Bipolar disorder is a serious illness affecting approximately 2-4% of the population and is one of the world’s leading causes of disability. In individuals with bipolar disorder, medical comorbidity associated with cardiovascular, respiratory and endocrine disorders is related to increased rates of mortality. Recent updates to multi-system inflammatory related conceptualizations of bipolar disorder focus on the unique power that medical illness and biological processes may play as factors associated with course and outcome in bipolar disorder. The current study examined medical comorbidity and its associations with various demographic and psychological variables in individuals with bipolar disorder, schizophrenia, and major depressive disorder with psychotic features followed for 10 years from their first hospital admission. When compared to an age, gender and race-matched control sample from the population, those with bipolar disorder had significantly higher medical comorbidity across a range of medical diagnoses both at 6 months and 10 years after first hospital admission. Ten years following initial hospitalization, individuals in all three diagnostic groups reported increased rates of diabetes (OR: 2.0 – 3.7), stroke (OR: 4.6 – 7.0) and asthma (OR: 1.9 - 3.1), and individuals with bipolar disorder reported increased rates of cancer (OR = 2.1). A number of psychological and demographic symptoms were examined for their ability to predict the development of medical illness across the assessment interval. Overall rates of medical illness were elevated both early in illness course and 10 years after diagnosis, suggesting that broad sequelae of multi-system inflammation are present early and progress over time.

O objetivo deste estudo foi estimar prevalência dos transtornos mentais comuns (TMC) e bebedores problemas (BP) e também a utilização de serviços, a partir de estudo seccional, populacional com amostragem aleatória. Incluiu-se sujeitos com 16 anos e mais, avaliando-se aspectos sócio-demográficos, uso de álcool, saúde mental e utilização de serviços. A prevalência de TMC foi 21,7%, de BP foi 4,4%. Na ultima quinzena 14,6% procuraram serviço de saúde. As prevalências observadas confirmam achados da literatura: TMC e BP são importantes problemas de saúde pública, com implicações para a organização de serviços e formação de recursos humanos / The aim of this cross-sectional study was to estimate the prevalence of common mental disorders (CMD) and problem drinking (PD), as well as health services use in an unselected populational sample. Subjects over 16 years were included and aspects related to socio-demographic characteristics, alcohol use, mental health and services use were studied. The prevalence of CMD was 21.7%, of PD 4.4%. In the two weeks preceeding the interview, 14.6% had used a health service. The results are in accordance with the literature: CMD and PD are important health problems, with implications for health services organization and formation of health professionals

Introdução: O Transtorno Obsessivo-Compulsivo (TOC) é reconhecido como um transtorno heterogêneo. Esta heterogeneidade dificulta a interpretação dos resultados dos estudos. A descrição de grupos de pacientes mais homogêneos pode facilitar a identificação desta busca, já que pode identificar fenótipos que sejam hereditários e válidos do ponto de vista genético. A abordagem categorial e dimensional são estratégias reconhecidas para a identificação de subgrupos mais homogêneos de pacientes. Dentro da abordagem categorial, o subgrupo de pacientes com início precoce dos sintomas obsessivo-compulsivo (SOC), e o subgrupo de TOC associado a transtorno de tiques apresentam características clínicas semelhantes, com evidências de sobreposição destas características entre os dois grupos. Os objetivos deste estudo foram: investigar características demográficas e clínicas dos pacientes com TOC de início precoce (GP) e TOC de início tardio (GT); e pesquisar características demográficas e clínicas dos pacientes com TOC de início precoce (GP) com tiques e pacientes com TOC de início precoce (GP) sem tiques. Metodologia: Trezentos e trinta pacientes com diagnóstico de TOC de acordo com o DSM-IV foram avaliados diretamente com os seguintes instrumentos: Entrevista Clínica Estruturada para o DSM-IV - Transtornos do Eixo I; Escala Yale-Brown de Sintomas Obsessivo-Compulsivos - Y-BOCS; Escala Dimensional para Avaliação de Presença e Gravidade de Sintomas Obsessivo-Compulsivos DY-BOCS; Escala de Avaliação Global de Tiques desenvolvida pelo Yale Child Study Center - YGTSS. Foi considerado TOC de início precoce se os sintomas dos pacientes tiveram início até os 10 anos de idade (160 pacientes). Os pacientes com início de sintomas entre 11 e 17 anos (95 pacientes) foram denominados grupo