Abstract Free flap surgery (FFS) is used for the reconstruction of head and neck defects after tumor resection. Compared to many other cancers requiring operative care, postoperative complications are frequent and the long-term outcome is poor in this patient group. The impact of postoperative complications on outcome, quality of life (QOL) and causes of death has not been well studied. The aim of this thesis was to study the factors associated with postoperative complications after FFS for cancer of the head and neck, as well as the impact of complications on QOL and long-term outcomes. The thesis includes one prospective and three retrospective studies. The study population was 146 head and neck patients undergoing FFS in Oulu University Hospital from 2008 to 2016. The impact of goal-directed fluid management using SVV (stroke volume variation) analysis on postoperative outcome was evaluated retrospectively. It led to a significant reduction in intraoperative fluid administration (6070 ml vs. 8185 ml) and length of stay (LOS) in hospital (11.5 vs. 14.0 days) but had no impact on the rate of postoperative complications. Postoperative complications were recorded in 60% of the patients and were related to alcohol abuse, complicated intraoperative course and fibular flap surgery. The patients with late complications (occurring after the fourth postoperative day) had higher mortality compared to those without. The QOL of 53 patients undergoing operations during 2013-2016 was evaluated using four questionnaires. Patients with medical complications (n=12, 22.6%) had significantly lower QOL in most domains of RAND-36 but QOL for those without complications was comparable to the general population. A total of 62/146 patients (42.5%) died by the end of 2016, and in 72.6% of cases the cause of death was the primary disease. In multivariate analysis male gender, low BMI, ASA above 2 and late medical complications were indicative for long-term mortality. In conclusion, postoperative complications have an impact on outcome after FFS for cancer of the head and neck in terms of QOL and long-term mortality. Patient-related factors were associated with unfavorable outcomes when intraoperative factors did not have as significant a role. Prevention of medical complications and adequate patient selection are essential when aiming to improve outcome after FFS. / Tiivistelmä Mikrovaskulaarikielekkeitä käytetään korjaamaan kasvaimen poiston vuoksi syntyneitä kudospuutoksia pään ja kaulan alueen syöpäpotilailla. Näihin toimenpiteisiin liittyy merkittävä komplikaatioriski ja myös itse syövän pitkäaikaisennuste on huono. Komplikaatioiden vaikutusta toipumisvaiheen elämänlaatuun ja kuolleisuuteen ei ole tutkittu. Tämän väitöskirjatyön tavoitteena oli selvittää tekijöitä, jotka liittyvät leikkauksen jälkeisiin komplikaatioihin, ja niiden merkitystä potilaiden elämänlaatuun ja pitkäaikaisennusteeseen. Tutkimuskokonaisuus koostuu kolmesta retrospektiivisestä tutkimuksesta ja yhdestä prospektiivisesta haastattelututkimuksesta. Tutkimukseen kuului 146 vuosina 2008–2016 Oulun yliopistollisessa sairaalassa leikattua pään ja kaulan alueen syöpäpotilasta. Tutkimuksessa selvitettiin tavoiteohjatun nestehoidon vaikutusta välittömään toipumisvaiheeseen, mutta tällä ei todettu olevan vaikutusta komplikaatioiden ilmaantumiseen. Sen sijaan potilaiden saama nestemäärä väheni merkitsevästi (6070 ml vs. 8185 ml) ja sairaalahoitojakson pituus lyheni (11,5 päivää vs. 14 päivää). Komplikaatioita todettiin 60 % leikkauksista ja useimmin komplikaation sai potilas, jolla oli alkoholin liikakäyttöä, ongelmia toimenpiteen aikana ja luullinen siirre. Neljännen leikkauksen jälkeisen päivän jälkeen ilmenneisiin komplikaatioihin liittyi korkeampi pitkäaikaiskuolleisuus. Elämänlaatu arvioitiin 53 potilaalta, jotka oli leikattu vuosina 2013–2016. Ei-kirurgisia komplikaatioita esiintyi 12 potilaalla ja heidän raportoimansa elämänlaatu oli merkitsevästi alentunut verrattuna muihin potilaisiin. Ilman komplikaatioita toipuneiden elämänlaatu oli verrattavissa väestöarvoihin. 42,5 % leikatuista potilaista oli kuollut vuoden 2016 loppuun mennessä ja 72,6 % heistä kuolema johtui hoidetusta syövästä. Monimuuttujamallissa pitkäaikaiskuolleisuuden riskitekijöitä olivat miessukupuoli, matala BMI, ASA-luokka yli 2 sekä todetut ei-kirurgiset komplikaatiot. Yhteenvetona voidaan todeta, että komplikaatioilla on merkitystä toipumisvaiheen elämänlaatuun ja pitkäaikaiskuolleisuuteen tässä potilasryhmässä. Potilaslähtöiset tekijät vaikuttavat merkittävästi komplikaatioiden ilmaantumiseen ja myös huonoon ennusteeseen. Ei-kirurgisten komplikaatioiden estäminen kuten myös oikea potilasvalinta ovat keskeisessä asemassa, kun tämän potilasryhmän hoidon tuloksia halutaan parantaa.

