Dada a complexidade epidemiológica do câncer de mama e a escassez de estudos sistemáticos sobre este assunto na região norte do Brasil, este trabalho consiste no primeiro levantamento epidemiológico e assistencial em saúde tomando como base a assistência ao câncer de mama no norte do Tocantins, entre 2010 e 2015, tendo como referência o Hospital Regional de Araguaína. Os objetivos foram: verificar a qualidade das informações cadastradas no SIS-RHC quanto à completude do preenchimento dos dados referentes às mulheres com câncer de mama; avaliar a variação temporal dos percentuais de casos em estádios precoce e tardio da doença no momento do diagnóstico; analisar o tempo decorrido para se conseguir a primeira consulta, o diagnóstico e o tratamento e, analisar a associação entre as variáveis sociodemográficas com o estadiamento do tumor no momento do diagnóstico (precoce e tardio). Foram excluídas as variáveis com grau de incompletude acima de 20%. Verificou-se que: a variável ocupação teve 35,1% de preenchimento incompleto e foi excluída da análise; escolaridade apresentou 10,6% de incompletude, alcoolismo 13,5% e tabagismo 12,8%; as demais variáveis apresentaram menos de 10% de incompletude; a maioria das pacientes se apresentou com doença avançada (51,1%); não houve diferença dos percentuais de pacientes com estádios precoces e tardios ao longo dos anos avaliados (p=0,757); a mediana do tempo para consulta foi de 158 dias e para tratamento foi de 182 dias; as mulheres com estadiamento precoce levaram mais tempo para iniciarem o tratamento comparativamente àquelas com estadiamento tardio (p=0,011); as mulheres de raça/cor preta (p=0,012), analfabeta (p=0,003) e de procedência do Pará (p=0,009) apresentaram maior porcentagem de estadiamento tardio no momento do diagnóstico. Assim, concluiu-se que as variáveis da base de dados são fontes de informação consideráveis; a maioria das mulheres foi diagnosticada com doença avançada e a evolução temporal da proporção de casos avançado e precoce não demonstrou mudanças variacionais ao longo dos anos; a qualidade do serviço ambulatorial do HRA para consultas em mastologia mostrou-se precária com tendência a priorizar o atendimento aos pacientes com doença avançada. Por fim, foi identificado associação de câncer de mama em estádio avançado nas mulheres de raça/cor preta, analfabetas e provenientes do estado do Pará. / Considering the epidemiological complexity of breast cancer and the few systematic studies on this subject in the North region of Brazil, this study is the first epidemiological and health care survey based on the assistance to breast cancer in the north of Tocantins, having as reference the Regional Hospital of Araguaína (RHA). The aims were: to verify the quality of the information of the variables registered in SIS-RHC regarding the completeness of the data on women with breast cancer; to evaluate the temporal variation of the percentages of cases in early and advanced stages of the disease at diagnosis; to evaluate the elapsed time to obtain the first consultation, the diagnosis and the treatment, and to analyze the association between sociodemographic variables with the tumor stage at diagnosis (early and advanced). This is an analytical study, with secondary data of breast cancer in women between 2000 and 2015 assisted at the RHA. Variables with a degree of incompleteness above 20% were excluded. It was verified that: the variable occupation was incomplete in 35.1% of the forms and was excluded from the analysis; schooling presented 10.6% of incompleteness, alcoholism 13.5% and smoking 12.8%; the other variables showed less than 10% of incompleteness; most of patients presented advanced disease (51.1%); there was no difference of the percentages of patients with early and late stages over the years assessed (p = 0.757); the median of time for consultation was 158 days and for treatment 182 days; women with early stage took more time to initiate treatment compared to those with advanced stage (p = 0.011); women of black race (p = 0.012) , illiterate (p = 0.003) and from the state of Pará (p = 0.009) had a higher percentage of advanced stage at the time of diagnosis. Thus, it was concluded that the database variables are considerable sources of information; most women were diagnosed with advanced disease and the temporal evolution of the proportion of advanced and early cases did not show variational changes over the years; the quality of the ambulatory service of the RHA for consultations on Mastology was shown to be precarious with tendency to prioritize care for patients with advanced disease. Finally, we identified an association of advanced stage breast cancer in women of black race, illiterate and that come from the state of Pará.