intermediário, enquanto aqueles após os 17 anos foram chamados grupo de início tardio (75 pacientes). Resultados: os pacientes do GP se diferenciaram dos pacientes do GT por apresentar maior freqüência do sexo masculino; maior freqüência de história familiar de SOC em familiares de primeiro grau; maiores escores da escala Y-BOCS para compulsões e Y-BOCS total; maior chance de ter obsessões de contaminação; maior chance de ter compulsões de repetição, colecionismo, diversas e compulsões do tipo tic-like; menor chance de ter compulsões de contagem; maior chance de apresentar sintomas da dimensão de \"colecionismo\"; maior gravidade nas dimensões de \"agressão/violência\", \"diversas\" e escore global da escala DY-BOCS; maior número médio de comorbidades; maior probabilidade de ocorrência de transtorno de ansiedade de separação, fobia social, transtorno dismórfico corporal e transtorno de tiques; menor chance de apresentar transtorno de estress pós-traumático; e maior chance de ter redução de 35% dos sintomas na escala Y-BOCS. O GP com tiques se diferenciou do GP sem tiques por apresentar maior prevalência de fenômenos sensoriais; menor chance e menor gravidade de ter a dimensão de \"contaminação/limpeza\" e menor gravidade no escore global da escala DY-BOCS; menor chance de apresentar transtorno de humor, transtorno unipolar, transtornos ansiosos, fobia social e skin picking, e maior a chance de apresentar diminuição de 35% dos sintomas na escala Y-BOCS. Os resultados sugeriram que as diferenças encontradas entre os grupos precoce, intermediário e tardio foram devidas à própria idade de início, e outras diferenças foram devidas à presença de tiques. / Introduction: Obsessive-compulsive disorder (OCD) is recognized as a heterogeneous condition. This heterogeneity obscures the interpretation of the results of the studies. The description of more homogeneous groups of patients can facilitate the identification of this search, since it can identify phenotypes that are hereditary and valid to the genetic point of view. Categorical and dimensional approaches are recognized strategies for the identification of more homogeneous subgroups of patients. Regarding the categorical approach, the subgroup of patients with early age at onset of the obsessive-compulsive symptoms (OCS), and the tic-related-OCD subgroup present similar clinical characteristics, with evidences of an overlap of these characteristics between the two groups. The aims of this study were: to investigate clinical and demographic characteristics of the early age at onset subgroup (EO), compared to the late onset subgroup (LO); and to investigate demographic and clinical characteristics of early age at onset OCD patients, with and without comorbid tic disorders. Methodology: Three hundred and thirty patients with the diagnosis of OCD according to the DSM-IV were directly assessed with the following instruments: Structured Clinical Interview for DSM-IV Axis I Disorders-patient edition - SCID-I/P; Yale-Brown Obsessive-Compulsive Scale - Y-BOCS; Dimensional Yale-Brown Obsessive-Compulsive Scale - DY-BOCS and Yale Global Tics Severity Scale - YGTSS. We considered early age at onset when OCS began before the age of 10 (160 patients). Patients with age at onset between 11 and 17 years old were termed intermediate group (95 patients), whereas those with age at onset after 17 years old were designated as late onset OCD (75 patients). Results: EO patients differed from LO patients in terms of presenting higher frequency of the male gender; higher frequency of a family history of OCS; higher Y-BOCS for compulsions and total Y-BOCS scores; higher chance of presenting contamination obsessions, repeating, hoarding, miscellaneous and tic-like compulsions; lower chance of having counting compulsions; higher probability of presenting symptoms of \"hoarding\" dimension; higher severity in \"aggression/violence\" and \"miscellaneous\" dimensions and global DY-BOCS scale score; higher mean number of comorbidities; higher probability of presenting separation anxiety disorder, social phobia, body dysmorphic disorder and tic disorders; lower chance of presenting posttraumatic stress disorder; and a higher chance of having a 35% reduction on the Y-BOCS scale. The EO subgroup with tic disorders differed from the EO without tics for presenting higher chance of having sensory phenomena, somatic obsessions; lower chance and lower score in the DY-BOCS scale; lower chance of presenting mood disorder, depressive disorder, anxiety disorders, social phobia and skin picking; higher chance of having a 35% reduction on the Y-BOCS scale. Results suggested that the differences found among early, intermediated and late onset groups with early onset were secondary to the own age at onset, and other differences were secondary to the presence of tics.