Made available in DSpace on 2015-07-15T13:31:37Z (GMT). No. of bitstreams: 1 TESE EDNA.pdf: 1820433 bytes, checksum: 2778120341ebf9c4e883791a305ba706 (MD5) Previous issue date: 2007-03-30 / Introduction: There has been considerable academic work documenting poor living conditions among the Afro-Brazilian population. However, there are few studies in the health literature that document the role of race/skin color as a contributor to health inequalities. Objectives: This study was conducted to analyze differences in mortality by external causes by race/color in Salvador, Bahia, Brazil during the period 1998-2003. Methods: First, we conducted a literature review on social inequalities in both the US and Brazil. Our inclusion criteria were: studies used race/color as a variable, were published in public health or epidemiologic literature, and were published over the period 1986-2005. Next, we conducted a descriptive study in which we calculated the years of potential life lost (PYLL) due to external causes, stratified by gender, age, type of external cause, and, by race and skin color classification. Finally, we conducted an ecological spatial study with areas equivalent to census tracts as the unit of analysis in Salvador. We used a binomial regression model to test the hypothesis that areas with a majority black male population between the ages of 15-49 years will have the highest proportion of mortality by all external causes and by homicide. Results: Of the 56 American studies and 7 Brazilian articles reviewed, 68% were published between 2002-5, 52 were cross studies, being 11 surveys, 6 were observational studies, 3 ecological and 2 were longitudinal studies. Of these, 60.3 % were population based studies and 39.7% studied the health of specific groups. The variable race/color or ethnicity was positively associated with the outcome studied in 84% of the analytical studies and the observed differences were statistically significant in all of the descriptive studies (where the author used a statistical test). The articles published in the US recognized the limitations of such analyses and have attempted to go beyond mere description of the disparity toward understanding the factors that contribute to these inequalities. On the other hand, the Brazilian literature appears to be at the beginning stage of documenting the existence of these inequalities. In the second study, we found that black males lost 21.8 times more PYLL compared to white men. The observed differences in the indicator PYLL/100.000 inhabitants and in the ratios of that indicator remained the same after the standardization by age. In the third study, we found that areas with the highest burden of mortality for all external causes and for homicide tended to cluster in areas with large proportions of black males age 15-49. (RR 1.18, p=0.03; IC 1.011 1,368) was obtained for the association between the proportion of the male population whose ages range from 15 to 49 years and the mortality rate by all the external causes adjusted by co-variables. Conclusions: We produced empirical evidence that black male population in the age range of 15-49, dies at a higher rate and shows major risk of death for external causes and specifically for homicide. We realize that these studies only reveal small facets of a very complex problem and thus we hope that these results will stimulate discussion about the causes and effects of inequalities on health among blacks in Brazil, and that such research will lead toward the development of public policies, which will address these inequalities. / Introdu??o: Existe uma razo?vel produ??o acad?mica em algumas ?reas do conhecimento que aponta piores condi??es de vida para a popula??o brasileira afro descendente. Entretanto, s?o poucos os estudos na ?rea de sa?de que abordam a ra?a/cor da pele como importante determinante da falta de equidade entre grupos. Objetivos: analisar os diferenciais da mortalidade por causas externas, segundo a ra?a/cor em Salvador, Bahia, Brasil, no per?odo 1998-2003. Material e M?todos: O primeiro dos tr?s artigos que comp?em o presente trabalho corresponde a uma revis?o de literatura sobre desigualdades sociais em sa?de no Brasil e nos Estados Unidos contemplando estudos que abordaram a ra?a/cor da pele, publicados em peri?dicos da ?rea de Sa?de Publica/Epidemiologia no per?odo de 1996 a 2005. O segundo ? um estudo descritivo no qual se calculou o n?mero de anos potenciais de vida perdidos (APVP) por causas externas por sexo, faixa et?ria e tipo de causa externa, segundo a ra?a/cor da pele. O terceiro artigo se constitui em um estudo ecol?gico espacial, que teve como unidade de an?lise as ?reas de pondera??o de Salvador. Mediante modelagem de Regress?o Binomial Negativa foi testada a hip?tese de que ?reas com maior propor??o de popula??o masculina negra entre 15 e 49 anos apresentavam maior mortalidade por todas as causas externas em conjunto e por homic?dio. Resultados: Dos 56 estudos norte-americanos e 7 brasileiros revistos, 68,7% foram publicados entre 2002 e 2005, 41 eram do tipo transversal (65,0%), 11 do tipo inqu?rito (17,5%), 6 eram de vigil?ncia (9,5%), 3 ecol?gicos (4,8%) e 2 longitudinais (3,2%). Desses 60,3% se referiram ? sa?de da popula??o e 39,7% a sa?de de grupos populacionais espec?ficos. A vari?vel ra?a/cor da pele/etnia esteve associada ao efeito estudado em 84,4% dos estudos anal?ticos e as diferen?as observadas se mostraram estatisticamente significantes em todos os estudos descritivos em que os autores utilizaram algum teste estat?stico. Todavia, enquanto nos artigos dos Estados Unidos se observou uma tend?ncia de supera??o das limita??es observadas nesses tipos de estudos, no Brasil essa literatura est? apenas come?ando a descrever a exist?ncia desse tipo de desigualdade. No segundo artigo verificou-se que os homens negros perderam 21,8 vezes mais anos potenciais de vida quando comparados aos homens brancos. As diferen?as observadas no APVP/100.000hab. e nas raz?es de APVP/100.000 se mantiveram mesmo ap?s a padroniza??o por idade. No ?ltimo estudo verificou-se que ?reas com altas taxas de mortalidade por todas as causas externas e por homic?dio tenderam a se aglomerar e tinham como caracter?sticas comuns uma maior propor??o de popula??o negra masculina com idade entre 15 e 49 anos. ?reas com maior propor??o de popula??o masculina negra entre 15 e 49 anos apresentavam maior mortalidade por causas externas (RR=1,18; p=0,03 para a associa??o entre propor??o da popula??o masculina negra com idade de 15 a 49 anos e taxa de mortalidade por todas as causas externas ajustada por propor??o de chefes de fam?lia negros com renda de ≤2SM ). Conclus?es: Foram produzidas evid?ncias de que a popula??o negra, especificamente a masculina negra com idade entre 15 e 49 anos, morre mais precocemente e apresenta maior risco de ?bito por causas externas e, especialmente por homic?dios. Entende-se que foram reveladas apenas uma das facetas de um problema bastante complexo, por?m, espera-se que tais resultados estimulem e subsidiem a discuss?o sobre a falta de equidade em sa?de segundo a ra?a/cor da pele e contribuam para a formula??o de pol?ticas p?blicas especificas.

