More than 1.2 million Americans are hospitalized annually with an acute coronary syndrome (ACS); many impaired quality of life after discharge with an ACS. This dissertation focuses on two novel aspects of patient health status (PHS) after ACS: how it can be predicted based on the socioeconomic status (SES) of the patient, and how it evolves over time. We used data from TRACE-CORE, a longitudinal prospective cohort of patients hospitalized with ACS. We measured PHS using both the SF-36 mental and physical component subscales (MCS and PCS) and the Seattle Angina Questionnaire (SAQ) health-related quality of life (HRQoL) and physical limitations subscales at the index hospitalization and at 1, 3, and 6-months post-discharge. Firstly, after adjusting for individual-level SES, we found that individuals living in the neighborhoods with the lowest neighborhood SES had significantly worse PHS. Secondly, we found that each of the components of PHS had subgroups with distinct patterns of evolution over time (trajectories). Both the PCS and the SAQ physical limitations subscale had two trajectories; one with average and one with impaired health status over time. For the HRQoL subscale of SAQ, we found three trajectories: Low, Average, and High scores. For MCS, we found four trajectories: High (consistently high scores), Low (consistently low scores), and two with average scores at baseline that either improved or worsened over time, referred to as Improving and Worsening, respectively. All PHS trajectories, except for MCS, predicted readmission and mortality during the 6 months to 1 year post-ACS discharge.

INTRODUÇÃO - Este estudo exploratório apresenta e avalia uma experiência de formação de Agentes Comunitários de Saúde (ACS) do município de Embu das Artes para o uso de Indicadores Clínicos de Risco para o Desenvolvimento Infantil (IRDI). O IRDI é um protocolo de base psicanalítica, validado e inespecífico para diagnóstico, composto de 31 itens que sinalizam a construção da subjetividade do bebê expressa na relação com seus cuidadores. É dividido em quatro etapas do desenvolvimento do bebê: 0-4; 4 a 8; 8 a 12; e 12 a 18 meses. A ausência de dois ou mais indicadores sinaliza tendência para problemas de desenvolvimento ou risco psíquico aos três anos da criança. O IRDI resultou de uma pesquisa realizada entre 2000 e 2008, por psicanalistas do Grupo Nacional de Pesquisadores (GNP), a pedido do Ministério da Saúde. OBJETIVOS - Avaliar as influências da formação para a prática dos ACS e os obstáculos enfrentados; investigar os usos e apropriações do IRDI, situando modos de apropriação com potencial efeito de permanência. METODOLOGIA Foram realizados quatro encontros formativos e o acompanhamento do uso do protocolo pelos ACS ao longo de 2011 e início de 2012. Utilizou-se pré-teste e pós-teste, trabalhados por análise de conteúdo. Os discursos emergentes durante o uso do protocolo foram analisados em uma vertente qualitativa. RESULTADOS 1. A prática dos ACS com bebês é centrada na avaliação do crescimento e em aspectos funcionais do desenvolvimento; 2. O aspecto relacional entre mãe e bebê passou a ser valorizado no decorrer da formação; 3. Influências do protocolo para a prática foram relatadas por 72,5% dos participantes a mais citada foi o aprimoramento da observação e do conhecimento sobre o bebê e seus cuidadores. 4. O protocolo foi utilizado tanto para a detecção como para a orientação à família sobre o contato com o bebê, na perspectiva da Promoção à Saúde. 5. Os itens relativos à primeira faixa do bebê (0 a 4 meses) foram os mais lembrados espontaneamente pelos ACS. 6. Houve dificuldades no manejo com itens referentes ao eixo teórico Alternância Presença-Ausência na relação entre a criança e seu cuidador. 7. O acompanhamento particularizado dos profissionais permitiu manejar as resistências psíquicas, contribuindo para a permanência de participantes. 8. Modos de apropriação favoráveis ocorreram pelo enlaçamento entre aspectos dos indicadores e um traço particular do sujeito. CONCLUSÕES - A inserção do IRDI na Atenção Primária deve considerar um percurso de longo prazo e as particularidades de cada unidade de saúde. É pertinente trabalhar com uma equipe pequena por vez, com formação diversificada. A realização de encontros formativos regulares e acompanhamento particularizado por um profissional psicólogo nos serviços envolvidos é uma proposta que se mostra mais favorável para que seu objetivo se consolide / INTRODUCTION - Exploratory study about an experience of Community Health Agents (CHA) training in the use of Clinical Risk Indicators for Child Development (CRICD) in the town of Embu das Artes. CRICD is a psychoanalytic based protocol, validated and unspecific for diagnosis, composed by 31 items that indicate the occurrence of the construction of the babys subjectivity, expressed in the relation with its caregivers. It is divided in four stages of the babys development: 0 to 4 months; 4 to 8; 8 to 12; and 12 to 18. The absence of two or more indicators signalizes a tendency to developmental problems or psychic risk at the childs age of three. CRICD has resulted from a research carried out between 2000 and 2008 by a group of psychoanalysts named National Group of Research (NGR), by request of the Health Ministry. METHODS - To the realization of this research, four formative encounters were made, plus the follow-up of the use of the protocol in service throughout 2011 and beginning of 2012. The articulation of Public Health and Psychoanalysis has suggested a methodological approach with distinct boundaries. We assessed the influences of the CHAs practical training and the obstacles faced. The uses and appropriations of the CRICD were investigated, placing modes of appropriation with potential effect of permanence. Pre-test and post-test were used for content analysis. The discourses that emerged during the use of the protocol were selected and analyzed according to the qualitative perspective. RESULTS 1.The CHAs practices with babies are centered in growth assessment and in functional aspects of development. 2. The relational aspects became more evident during the training. Among the participants, 3. 72.5% have reported influences of the protocol in their practices, specially the improvement of observation and knowledge of the baby and its caregivers. 