Die vorliegende Arbeit beschäftigt sich mit der Tätigkeit konsiliarpsychiatrischer Dienste am Allgemeinkrankenhaus. In einem historischen Abriß wird zunächst die Integration des psychiatrischen Fachgebiets in die Allgemeinkrankenhäuser als wesentliche Bedingung für die Entwicklung der Konsiliarpsychiatrie am Beispiel der USA dargestellt, gefolgt von europäischen Perspektiven und der Entwicklung in Deutschland, unter besonderer Berücksichtigung der Psychiatrie-Enquête. Anschließend werden Aspekte somatopsychischer Komorbidät als Grundlage der Konsiliarpsychiatrie und ihre Implikationen für Diagnostik und Therapie skizziert. Vorschläge zur Bestimmung des Bedarfs der konsiliarpsychiatrischen Versorgung werden diskutiert. Das Spektrum konsiliar-liaisonpsych-iatrischer Versorgungsmöglichkeiten wird dargestellt, Interventionsmöglichkeiten mit ihren differentia specifica im Setting des Allgemeinkrankenhauses am Beispiel von supportiver Psychotherapie und Psychopharmakatherapie bei körperlich kranken Patienten werden verdeutlicht. Im empirischen Teil wird auf Grundlage einer Längsschnittstudie über einen 10jährigen Be-obachtungszeitraum eines amerikanischen, sowie einer Vergleichsstudie der Tätigkeit eines deutschen und eines amerikanischen Konsildienstes über einen einjährigen Beobachtungszeitraum versucht, einen Kernbereich konsiliarpsychiatrischer Tätigkeit am Allgemeinkrankenhaus zu definieren. In der Längsschnittuntersuchung wurde ein zeitüberdauernder Bereich konsiliarpsychiatrischer Tätigkeit identifiziert, der im Vergleich mit ähnlichen, allerdings weniger detaillierten Studien (Lipowski & Wolston 1981, Paddison et al. 1989) ebenfalls überwiegend Gemeinsamkeiten deutlich werden läßt. Auch die vergleichende Querschnittsuntersuchung zeigte, daß psychiatrische Konsiliartätigkeit über nationale Grenzen hinweg eine Reihe von Gemeinsamkeiten aufweist. Auch dies konnte im Vergleich mit anderen Studien bestätigt werden (vgl. Übersichten bei Hengeveld et al. 1984, Diefenbacher 1999, Huyse et al. 1997). Anschließend werden Veränderungen im Gefolge der Tätigkeit eines neu beginnenden psychiatrischen Konsiliars über einen einjährigen Beobachtungszeitraum untersucht und im Hinblick auf die Implementation eines Konsildiensten auf für die konsiliarpsychiatrische Praxis bzw. Interventionsforschung wichtige Parameter wie z.B. Zusammenarbeit mit den Stationsteams und Beeinflussung von Krankenhausverweildauer und Zeitintervall zwischen stationärer Aufnahme und Konsilanforderung diskutiert. Zusammenfassend wird ein Kernbereich konsiliarpsychiatrischer Tätigkeit beschrieben, von dem erwartet wird, daß er für die nahe Zukunft konstant bleibt und somit als Orientierungshilfe für administrative und evaluative Zwecke dienen kann. Abschließend werden Perspektiven weiterer Forschung in der Konsiliarpsychiatrie diskutiert und auf Aspekte der Fort- und Weiterbildung im psychiatrischen Konsiliar-Liaisondienst in der psychiatrischen Facharztweiterbildung, sowie auf Schnittstellen für eine mögliche Zusammenarbeit mit dem hausärztlichen Bereich eingegangen. / Psychiatric consultation-liaison (c-l) service delivery in the general hospital is the topic of this study. In the first part, an historical outline of the development of psychiatric c-l-services in the USA is presented, followed by recent developments in Europe and Germany, with special emphasis - for the latter - of the impact of the so-called "Psychiatrie-Enquête" (1975) on the implementation of psychiatric departments in general hospitals since the 1980s. The issue of somato-psychic comorbidity of general hospital inpatients, the very reason of existence of c-l-psychiatry, is discussed, as are its implications for diagnosis and treatment. Proposals for the evaluation of need for such services are presented, as is the scope of c-l-psychiatric interventions and their special nature with the example of supportive psychotherapy and psychopharmaco-therapy in the medically and psychiatrically ill inpatient. The second empirical part consists of a 10-year-longitudinal study of a c-l-psychiatric service in New York City, and a comparative cross-sectional study (over a 1-year-period) of a German and an American c-l-psychiatric service in order to delineate a common core of psychiatric c-l-service delivery in the general hospital. In both studies, a cross-national common core and a time stable course over time, respectively, are identified and then discussed in comparison to other less detailed studies (e.g. Lipowski & Wolston 1981, Hengeveld et al. 1984, Huyse et al. 1997). In addition, the implementation phase of a newly started psychiatric c-l-service is studied over a 1-year-period with regard to variables important for c-l-psychiatric intervention studies, such as influence on length of stay in hospital, lagtime between admission to hospital and day of consultation request, and cooperation with staff. In conclusion, a core field of psychiatric c-l-service delivery in the general hospital is identified, that is expected to remain stable in years to come and thus might help as an orientation for administrative and evaluative purposes. Finally, perspectives for further research in the field, for training and education, and for the cooperation with primary care doctors are discussed.