Diversos estudos observaram uma correlação entre doenças na idade adulta e o ambiente durante a vida fetal. O estudo realizado por Barker e colaboradores foi um dos primeiros a relatar a hipótese de um possível envolvimento do ambiente intra-uterino com o desenvolvimento de doenças cardiovasculares, mas os mecanismos responsáveis por esta associação ainda não são totalmente conhecidos. Estudos demonstraram uma associação entre baixo peso ao nascimento com resistência à insulina e intolerância à glicose na vida adulta. Recentemente, verificamos que o consumo de dieta hipossódica, conhecido modelo de resistência à insulina, durante a gestação e lactação está vinculado a menor sensibilidade à insulina na prole adulta. Visto que a presença de resistência à insulina durante a gestação leva a diversas alterações metabólicas na prole adulta, pode-se supor que a sobrecarga de sacarose, um modelo de resistência à insulina, durante a gestação e lactação influencie no desenvolvimento da prole. Assim, o objetivo do presente estudo foi verificar a repercussão da resistência à insulina, durante a gestação sobre a prole adulta. Para tanto, ratas Wistar foram alimentadas com dieta hipo (HO) ou normossódica (NR) suplementadas ou não com sacarose (NR+SAC - 20g/dL) ou maltodextrina (NR+MALTO - 20g/dL) desde a oitava semana de vida até o final da gestação e amamentação. Na prole resultante destes animais foi observado menor peso ao nascimento nos grupos HO, NR+SAC e NR+MALTO. Esta alteração resultou no desenvolvimento de maior insulinemia, pressão arterial e maior captação de glicose na prole de fêmeas das mães do grupo NR+SAC. Os machos apresentaram menor índice de adiposidade e maior expressão gênica renal dos componentes do sistema renina-angiotensina. Tais resultados nos permitem concluir que a sobrecarga de carboidratos durante a gestação e lactação está associada a alterações no peso ao nascimento e no metabolismo da insulina na idade adulta. É possível que a ativação do sistema renina-angiotensina materno induzido pela sobrecarga de carboidrato esteja associada a alterações deste mesmo sistema observado na prole adulta. / Many studies observed a correlation between diseases in adult subjects and the environment during the fetal life. Barker and coworkers hypothesized that there is a possible intrauterine enviroment association with cardiovascular diseases in adulthood. The mechanisms responsible for this association are still not very well known. Recently, we have verified that low-salt diet consumption, a well-known model of insulin resistance, during pregnancy and lactation is associated with a lower insulin sensitivity in the adult offspring. Since insulin resistance during pregnancy leads to many metabolic alterations in the adult offspring, we suppose that sucrose overload during pregnancy and lactation could influence the offspring development. The aim of this study was to verify the effects on adult offspring of insulin resistance during pregnancy and lactation. Female Wistar rats were fed low (LSD) and normal-salt diet (NSD) supplemented or not with sucrose (SUC - 20 g/dL) or maltodextrin (MALTO - 20 g/dL) until the end of pregnancy and lactation. Lower birth weight was observed in offspring of LSD, SUC and MALTO groups. Higher plasma insulin level, blood pressure and glucose uptake was detected in the adult SUC female offspring. SUC male offspring had lower adiposity index and higher gene expression of the renal renin-angiotensin components. These results show that carbohydrate overload during pregnancy and lactation is associated with alterations in birth weight and in insulin metabolism at adult life. It is possible that the maternal renin-angiotensin system activation by the carbohydrate overload is associated with alterations in the same system observed in the adult offspring.