4. The CRICD was used to detection as well as to guidance for the families about contact with the baby, in the Promotion of Health perspective. 5. The items of the first group were the most recollected by the CHA. 6. Among the difficulties, we emphasize the handling of the items that refer to the theoretical axe of Alternation Presence-Absence in the relation between the child and its caregiver. 7. The particularized follow-up of the professionals allowed us to handle the psychic resistances, contributing to the permanence of the participants. 8. The favorable modes of appropriation were outlined in the situations in which there was an interface between aspects of the indicators and a particular trace of the subject. CONCLUSION- We suggest that the proposals of insertion of the CRICD in Primary Attention consider a long-term path, undertaken in one health unit per time because the resistances in institutional level have revealed themselves as a challenge. We found to be pertinent to work with a small staff with diverse educational backgrounds, composed of CHA, nursing and pediatric professionals. The most favorable proposal for its aim to be reached is the realization of regular formative encounters with a few months of space between them, during which supervision of the tasks involved is done

Introdução: O conceito de contratransferência evoluiu de “um obstáculo ao tratamento” à ferramenta útil à compreensão do paciente dentro de uma relação bi-pessoal. Atualmente, buscam-se evidências da sua especificidade, correlacionando padrões específicos de contratransferência com características do paciente e terapeuta, classes diagnósticas e desfechos do tratamento. Acredita-se que, devido à intensidade das reações emocionais despertadas nos terapeutas que atendem vítimas de trauma, o estudo da contratransferência nesta população auxilie no autoconhecimento dos terapeutas, amplie a compreensão sobre o fenômeno e contribua para um melhor atendimento dos pacientes. O desenvolvimento de pesquisas nesta área esbarra no reduzido número de escalas validadas para acessar a contratransferência. No Brasil, estão disponíveis a escala para Avaliação da Contratransferência e as versões traduzidas do Inventory of Countertransference Behavior e Mental States Rating System, mas nenhuma validada.A Escala para a Avaliação da Contratransferência (EACT) foi criada em nosso meio, com elevada validade de face, construída em torno de três dimensões conceituais de sentimentos. Entretanto, suas propriedades psicométricas ainda não foram avaliadas. Objetivos: Investigara validade de construto da EACT, respondida por terapeutas de vítimas de trauma psíquico (Artigo 1). Secundariamente, analisar a correlação entre a contratransferência inicial com vítimas de trauma psíquico e os dados demográficos e clínicos de terapeutas e pacientes e o tipo de trauma, e investigar a associação entre a contratransferência inicial e a adesão dos pacientes ao tratamento e o seu desfecho, operacionalizado como alta ou abandono (Artigo 2). Método: Delineamento transversal (Artigo 1) e análises secundárias com dados longitudinais (Artigo 2). A amostra foi composta por 50 psiquiatras no segundo ano de formação durante estágio no Núcleo de Estudos e Tratamento de Trauma Psíquico do Hospital de Clínicas de Porto Alegre, Brasil. Esses terapeutas atenderam 131 pacientes recrutados consecutivamente durante 4 anos, que incluiu a primeira ou segunda consulta de vítimas de abuso sexual, seqüestro, assalto, agressão física, tentativa de homicídio, tortura e trauma indireto, independentemente do tempo decorrido entre a consulta atual e o evento traumático. Foram excluídos atendimentos de pacientes que chegaram à primeira consulta com ideação suicida grave, sintomas psicóticos e/ou com indicação de internação psiquiátrica. Os pacientes foram selecionados após triagem, que avaliou as variáveis clínicas e o diagnóstico segundo os critérios do DSM-IV-TR. Na primeira consulta, foram coletados os dados demográficos e clínicos e avaliada a contratransferência identificada pelo terapeuta através da EACT. Os pacientes foram acompanhados ao longo do tratamento psiquiátrico para determinar o número de consultas, faltas e o desfecho: alta ou abandono. A EACT é uma escala auto-aplicável, composta por 23 itens pontuados para 3 momentos da sessão (início, durante e final) em escala tipo Likert (0=ausência a 3=muito), e distribuídos em 3 domínios: aproximação (10 itens), afastamento (10 itens) e indiferença (3 itens). A validade de constructo da EACT no atendimento desta população foi avaliada através da análise fatorial exploratória (EFA) e consistência interna (α de Cronbach). O tamanho amostral foi calculado a partir de pelo menos 5 aplicações da EACT para cada item da escala (mínimo N = 115). E a análise fatorial confirmatória foi usada para determinar os parâmetros de adequação (goodness-of-fit) da versão da EACT no atendimento de vítimas de trauma obtida na EFA em comparação com a versão original. Resultados: A EFA mostrou 3 fatores com homogeneidade consistente, sendo distinta da versão original da EACT a correlação entre os itens e o terceiro fator: afastamento (9 itens com 24% da variância; α = 0,88), aproximação (7 itens com 15% da variância; α=0,82) e tristeza (6 itens com 9% da variância; α = 0,72). O item alegria, com carga fatorial baixa, foi retirado da análise por ser considerado irrelevante neste contexto. A análise fatorial confirmatória evidenciou melhores critérios de goodness-of-fit em todos os parâmetros testados para a presente versão da EACT do que a original. Secundariamente, as características demográficas e clínicas dos terapeutas e dos pacientes dos grupos alta e abandono foram similares. Os terapeutas com idade ≤ 27 anos pontuaram maior afastamento que os mais velhos (0,14 ± 1 vs. -0,21 ± 0,9; P=0,019). Os pacientes casados induziram nos terapeutas mais sentimentos de afastamento (0,20 ±1 vs. -0,19 ± 0,9; P = 0,016) e tristeza (0,18 ±1 vs. -0,17 ± 1; P = 0,049) que os que vivem sozinhos. Nas variáveis clínicas, as vítimas de trauma indireto e de múltiplos traumas despertaram mais tristeza (0,38 ± 1 e 0,76 ± 0,4, respectivamente), comparadas às vítimas de violência sexual (0,03 ± 0,9) e urbana (-0,3 ± 1) (P = 0,039). A mediana de consultas realizadas foi 5 [4; 8], faltas 1 [0; 1] e a taxa de abandono foi de 34,4%. Na análise multivariada, identificou-se que os pacientes com relato de história de trauma na infância