Abstract Bullous pemphigoid (BP) is the most common autoimmune blistering disease. It mostly affects elderly patients and is characterized by intense pruritus and blistering or bullae. Treatment options include topical and systemic corticosteroids, other immunosuppressive drugs and doxycycline. Disease course may be chronic and relapses are common. The incidence of BP has been reported to have increased in the last few decades, but the reason for this trend is not known. The aim of this thesis was to study the risk factors of BP. Firstly, the influence of the use of dipeptidyl peptidase (DPP-4) inhibitors was analyzed as a risk factor, and then those of other oral diabetes medications. This study also aimed to determine whether drugs used for psychiatric and neurologic conditions are risk factors for BP. Finally, previously diagnosed dermatitis herpetiformis (DH) and celiac disease (CD) were examined as potential risk factors for subsequent BP. For this retrospective, matched case-control study, patient data were obtained from the Finnish Care Register for Health Care database, and data on reimbursed drugs from the Social Insurance Institution of Finland. In the present study, prior use of DPP-4 inhibitors was found to increase the risk of BP twofold and in particular, vildagliptin increased the risk tenfold. The mean time between the initiation of vildagliptin and diagnosis of BP was 449 days. Metformin and other conventional diabetes drugs were not risk factors for BP. Several drugs used for neurological and psychiatric diseases were associated with an elevated risk for BP, but no pharmacological or chemical properties of these drugs emerged as candidates to explain the increased risk. A prior diagnosis of DH increased the risk of BP 22-fold and a diagnosis of CD doubled it. Dapsone had been used in the two years before BP diagnosis by 44% of patients whose BP was preceded by DH. The mean time between the diagnoses of DH and BP was 3.3 years. This study confirms the view that DPP-4 inhibitors increase the risk for BP. No such association was found with other classes of diabetes drugs and therefore their use can be continued following a diagnosis of BP. Doctors treating patients with DH should be aware of the association between DH and BP, and be particularly vigilant if a DH patient’s skin symptoms change or become unresponsive to a gluten-free diet and/or dapsone. / Tiivistelmä Rakkulainen pemfigoidi (pemfigoidi) on yleisin ihon autoimmuunirakkulatauti. Pemfigoidi on pääasiassa ikääntyneiden sairaus, ja sen tyypillisiä oireita ovat kova kutina ja rakkulat iholla. Pemfigoidin hoitoon käytetään paikallisia ja systeemisiä kortikosteroideja, muita immunosuppressiivisia lääkkeitä sekä doksisykliiniä. Taudinkulku on usein krooninen ja uusiutumiset ovat yleisiä. Rakkulaisen pemfigoidin ilmaantuvuuden on raportoitu lisääntyneen, mutta syitä tähän muutokseen ei täysin ymmärretä. Tämän tutkimuksen tavoite oli tutkia pemfigoidin riskitekijöitä Suomessa. Retrospektiivisessä tapaus-verrokkitutkimuksessa käytettiin aineistona Terveyden ja hyvinvoinnin laitoksen hoitoilmoitusrekisteristä poimittuja pemfigoidipotilaita (N=3397) ja verrokkeina ihon tyvisolusyöpäpotilaita (N=12941). Tiedot korvatuista lääkeostoista saatiin Kelan lääkekorvausrekisteristä. Tutkimuksessa todettiin DPP-4:n salpaajien kaksinkertaistavan pemfigoidin riskin ja DPP-4:n salpaaja vildagliptiini lisäsi riskiä jopa kymmenkertaiseksi. Vildagliptiinin aloituksen ja pemfigoidin toteamisen välillä kului keskimäärin 449 vuorokautta. Metformiini ja muut tutkitut suun kautta otettavat diabeteslääkkeet eivät lisänneet pemfigoidin riskiä. Useiden psykiatrisiin ja neurologisiin sairauksiin käytettävien lääkkeiden todettiin lisäävän pemfigoidin riskiä. Pemfigoidin on kuvattu voivan puhjeta ihokeliakian jälkeen, mutta laajempia tutkimuksia näiden sairauksien yhteydestä ei oltu aiemmin tehty. Tämän vuoksi samassa potilasaineistossa tutkittiin ihokeliakiaa ja keliakiaa pemfigoidin riskitekijöinä. Edeltävä ihokeliakia lisäsi pemfigoidin toteamisen riskiä selvästi, jopa 22-kertaiseksi ja keliakia kaksikertaiseksi. Huomattava osa potilaista oli ostanut ihokeliakian hoitoon käytettävää dapsonia edeltävän 2 vuoden aikana ennen pemfigoidin toteamista, mikä voi kertoa ihokeliakian oireiden aktiivisuudesta. Tämä tutkimus vahvistaa näkemystä siitä, että DPP-4:n salpaajat ovat pemfigoidin riskitekijä. Muut tutkitut diabeteslääkkeet eivät lisänneet riskiä ja voidaan ajatella, että ne eivät edelleen hankaloita aiemmin todetun pemfigoidin oireita. Koska ihokeliakian todettiin olevan pemfigoidin riskitekijä, tulee näitä potilaita hoitavan lääkärin muistaa pemfigoidin mahdollisuus, jos ihokeliakian oireet muuttuvat tai hoitovaste menetetään.