O Serviço de Verificação de Óbitos (SVO) foi criado para elucidar causas de óbitos naturais mal definidas por meio de exames necroscópicos e registrar informações mais completas sobre as causas de morte no Sistema de Informação de Mortalidade (SIM). Desde a criação da rede nacional de SVO, poucos estudos avaliaram a qualidade dos registros de óbitos dos SVO no SIM. Foram estudados 19780 registros de óbitos não fetais de residentes no Estado do Tocantins entre os anos de 2012, 2011 e 2012, obtidos por download do site do DATASUS do Ministério da Saúde. Além de estabelecer o perfil social demográfico dos óbitos, foram estudadas a completude das informações, as cinco principais causas de morte e as causas básicas registradas pelo SVO e demais atestantes dentro do SIM. Óbitos do sexo masculino, cor parda, casados, sem escolaridade, hospitalares de aposentados e maiores de 75 anos predominaram. A incompletude de dados registrados no SIM para o Estado do Tocantins foi superior a 10% e não houve diferença estatística significativa entre a completude de dados registrados pelo SVO e pelos demais atestantes. As doenças do aparelho circulatório foram as principais causas de morte registradas pelos atestantes, exceto pelo IML, onde as causas externas predominaram. 15% dos registros de causas básicas externas não pertenciam ao IML e o SVO apresentou uma grande proporção de registros de causas básicas mal definidas. A qualificação das informações sobre mortalidade, imprescindível à elaboração de políticas públicas sanitárias, persiste desafiadora no Estado do Tocantins. A criação de uma cultura da informação epidemiológica passa pela inserção curricular, educação e sensibilização médica continuada. / The Death Verification Service (SVO) was created to elucidate causes of natural deaths poorly defined by postmortem examinations and record more complete information on the causes of death in the Mortality Information System (SIM). Since the establishment of the national network of SVO, few studies have evaluated the quality of death records of SVO SIM. We studied 19780 no fetal death records of residents in the State of Tocantins between the years 2012, 2011 and 2012, downloaded the DATASUS website of the Ministry of Health. In addition to establishing the demographic social profile of the deaths were studied completeness information, the five leading causes of death and root causes recorded by the SVO and other informers within the SIM. Deaths male, mulatto, married, uneducated, retired hospital and over 75 years predominated. The incompleteness of data in SIM for the State of Tocantins was higher than 10% and there was no statistically significant difference between the completeness of data recorded by the SVO and the other informers. The circulatory diseases were the main causes of death recorded by informers except for IML, where external causes predominated. 15% of the records of external root causes did not belong to the IML and the SVO had a large proportion of ill-defined basic causes records. The qualification of information on mortality, essential to the development of health policies, remains defiant in the State of Tocantins. Creating a culture of epidemiological information passes through curriculum integration, education and continuing medical awareness.

Introdução: Estudos recentes mostram que pacientes com lesão renal aguda apresentam maior mortalidade em longo prazo e evoluem mais para doença renal crônica do que pacientes com controles sem lesão renal aguda. Os fatores associados à pior evolução desses pacientes são controversos e suas causas de óbito desconhecidas. Objetivos: Avaliar a sobrevida e as causas de óbito após a alta hospitalar de pacientes com lesão renal aguda. Analisar a recuperação da função renal na alta hospitalar e a sua evolução em longo prazo. Métodos: Estudo retrospectivo de pacientes internados em 2005 e 2006 com lesão renal aguda e que tiveram lata hospitalar livres de diálise. Foram analisadas as suas características clínicas e laboratoriais, e verificadas a mortandade e a evolução da função renal até 31 de maio de 2008. As causas de óbito foram pesquisadas no \"Programa de Aprimoramento das Informações de Mortalidade\" da cidade de São Paulo e comparadas com a população geral da mesma faixa etária. A curva de sobrevida dos pacientes com lesão renal aguda foi comparada com a da população de São Paulo. A evolução da filtração glomerular durante o primeiro ano após a alta hospitalar foi avaliada considerando-se os valores da creatina sérica encontradas em medidas ambulatoriais. Resultados: Foram incluídos 507 pacientes que foram seguidos por um tempo mediano de 21 meses. Ao final do estudo 38% haviam morrido. As principais causas de óbito foram doenças do aparelho circulatório e neoplasias, achado semelhante ao da população de São Paulo. A causa de óbito se relacionou com a presença de comorbidades existentes antes da lesão renal aguda. A sobrevida dos pacientes foi pior do que a da população de São Paulo e os fatores associados à sua pior sobrevida foram a presença de hepatopatia, índice de Khan de alto risco, internação em serviço clínico e novo episódio de lesão renal aguda na mesma internação. Na alta hospitalar, 50% dos pacientes apresentavam recuperação completa da função renal, 36% recuperação parcial e 14% não tinham recuperado a função renal. Os fatores associados com a recuperação completa da função renal foram: menor gravidade na lesão renal aguda, presença de provável doença renal crônica e necessidade de ventilação mecânica. O estudo da evolução da função renal se restringiu a 278 pacientes. Estes mostraram dois tipos de comportamento: aqueles com recuperação completa da função renal apresentavam, na alta hospitalar, um filtração glomerular maior do que a referência, e estes valores foram se aproximando ao longo do primeiro ano após a alta. Já aqueles com recuperação parcial e os que não recuperaram a função renal evoluíram com melhora da filtração glomerular durante o primeiro ano, porém sem atingir os valores de referência. Conclusões: Os pacientes que apresentam lesão renal aguda mantêm uma alta mortalidade após a alta hospitalar que está relacionada à presença de comorbidades anteriores à internação. Somente metade dos pacientes apresenta recuperação completa da função renal na alta hospitalar, e a recuperação está associada à menor gravidade da lesão renal aguda. A ausência de informação sobre a função renal após a alta hospitalar ocorreu em 25% dos pacientes. No primeiro ano após a alta hospitalar a filtração glomerular tende a se aproximar dos valores de