abandonaram menos o tratamento (OR = 0,39; P = 0,039; CI 95% 0,16- 0,95). Não foi detectada associação entre sentimentos contratransferenciais iniciais com os desfechos do tratamento. Conclusões: A EACT apresentou propriedades psicométricas consistentes, demonstrando ser um instrumento confiável para acessara contratransferência inicial de terapeutas de vítimas de trauma psíquico. Os sentimentos contratransferenciais no atendimento inicial destes pacientes associaram-se a parâmetros demográficos e clínicos, mas não se associaram ao abandono do tratamento. Estudos futuros devem avaliar a modificação dos sentimentos contratransferenciais ao longo do tratamento e o seu impacto sobre os desfechos do tratamento. / Introduction: The concept of countertransference (CT) evolved from an “obstacle to treatment” to "an useful tool to understand patients within a bi-personal relationship". Currently, evidences of its specificity are searched for, correlating specific CT patterns to patients and therapists’ features, diagnostic classes, and treatment outcomes. Due to the intensity of emotional reactions aroused in therapists caring for trauma victims, it is believed that the study of CT in this population will help self-knowledge of therapists and contribute for a better patient care. The development of studies in this field is hindered by the reduced number of validated scales to assess CT. In Brazil, the Assessment of Countertransference Scale and the translated versions of the Inventory of Countertransference Behavior and Mental States Rating System are available, however, none of them has been validated. The Assessment of Countertransference Scale (ACS) has been created in our department with high face validity, built around three conceptual dimensions of feelings. However, its psychometric properties have not been assessed yet. Objectives: To investigate the construct validity of the ACS answered by therapists of psychological trauma victims (Article 1). Then, to assess the correlation between initial CT with victims of psychological trauma and the clinical and demographic data of therapists and patients and the type of trauma, and to investigate the association between initial countertransference and patients’ adherence to treatment and its outcome, defined as discharge or drop-out (Article 2). Methods: A Cross-sectional study (Article 1) and secondary analysis with longitudinal data (Article 2) were carried out. The sample was formed by 50 psychiatrists in the second year of training in their internship in the Center for Study and Treatment of Traumatic Stress in Hospital de Clínicas de Porto Alegre, Brazil. These therapists cared for 131 patients consecutively recruited for 4 years, including the first and second appointment with victims of sexual abuse, kidnapping, robbery, physical assault, homicide attempt, torture and indirect trauma, regardless of the time elapsed between the current appointment and the trauma event. We have excluded patients that arrived in the first appointment with severe suicidal ideation, psychotic symptoms and/or referral for psychiatric hospitalization. Patients have been selected after screening, which assessed the clinical variables and the diagnoses according to DSM-IV-TR criteria. In the first appointment, demographic and clinical data were collected and CT, identified by therapists through the ACS, was assessed. Patients were followed-up during psychiatric treatment to determine the number of appointments, absences, and the outcome: discharge or drop-out. ACS is a self-applied scale composed by 23 items scored for 3 moments of the session (start, midpoint and end) in a Likert-type scale (0=absence to 3=very), and distributed into 3 dimensions: closeness (10 items), distance (10 items) and indifference (3 items). The construct validity of ACS in the care for this population was assessed through the Exploratory Factor Analysis (EFA) and the internal consistency (α de Cronbach). The sample size was calculated for at least 5 applications of ACS for each item of the scale (minimum N = 115). The Confirmatory Factor Analysis (CFA) was used to determine the goodness of fit parameters of the ACS version in the care for trauma victims obtained in the EFA compared to the original version. Results: EFA showed 3 factors with consistent homogeneity, but the correlation between the items and the third factor were different from the original version, in the following: rejection (9 items with 24% of variance; α = 0.88), closeness (7 items with 15% of variance; α = 0.82) and sadness (6 items with 9% of variance; α = 0.72). The item “happiness”, with low factorial load, was withdrawn from the analysis because it was considered to be irrelevant in this context. CFA showed better goodness of fit criteria in all tested parameters for the present version of ACS compared to the original version. Secondly, the demographic and clinical characteristics of therapists and patients of the discharge and drop-out groups were similar. Therapists with ages ≤ 27 years scored more rejection than older therapists (0.14 ± 1 vs. -0.21 ± 0.9; P = 0.019). Married patients induced in therapists more feelings of rejection (0.20 ± 1 vs. -0.19 ± 0.9; P = 0.016) and sadness (0.18 ± 1 vs. -0.17 ± 1; P = 0.049) than those patients living alone. In the clinical variables, the victims of indirect trauma and of several traumas aroused more feelings of sadness (0.38 ± 1 and 0.76 ± 0.4, respectively) compared to sexual violence (0.03 ± 0.9) and urban violence victims (-0.3 ± 1) (P = 0.039). Median of appointments performed was 5 [4; 8], absences 1 [0; 1] and the drop-out rate was 34.4%. In the multivariate analysis, we have identified that patients with reported history of childhood trauma were less likelihood of dropping out treatment (OR=0.39; P = 0.039; CI 95% 0.16-0.95). Association between the initial CT feelings and the treatment outcomes has not been detected. Conclusions: ACS presented sound psychometric properties, and it has been demonstrated to be a reliable instrument to access initial CT of therapists in victims of psychological trauma. Countertransference feelings in the initial care of patients were associated with clinical and demographic parameters, but it were not associated with treatment drop-out. Further studies should assess the changes in CT feelings over treatment and their impact on treatment outcomes.

