilizando dados secundários coletados prospectivamente de prontuários de casos de TB, maiores de 18anos, submetidos ao tratamento com esquema básico para tuberculose, em duas Unidades Básicas de Saúde da região metropolitana de Goiânia. RESULTADOS: Foram incluídos no estudo 40 casos de TB. A taxa de cura foi de 67,5% (27/40), a de abandono de 17,5% (7/40) e a não ocorreram casos de falência. Houve relato de reações adversas em 47% (19/40) num total de 31 ocorrências. Dessas, 87% foram leves e 13% moderadas. Em nenhum caso houve necessidade de mudança ou suspensão do esquema. CONCLUSÕES: A taxa de cura do esquema 4RHZE/2RH em DFC sob regime autoadministrado foi semelhante às taxas históricas do tratamento com 2RHZ/4RH. A taxa de abandono na amostra estudada foi superior a taxa preconizada como adequada (até 5%).

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

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

INTRODUÇÃO: O tratamento da exposição gengival excessiva ao sorrir, também conhecida como sorriso gengival, pode ser realizado de três formas: com técnicas que diminuem a gengiva por meio de remodelação gengival; com técnicas que diminuem a altura maxilar, por meio de uma cirurgia de impactação óssea; ou por meio de técnicas que diminuem a capacidade de elevação do lábio superior. Existe uma carência de técnicas cirúrgicas efetivas, da última categoria, para o tratamento do sorriso gengival. Visando corrigir ou amenizar tal alteração, Ishida et al. desenvolveram uma técnica cirúrgica baseada na associação dos seguintes procedimentos: a secção do músculo levantador do lábio superior, a dissecção da pele e mucosa do lábio superior e o alongamento do freio do lábio superior (1). O presente estudo tem como objetivo, avaliar os efeitos da aplicação dessa técnica cirúrgica em pacientes portadoras de exposição gengival excessiva. MÉTODOS: 18 pacientes do sexo feminino portadoras de exposição gengival excessiva foram operadas utilizando a técnica proposta neste estudo. Por meio de documentação fotográfica e vídeo, a quantidade de exposição gengival e o comprimento do lábio superior foram medidos antes e depois do procedimento cirúrgico. O período de seguimento variou de 6 a 26 meses após a cirurgia, sendo a média de 10,05 ± 7,02 meses. RESULTADOS: O comprimento total do lábio superior antes da cirurgia variou de 17,40 a 26,89 mm, sendo a média de 22,28 ± 2,47 mm. Após a cirurgia, esse comprimento variou de 18,96 a 27,32 mm, sendo a média de 22,85 ± 2,04 mm, havendo um aumento médio dessa distância de 0,57 mm (p<0,05). Todas as pacientes apresentaram diminuição da exposição da gengiva superior no sorriso forçado. A exposição gengival antes da cirurgia variou de 2,03 a 7,16 mm, sendo a média de 5,10 ± 1,51 mm. Após a cirurgia, a exposição variou de 0,09 a 5,19 mm, sendo a média de 1,74 ± 1,39 mm. A diminuição da exposição gengival variou de 1,13 a 5,31 mm, sendo a diminuição média de 3,37 ± 1,27 mm (p<0,001). Não foram observadas complicações decorrentes do procedimento. CONCLUSÕES: Os resultados permitiram-nos concluir que a utilização da técnica cirúrgica avaliada neste estudo se demonstrou eficiente na diminuição de uma média de 3,37 mm da exposição gengival excessiva no sorriso forçado nas pacientes estudadas / INTRODUCTION: The treatment of excessive gingival exposure when smiling, also known as gummy smile, can be performed in three different manners: with techniques that reduce the gum through gingival remodeling; with techniques that reduce the maxillary height, through a surgery of maxillary impaction; or using techniques that reduce the capacity of elevation of the upper lip. There is a shortage of surgical techniques in this last category, which are proven effective and long lasting, for treatment of the gummy smile. In order to correct or diminish such deformity, Ishida et al. developed a surgical technique that associates the section of muscle levator of the upper lip; with a dissection of the skin and mucosa of the upper lip; and with a frenuloplasty of the upper lip (1). The aim of this study is to evaluate the effects of this surgical technique in patients with excessive gingival exposure. METHODS: 18 female patients with excessive gingival exposure were operated using the technique proposed in this study. Through photographic documentation and video recordings, the amount of gingival exposure in a forced smile and length of the upper lip were measured before and after the surgical procedure. The follow-up period ranged from 6 to 26 months after the surgery, the average being 10.05 ± 7.02 months. RESULTS: The total length of the upper lip before surgery ranged from 17.40 to 26.89 mm, the average being 22.28 ± 2.47 mm. After the surgery, this length ranged from 18.96 to 27.32 mm, the average being 22.85 ± 2.04 mm, and there was an average increase of 0.57 mm (p<0.05 ). All patients showed a decrease in the exposure of the upper gum when smiling. The gingival exposure before surgery ranged from 2.03 to 7.16 mm, the average being 5.10 ± 1.51 mm. The gingival exposure after surgery ranged from 0.09 to 5.19 mm, the average being 1.74 ± 1.39 mm. The reduction of gingival exposure ranged from 1.13 to 5.31 mm. Being the average decrease of 3.37 ± 1.27 mm (p<0.001). No complications were observed resulting from the procedure. CONCLUSIONS: The results led us to conclude that the surgical technique assessed in the present study demonstrated efficient in reducing an average of 3.37 mm of excessive gingival exposure in forced smile

