Thesis (M.H.A.)--University of Michigan, 1969.

Thesis--Universität zu Köln, 1997.

Thesis--Universität zu Köln, 1997.

Thesis (M.Sc.)--Memorial University of Newfoundland, 2002. / Bibliography: leaves 82-86.

Thesis (Ph. D.)--Cornell University, June, 1974. / Includes bibliographical references (leaves 223-236).

Thesis (M.S.)--University of Michigan, 1983.

Thesis (Ph. D.)--Cornell University, June, 1974. / Includes bibliographical references (leaves 223-236).

A asma é considerada um problema de saúde pública mundial. É necessário expandir o conhecimento sobre seus custos associados em diferentes regiões. O principal objetivo foi estimar os custos do tratamento da asma em uma população de asmáticos com diferentes níveis de gravidade, sob tratamento ambulatorial especializado. Os objetivos secundários foram analisar as características clínicas e sócio-econômicas da população e o custo incremental da associação com a rinite e infecções respiratórias (IR). Asmáticos &#8805; 6 anos de idade com asma persistente foram incluídos consecutivamente de março de 2011 a setembro de 2012. Todos realizaram visitas clínicas de rotina com intervalos de 3-4 meses e 2 entrevistas com intervalos de 6 meses para coleta dados. Variáveis clínicas e dados primários sobre os custos da asma, rinite e infecções respiratórias (IR) foram coletados diretamente dos pacientes ou responsáveis (< 18 anos), sob uma perspectiva da sociedade. Os custos em reais foram convertidos em dólares usando a paridade do poder de compra em 2012 (US$ 1,00 = R$ 1,71). Cento e oito pacientes completaram o estudo, sendo 73,8% mulheres. A maioria (75,0%) reside no município do RJ, sendo que 60,1% destes moram longe da unidade de saúde. Rinite crônica estava presente em 83,3%, e mais da metade tinha sobrepeso ou obesidade, nos quais a prevalência de asma grave foi maior (p = 0,001). Metade ou mais dos trabalhadores e estudantes faltaram as suas atividades em decorrência da asma. A renda familiar mensal (RFM) média foi de US$ 915,90 (DP=879,12). O custo médio estimado da asma/rinite/IR foi de US$ 1.276,72 por paciente-ano (DP=764,14) e o custo médio específico da asma foi de US$ 1.140,94 (DP=760,87). Asmáticos obesos, graves ou não controlados tiveram maiores custos em comparação aos não obesos, moderados/leves e controlados (p <0,05 em todas as comparações). A população estudada tem nível sócio-econômico médio/baixo, alta prevalência de rinite crônica e de sobrepeso/obesidade. Maior peso e menor RFM foram mais frequentes entre os graves e não controlados, respectivamente. Asmáticos obesos, graves ou não controlados tiveram maiores custos. O custo incremental da rinite e IR foi de 12%. O custo médio da asma foi equivalente à metade do relatado na União Européia e nos Estados Unidos da América, e foi maior do que a média na região Ásia-Pacífico. Num cenário ideal, onde todos os asmáticos brasileiros recebessem tratamento no Sistema Único de Saúde de acordo com a Iniciativa Global para Asma, o custo total da asma seria equivalente a 3,4-4,5% e 0,4-0,6% do Produto Interno Bruto (PIB) da saúde e do PIB brasileiro, respectivamente. Estratégias de saúde pública com programas estruturados que facilitem o melhor controle da asma e estimulem a redução de peso poderão contribuir para reduzir os custos da doença, o que poderia tornar a oferta de tratamento medicamentoso gratuito para todos os asmáticos persistentes no SUS uma meta alcançável. Recomendamos estender este estudo de custo da asma para diferentes regiões do país. / Asthma is considered a health problem worldwide. It is necessary to expand our knowledge in different regions of the world, including its associated costs. The major aim was to estimate economic costs of asthma treatment in a cohort of persistent asthmatics with different severity levels under specialized ambulatory care. Secondary aims were to analyze the clinical and socioeconomic characteristics of this population and to estimate the incremental cost associated to rhinitis and respiratory infections. Patients &#8805; 6 years old with persistent asthma were consecutively included from March 2011 to September 2012. They made routine clinical visits with 3 to 4-month intervals and 2 interviews with 6-month intervals. Clinical variables and asthma, rhinitis and respiratory infections (RI) primary data on costs were collected directly from patients or their parents (patients under 18 years old), regarding the two 6-month prior periods in a societal perspective. Brazilian costs were converted into USD using the purchasing power parity in 2012 (US$ 1.00=R$ 1.71). One hundred and eight out of 117 subjects completed the study. 73.8% were women, 60.1% lived far from the health care unit. Chronic rhinitis was present in 83.3% and more than 50.0% were overweight or obese, in whom the prevalence of severe asthma was greater (p=0.001). 75% of the students and half of the workers had missed activity days because asthma. Mean monthly family income (MFI) was US$ 915.90 (SD=879.12). The estimated mean total cost of asthma, rhinitis and RI was US$ 1,276.72 per patient-year (SD=764.14) and the mean specific annual asthma cost was US$ 1,140.94 (SD=760.87) per patient. Obese, severe or uncontrolled asthmatics had greater costs compared to non-obese, mild/moderate and controlled ones, respectively (p<0.05 in all comparisons). The population had medium to low socio-economic status, a high prevalence of associated chronic rhinitis and overweight or obesity. High body weight and lower MFI were more frequent among patients with greater severity and worse control, respectively. Obese, severe or uncontrolled asthmatics had greater costs. Asthma had a great impact on absenteeism. The mean cost of asthma was equivalent to the half of that in European Union and United States of America and was greater than the mean of Asia-Pacific region. In an ideal scenario, where all asthmatics would be receiving GINA guided treatment in the Unified Health System (UHF), like ours, the total cost of asthma would be equivalent to 3.4 to 4.5% and 0.4 to 0.6% of Brazilian health gross domestic product (HGDP) and Brazilian GDP, respectively. Public health strategies with programs aiming get better control and stimulating weight reduction could contribute to lower cost of asthma, possibly making the offer of free asthma medication to all persistent asthmatics in UHF a more achievable task. We recommend to expand this study to other different regions.