Introdução: O conceito de contratransferência evoluiu de “um obstáculo ao tratamento” à ferramenta útil à compreensão do paciente dentro de uma relação bi-pessoal. Atualmente, buscam-se evidências da sua especificidade, correlacionando padrões específicos de contratransferência com características do paciente e terapeuta, classes diagnósticas e desfechos do tratamento. Acredita-se que, devido à intensidade das reações emocionais despertadas nos terapeutas que atendem vítimas de trauma, o estudo da contratransferência nesta população auxilie no autoconhecimento dos terapeutas, amplie a compreensão sobre o fenômeno e contribua para um melhor atendimento dos pacientes. O desenvolvimento de pesquisas nesta área esbarra no reduzido número de escalas validadas para acessar a contratransferência. No Brasil, estão disponíveis a escala para Avaliação da Contratransferência e as versões traduzidas do Inventory of Countertransference Behavior e Mental States Rating System, mas nenhuma validada.A Escala para a Avaliação da Contratransferência (EACT) foi criada em nosso meio, com elevada validade de face, construída em torno de três dimensões conceituais de sentimentos. Entretanto, suas propriedades psicométricas ainda não foram avaliadas. Objetivos: Investigara validade de construto da EACT, respondida por terapeutas de vítimas de trauma psíquico (Artigo 1). Secundariamente, analisar a correlação entre a contratransferência inicial com vítimas de trauma psíquico e os dados demográficos e clínicos de terapeutas e pacientes e o tipo de trauma, e investigar a associação entre a contratransferência inicial e a adesão dos pacientes ao tratamento e o seu desfecho, operacionalizado como alta ou abandono (Artigo 2). Método: Delineamento transversal (Artigo 1) e análises secundárias com dados longitudinais (Artigo 2). A amostra foi composta por 50 psiquiatras no segundo ano de formação durante estágio no Núcleo de Estudos e Tratamento de Trauma Psíquico do Hospital de Clínicas de Porto Alegre, Brasil. Esses terapeutas atenderam 131 pacientes recrutados consecutivamente durante 4 anos, que incluiu a primeira ou segunda consulta de vítimas de abuso sexual, seqüestro, assalto, agressão física, tentativa de homicídio, tortura e trauma indireto, independentemente do tempo decorrido entre a consulta atual e o evento traumático. Foram excluídos atendimentos de pacientes que chegaram à primeira consulta com ideação suicida grave, sintomas psicóticos e/ou com indicação de internação psiquiátrica. Os pacientes foram selecionados após triagem, que avaliou as variáveis clínicas e o diagnóstico segundo os critérios do DSM-IV-TR. Na primeira consulta, foram coletados os dados demográficos e clínicos e avaliada a contratransferência identificada pelo terapeuta através da EACT. Os pacientes foram acompanhados ao longo do tratamento psiquiátrico para determinar o número de consultas, faltas e o desfecho: alta ou abandono. A EACT é uma escala auto-aplicável, composta por 23 itens pontuados para 3 momentos da sessão (início, durante e final) em escala tipo Likert (0=ausência a 3=muito), e distribuídos em 3 domínios: aproximação (10 itens), afastamento (10 itens) e indiferença (3 itens). A validade de constructo da EACT no atendimento desta população foi avaliada através da análise fatorial exploratória (EFA) e consistência interna (α de Cronbach). O tamanho amostral foi calculado a partir de pelo menos 5 aplicações da EACT para cada item da escala (mínimo N = 115). E a análise fatorial confirmatória foi usada para determinar os parâmetros de adequação (goodness-of-fit) da versão da EACT no atendimento de vítimas de trauma obtida na EFA em comparação com a versão original. Resultados: A EFA mostrou 3 fatores com homogeneidade consistente, sendo distinta da versão original da EACT a correlação entre os itens e o terceiro fator: afastamento (9 itens com 24% da variância; α = 0,88), aproximação (7 itens com 15% da variância; α=0,82) e tristeza (6 itens com 9% da variância; α = 0,72). O item alegria, com carga fatorial baixa, foi retirado da análise por ser considerado irrelevante neste contexto. A análise fatorial confirmatória evidenciou melhores critérios de goodness-of-fit em todos os parâmetros testados para a presente versão da EACT do que a original. Secundariamente, as características demográficas e clínicas dos terapeutas e dos pacientes dos grupos alta e abandono foram similares. Os terapeutas com idade ≤ 27 anos pontuaram maior afastamento que os mais velhos (0,14 ± 1 vs. -0,21 ± 0,9; P=0,019). Os pacientes casados induziram nos terapeutas mais sentimentos de afastamento (0,20 ±1 vs. -0,19 ± 0,9; P = 0,016) e tristeza (0,18 ±1 vs. -0,17 ± 1; P = 0,049) que os que vivem sozinhos. Nas variáveis clínicas, as vítimas de trauma indireto e de múltiplos traumas despertaram mais tristeza (0,38 ± 1 e 0,76 ± 0,4, respectivamente), comparadas às vítimas de violência sexual (0,03 ± 0,9) e urbana (-0,3 ± 1) (P = 0,039). A mediana de consultas realizadas foi 5 [4; 8], faltas 1 [0; 1] e a taxa de abandono foi de 34,4%. Na análise multivariada, identificou-se que os pacientes com relato de história de trauma na infância abandonaram menos o tratamento (OR = 0,39; P = 0,039; CI 95% 0,16- 0,95). Não foi detectada associação entre sentimentos contratransferenciais iniciais com os desfechos do tratamento. Conclusões: A EACT apresentou propriedades psicométricas consistentes, demonstrando ser um instrumento confiável para acessara contratransferência inicial de terapeutas de vítimas de trauma psíquico. Os sentimentos contratransferenciais no atendimento inicial destes pacientes associaram-se a parâmetros demográficos e clínicos, mas não se associaram ao abandono do tratamento. Estudos futuros devem avaliar a modificação dos sentimentos