Made available in DSpace on 2016-04-29T13:17:34Z (GMT). No. of bitstreams: 1 Luiz Antonio Bernardes.pdf: 1976580 bytes, checksum: 6ad8d0432468ef57ee98d69a20f6acf7 (MD5) Previous issue date: 2011-05-25 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The purpose of this work was to identify the variables that could or couldn‟t contribute to the emission of children responses that would produce larger and delayed reinforcers. This was made in order to answer the following question: which responses children emit while they were waiting for larger and delayed reinforcers? Does it occur chaining or stereotyped behaviors during the waiting period? Are there any relations between what is done and the waiting time so that it would facilitate the waiting period? Can a hand puppet work as an audience to the participants so that it could extend the chain of public events and diminish the chain of covert events? Those children that were waiting in pairs or using a puppet waited for longer periods in order to receive larger and delayed reinforcers? The experimental design was based on the Mischel‟s, Ebbesen e Zeiss (1972) study. Fifteen children participated in the study divided in three experimental conditions: alone , hand puppet and peers . They should wait for 15 minutes so that they would obtain two chocolates. If they didn‟t wait, they should ring a bell and the experimenter would return and the children/child would gain the chocolate that was close to her. The results showed that four of the 15 children didn‟t wait for the whole time. The children emitted 14 categories of responses and the more frequent categories were similar for all of them. In the condition alone it was observed a smaller variation on the distribution of the responses between the categories and a smaller number of responses per minute. The condition hand puppet was the only one in which all the participants waited. However, only one participant emitted public oral verbal responses, which doesn‟t allow the experimenter to say that the hand puppet enhancing the emission of these verbal responses. Otherwise, the report of one of the participants does not allow us to discard it entirely as an audience. The standard of the observed responses on the hand puppet condition was similar to the alone condition, but with a higher average of responses per minute. For the peers condition was possible to observe that an interlocutor facilitated the waiting and enhanced the number of responses in new categories. This condition presented the higher average of responses per minute. The results indicated that oral verbal responses were emitted almost exclusively in this condition. The categorized verbal operants most common were tacts and mands about the experimental condition and unrelated subjects . Stereotypy was observed in only one participant (P5). The low variability in the 'alone' condition and greater variability in the other conditions have revealed that more complex environments allowed the participants to respond into new categories. The children who had longer waiting times were the ones with the most responses per minute and/or responded in as many categories as possible / O objetivo do presente trabalho foi identificar variáveis que poderiam contribuir ou não para que crianças emitissem respostas que produziriam reforçadores maiores e atrasados. A partir de então, responder as seguintes perguntas: quais as respostas que crianças emitem enquanto esperam por reforçadores maiores e atrasados? Dentre as respostas observadas, existem encadeamentos ou estereotipias comportamentais? Existe algum tipo de relação ente o que se faz e o tempo de espera de maneira a facilitar a espera? Um fantoche poderia funcionar como audiência para o participante ampliando assim a cadeia de eventos públicos e diminuindo por sua vez a cadeia de eventos encobertos? Crianças esperando em duplas ou usando um fantoche teriam maiores tempos de espera por reforçadores maiores e atrasados? O arranjo experimental foi baseado nos estudos de Mischel, Ebbesen e Zeiss (1972). Participaram 15 crianças divididas em três condições experimentais: sozinha‟, fantoche‟ e duplas‟. Elas deveriam esperar 15 minutos para obter dois chocolates e caso não esperassem, tocariam um sino, o experimentador retornaria e a criança ganharia o chocolate que estava junto dela. Os resultados mostraram que quatro das 15 crianças, não esperaram o tempo total. As crianças emitiram 14 categorias de respostas e as mais frequentes foram semelhantes para todas. Na condição sozinho‟ houve menor variação na distribuição das respostas entre as categorias e menor número de respostas por minuto. A condição fantoche‟ foi a única em que todos os participantes esperaram. Entretanto apenas um participante emitiu respostas verbais orais públicas, e isto não permite afirmar que o fantoche foi capaz de aumentar a emissão destas respostas verbais. Todavia o relato de um dos participantes não nos permite descartá-lo completamente como audiência. O padrão de respostas observáveis da condição fantoche‟ foi semelhante ao da condição sozinho‟, mas com uma média maior de respostas por minuto. Para a condição duplas‟ foi possível observar que ter um interlocutor facilitou a espera e aumentou o número de respostas em novas categorias. Esta condição apresentou as maiores médias de respostas por minuto. Os resultados indicaram que as respostas verbais orais foram quase que exclusivamente nesta condição e os operantes verbais classificados mais comuns foram tatos e mandos sobre a condição experimental‟ e assuntos não relacionados‟. Foi observada estereotipia em apenas um participante (P5). A pouca variabilidade na condição sozinho‟ e a maior variabilidade nas outras condições permitem afirmar que ambientes mais complexos permitiram a emissão de respostas em novas categorias. As crianças que tiveram tempos de espera mais longos foram as que apresentaram mais respostas por minuto e/ou responderam em tantas categorias quantas possíveis