INTRODUÇÃO: Indivíduos com deformidade dentofacial apresentam alterações faciais verticais e/ou ântero-posteriores, com conseqüente presença de oclusão instável e pobre intercuspidação dentária, que podem causar comprometimentos nas funções do Sistema Miofuncional Orofacial sendo verificadas geralmente adaptações funcionais para cada tipo de deformidade. O objetivo desta tese foi realizar um ensaio clínico randomizado cuja variável de relevância foi a resposta funcional da mastigação após intervenção fonoaudiológica experimental em pacientes submetidos à cirurgia ortognática. MÉTODOS: Todos os pacientes submetidos à cirurgia ortognática, num período de 12 meses, que concordaram em participar do estudo. Os pacientes foram randomicamente distribuídos em dois grupos: grupo experimental (EG=6) e grupo de instrução (IG=5). O grupo controle foi constituído por indivíduos com oclusão dentária normal (CG=6). Os pacientes do EG foram submetidos a um protocolo de tratamento fonoaudiológico estruturado em seis sessões com enfoque técnico na função da mastigação. Os pacientes do IG foram submetidos a duas sessões supervisionadas de instruções direcionadas aos cuidados com a mastigação (tratamento padrão). As variáveis adotadas para a comparação dos grupos foram obtidas por meio de avaliação clínica e de avaliação eletromiográfica de superfície (EMGs), sendo elas: mobilidade orofacial, desempenho durante as funções de deglutição/mastigação, movimentos mandibulares e atividade elétrica dos músculos mastigatórios. Esses parâmetros foram avaliados pré e pós-cirúrgico longo prazo (12 meses). Os indivíduos do CG foram testados em dois momentos distintos com um intervalo de 12 meses entre os mesmos. RESULTADOS: após um ano da realização da cirurgia ortognática o EG apresentou melhora significativa na mobilidade orofacial (p = 0,001); no desempenho durante as funções de deglutição/mastigação (p = 0,001); na lateralização da mandíbula (p = 0,001) e na protrusão da mandíbula (p = 0,011). Os dois grupos de pacientes (EG e IG) não apresentaram diferenças significativas para os resultados da EMGs atividade elétrica dos músculos mastigatórios - nos diferentes momentos. O CG não apresentou variações significativas de desempenho para qualquer das variáveis investigadas na comparação entre os diferentes momentos. CONCLUSÃO: os resultados sugerem que o tratamento fonoaudiológico experimental demonstrou resultado positivo. Não foram identificados efeitos adversos. Houve aderência ao tratamento. O tamanho da amostra, embora relevante para a área, exige cuidado quanto ao poder de generalização dos resultados / INTRODUCTION: Individuals with dentofacial abnormalities present facial alteration - in the vertical and/or anterior posterior plane -, with consequent unstable occlusion and poor dental intercuspation. These alterations can cause impairments in the functions of the orofacial myofunctional system, and functional adaptations are usually observed for each type of deformity. The aim of this thesis was to conduct a randomized clinical trial that the relevance variable was the functional response of the mastication after the rehabilitative experimental program in patients submitted to orthognathic surgery. METHODS: All patients underwent to the orthognathic surgery, in a period of 12 months, which agreed to participate of this study. Patients were randomized assigned into two groups: experimental group (EG = 6) and group instruction (GI = 5). A control group consisted of individuals with normal dental occlusion (CG = 6). The EG patients underwent a structured treatment protocol, in six sessions, with technical focus was on the function of mastication. Patients in the IG were submitted to two supervised sessions for instruction related to the look out of mastication (standard treatment). The variables adopted for the comparison groups were obtained by clinical evaluation and by assessment of surface electromyography (sEMG) that was: orofacial mobility, masticatory/deglutition clinical performance, jaw movements and muscle activation (electrical activity) of the masticatory muscles. These parameters were evaluated pre-and postoperative long-term (12 months). The subjects in the CG were also tested in two distinct moments, with a one year interval. RESULTS: One year after orthognathic surgery, EG showed a significant improvement in orofacial mobility (p=0.001), masticatory/deglutition clinical performance (p=0.001), jaw lateralization (p=0.001) and jaw protrusion (p=0.011). Both groups of patients presented no significant differences for the sEMG results. The CG presented no significant variations in performance for any of the investigated variables when comparing the different time points. CONCLUSION: The results suggest that the rehabilitative experimental program demonstrated a positive result. No adverse effects were identified. There was adherence to the treatment. The sample size, although relevant to the area, requires careful about the power of generalization of the results.