Está bem estabelecido que o Transtorno Alimentar (TA), uma patologia predominantemente compulsiva, e o Transtorno de Déficit de Atenção/Hiperatividade (TDAH), uma patologia predominantemente impulsiva, coocorrem em uma frequência maior do que esperado ao acaso. A avaliação fenotípica e o estudo detalhado de pacientes que apresentam ambas as patologias (TA-TDAH) oferecem a oportunidade de compreender melhor o tipo de interação entre esses dois traços comportamentais, fundamentais no entendimento das patologias dos comportamentos aditivos. Este é um estudo transversal com 63 mulheres com diagnóstico atual de Anorexia Nervosa (AN) ou Bulimia Nervosa (BN) recrutadas do Programa de Transtorno Alimentar do Hospital de Clínicas de Porto Alegre e 254 mulheres com diagnóstico de TDAH provenientes do Programa de Déficit de Atenção e Hiperatividade do mesmo hospital, entre os anos de 2002 e 2016. A coocorrência TA-TDAH foi diagnosticada em ambos os grupos através de entrevista clínica e instrumentos validados. A partir destes achados, o grupo TA-TDAH foi comparado em termos de perfil demográfico, sintomatologia clínica e comorbidades psiquiátricas, com sua contraparte com TDAH e sem TA e com TA sem TDAH. Nossos resultados mostraram que os indivíduos com TA-TDAH apresentam aumento da prevalência de transtorno de ansiedade generalizada e transtorno obsessivo compulsivo quando comparado ao grupo com TDAH. Ainda, o grupo de TATDAH apresenta aumento das taxas de comorbidades com uso de substâncias psicoativas (SPA) e uso de bebida alcoólica quando comparados com ambos os grupos, TA e TDAH. Este aumento excedeu o efeito meramente aditivo encontrado no padrão para as comorbidades inicialmente descritas, demonstrando um padrão sinérgico, resultante provavelmente da interação entre os comportamentos compulsivos e impulsivos. Se considerando a avaliação de funcionalidade, o grupo TDAH-TA apresentou piores escores nas áreas de lazer quando comparado ao grupo TDAH e nas áreas de finanças e cognição quando comparado ao grupo com TA. Estes resultados são relevantes clinicamente pois demonstram que a coocorrência de TA e TDAH está associada ao desenvolvimento de um perfil clínico mais severo, que provavelmente exija uma abordagem diferenciada para este tipo de paciente. / It is well established that an Eating Disorder is a predominantly compulsive pathology, and that the Attention Deficit Hyperactivity Disorder (ADHD) is a predominantly impulsive pathology, which occur at a frequency deemed higher than what one would expect for events occurring at random. The phenotype assessment and the detailed study of patients diagnosed with both pathologies provide us with the opportunity to better understand the type of interaction between these two behavioral traits, which are essential to the understanding of the pathologies related to addictive behaviors. This is a cross-sectional study involving 63 women who have been currently diagnosed with Anorexia Nervosa (AN) or Bulimia Nervosa (BN), recruited from the Eating Disorder Program at Hospital das Clínicas de Porto Alegre, was well as 254 women diagnosed with ADHD from the Attention Deficit Hyperactivity Disorder Program at the same hospital, carried out between 2002 and 2016. From clinical interviews and the use of validated instruments, we have been able to attest the co-occurrence of Eating Disorders and ADHD in both groups. Then, from these findings, a comparison was made in terms of demographics, clinical symptomatology and psychiatric comorbidities: the group diagnosed with an Eating Disorder and ADHD with the group diagnosed with ADHD without an Eating Disorder and the group with an Eating Disorder without ADHD. Our results have shown that individuals with an Eating Disorder and ADHD have presented higher numbers of generalized anxiety disorder and obsessive-compulsive disorder, when compared to the group diagnosed solely with ADHD. Moreover, the group diagnosed with an Eating Disorder and ADHD presented an increase in comorbidity rates with the use of psychotropic drugs and alcohol, when compared to the groups diagnosed solely with an Eating Disorder or ADHD. This increase has exceeded the purely addictive effect found in the patterns related to the comorbidities initially described, showing a synergistic pattern, most likely resulting from the interaction between compulsive and impulsive behaviors. When taking into account the assessment of functionality, the group diagnosed with an Eating Disorder and ADHD presented the lowest numbers in leisurely areas, when compared to the group diagnosed solely with ADHD, and the lowest number in financial and cognitive areas, when compared to the group diagnosed solely with an Eating Disorder. These results are relevant from a clinical standpoint, since they demonstrated that the co-occurrence of an Eating Disorder and ADHD is linked to the development of a more serious clinical profile, which will likely demand a unique approach towards these patients.