referência, porém sem atingi-los. / Introduction: Recent studies show that the patients who suffered an acute kidney injury episode have increased long-term mortality and develop more chronic kidney disease than those without acute kidney injury. Factors associated with this poor outcome are controversial, and causes of death of these patients are unknown. Objectives: To evaluate survival and causes of death after hospital discharge of patients with acute kidney injury. To analyze the recovery of renal function at hospital discharge its long-term outcome. Methods: A retrospective study of patients hospitalized in 2005 and 2006 with acute kidney injury who were discharged free of dialysis. We analyzed their clinical and laboratorial features, and checked the mortality and evolution of their renal function until May, 2008. Causes of death were investigated in the \"Programa de Aprimoramento das Informações de Mortalidade\" of São Paulo City and compared with general population of similar age. The survival curve of patients who suffered an acute kidney injury episode was compared with the survival curve of São Paulo population. The evolution of glomerular filtration rate during the first year after hospital discharge was assessed by considering the values of serum creatinine measurements found in outpatients. Results: We included 507 patients who were followed for a median of 21 months. At the end of the study 38% of them had died. The main causes of death were circulatory diseases and neoplasms; a finding similar to São Paulo population. The causes of death were related to the presence of comorbidities before the acute kidney injury. The survival curve of these patients was worse than those of São Paulo population; the factors associated with poor survival were presence of chronic liver failure, Khan index of high risk, admission in medical ward and a new episode of acute kidney injury during the same hospitalization. At hospital discharge, 50% of patients had complete renal recovery, 36% partial renal recovery and 14% had not recovered renal function. The factors associated with complete recovery of renal function were less severe acute kidney injury, presence of presumed chronic kidney disease and need for mechanical ventilation. The study of the evolution of renal function was restricted to 278 patients. These patients showed two types of evolution: those with complete renal recovery were discharged with a glomerular filtration rate greater than the reference, and these values were approached during the first year after discharge. Patients with partial renal recovery and those who did recover renal function at hospital discharge had an improvement in glomerular filtration rate during the first year, without reaching the reference value. Conclusion: Patients with acute kidney injury remain a high mortality after hospital discharge which is related to the presence of comorbidities before hospitalization. Only half of patients had complete renal recovery at hospital discharge, and recovery is associated with reduced severity of acute kidney injury. The lack of information on renal function after discharge occurred in 25% of the included patients. During the first year after hospital discharge the glomerular filtration rate tends to approach to reference values but without reach them.

Introdução: Estudos recentes mostram que pacientes com lesão renal aguda apresentam maior mortalidade em longo prazo e evoluem mais para doença renal crônica do que pacientes com controles sem lesão renal aguda. Os fatores associados à pior evolução desses pacientes são controversos e suas causas de óbito desconhecidas. Objetivos: Avaliar a sobrevida e as causas de óbito após a alta hospitalar de pacientes com lesão renal aguda. Analisar a recuperação da função renal na alta hospitalar e a sua evolução em longo prazo. Métodos: Estudo retrospectivo de pacientes internados em 2005 e 2006 com lesão renal aguda e que tiveram lata hospitalar livres de diálise. Foram analisadas as suas características clínicas e laboratoriais, e verificadas a mortandade e a evolução da função renal até 31 de maio de 2008. As causas de óbito foram pesquisadas no \"Programa de Aprimoramento das Informações de Mortalidade\" da cidade de São Paulo e comparadas com a população geral da mesma faixa etária. A curva de sobrevida dos pacientes com lesão renal aguda foi comparada com a da população de São Paulo. A evolução da filtração glomerular durante o primeiro ano após a alta hospitalar foi avaliada considerando-se os valores da creatina sérica encontradas em medidas ambulatoriais. Resultados: Foram incluídos 507 pacientes que foram seguidos por um tempo mediano de 21 meses. Ao final do estudo 38% haviam morrido. As principais causas de óbito foram doenças do aparelho circulatório e neoplasias, achado semelhante ao da população de São Paulo. A causa de óbito se relacionou com a presença de comorbidades existentes antes da lesão renal aguda. A sobrevida dos pacientes foi pior do que a da população de São Paulo e os fatores associados à sua pior sobrevida foram a presença de hepatopatia, índice de Khan de alto risco, internação em serviço clínico e novo episódio de lesão renal aguda na mesma internação. Na alta hospitalar, 50% dos pacientes apresentavam recuperação completa da função renal, 36% recuperação parcial e 14% não tinham recuperado a função renal. Os fatores associados com a recuperação completa da função renal foram: menor gravidade na lesão renal aguda, presença de provável doença renal crônica e necessidade de ventilação mecânica. O estudo da evolução da função renal se restringiu a 278 pacientes. Estes mostraram dois tipos de comportamento: aqueles com recuperação completa da função renal apresentavam, na alta hospitalar, um filtração glomerular maior do que a referência, e estes valores foram se aproximando ao longo do primeiro ano após a alta. Já aqueles com recuperação parcial e os que não recuperaram a função renal evoluíram com melhora da filtração glomerular durante o primeiro ano, porém sem atingir os valores de referência. Conclusões: Os pacientes que apresentam lesão renal aguda mantêm uma alta mortalidade após a alta hospitalar que está relacionada à presença de comorbidades anteriores à internação. Somente metade dos pacientes apresenta recuperação completa da função renal na alta hospitalar, e a recuperação está associada à menor gravidade da lesão renal aguda. A ausência de informação sobre a função renal após a alta hospitalar ocorreu em 25% dos pacientes. No primeiro ano após a alta hospitalar a filtração glomerular tende