Racial and ethnic minority populations suffer disproportionally from mental health disparities in the United States (Dillon et al., 2015; Holden et al., 2014). Research has indicated that a lack of culturally competent care contributes to these disparities (Holden & Xanthos, 2009). As multicultural competencies (American Psychological Association [APA], 2002; Council of National Psychological Associations for the Advancement of Ethnic Minority Interests, 2003) have been widely endorsed and implemented in professional organizations and training programs, research on their need and usefulness has increased over the last three decades (Worthington et al., 2007). However, the majority of research on multicultural competencies has relied on analogue studies, college students, and trainees as participants (Ridley & Shaw-Ridley, 2011; Worthington et al., 2007). The current study contributed to the multicultural competency literature by including perspectives from real clients with diverse backgrounds in community settings, along with assessing therapist multicultural competency (MCC). The study examined the relationship between therapist (n = 28) multicultural competency (MCC) and psychotherapy outcomes of clients (n = 2024) from diverse racial/ethnic backgrounds in a community mental health agency. Therapist MCC did not have a statistically significant positive relationship with treatment outcome. Therapist MCC also did not have a statistically significant positive relationship with reliable or clinically significant change in treatment outcome. Results do not indicate any mediating effect of therapist MCC between race and treatment outcomes. Gender predicted overall treatment outcomes, clinically significant change and reliable change in treatment. Findings suggest cultural variables may have played a role in treatment outcomes given the differences in treatment outcomes for female clients, despite the lack of association found between therapist MCC and treatment outcomes. Implications for clinical practice and research are discussed.