contratransferenciais ao longo do tratamento e o seu impacto sobre os desfechos do tratamento. / Introduction: The concept of countertransference (CT) evolved from an “obstacle to treatment” to "an useful tool to understand patients within a bi-personal relationship". Currently, evidences of its specificity are searched for, correlating specific CT patterns to patients and therapists’ features, diagnostic classes, and treatment outcomes. Due to the intensity of emotional reactions aroused in therapists caring for trauma victims, it is believed that the study of CT in this population will help self-knowledge of therapists and contribute for a better patient care. The development of studies in this field is hindered by the reduced number of validated scales to assess CT. In Brazil, the Assessment of Countertransference Scale and the translated versions of the Inventory of Countertransference Behavior and Mental States Rating System are available, however, none of them has been validated. The Assessment of Countertransference Scale (ACS) has been created in our department with high face validity, built around three conceptual dimensions of feelings. However, its psychometric properties have not been assessed yet. Objectives: To investigate the construct validity of the ACS answered by therapists of psychological trauma victims (Article 1). Then, to assess the correlation between initial CT with victims of psychological trauma and the clinical and demographic data of therapists and patients and the type of trauma, and to investigate the association between initial countertransference and patients’ adherence to treatment and its outcome, defined as discharge or drop-out (Article 2). Methods: A Cross-sectional study (Article 1) and secondary analysis with longitudinal data (Article 2) were carried out. The sample was formed by 50 psychiatrists in the second year of training in their internship in the Center for Study and Treatment of Traumatic Stress in Hospital de Clínicas de Porto Alegre, Brazil. These therapists cared for 131 patients consecutively recruited for 4 years, including the first and second appointment with victims of sexual abuse, kidnapping, robbery, physical assault, homicide attempt, torture and indirect trauma, regardless of the time elapsed between the current appointment and the trauma event. We have excluded patients that arrived in the first appointment with severe suicidal ideation, psychotic symptoms and/or referral for psychiatric hospitalization. Patients have been selected after screening, which assessed the clinical variables and the diagnoses according to DSM-IV-TR criteria. In the first appointment, demographic and clinical data were collected and CT, identified by therapists through the ACS, was assessed. Patients were followed-up during psychiatric treatment to determine the number of appointments, absences, and the outcome: discharge or drop-out. ACS is a self-applied scale composed by 23 items scored for 3 moments of the session (start, midpoint and end) in a Likert-type scale (0=absence to 3=very), and distributed into 3 dimensions: closeness (10 items), distance (10 items) and indifference (3 items). The construct validity of ACS in the care for this population was assessed through the Exploratory Factor Analysis (EFA) and the internal consistency (α de Cronbach). The sample size was calculated for at least 5 applications of ACS for each item of the scale (minimum N = 115). The Confirmatory Factor Analysis (CFA) was used to determine the goodness of fit parameters of the ACS version in the care for trauma victims obtained in the EFA compared to the original version. Results: EFA showed 3 factors with consistent homogeneity, but the correlation between the items and the third factor were different from the original version, in the following: rejection (9 items with 24% of variance; α = 0.88), closeness (7 items with 15% of variance; α = 0.82) and sadness (6 items with 9% of variance; α = 0.72). The item “happiness”, with low factorial load, was withdrawn from the analysis because it was considered to be irrelevant in this context. CFA showed better goodness of fit criteria in all tested parameters for the present version of ACS compared to the original version. Secondly, the demographic and clinical characteristics of therapists and patients of the discharge and drop-out groups were similar. Therapists with ages ≤ 27 years scored more rejection than older therapists (0.14 ± 1 vs. -0.21 ± 0.9; P = 0.019). Married patients induced in therapists more feelings of rejection (0.20 ± 1 vs. -0.19 ± 0.9; P = 0.016) and sadness (0.18 ± 1 vs. -0.17 ± 1; P = 0.049) than those patients living alone. In the clinical variables, the victims of indirect trauma and of several traumas aroused more feelings of sadness (0.38 ± 1 and 0.76 ± 0.4, respectively) compared to sexual violence (0.03 ± 0.9) and urban violence victims (-0.3 ± 1) (P = 0.039). Median of appointments performed was 5 [4; 8], absences 1 [0; 1] and the drop-out rate was 34.4%. In the multivariate analysis, we have identified that patients with reported history of childhood trauma were less likelihood of dropping out treatment (OR=0.39; P = 0.039; CI 95% 0.16-0.95). Association between the initial CT feelings and the treatment outcomes has not been detected. Conclusions: ACS presented sound psychometric properties, and it has been demonstrated to be a reliable instrument to access initial CT of therapists in victims of psychological trauma. Countertransference feelings in the initial care of patients were associated with clinical and demographic parameters, but it were not associated with treatment drop-out. Further studies should assess the changes in CT feelings over treatment and their impact on treatment outcomes.