O presente estudo teve como objetivo verificar o nível de consciência fonológica na Língua de Sinais Brasileira (Libras) em crianças, adolescentes e adultos surdos bilíngues, analisando os possíveis efeitos do início precoce ou tardio da aquisição da linguagem nas crianças e adolescentes surdos. Os participantes foram 34 crianças e adolescentes surdos, com idade entre 9 e 14 anos, com início da aquisição da primeira língua (L1), a Libras, entre 1-4 anos de idade (precoce) ou após 4 anos de idade (tardia), e 7 adultos surdos com início da aquisição da Libras como L1 entre 0-4 anos de idade. Nesta pesquisa de cunho psicolinguístico, foi desenvolvido um Teste de Consciência Fonológica na Libras (TCF-Libras), projetado no software E-Prime®, que mediu percentual de erro e tempo de resposta. O TCF-Libras contemplou os três principais parâmetros que formam os sinais, a saber: configuração de mão, locação/ponto de articulação e movimento. Na análise dos resultados, foi constatado que crianças e adolescentes surdos com aquisição precoce têm vantagens linguísticas quando comparados aos seus pares com aquisição tardia, e que efeitos nocivos do início da aquisição tardia da L1, reportados em estudos anteriores em diferentes níveis linguísticos, também foram constatados no presente estudo na consciência fonológica da Libras. Os participantes com início da aquisição tardia obtiveram maior percentual de erro e foram mais lentos na realização do TCF-Libras do que os participantes com início da aquisição precoce, ou seja, houve desvantagem tanto no nível de consciência fonológica como no tempo de processamento fonológico. Além disso, a comparação entre dois grupos de participantes com aquisição precoce da Libras como L1, adolescentes surdos (com maior tempo de exposição linguística) e adultos surdos, revelou que os grupos não diferiram estatisticamente, indicando que o TCF-Libras pode ser utilizado em futuras pesquisas com adultos surdos. Os resultados do presente estudo contribuem para os estudos sobre aquisição da linguagem por surdos, consciência fonológica, desenvolvimento de testes em línguas de sinais, e para informar e alertar profissionais da saúde, pais de crianças surdas e a população em geral sobre a importância de bebês surdos e crianças surdas iniciarem seu processo de aquisição da L1, na língua de sinais, o mais cedo possível. Ainda, reforçam a necessidade de que sejam promovidos programas de intervenção/estimulação linguística para bebês e crianças surdas que não possuem acesso completo aos sons, assim como com seus pais/cuidadores/familiares, para que iniciem a aquisição da língua de sinais logo após a perda auditiva ser diagnosticada. / The present study aimed to examine the level of phonological awareness in Brazilian Sign Language (Libras) in deaf bilingual children, adolescents and adults, analyzing the possible effects of language-onset in deaf bilingual children and adolescents. The participants were 34 deaf children and adolescents, aging between 9-14 years old, who acquired (L1) Libras between 1-4 years of age (early) or after 4 years of age (late), and 7 deaf adults, exposed to L1 Libras between 0-4 years of age (early). In this psycholinguistic study, a Phonological Awareness Test in Libras (PAT-Libras/ TCF-Libras) was developed and designed with the help of E-Prime®, and error percentage and response time were measured. The task includes items that test the three main parameters that form signs, namely: handshape, location/ place of articulation and movement. The analysis revealed linguistics advantages to deaf children and adolescents with early language-onset when compared to their peers with late language-onset. In addition, negative effects of delayed L1 acquisition, reported in previous studies in different linguistic levels, were also observed in the present study on phonological awareness in Libras. The participants with late language-onset scored higher percentage of errors and response time in the task than participants with early language-onset, that is, there was a disadvantage both in the phonological awareness level as well as in phonological processing time. The comparison between two groups of participants with early L1 Libras-onset deaf adolescents (with longer linguistic exposure) and deaf adults revealed that the scores did not differ statistically, showing that the task can be used in future research with deaf adults. The results of the present study contribute to the studies on language acquisition by deaf, phonological awareness, sign language test development, and to inform and to alert health professionals, deaf children‟s parents and the general population about the importance of giving deaf babies and deaf children opportunity to begin their first language acquisition, in sign language, the earliest possible. Furthermore, the results reinforce the need of intervention/stimulation programs directed to deaf babies and deaf children who not have complete access to sounds, as well to parents/caregivers/family, so that babies and children can begin sign language acquisition soon after the diagnosis of hearing loss.