a se aproximar dos valores de referência, porém sem atingi-los. / Introduction: Recent studies show that the patients who suffered an acute kidney injury episode have increased long-term mortality and develop more chronic kidney disease than those without acute kidney injury. Factors associated with this poor outcome are controversial, and causes of death of these patients are unknown. Objectives: To evaluate survival and causes of death after hospital discharge of patients with acute kidney injury. To analyze the recovery of renal function at hospital discharge its long-term outcome. Methods: A retrospective study of patients hospitalized in 2005 and 2006 with acute kidney injury who were discharged free of dialysis. We analyzed their clinical and laboratorial features, and checked the mortality and evolution of their renal function until May, 2008. Causes of death were investigated in the \"Programa de Aprimoramento das Informações de Mortalidade\" of São Paulo City and compared with general population of similar age. The survival curve of patients who suffered an acute kidney injury episode was compared with the survival curve of São Paulo population. The evolution of glomerular filtration rate during the first year after hospital discharge was assessed by considering the values of serum creatinine measurements found in outpatients. Results: We included 507 patients who were followed for a median of 21 months. At the end of the study 38% of them had died. The main causes of death were circulatory diseases and neoplasms; a finding similar to São Paulo population. The causes of death were related to the presence of comorbidities before the acute kidney injury. The survival curve of these patients was worse than those of São Paulo population; the factors associated with poor survival were presence of chronic liver failure, Khan index of high risk, admission in medical ward and a new episode of acute kidney injury during the same hospitalization. At hospital discharge, 50% of patients had complete renal recovery, 36% partial renal recovery and 14% had not recovered renal function. The factors associated with complete recovery of renal function were less severe acute kidney injury, presence of presumed chronic kidney disease and need for mechanical ventilation. The study of the evolution of renal function was restricted to 278 patients. These patients showed two types of evolution: those with complete renal recovery were discharged with a glomerular filtration rate greater than the reference, and these values were approached during the first year after discharge. Patients with partial renal recovery and those who did recover renal function at hospital discharge had an improvement in glomerular filtration rate during the first year, without reaching the reference value. Conclusion: Patients with acute kidney injury remain a high mortality after hospital discharge which is related to the presence of comorbidities before hospitalization. Only half of patients had complete renal recovery at hospital discharge, and recovery is associated with reduced severity of acute kidney injury. The lack of information on renal function after discharge occurred in 25% of the included patients. During the first year after hospital discharge the glomerular filtration rate tends to approach to reference values but without reach them.

The Sami people are the Natives of northern Scandinavia. The knowledge of the health and living conditions of the Swedish Sami is extremely limited which is in contrast to the large amount of detailed information on health and socioeconomic issues that is available for other circumpolar Natives. The encounter with the western society and the acculturation process has for many native populations had serious health consequences, causing a dramatic increase of lifestyle related diseases such as cancer, diabetes, stroke, obesity and hypertension as well as a dramatic increase of suicide and drug abuse. The overall objective of this thesis was to investigate the health conditions of the Sami population of Sweden using causes of death and incidences of cancer and cardiovascular diseases (CVD) as health indicators, and to evaluate their possible association with acculturative factors such as assimilation, integration, separation and marginalization. A Sami population was identified containing a total of 41 721 individuals. Specific cohorts were selected from this population for the different studies. A four times as large demographically matched non-Sami control population was used for comparisons. A study of causes of death, 1961-2000, showed small differences in overall mortality and life expectancy between the Sami and the non-Sami. However, Sami men showed significantly lower mortality risks for cancers but higher for external cause of injury and Sami women higher risks for diseases of the circulatory system (CVD) and of the respiratory system. An increased risk of dying from subarachnoid haemorrhage (SAH) was observed among both Sami men and women. The increased risk of dying from accidents among male reindeer herders is suggested to be caused by the increased socioeconomic pressure and the extensive use of terrain vehicles. It is concluded that commercial reindeer management is one of the most dangerous occupations in Sweden. In a study of the cancer risk among the reindeer herding Sami between 1961-1997, an overall lower risk to develop cancers, particularly prostate and malignant lymphoma was observed among the reindeer herding Sami. The risk for stomach cancer was significantly higher in relation to their non-Sami neighbours. The Sami and the non-Sami had similar risk factor-patterns for CVD. The main differences were related to working conditions and lifestyle factors of the reindeer herding Sami - the women showed a more unfavourable risk factor pattern than the men. Higher incidences of stroke were observed among Sami men and women compared to their non-Sami neighbours while the mortality rates of stroke were similar. The mortality ratio of AMI was increased for Sami women in spite of similar incidence ratios. A higher risk of SAH was observed among all groups of Sami. According to traditional socioeconomic risk factors, the differences in the levels of income and education observed between the Sami and the non-Sami, were poorely associated with the disparities of CVD. As has been shown, only minor differences in the health indicators were found between the Sami and their non-Sami neighbours. This is in clear contrast to several other native populations for which the health situation is largely unfavourable in comparison with that of the general population. The observed differences between the Sami and the non-Sami probably reflect differences in lifestyle, psychosocial and genetic factors. The relation between these factors and the acculturation process is dicussed, and it is suggested that separation or segregation of the reindeer herding Sami and the assimilation of the other Sami have influenced the health condition of the Sami, but with the largest impact probably prior to 1961 and the earliest start of follow-up for the studies in this thesis. Thus, the similarities in health between the Sami and the non-Sami 1961-2002, are probably a result of centuries of close interaction that has caused similarities in culture, attitudes and lifestyle, as well as equal accessibility to the health care services and the social security systems.