Embora adolescentes do sexo masculino e feminino consumam drogas na mesma proporção, a procura por tratamento especializado é maior entre o sexo masculino. Poucos são os estudos sobre as diferenças entre os sexos dos adolescentes usuários de drogas, principalmente no Brasil. O objetivo deste estudo é descrever as características e investigar possíveis diferenças entre os gêneros dos adolescentes usuários de drogas em tratamento quanto ao padrão de consumo de drogas, conseqüências do uso e evolução no tratamento. Foram avaliadas as diferenças entre os gêneros de 124 adolescentes em tratamento. As variáveis estudadas foram: idade de início do uso de drogas e quando procurou tratamento, companhia do primeiro uso, antecedente familiar, tipos de drogas consumidas, envolvimento em atos ilícitos, problemas com a polícia, atraso escolar, comorbidades, tempo de abstinência durante o tratamento e tempo de tratamento. O sexo masculino foi mais prevalente do que o feminino (81,5% e 18,5%, respectivamente). A idade média na admissão foi de 15,4 ± 1,3 ano e a idade de primeiro uso foi de 13,3 ± 1,5 ano. Setenta e oito porcento dos adolescentes tinham antecedente familiar de uso de drogas. A primeira droga ilícita consumida foi a maconha, sendo esta também a principal droga consumida no ano anterior ao tratamento. Aproximadamente 78% dos adolescentes tinham envolvimento em atividades ilegais, 1,6% tinham comorbidade com transtorno de déficit de atenção e hiperatividade e 5,6% com transtorno de conduta. A média de permanência em tratamento foi de 21,1 ± 19,7 semanas e ____ estavam abstinentes ao final do tratamento. Em todas estas variáveis não houve diferenças entre os gêneros. O sexo feminino apresentou maior prevalência de uso de benzodiazepínico na vida (17,4%), primeiro uso de drogas com familiares (21,1%), outros diagnósticos além do transtorno por uso de substância (25,4%), transtorno depressivo maior (43,5%), tentativa de suicídio (35,5%) e maior período de abstinência durante o tratamento (média de 30,2 ± 24,4 semanas). Entre o sexo masculino foi observado maior prevalência de repetência (87,1%) e problemas com a polícia (48,5%). As conseqüências do uso de drogas (problemas com a polícia e atraso escolar) são mais evidentes entre o sexo masculino, o que poderia explicar a maior prevalência do sexo masculino em tratamentos especializados. Apesar disso, o sexo feminino consome drogas e pratica atividades ilegais nas mesmas proporções do sexo masculino. Tentativas de suicídio e depressão são mais prevalentes entre o sexo feminino, o que parece ser um fator precipitante para a busca de tratamento especializado neste sexo. Estas diferenças observadas justificam a necessidade de diferentes abordagens terapêuticas para ambos os sexos, assim como o desenvolvimento de programas para ajudar a identificação de problemas relacionados ao uso de drogas principalmente entre o sexo feminino. / Although male and female adolescents consume drugs in the same proportion, male adolescents are referred for specialized treatment more frequently than females. There are a few studies about the differences among genders of adolescent drug abusers, especially in Brazil. The objective of this study is to describe the characteristics and access possible differences in the drug using between genders of adolescents in treatment considering the pattern of drug abuse, consequences of this use, and treatment outcome. The differences among genders of 124 adolescents in treatment were accessed. The following variables were accessed: age at the first drug use and they looked for treatment, with whom they first use drugs, family history of drug use, drugs ever consumed, illegal behaviours, court problems, scholar delay, co-morbidities, abstinence during treatment, and treatment period. Male were more prevalent than female (81.5% vs. 18.5%, respectively). The mean age at the admission to the program was 15,4 ± 1,3 years, the mean age at the first time they used illegal drug was 13,3 ± 1,5 years. Seventy eight percent had family history of drug use. The first illegal drug consumed was marijuana, and this was the most drugs consumed during the last year before the treatment admission, as well. Almost 78% of the adolescents had history of illegal behaviours, 5,6% had co-morbidity with conduct disorder and 1,6% had attention deficit and hyperactivity disorder. The mean permanence in treatment was 21,1 ± 19,7 weeks, and ____% was abstinent at the end of treatment. No differences between genders were found considering these variables. Among female adolescents there were more prevalence of benzodiazepine use, at least once in their lives (17,4%), first drug use with family members (21,1%), prevalence of co-morbidities (25,4%), major depression disorder (43,5%), suicidal attempt (35,5%), and period of abstinence during treatment (mean of 30,2 ± 24,4 weeks). Among males, scholar delay (87,1%) and court problems (48,5%) were more frequent than among females. Consequences of drug abuse (court problems and scholar delay) are much more evident among male, which could explain the higher prevalence of males in specialized treatment sets. However, females consume the same amount of drugs and engage in illegal behavior as males. Suicidal attempts and depression are higher among female abusers, which may be the precipitant factor for female specialized treatment. These differences may justify different treatment approach for each gender, as well as, the development of programs to identify problems related to drug use, especially among female adolescents.

Le travail de cette thèse s’interroge sur les réponses à apporter en terme d’organisation de l’offre médico-technique et de sa juste répartition sur les territoires en particulier pour les patients âgés poly-pathologiques. Il part de l’hypothèse qu’il existe un espace pour des concepts de petits établissements de santé ambulatoires pluridisciplinaires, dotés d’un petit plateau médico-technique, qui permettraient de participer à fluidifier et optimiser les parcours de soins. La méthode a consisté d’une part à étudier des structures plus petites de proximité en Allemagne, les MVZ, avec une expérience plus ancienne que celle dont nous disposons en France avec les MSP ou les Centres de Santé, et d’autre part à analyser les données PMSI pour faire émerger à la fois l’existence de groupes homogènes de co-morbidités et de groupes homogènes de parcours de soins. Les résultats sont constructifs, à la fois dans l’analyse par les sciences des réseaux et par l’automatisation de représentations de parcours de soins complexes. Ils ont permis de faire émerger des patterns représentatifs de groupes, d’en caractériser la consommation de soins, en matière de dispositifs médicaux et de ressources humaines, de quantifier les distances parcourues cumulées et les coûts cumulés par les patients selon leur lieu d’habitation et les institutions de santé auxquelles elles sont adressées. Nous en tirons des éléments pour la définition et la labellisation de nouvelles structures de santé de proximité satellites d’hôpitaux plus importants. Ce travail représente une avancée particulièrement utile, à la fois conceptuelle et pratique, pour les études de données de santé complexes des personnes âgées. / This work questions the answer to be given in terms of organization of the health technical offer and its fair distribution in the territories especially for the elderly patients with multimorbidities. It is based on the assumption that there is space for a concept of small multi-disciplinary outpatient health facilities, with a small health-technical platform, which would help to streamline and optimize care pathways. The method consisted on the one hand to study in Germany smaller community interdisciplinary health care center (the MVZ) in operation for a longer time than the the French multidisciplinary médical care centers. And on the other hand it analyzed the national heath data to reveal both the existence of comorbidités related groups and homogeneous care pathways related groups. The results are positive, both in network science analysis and in the automation of representations of complex care pathways. They made it possible to create representative patterns of groups, to characterize the consumption of care, in terms of medical devices and human resources, to quantify the cumulative distances traveled and the costs accumulated by patients according to their place of residence and the health institutions to which they are sent. We get addition elements for the definition and labeling of small community health centers, satellite of larger hospitals. This work represents a particularly useful step, both conceptual and practical, for complex health data studies of elderly.