Introdução: O conceito de contratransferência evoluiu de “um obstáculo ao tratamento” à ferramenta útil à compreensão do paciente dentro de uma relação bi-pessoal. Atualmente, buscam-se evidências da sua especificidade, correlacionando padrões específicos de contratransferência com características do paciente e terapeuta, classes diagnósticas e desfechos do tratamento. Acredita-se que, devido à intensidade das reações emocionais despertadas nos terapeutas que atendem vítimas de trauma, o estudo da contratransferência nesta população auxilie no autoconhecimento dos terapeutas, amplie a compreensão sobre o fenômeno e contribua para um melhor atendimento dos pacientes. O desenvolvimento de pesquisas nesta área esbarra no reduzido número de escalas validadas para acessar a contratransferência. No Brasil, estão disponíveis a escala para Avaliação da Contratransferência e as versões traduzidas do Inventory of Countertransference Behavior e Mental States Rating System, mas nenhuma validada.A Escala para a Avaliação da Contratransferência (EACT) foi criada em nosso meio, com elevada validade de face, construída em torno de três dimensões conceituais de sentimentos. Entretanto, suas propriedades psicométricas ainda não foram avaliadas. Objetivos: Investigara validade de construto da EACT, respondida por terapeutas de vítimas de trauma psíquico (Artigo 1). Secundariamente, analisar a correlação entre a contratransferência inicial com vítimas de trauma psíquico e os dados demográficos e clínicos de terapeutas e pacientes e o tipo de trauma, e investigar a associação entre a contratransferência inicial e a adesão dos pacientes ao tratamento e o seu desfecho, operacionalizado como alta ou abandono (Artigo 2). Método: Delineamento transversal (Artigo 1) e análises secundárias com dados longitudinais (Artigo 2). A amostra foi composta por 50 psiquiatras no segundo ano de formação durante estágio no Núcleo de Estudos e Tratamento de Trauma Psíquico do Hospital de Clínicas de Porto Alegre, Brasil. Esses terapeutas atenderam 131 pacientes recrutados consecutivamente durante 4 anos, que incluiu a primeira ou segunda consulta de vítimas de abuso sexual, seqüestro, assalto, agressão física, tentativa de homicídio, tortura e trauma indireto, independentemente do tempo decorrido entre a consulta atual e o evento traumático. Foram excluídos atendimentos de pacientes que chegaram à primeira consulta com ideação suicida grave, sintomas psicóticos e/ou com indicação de internação psiquiátrica. Os pacientes foram selecionados após triagem, que avaliou as variáveis clínicas e o diagnóstico segundo os critérios do DSM-IV-TR. Na primeira consulta, foram coletados os dados demográficos e clínicos e avaliada a contratransferência identificada pelo terapeuta através da EACT. Os pacientes foram acompanhados ao longo do tratamento psiquiátrico para determinar o número de consultas, faltas e o desfecho: alta ou abandono. A EACT é uma escala auto-aplicável, composta por 23 itens pontuados para 3 momentos da sessão (início, durante e final) em escala tipo Likert (0=ausência a 3=muito), e distribuídos em 3 domínios: aproximação (10 itens), afastamento (10 itens) e indiferença (3 itens). A validade de constructo da EACT no atendimento desta população foi avaliada através da análise fatorial exploratória (EFA) e consistência interna (α de Cronbach). O tamanho amostral foi calculado a partir de pelo menos 5 aplicações da EACT para cada item da escala (mínimo N = 115). E a análise fatorial confirmatória foi usada para determinar os parâmetros de adequação (goodness-of-fit) da versão da EACT no atendimento de vítimas de trauma obtida na EFA em comparação com a versão original. Resultados: A EFA mostrou 3 fatores com homogeneidade consistente, sendo distinta da versão original da EACT a correlação entre os itens e o terceiro fator: afastamento (9 itens com 24% da variância; α = 0,88), aproximação (7 itens com 15% da variância; α=0,82) e tristeza (6 itens com 9% da variância; α = 0,72). O item alegria, com carga fatorial baixa, foi retirado da análise por ser considerado irrelevante neste contexto. A análise fatorial confirmatória evidenciou melhores critérios de goodness-of-fit em todos os parâmetros testados para a presente versão da EACT do que a original. Secundariamente, as características demográficas e clínicas dos terapeutas e dos pacientes dos grupos alta e abandono foram similares. Os terapeutas com idade ≤ 27 anos pontuaram maior afastamento que os mais velhos (0,14 ± 1 vs. -0,21 ± 0,9; P=0,019). Os pacientes casados induziram nos terapeutas mais sentimentos de afastamento (0,20 ±1 vs. -0,19 ± 0,9; P = 0,016) e tristeza (0,18 ±1 vs. -0,17 ± 1; P = 0,049) que os que vivem sozinhos. Nas variáveis clínicas, as vítimas de trauma indireto e de múltiplos traumas despertaram mais tristeza (0,38 ± 1 e 0,76 ± 0,4, respectivamente), comparadas às vítimas de violência sexual (0,03 ± 0,9) e urbana (-0,3 ± 1) (P = 0,039). A mediana de consultas realizadas foi 5 [4; 8], faltas 1 [0; 1] e a taxa de abandono foi de 34,4%. Na análise multivariada, identificou-se que os pacientes com relato de história de trauma na infância abandonaram menos o tratamento (OR = 0,39; P = 0,039; CI 95% 0,16- 0,95). Não foi detectada associação entre sentimentos contratransferenciais iniciais com os desfechos do tratamento. Conclusões: A EACT apresentou propriedades psicométricas consistentes, demonstrando ser um instrumento confiável para acessara contratransferência inicial de terapeutas de vítimas de trauma psíquico. Os sentimentos contratransferenciais no atendimento inicial destes pacientes associaram-se a parâmetros demográficos e clínicos, mas não se associaram ao abandono do tratamento. Estudos futuros devem avaliar a modificação dos sentimentos