<b>Background</b> Antibiotic resistance is an important societal health issue. The greatest risk factor for developing a resistant infection is antibiotic use. Almost 75% of all antibiotics in the UK are prescribed in the community, and mostly for acute respiratory tract infections (RTIs). Yet, the majority of RTIs are self-limiting, viral and do not need antibiotic treatment, especially in young children. While the effects of antibiotic-resistant infections have been widely studied in hospitals (e.g. the MRSA 'superbug'), we know less about how antibiotic-resistant infections affect people in the community, even though this is where most antibiotics are prescribed. There is also widespread public misconception about antibiotic use and resistance despite several high-profile, multimillion antibiotic awareness campaigns. This is important to address because consultation behaviour and expectations for antibiotics are a significant determinant of antibiotic use in the community. <b>Methods</b> Three studies were conducted for this thesis. First, a systematic review and meta-analysis to assess the evidence of the impact of antibiotic resistance for patients with common infections in the community; second, a retrospective analysis of routinely collected primary care data to examine the relationship between antibiotic exposure and antibiotic 'response failure' in preschool children presenting with acute RTIs; third, a qualitative interview study to explore parents' perceptions and understanding of antibiotic use and resistance when they consider consulting in the community with their preschool child who has a respiratory tract infection. <b>Results</b> Antibiotic resistance significantly impacts on patients' illness burden for common infections in the community. Patients who presented in community health care settings with antibiotic-resistant E. coli urinary tract infections and S. pneumoniae respiratory tract infections were more likely to experience delays in recovery after antibiotic treatment. From routinely collected primary data (2009-2016), preschool children receiving two or more antibiotic courses in the previous year for acute RTIs had greater likelihood of antibiotic 'response failure' to treatment for subsequent acute RTIs compared to children that had received no previous antibiotics. When interviewing parents of young children, most parents were quite reticent about antibiotics for their children. However, very few considered antibiotic resistance as a possible harm of antibiotics. Parents thought their families were at low risk of antibiotic resistance because their families were 'low users' of antibiotics and did not perceive any association between their individual consumption of antibiotics and the development and spread of antibiotic-resistant bacteria in the community. They wanted future antibiotic awareness campaigns to have a universal message relevant to their families that fit into their daily lives. <b>Conclusions</b> The findings challenge the perception that antibiotic prescribing and resistance in the community poses little or no additional risk to patients in the community, or is remote from everyday prescribing decisions. Rapid diagnostic tests and other prognostic tools need to be promoted and evaluated to better identify patients who might need an antibiotic, and reduce the risk antibiotic response failures. Clinicians and parents should exercise caution about whether further antibiotics for acute RTIs are likely to be beneficial in those children who have received two or more antibiotic prescriptions for acute RTIs during the previous 12 months. Incorporating this into clinical practice guidelines and decision-support systems will help clinicians and parents consider a non-antibiotic strategy for acute RTIs. Future guidelines, campaigns and interventions around antibiotic resistance should tailor initiatives to outcomes that patients and clinicians in the community can relate to and slot into their daily lives. More research is needed to evaluate the impact of other common infections in primary care, and determine the relative contribution of antibiotic resistance to patients not responding to antibiotic treatment for common infections.