<p>Булимија је у великом броју случајева праћена учесталим повраћањем, које у дужем временском периоду може резултирати иреверзибилним губитком зубних ткива и хиперсензитивношћу, као и квантитативним и квалитативним променама нестимулисане и стимулисане пљувачке. Циљ истраживања је био да се утврди присуство, локализација и степен денталних ерозија употребом BЕWЕ (Basic Erosive Wear Examination) индексног система, као и утврђивање вредности индекса меких наслага и гингивалног индекса папиларног крварења код пацијената са булимијом праћеном повраћањем и здравих испитаника. Циљ лабораторијских испитивања је био да се утврди количина и pH вредност нестимулисане и стимулисане пљувачке, као и концентрације јона калцијума, фосфата, бикарбоната и урее код пацијената са булимијом праћеном повраћањем и здравих испитаника. У истраживању је учествовало 30 испитаника оболелих од булимије праћене повраћањем и 30 здравих испитаника, а коришћене су анкетне методе (упитник), клиничко и лабораторијско испитивање. Клинички преглед обухватио је ектраоралну и интраоралну инспекцију, уз бележење статуса зуба и примену BЕWЕ индекса, индекса меких наслага и индекса гингивалног крварења. Лабораторијске методе подразумевале су обраду узорковане пљувачке уз утврђивање количине пљувачке, pH вредности и концентрације електролита. На основу резултата спроведеног истраживања утврђено је да пацијенти оболели од булимије праћене повраћањем значајно чешће имају денталне ерозије у односу на контролне испитанике, да су еродоване лезије тежег степена у булимичној групи што је праћено интензивнијим болним сензацијама на надражај, као и да су оне значајно чешће локализоване на оралним површинама зуба у оболелој групи. Утврђено је и да булимични испитаници имају више вредности гингивалног индекса папиларног крварења у односу на контролну групу, док су анализе пљувачке указале да булимични испитаници имају значајно мању количину нестимулисане пљувачке, значајно ниже pH вредности у обе фракције пљувачке, више концентрације калцијума у нестимулисаној пљувачки, ниже концентрације фосфата у обе фракције, ниже концентрације бикарбоната у нестимулисаној фракцији и ниже вредности урее у обе фракције пљувачке.</p> / <p>Bulimija je u velikom broju slučajeva praćena učestalim povraćanjem, koje u dužem vremenskom periodu može rezultirati ireverzibilnim gubitkom zubnih tkiva i hipersenzitivnošću, kao i kvantitativnim i kvalitativnim promenama nestimulisane i stimulisane pljuvačke. Cilj istraživanja je bio da se utvrdi prisustvo, lokalizacija i stepen dentalnih erozija upotrebom BEWE (Basic Erosive Wear Examination) indeksnog sistema, kao i utvrđivanje vrednosti indeksa mekih naslaga i gingivalnog indeksa papilarnog krvarenja kod pacijenata sa bulimijom praćenom povraćanjem i zdravih ispitanika. Cilj laboratorijskih ispitivanja je bio da se utvrdi količina i pH vrednost nestimulisane i stimulisane pljuvačke, kao i koncentracije jona kalcijuma, fosfata, bikarbonata i uree kod pacijenata sa bulimijom praćenom povraćanjem i zdravih ispitanika. U istraživanju je učestvovalo 30 ispitanika obolelih od bulimije praćene povraćanjem i 30 zdravih ispitanika, a korišćene su anketne metode (upitnik), kliničko i laboratorijsko ispitivanje. Klinički pregled obuhvatio je ektraoralnu i intraoralnu inspekciju, uz beleženje statusa zuba i primenu BEWE indeksa, indeksa mekih naslaga i indeksa gingivalnog krvarenja. Laboratorijske metode podrazumevale su obradu uzorkovane pljuvačke uz utvrđivanje količine pljuvačke, pH vrednosti i koncentracije elektrolita. Na osnovu rezultata sprovedenog istraživanja utvrđeno je da pacijenti oboleli od bulimije praćene povraćanjem značajno češće imaju dentalne erozije u odnosu na kontrolne ispitanike, da su erodovane lezije težeg stepena u bulimičnoj grupi što je praćeno intenzivnijim bolnim senzacijama na nadražaj, kao i da su one značajno češće lokalizovane na oralnim površinama zuba u oboleloj grupi. Utvrđeno je i da bulimični ispitanici imaju više vrednosti gingivalnog indeksa papilarnog krvarenja u odnosu na kontrolnu grupu, dok su analize pljuvačke ukazale da bulimični ispitanici imaju značajno manju količinu nestimulisane pljuvačke, značajno niže pH vrednosti u obe frakcije pljuvačke, više koncentracije kalcijuma u nestimulisanoj pljuvački, niže koncentracije fosfata u obe frakcije, niže koncentracije bikarbonata u nestimulisanoj frakciji i niže vrednosti uree u obe frakcije pljuvačke.