contratransferenciais ao longo do tratamento e o seu impacto sobre os desfechos do tratamento. / Introduction: The concept of countertransference (CT) evolved from an “obstacle to treatment” to "an useful tool to understand patients within a bi-personal relationship". Currently, evidences of its specificity are searched for, correlating specific CT patterns to patients and therapists’ features, diagnostic classes, and treatment outcomes. Due to the intensity of emotional reactions aroused in therapists caring for trauma victims, it is believed that the study of CT in this population will help self-knowledge of therapists and contribute for a better patient care. The development of studies in this field is hindered by the reduced number of validated scales to assess CT. In Brazil, the Assessment of Countertransference Scale and the translated versions of the Inventory of Countertransference Behavior and Mental States Rating System are available, however, none of them has been validated. The Assessment of Countertransference Scale (ACS) has been created in our department with high face validity, built around three conceptual dimensions of feelings. However, its psychometric properties have not been assessed yet. Objectives: To investigate the construct validity of the ACS answered by therapists of psychological trauma victims (Article 1). Then, to assess the correlation between initial CT with victims of psychological trauma and the clinical and demographic data of therapists and patients and the type of trauma, and to investigate the association between initial countertransference and patients’ adherence to treatment and its outcome, defined as discharge or drop-out (Article 2). Methods: A Cross-sectional study (Article 1) and secondary analysis with longitudinal data (Article 2) were carried out. The sample was formed by 50 psychiatrists in the second year of training in their internship in the Center for Study and Treatment of Traumatic Stress in Hospital de Clínicas de Porto Alegre, Brazil. These therapists cared for 131 patients consecutively recruited for 4 years, including the first and second appointment with victims of sexual abuse, kidnapping, robbery, physical assault, homicide attempt, torture and indirect trauma, regardless of the time elapsed between the current appointment and the trauma event. We have excluded patients that arrived in the first appointment with severe suicidal ideation, psychotic symptoms and/or referral for psychiatric hospitalization. Patients have been selected after screening, which assessed the clinical variables and the diagnoses according to DSM-IV-TR criteria. In the first appointment, demographic and clinical data were collected and CT, identified by therapists through the ACS, was assessed. Patients were followed-up during psychiatric treatment to determine the number of appointments, absences, and the outcome: discharge or drop-out. ACS is a self-applied scale composed by 23 items scored for 3 moments of the session (start, midpoint and end) in a Likert-type scale (0=absence to 3=very), and distributed into 3 dimensions: closeness (10 items), distance (10 items) and indifference (3 items). The construct validity of ACS in the care for this population was assessed through the Exploratory Factor Analysis (EFA) and the internal consistency (α de Cronbach). The sample size was calculated for at least 5 applications of ACS for each item of the scale (minimum N = 115). The Confirmatory Factor Analysis (CFA) was used to determine the goodness of fit parameters of the ACS version in the care for trauma victims obtained in the EFA compared to the original version. Results: EFA showed 3 factors with consistent homogeneity, but the correlation between the items and the third factor were different from the original version, in the following: rejection (9 items with 24% of variance; α = 0.88), closeness (7 items with 15% of variance; α = 0.82) and sadness (6 items with 9% of variance; α = 0.72). The item “happiness”, with low factorial load, was withdrawn from the analysis because it was considered to be irrelevant in this context. CFA showed better goodness of fit criteria in all tested parameters for the present version of ACS compared to the original version. Secondly, the demographic and clinical characteristics of therapists and patients of the discharge and drop-out groups were similar. Therapists with ages ≤ 27 years scored more rejection than older therapists (0.14 ± 1 vs. -0.21 ± 0.9; P = 0.019). Married patients induced in therapists more feelings of rejection (0.20 ± 1 vs. -0.19 ± 0.9; P = 0.016) and sadness (0.18 ± 1 vs. -0.17 ± 1; P = 0.049) than those patients living alone. In the clinical variables, the victims of indirect trauma and of several traumas aroused more feelings of sadness (0.38 ± 1 and 0.76 ± 0.4, respectively) compared to sexual violence (0.03 ± 0.9) and urban violence victims (-0.3 ± 1) (P = 0.039). Median of appointments performed was 5 [4; 8], absences 1 [0; 1] and the drop-out rate was 34.4%. In the multivariate analysis, we have identified that patients with reported history of childhood trauma were less likelihood of dropping out treatment (OR=0.39; P = 0.039; CI 95% 0.16-0.95). Association between the initial CT feelings and the treatment outcomes has not been detected. Conclusions: ACS presented sound psychometric properties, and it has been demonstrated to be a reliable instrument to access initial CT of therapists in victims of psychological trauma. Countertransference feelings in the initial care of patients were associated with clinical and demographic parameters, but it were not associated with treatment drop-out. Further studies should assess the changes in CT feelings over treatment and their impact on treatment outcomes.