Made available in DSpace on 2014-12-17T14:46:34Z (GMT). No. of bitstreams: 1 MariaCleiaOV.pdf: 925431 bytes, checksum: dd521fc21569982659a02d8374a9b70d (MD5) Previous issue date: 2008-04-30 / This present study of quantitative/qualitative approach, aims to analyze the outpatient care at the Hospital Universit?rio Onofre Lopes (HUOL), and, having as guide, the reception of the user. In this regard were invited and interviewed 20 users. Besides the interviews, conducted in a period of 45 days, in this same period of time was used a field diary for more significant notes of observations more significant. In the analysis, we drafted the socio-demographic profile of the group and identified their main complaints, problems and suggestions. For this, we have built graphics, tables and pictures, in addition to standing out their testimony, as a resource for better understanding of the subjective aspects. The theoretical reference consisted of documents from the Ministry of Health about the reception and humanization, and the studies of Merhy, Franco, Pinheiro, Matumoto, Mariotti, Teixeira, among others. The results show the ambulatory of HUOL as a privileged space and of credibility, where users commonly, find answers to their problems. However, these same users were unanimous in saying the difficulties they face in obtaining consultations, from the basic unit, until the hospital. Regarding the service, although they feel satisfied as for the assistance received, they list a series of problems, of structural relationship order: lack of visual signalling, information, wheelchairs, hygiene, in the waiting rooms that offer some comfort, besides the inattention of some professionals. In summary, in the study, undertaken now, we cannot say that there is in the reality studied, the reception, in its full meaning, but the HUOL as hospital-school, has all the potential to accomplish it / O presente estudo de abordagem quantitativa / qualitativa tem como objetivo analisar a assist?ncia ambulatorial no Hospital Universit?rio Onofre Lopes (HUOL), tendo, como fio condutor, o acolhimento do usu?rio. Com este prop?sito foram convidados e entrevistados 20 usu?rios. Al?m das entrevistas, realizadas em um espa?o de 45 dias, neste mesmo lapso de tempo foi utilizado um di?rio de campo para anota??es das observa??es mais significativas. Na an?lise, tra?amos o perfil sociodemogr?fico do grupo e identificamos suas principais queixas, dificuldades e sugest?es. Para isto, constru?mos gr?ficos, quadros e figuras, al?m de destacarmos seus depoimentos, como recurso para melhor compreens?o dos aspectos subjetivos. O referencial te?rico constou de documentos do Minist?rio da Sa?de acerca do acolhimento e da humaniza??o, bem como dos estudos de Merhy, Franco, Pinheiro, Matumoto Mariotti, Teixeira, entre outros. Os resultados apontam o ambulat?rio do HUOL como um espa?o privilegiado e de credibilidade, onde os usu?rios encontram, comumente, respostas para seus problemas. No entanto, estes mesmos usu?rios foram un?nimes em afirmar as dificuldades que enfrentam para a obten??o de consultas, desde a unidade b?sica, at? chegar ao hospital. Referindo-se ao atendimento, embora sintam-se satisfeitos quanto ? assist?ncia recebida, elencam uma s?rie de problemas, de ordem estrutural e de relacionamento: falta de sinaliza??o visual, de informa??o, de cadeira de rodas, de higiene, de salas de espera que ofere?am algum conforto, al?m da desaten??o de alguns profissionais. Em s?ntese, o estudo, ora empreendido, n?o nos permite afirmar que exista, na realidade estudada, o acolhimento, em seu sentido pleno; no entanto, o HUOL, como hospital-escola, disp?e de todo um potencial para realiz?-lo