Syfte: Sammanställa och granska studier gällande postoperativ behandling vid ruptur av ligament patella. Detta för att beskriva effekt och kvalitet på studier om postoperativ behandling. Metod: En beskrivande litteraturstudie valdes som design, med sökorden: patellar ligament, patellar tendon, rupture, knee injuries, surgery. Av totalt 1240 träffar valdes 13 relevanta artiklar publicerade mellan 1999-2013 efter sökningar i databaserna PubMed, PEDro, COCHRANE, SCOPUS, CINAHL, SPORTDiscus och AMED. Artiklarna kvalitetsgranskades enligt PEDro scale. Resultat: Två postoperativa behandlingar beskrevs, tidig och sen mobilisering. Antingen placeras knäleden i ett stabiliserande knäskydd som till en början låser knäleden i full extension eller så påbörjas tidig mobilisering av den opererade knäleden. Ingen signifikant skillnad påvisades mellan tidig och sen mobilisering vad gäller effekten på muskelstyrka, rörelseomfång och återgång till tidigare aktivitetsnivå. Vidare var kvaliteten på de granskade artiklarna genomgående låg (PEDro scale ≤ 5). Konklusion: Ytterligare forskning krävs för att fastställa vilken postoperativ behandling som ger bäst effekt. / Objective: Summarize and examine studies regarding postoperative treatment following rupture of the patellar ligament. Further the aim was to evaluate the effect of the postoperative treatment and the quality of the studies. Method: As design, a descriptive review was chosen, keywords: patellar ligament, patellar tendon, rupture, knee injuries, surgery. From a total of 1240 items, 13 relevant articles published 1999-2013 were selected after search in the databases PubMed, PEDro, COCHRANE, SCOPUS, CINAHL, SPORTDiscus and AMED. The articles were quality-graded according to PEDro scale. Results: Two postoperative treatments were described, early and delayed mobilization. There was no significant difference between them regarding the effect on muscle strength, range of motion and return to preinjury level of activity. The quality-graded articles had overall low quality (PEDro scale ≤ 5). Conclusion: Further researches are required to determine which postoperative treatment has the best effect.

Pseudomyxoma peritonei (PMP) is a rare disease characterized by mucinous peritoneal metastasis (PM). Different loco-regional treatment strategies, i.e. debulking surgery and cytoreductive surgery (CRS) in combination with hyperthermic intraperitoneal chemotherapy (HIPEC), have changed the prognosis for these patients. CRS is an aggressive surgical procedure with a long learning curve. PMP exists in different types; how many depends on which classification is used. The aims of this thesis were to investigate the time-frame of PMP development from an isolated appendiceal neoplasm, examine the learning process for CRS, evaluate the differences in treatment outcome between debulking surgery and CRS in combination with HIPEC, to evaluate a more detailed PMP classification and to investigate particularly interesting new cysteine-histidine (PINCH) protein as a prognostic factor for PMP. Retrospectively 26 PMP patients were identified as having had an appendectomy with a neoplasm in the appendix but with no evidence of PM at the appendectomy. They were treated for PMP within a median of 13.1 months (3.8-95.3) after the appendectomy. No difference was seen between the types of PMP regarding the time to a clinically significant development of PMP and how much tumour was found at treatment. CRS is a highly invasive treatment and stabilization in the learning curve was seen after 220±10 procedures. Patients treated with CRS+HIPEC had a better 5-year overall survival (OS) than patients treated with debulking surgery, 74% vs. 40%. CRS increased the rate of complete cytoreduction from 25% in patients treated with debulking surgery to 72%. The new four-grade PMP classification showed very good inter-rater agreement between two independent pathologists and a difference in survival rates was observed between the different grades. A positive PINCH staining was recorded in 83% of the tumours and that was associated with poorer survival.

Adams et al. was the first to demonstrate an association between improved outcomes and provider experience in a 1973 study examining complication rates from coronary arteriograms.[1] In this study, a questionnaire was mailed to the directors of coronary arteriography laboratories throughout the US. They found that mortality was eight times higher in institutions performing fewer than 200 examinations per two-year period compared to institutions performing more than 800 examinations per two-year period. It was not until 1979, however, that efforts to systematically study outcomes in surgery were made by Luft and colleagues.[2] They demonstrated lower mortality rates at high-volume centers compared with low-volume centers for several high risk procedures, such as coronary artery bypass graft surgery (CABG) and vascular surgery. This landmark study set the stage for outcomes research in surgery. Over the past decade, additional studies have continued to show higher surgeon or hospital volumes to be associated with improved patient outcomes. [3-13] To what degree surgeon versus hospital volume each contribute to outcomes is controversial and depends on the procedure examined. Nevertheless, formal recommendations encouraging certain high-risk procedures be performed at high-volume hospitals began as early as 2000 by the Leapfrog group and other policy initiatives.[14, 15] Formal recommendations for surgeon volume, on the other hand, have been lacking. There has been mounting evidence, particularly in the last decade, that surgeon volume is associated with improved patient outcomes, independent of hospital volume. To what measure these data have influenced referral patterns from low- to high-volume surgeons is unknown.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2010. / Härtill 4 uppsatser.