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / This doctoral thesis involved the study of diseases in pigs, including the description of a case of granulocytic sarcoma and outbreaks of eosinophilic salt poisoning. The study of the characteristics and frequency of disease in swine population in the region covered by the Laboratório de Patologia Veterinária (LPV), Universidade Federal de Santa Maria (UFSM) was conducted through a retrospective study of all autopsy diagnoses. Five hundre and sity four with conclusive diagnoses were set apart. The pig population in the region covered by the study is predominantly family and diagnosed diseases reflect this reality. The infectious and parasitic diseases were the most prevalent [384 (68.1%)], followed, in descending order, nutritional and metabolic diseases [64 (11.,3%)], poisoning and toxi-infections [33(5,8%)] and developmental disorders [17(3.1%)]. Other changes to various etiologies, especially trauma, were cause of death in just over 11% of the protocols examined. Bacterial diseases were responsible for more than half of the causes of death or reason for euthanasia of animals studied, pointing to the influence of management, environmental and nutritional regional husbundry . The main disease diagnosed in pigs in the region covered by the study is the edema disease and along with other forms of infection by Escherichia coli is responsible for 23% of deaths of viral diseases and cancer are not major causes of death in pigs in the region studied. Nutritional hepatose and aflatoxicosis are important diseases in the region and and there cuasation are mainly linked to nutritional management. For description of eosinophilic granulocytic sarcoma, a set of techniques (cytology, histology, histochemistry and immunohistochemistry)were used and which proved to be essential for the confirmation of macroscopic tentive diagnosis. Salt poisoning is a condition recognized in pigs as far back as the first half of the last century and still remains as an important cause of mortality; the large amount of salt accumulated in the body in cases of poisoning can be demonstrated by determination of sodium ion in the liver, muscle, CSF, serum and aqueous humor, and these are acillary data to confirm the diagnosis. Pigs affected by salt poisoning have eosinopenia due to severe meningoencephalitis and infiltration of eosinophils in tissues, acute neuronal necrosis which develops into deeplaminar cortical necrosis as the clinical progresses. / Esta tese envolveu o estudo de doenças de suínos, incluindo a descrição de um sarcoma granulocítico eosinofílico e surtos de intoxicação por sal. O estudo das características e frequência das doenças na população suína na região de abrangência do Laboratório de Patologia Veterinária (LPV) da Universidade Federal de Santa Maria (UFSM) foi realizado através de um estudo retrospectivo de todos os diagnósticos de necropsias. Foram separados 564 casos com diagnósticos conclusivos. A população suína na região de abrangência do estudo é predominantemente familiar e as doenças diagnosticadas, refletem esta realidade. As doenças infecciosas e parasitárias foram as mais prevalentes [384 (68,1%)], seguidas, em ordem decrescente, das doenças metabólicas e nutricionais [64 (11,3%)], intoxicações e toxiinfecções [33 (5,8%)], e distúrbios do desenvolvimento [17 (3,1%)]. Outras alterações de diversas etiologias, sobretudo de trauma, foram causa de morte em pouco mais de 11% dos protocolos examinados. Doenças bacterianas são responsáveis por mais da metade das causas de morte ou razão para eutanásia dos suínos estudados, revelando a influência de fatores de manejo, ambientais e nutricionais do modo de vida local. A principal doença diagnosticada em suínos na região de abrangência do estudo é a doença do edema e juntamente com outras formas de infecção por Escherichia coli é responsável por 23% das mortes Doenças de etiologia viral e neoplasias não são importantes causas de morte em suínos na região estudada. Hepatose nutricional e aflatoxicose são importantes doenças da região e se devem, sobretudo, a fatores de manejo nutricional. Para descrição do sarcoma granulocítico eosinofílico, foi utilizado um conjunto de técnicas (citologia, histologia, histoquímica e imuno-histoquímica), indispensáveis para a confirmação da suspeita macroscópica. Intoxicação por sal é uma condição reconhecida em suínos desde a primeira metade do século passado e continua uma importante causa de mortalidade e a grande quantidade de sal acumulada em casos de intoxicação pode ser comprovada pelas dosagens do íon sódio no fígado, músculo, líquor, soro e humor aquoso, e esses dados servem como forma de diagnóstico. Suínos intoxicados por sal apresentam eosinopenia devido a grave infiltração de eosinófilos e a meningoencefalite eosinofílica evolui para uma necrose neuronal laminar, à medida que se desenvolve o curso clínico da doença.