Les noyaux super lourds offrent la possibilité d’étudier la structure nucléaire à trois limites simultanément: en charge Z, spin I et énergie d’excitation E∗. Ces noyaux existent seulement grâce à une barrière de fission créée par les effets de couche. Il est donc important de déterminer cette barrière de fission et sa dépendance en spin Bf(I), qui nous renseigne sur l’énergie de couche Eshell(I). Les théories prédisent des valeurs différentes pour la hauteur de la barrière de fission, allant de Bf(I = 0) = 6.8 MeV dans un modèle macro-microscopique à 8.7 MeV pour des calculs de la théorie de la fonctionnelle de la densité utilisant l’interaction Gogny ou Skyrme. Une mesure de Bf fournit donc un test des théories.Pour étudier la barrière de fission, la méthode établie est de mesurer, par réaction de transfert, l’augmentation de la fission avec l’énergie d’excitation, caractérisée par le rapport des largeurs de décroissance Γfission/Γtotal,. Cependant, pour les éléments lourds comme 254No, il n’existe pas de cible appropriée pour une réaction de transfert. Il faut s’en remettre à un rapport de largeur de décroissance complémentaire: Γγ/Γfission et sa dépendance en spin, déduite de la distribution d’entrée (I, E∗).Des mesures de la multiplicité et l’énergie totale des rayons γ de254No ont été faites aux énergies de faisceau 219 et 223 MeV pour la réaction 208Pb(48Ca,2n) à ATLAS (Argonne Tandem Linac Accelerator System). Les rayons γ du 254No ont été détectés par le multi-détecteur Gammasphere utilisé comme calorimètre – et aussi comme détecteur de rayons γ de haute résolution. Les coïncidences avec les résidus d’évaporation au plan focal du Fragment Mass Analyzer ont permis de séparer les rayons γ du 254No de ceux issus de la fission, qui sont > 10^6 fois plus intenses. De ces mesures, la distribution d’entrée – c’est-à-dire la distribution initiale en I et E∗ – est reconstruite. Chaque point (I,E∗) de la distribution d’entrée est un point où la décroissance γ l’a emporté sur la fission, et ainsi, contient une information sur la barrière de fission.La distribution d’entrée mesurée montre une augmentation du spin maximal et de l’énergie d’excitation entre les énergies de faisceau 219 et 223 MeV. La distribution présente une saturation de E∗ à hauts spins. Cette saturation est attribuée au fait que, lorsque E∗ augmente au-dessus de la barrière, Γfission domine rapidement. Il en résulte une troncation de la distribution d’entrée à haute énergie qui permet la détermination de la hauteur de la barrière de fission.La mesure expérimentale de la distribution d’entrée est également comparée avec des distributions d’entrée calculées par des simulations de cascades de décroissance qui prennent en compte le processus de formation du noyau, incluant la capture et la survie, en fonction de E∗ et I. Dans ce travail, nous avons utilisé les codes KEWPIE2 et NRV pour simuler les distributions d’entrée. / Super heavy nuclei provide opportunities to study nuclear structure near three simultaneous limits: in charge Z, spin I and excitation energy E∗. These nuclei exist only because of a fission barrier, created by shell effects. It is therefore important to determine the fission barrier and its spin dependence Bf(I), which gives information on the shell energy Eshell(I). Theoretical calculations predict different fission barrier heights from Bf(I = 0) = 6.8 MeV for a macro-microscopic model to 8.7 MeV for Density Functional Theory calculations using the Gogny or Skyrme interactions. Hence, a measurement of Bf provides a test for theories.To investigate the fission barrier, an established method is to measure the rise of fission with excitation energy, characterized by the ratio of decay widths Γfission/Γtotal, using transfer reactions. However, for heavy elements such as 254No, there is no suitable target for a transfer reaction. We therefore rely on the complementary decay widths ratio Γγ/Γfission and its spin dependence, deduced from the entry distribution (I, E∗).Measurements of the gamma-ray multiplicity and total energy for 254No have been performed with beam energies of 219 and 223 MeV in the reaction 208Pb(48Ca,2n) at ATLAS (Argonne Tandem Linac Accelerator System). The 254No gamma rays were detected using the Gammasphere array as a calorimeter – as well as the usual high resolution γ-ray detector. Coincidences with evaporation residues at the Fragment Mass Analyzer focal plane separated 254No gamma rays from those from fission fragments, which are > 10^6 more intense. From this measurement, the entry distribution – i.e. the initial distribution of I and E∗ – is constructed. Each point (I,E∗) of the entry distribution is a point where gamma decay wins over fission and, therefore, gives information on the fission barrier.The measured entry distributions show an increase in the maximum spin and excitation energy from 219 to 223 MeV of beam energy. The distributions show a saturation of E∗ for high spins. The saturation is attributed to the fact that, as E∗ increases above the saddle, Γfission rapidly dominates. The resulting truncation of the entry distribution at high E∗ allows a determination of the fission barrier height.The experimental entry distributions are also compared with entry distributions calculated with decay cascade codes which take into account the full nucleus formation process, including the capture process and the subsequent survival probability as a function of E∗ and I. We used the KEWPIE2 and NRV codes to simulate the entry distribution.