USING DATA MINING METHODS FOR DEMOGRAPHIC SURVEY DATA PROCESSING Abstract The goal of the thesis was to describe and demonstrate principles of the process of knowledge discovery in databases - data mining (DM). In the theoretical part of the thesis, selected methods for data mining processes are described as well as basic principles of those DM techniques. In the second part of the thesis a DM task is realized in accordance to CRISP-DM methodology. Practical part of the thesis is divided into two parts and data from the survey of American Community Survey served as the basic data for the practical part of the thesis. First part contains a classification task which goal was to determinate whether the selected DM techniques can be used to solve missing data in the surveys. The success rate of classifications and following data value prediction in selected attributes was in 55-80 % range. The second part of the practical part of the thesis was then focused of determining knowledge of interest using associating rules and the GUHA method. Keywords: data mining, knowledge discovery in databases, statistic surveys, missing values, classification, association rules, GUHA method, ACS

The thesis deals wiring design of automated analyzer ACS 820 for carbon and sulfur. Describes individually all parts and their functionality. Evaluates applicable control components. Thesis discuss design of safety circuit, that will secure safe use of instrument. Part of the thesis is realisation of electrical design and completing the control box.

Background. AHA guidelines have been established to reduce Acute Coronary Syndrome (ACS)-related morbidity, mortality and recurrent events post-discharge. These recommendations emphasize the patient as an engaged member of the health care team in secondary prevention efforts. Patients with high levels of activation are more likely to perform activities that will promote their own health and are more likely to have their health care needs met. Despite evidence and strong expert consensus supporting patients as active collaborators in their own ACS care, the complexity and unexpected realities of self-managing one’s care at home are often underestimated. This study seeks to examine the correlates of patient activation at hospital discharge and then identifies activation trajectories in this same cohort in subsequent months. Lastly, this study examines the association between patient activation and health care utilization in the year subsequent to an ACS event. Methods. This study incorporates three aims: Aim 1, identification of the correlates of low patient activation post-discharge; Aim 2, identification of patient activation trajectories among this same cohort in the months following hospitalization; and Aim 3, examination of the association between patient activation and health utilization, post-discharge. Results. Fifty-nine percent of ACS patients identified as being at the lowest two activation stages at the time of hospital discharge. Perceived stress (pidentified post-discharge: low, stable (T1), high, sharp decline (T2), and sharp improvement (T3). The majority of patients (67%) identified as being in T1. Those patients of older age (OR: 2.22; CI 1.4- 3.5), identifying as Black in race (OR: 2.14: CI 1.1- 4.3), and reporting moderate/high perceived stress (OR: 2.54: CI 1.4- 4.5) had increased odds of being in the low, stable trajectory. The bivariate analysis indicated a significant association (P=0.008) between low patient activation and self-reported hospital readmissions in the months following discharge. In the final model, moderate to severe depression (OR: 1.60; CI 1.1- 2.3) was the strongest predictor of readmissions in the 12 months subsequent to discharge. Conclusions: Patients reported low activation at hospital discharge after an ACS event indicated that these patients were not prepared to take an active role in their own care. Correlates of low activation at discharge include moderate to high perceived stress, depression, and low social support. Furthermore, in the months following hospital discharge, the majority of these patients followed either a low/stable or a sharp decline activation trajectory. Hence, these results suggest that over time patients feel less and less confident to take an active role in self-management. Lastly, we found that patient activation may impact healthcare utilization in the year subsequent to hospital discharge, although patient self-reported depression appears to be the strongest predictor of utilization in the subsequent year. Future research is needed to better understand the relationship(s) among patient activation, depression, and health care utilization.

Sickle cell disease is a disabling chronic autosomal recessive blood disease characterized by abnormal hemoglobin, pain crises, and frequent emergency department visits. Adherence to hydroxyurea therapy has been shown to improve these patient outcomes. Guided by the theory of comfort, the purpose of this project was to determine if an educational intervention would increase adherence to hydroxyurea therapy in pediatric patients between 2 and 17 years of age recruited from an urban university hospital hematology clinic. The RE-AIM model was used to support the translation of evidence and the change process. An educational video produced by AFLAC was viewed by patients' parents 4 weeks after enrollment into this pretest/posttest design project. A total of 22 African-American parent participants completed the 8-item Morisky Medication Adherence Scale at baseline and again at 8 weeks to assess hydroxyurea adherence. The Short Test of Functional Health Literacy in Adults tool was used to assess parents' health learning needs; all parents met the adequate literacy level at baseline. Using t test statistics, no statistically significant differences were found pretest to posttest on the Morisky Medication Adherence Scale scores, mean corpuscular hemoglobin, and fetal hemoglobin percentages. Wilcoxon Signed Rank tests showed no significant differences in emergency room visits nor number of pain crisis. Although no significant changes emerged in short-term hematologic findings, emergency room visits, and pain crises, social change in the health care setting was promoted by confirming parents were able to understand education and a high level of hydroxyurea adherence was maintained; literature indicated that long-term adherence to hydroxyurea limits severe attacks.

No description available.