Abstract Emergency medical services (EMS) are designed to provide prompt response, on-scene treatment and transport for definitive care in patients with acute illness or injury. In recent years, the growing number of missions for non-urgent matters has challenged emergency care to design risk assessment protocols and tools to support decision-making and resource management at both dispatch and on-scene. The present study was designed to examine the efficacy of a criteria based dispatch protocol and National Early Warning Score (NEWS) in the Finnish EMS system. In addition, the aim of the research was to obtain data on patient allocation and mortality in the Northern Finnish population. The study data included 13,354 EMS missions from a six-month cohort (1.1.2014 - 30.6.2014) of prehospital emergency patients in two hospital districts – Kainuu and Länsi-Pohja – in Northern Finland, using a retrospective, observational design. Prehospital data including patient clinical physiological variables were combined with the national Finnish registries (Care Registry for Health Care, Intensive Care Consortium Database and Cause of Death Registry) in order to examine risk assessment in EMS and prehospital patient outcomes. Based on the result, the risk assessment at the dispatch was correct in 67.5% of the cases and four out of ten EMS missions did not lead to transportation by an ambulance. The use of the Finnish dispatch protocol resulted in an overall rate of 23% of over-triage and a 9% rate of under-triage. The highest NEWS category showed a good sensitivity for 1-day mortality but failed to adequately discriminate patients in need of intensive care or who died within 30-days in a large, unselected, typical EMS population. In conclusion, the criteria based dispatch protocol resulted in over-triage of a quarter of missions and in a significant rate of EMS missions without ambulance transportation. In addition, the predictive value of prehospital NEWS regarding the patient´s risk of death and need for intensive care was low. / Tiivistelmä Ensihoitopalvelu on suunniteltu tarjoamaan nopeaa vastetta, paikalla tapahtuvaa hoitoa ja kuljetusta lopulliseen hoitopaikkaan potilaille, joilla on akuutti sairaus tai vamma. Viime vuosien lisääntyneet yhteydenotot ei-kiireellisissä asioissa on johtanut riskinarviotyökalujen kehittämiseen tukemaan päätöksentekoa ja resurssienhallintaa hätäpuhelun aikana ja tapahtumapaikalla. Tässä tutkimuksessa tarkasteltiin kriteeripohjaista hätäpuhelun käsittelyä sekä varhaisen varoituspistejärjestelmän (NEWS) tehokkuutta suomalaisessa ensihoitojärjestelmässä. Lisäksi tutkimuksen tavoitteena oli saada tietoa ensihoitopotilaiden hoitotuloksista ja kuolleisuudesta Pohjois-Suomessa. Tutkimukseen sisältyi 13 354 ensihoitotehtävää kuuden kuukauden kohortista (1.1.2014 – 30.6.2014) kahden sairaanhoitopiirin alueelta – Kainuu ja Länsi-Pohja – Pohjois-Suomessa käyttämällä retrospektiivistä havainnoivaa tutkimusmenetelmää. Ensihoidon aikana kerätty tieto, mukaan lukien potilaan kliiniset fysiologiset arvot, yhdistettiin kansallisiin rekistereihin (hoitoilmoitusrekisteri, tehohoitokonsortion laatutietokanta sekä kuolinsyyrekisteri) jotta ensihoitopotilaiden riskinarviota ja hoitotuloksia voitiin tutkia. Tutkimustulosten mukaan 67.5 prosentissa tapauksista riskinarvio hätäkeskuksessa oli oikea ja neljä kymmenestä ensihoitotehtävästä ei johtanut kuljetukseen ambulanssilla. Suomalaisen hälytysprotokollan käyttö johti yliarviointiin 23 prosentissa tapauksista ja aliarviointiin 9 prosentissa tapauksista. Korkeariskin NEWS-luokan herkkyys 1-päivän kuolleisuudelle oli hyvä, mutta se ei kyennyt erottelemaan riittävän hyvin potilaita, jotka tarvitsivat tehohoitoa tai kuolivat 30 päivän sisällä suuressa ei-valikoidussa tyypillisessä ensihoitopotilasväestössä. Yhteenvetona todettiin, että kriteeripohjaisen riskinarvion käyttö johti yliarvioon neljänneksestä tapauksista sekä huomattavaan ensihoitotehtävämäärään ilman ambulanssikuljetusta. Lisäksi ensihoidon aikana käytetyn varhaisen varoituspistejärjestelmän ennusteellinen arvo potilaan kuolemanriskin ja tehohoidon tarpeeseen oli matala.

Submitted by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2014-10-13T17:24:00Z No. of bitstreams: 1 TESE RITA NASCIMENTO. 2014.pdf: 1627254 bytes, checksum: f63f2d910510cf11be43ae812800b828 (MD5) / Approved for entry into archive by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2014-10-13T18:13:40Z (GMT) No. of bitstreams: 1 TESE RITA NASCIMENTO. 2014.pdf: 1627254 bytes, checksum: f63f2d910510cf11be43ae812800b828 (MD5) / Made available in DSpace on 2014-10-13T18:13:40Z (GMT). No. of bitstreams: 1 TESE RITA NASCIMENTO. 2014.pdf: 1627254 bytes, checksum: f63f2d910510cf11be43ae812800b828 (MD5) / A mortalidade perinatal constitui-se na atualidade um grande desafio para as autoridades no mundo inteiro, em face da dificuldade para evitar estes óbitos, haja vista a complexidade dos fatores de risco. É grande a sua magnitude, mas não tão expressivas são as medidas de prevenção, especialmente nos países menos desenvolvidos. Assim sendo, representa um indicador sensível da qualidade e acesso à assistência obstétrica e neonatal. Esta pesquisa teve como objetivos identificar as áreas de risco, a evitabilidade das causas, os fatores associados à mortalidade perinatal e as desigualdades sociais nesta mortalidade em Salvador, Bahia, no ano de 2007. As unidades de análise foram as 62 áreas de ponderação desta capital soteropolitana. Os dados foram obtidos dos Sistemas de Informação de Nascidos Vivos e sobre Mortalidade, bem como do Censo Demográfico de 2010. A análise estatística foi realizada utilizando os softwares Arc-View, GeoDa, STATA e R. Para análise da evitabilidade, tomou-se como referência a Lista de Causas de Mortes Evitáveis por Intervenções do Sistema Único de Saúde do Brasil. A mortalidade perinatal em Salvador foi elevada no ano em estudo (25,81000/NV) e as maiores taxas se localizaram ao centro e algumas áreas concentradas ao norte, oeste, sul e leste. Não foi detectada dependência espacial para esta mortalidade pela estatística de I de Moran no estudo, a não ser para a mortalidade perinatal evitável pela atenção à gestação, pelo C de Geary, cujas áreas de risco se encontravam ao norte. Quase a totalidade dos óbitos foi evitável (92,1%) e quase metade destes ocorreu pelas causas evitáveis na atenção o parto, sendo a asfixia ao nascer a principal causa (31,5%). Em se tratando dos fatores associados à mortalidade perinatal, baixo peso ao nascer (β = 0,477; p<0,01), raça negra (β = 0,048; p<0,01) e local de nascimento em hospital público (β = 0,026; p<0,01) foram os preditores da variação espacial desta mortalidade. Para a mortalidade perinatal evitável, independentemente do local de nascimento, os recém- nascidos foram expostos até sete vezes mais ao risco pelo efeito do baixo peso ao nascer. Não houve gradiente na mortalidade perinatal quando analisada por estratos do Índice de Condição de Vida, porém os indicadores socioeconômicos apresentaram risco relativo 71,0% superior para nas áreas de ponderação cuja renda domiciliar per capita era inferior a 2,2 salários mínimos. Este resultado foi similar quando a variável dependente analisada tratou-se da mortalidade perinatal por causa evitável. Os resultados deste estudo demonstraram que a mortalidade perinatal em Salvador teve forte influencia dos fatores