</p> / <p>Bulimia is in many cases followed by frequent vomiting, which in long term can result in irreversible loss of dental tissue and hypersensitivity, as well as quantitative and qualitative changes of unstimulated and stimulated saliva. The aim of the research was to determine the presence, localization and degree of dental erosion using BEWE (Basic Erosive Wear Examination) index system, as well as to determine the values of soft debris index and papilla bleeding index in patients with purging bulimia and healthy subjects. The aim of laboratory research was to determine the amount and pH value of unstimulated and stimulated saliva, as well as the concentration of calcium, phosphate, bicarbonate and urea in patients with purging bulimia and healthy subjects. The study involved 30 bulimic patients and 30 healthy subjects. Used methods were survey (questionnaire), clinical and laboratory testing. The clinical examination included extraoral and intraoral inspection, assessment of dental status and application of BEWE index, soft debris index and papilla bleeding index. Laboratory methods involved the processing of sampled saliva and determination of saliva quantity, pH value and electrolyte concentrations. On the bases of conducted research, it has been found that purging bulimic patients have significantly more dental erosion than control subjects, that eroded lesions are more severe in the bulimic group, followed by more intense pain sensations on the stimulants, and that erosions are significantly more often located on oral surfaces of the teeth in the diseased group. It has been found that bulimic patients have higher values of papilla bleeding index then control subjects, while analyzes of saliva indicated that bulimic subjects had a significantly lower amount of unstimulated saliva, a significantly lower pH value in both salivary fractions, higher calcium levels in nonstimulated saliva, lower concentrations of phosphate in both fractions, lower bicarbonate concentrations in the unstimulated fraction and lower urea values in both salivary fractions.</p>

Syftet med denna studie var att undersöka hur man inom socialtjänst och psykiatri i en kommun i mellansverige arbetar med samsjuklighet avseende missbruk och psykisk ohälsa, samt vilka utmaningar de yrkesverksamma möter i arbetet. För att uppnå syftet har en kvalitativ metod använts där datainsamling utgjorts av semistrukturerade intervjuer med tre yrkesverksamma personer från respektive verksamhet. Kvalitativ innehållsanalys har därefter använts för att kunna strukturera och tolka det insamlade materialet. Resultatet visade att det finns en tydlig uppdelning mellan de båda verksamheterna avseende arbetsuppgifter och ansvar. Psykiatrin arbetar med psykologisk behandling medan socialtjänstens arbete är inriktad på missbruksproblematik. Således kräver arbetet med samsjuklighet att de båda verksamheterna samverkar med varandra. Resultatet visade också att samverkan inte fungerar bra. Den största utmaningen är, enligt intervjupersonerna, att socialtjänsten får bära det största ansvaret för att kunna skapa en välfungerande samverkan. För att ytterligare förstå resultatet har systemteori tillämpats i analysavsnittet. Det systemteoretiska greppet om studien visar att socialtjänsten och psykiatrin kan förstås som delsystem av det mer övergripande välfärdssystemet. Den icke-fungerande samverkan gör att syftet med välfärdssystemet inte uppnås, eftersom de hjälpsökande människorna inte får tillgång till relevanta insatser. / The aim of this study was to survey the work with comorbidity (mental illness and drug addiction), and to reach the purpose of this study a qualitative method was used. Semi-structured interviews were conducted with professionals from the social service and the psychiatric care, six in total, three from each organization. These interviews formed the basis of this study. A content analysis was applied to analyse the gathered empirical data. The result showed that there is a distinct division between the two organizations regarding duties and responsibility concerning people with comorbidity. The psychiatric care works with psychological treatment for their patients while the social service’s mission is to treat their clients’ drug addiction. According to these facts the result indicated that these two parties have to collaborate to be able to work with comorbidity. It also showed that collaboration between these two is not well-functioning. According to the study’s informants, the largest responsibility in order to accomplish a well-functioning collaboration concerning people with comorbidity lies with the social service. The result has been analysed with systems theory in order to obtain a more profound understanding. This analysis implied that the social service and the psychiatric care are two subsystems in a lager context, the welfare system. When the collaboration is not well-functioning the mission of the welfare system does not get fulfilled, because the people with comorbidity do not receive appropriate interventions.