sociais, considerando as áreas de risco em locais de infraestrutura precária, as desigualdades de renda e os preditores para a mortalidade perinatal proxy de condições socioeconômicas. Avaliar a mortalidade perinatal com enfoque das áreas de risco, fatores associados, evitabilidade e desigualdades sociais, permitiu melhor compreensão da magnitude desta mortalidade em Salvador e poderá contribuir para orientar estratégias de prevenção. / Nowadays the perinatal mortality constitutes a major challenge for authorities worldwide, due to the difficulty in preventing these deaths, given the complexity risk factors. So great is its magnitude, but not as significant are the preventive measures, especially in less developed countries. Thus, it is a sensitive indicator of the quality and access of obstetric and neonatal care. The aims of this study were to identify risk areas, avoidable causes, risk factors to perinatal mortality and social inequities in this mortality in Salvador, Bahia, Brazil, 2007. The units of analysis were the 62 weighting areas of the capital’s Bahia state. The data were obtained from the Information Live Births and Mortality Systems as well as of the Census 2010. The statistical analysis was performed using the Arc-View, GeoDa, R and STATA softwares. For analysis of avoidability, it was used as reference the List of avoidable causes of deaths due to interventions of the Brazilian Health System. Perinatal mortality was high in Salvador in the year of the study (25.81000/NV) and the highest rates were located in the center and some concentrated areas north, west, south and east. No spatial dependence was found for this mortality by Moran's I statistic, except to preventable perinatal mortality due care during pregnancy, at Geary’s C, whose risk areas were at north. Almost all of the deaths were preventable (92.1 %) and almost half of these occurred by preventable causes in childbirth care, and asphyxia at birth the leading cause (31.5 %). In terms of factors associated with perinatal mortality, low birth weight (β = 0.477; p<0.01), black race (β = 0.048; p<0.01), and place of birth in public hospitals (β = 0.026; p<0.01) were predictors of spatial variation of this mortality. For avoidable perinatal mortality, regardless of place of birth, newborns were exposed until seven times more to risk by the effect of low birth weight. There was no gradient in perinatal mortality when analyzed by stratum index of living conditions, however, socioeconomic indicators showed relative risk 71.0 % higher for the spatial variation of perinatal mortality in the weighting area whose household income was less than 2.2 wages minimum. This result was similar when the dependent variable analyzed was the avoidable perinatal death. The results of this study showed that perinatal mortality in Salvador had strong social factors influence, considering the risk areas in places of poor infrastructure, income inequality and predictors of perinatal mortality as a proxy for socioeconomic status. To evaluate the perinatal mortality with a focus in risk areas, associated factors, avoidability causes and social inequalities, allowed better understanding of the magnitude of this local mortality and may contribute to prevention strategies.

A taxa de mortalidade perinatal (TMP) é um dos importantes indicadores de saúde que refletem a qualidade da assistência prestada durante a gestação, o parto e ao recém nascido. A TMP possui dois componentes: a taxa e mortalidade fetal e a taxa de mortalidade infantil neonatal precoce. O objetivo do presente estudo foi analisar a mortalidade perinatal na região do Médio Paraíba, estado do Rio de Janeiro, Brasil no período de 2005 a 2009, segundo causa básica dos óbitos, componentes do período perinatal e critérios de evitabilidade. Foram utilizados os dados referentes aos óbitos fetais e infantis neonatais precoces e de nascidos vivos, registrados, respectivamente, nos Sistemas de Informações sobre Mortalidade (SIM) e Nascidos Vivos (SINASC). A TMP na região foi de 18,4 óbitos por mil nascimentos totais. As taxas de mortalidade fetal e infantil neonatal precoce no período alcançaram, espectivamente 10,7 óbitos por mil nascimentos totais e 7,7 óbitos por mil nascidos vivos. A TMP apresentou redução ao longo do quinquênio analisado associada à queda do componente neonatal precoce, mantendo-se estável o componente fetal. As principais causas básicas dos óbitos perinatais, segundo a lista de mortalidade CID BR, foram as afecções originadas no período perinatal (89%) e as malformações congênitas, deformidades e anomalias cromossômicas (10,5%). Utilizando os critérios de evitabilidade segundo Ortiz, para os óbitos infantis neonatais precoces foi observado que mais de 41% eram reduzíveis por diagnósticos e tratamento precoces. Ressalta-se a necessidade da implementação de ações de assistência à saúde da gestante e de cuidados com o recémnascido com vistas à redução da mortalidade perinatal na região do Médio Paraíba. / The perinatal mortality rate (PMR) is an important health indicator that reflects the quality of health care provided during pregnancy, childbirth and to the newborns. The PMR has two components: the fetal mortality rate and the early neonatal mortality rate. The objective of this study was to analyze the perinatal mortality in the Médio Paraíba region, Rio de Janeiro state, Brazil between 2005 and 2009, according to the underlying cause of deaths, components of the perinatal period and criteria of avoidability. Data regarding fetal and early neonatal deaths and live births was provided by the National Death (SIM) and Live Birth (SINASC) Information Systems, respectively. The PMR in the region was 18.4 deaths per thousand total births. Fetal and early neonatal mortality rates reached 10.7 deaths per thousand total births and 7.7 deaths per thousand live births, respectively. The PMR declined during the five year period, associated with the fall of its early neonatal component, remaining stable the fetal component. The main underlying causes of perinatal deaths, according to the ICD Mortality List for use in Brazil - ICD BR, were certain conditions originating in the perinatal period (89%) and congenital malformations, deformations and chromosomal abnormalities (10,5%). Using the criteria of avoidability according to Ortiz, for early neonatal infant deaths was observed that over 41% were avoidable through early diagnosis and treatment . Efforts aimed at improving health care during pregnancy and childbirth are needed in order to reduce perinatal mortality levels in the Médio Paraíba region.