This thesis explores physiological changes occurring after acute brain injury. The first two chapters focus on traumatic brain injury (TBI), a significant cause of disability and death worldwide. I discuss the evidence behind current management of secondary brain injury with emphasis on partial brain oxygen tension (PbtO2) and intracranial pressure (ICP). The second chapter describes a subgroup analysis of the effect of hypothermia on ICP and PbtO2 in 17 patients enrolled to the Eurotherm3235 trial. There was a mean decrease in ICP of 4.1 mmHg (n=9, p < 0.02) and a mean decrease in PbtO2 (7.8 ± 3.1 mmHg (p < 0.05)) in the hypothermia group that was not present in controls. The findings support previous studies in demonstrating a decrease in ICP with hypothermia. Decreased PbtO2 could partially explain worse outcomes seen in the hypothermia group in the Eurotherm3235 trial. Further analysis of PbtO2 and ICP guided treatment is needed. The third chapter focuses on delayed cerebral ischaemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH), another form of acute brain injury that causes significant morbidity and mortality. I include a background of alpha-calcitonin gene-related peptide (αCGRP), a potential treatment of DCI, along with results from a systematic review and meta-analysis of nine experimental models investigating αCGRP. The meta-analysis demonstrates a 40.8 ± 8.2% increase in cerebral vessel diameter in those animals treated with αCGRP compared with controls (p < 0.0005, 95% CI 23.7 to 57.9). Neurobehavioural scores were reported in four publications and showed a Physiological responses to brain tissue hypoxia and blood flow after acute brain injury standardised mean difference of 1.31 in favour of αCGRP (CI -0.49 to 3.12). I conclude that αCGRP reduces cerebral vessel narrowing seen after SAH in animal studies but note that there is insufficient evidence to determine its effect on functional outcomes. A review of previous trials of αCGRP administration in humans is included, in addition to an original retrospective analysis of CSF concentrations of αCGRP in humans. Enzyme-linked immunosorbent assay of CSF (n = 22) was unable to detect αCGRP in any sample, which contrasts with previous studies and was likely secondary to study methodology. Finally, I summarise by discussing a protocol I designed for a dose-toxicity study involving the intraventricular administration of αCGRP to patients with aSAH and provide some recommendations for future research. This protocol was based upon the systematic review and was submitted to the Medical Research Council's DPFS funding stream during the PhD.

Submitted by ÂNGELA FERREIRA BARROS null (anbarros@yahoo.com.br) on 2017-03-07T03:39:13Z No. of bitstreams: 1 Tese_Ângela Ferreira Barros FINAL.pdf: 1155577 bytes, checksum: aa80e4897484ab3c60b5f04c4cd45b14 (MD5) / Approved for entry into archive by LUIZA DE MENEZES ROMANETTO (luizamenezes@reitoria.unesp.br) on 2017-03-10T17:08:20Z (GMT) No. of bitstreams: 1 barros_af_dr_bot.pdf: 1155577 bytes, checksum: aa80e4897484ab3c60b5f04c4cd45b14 (MD5) / Made available in DSpace on 2017-03-10T17:08:20Z (GMT). No. of bitstreams: 1 barros_af_dr_bot.pdf: 1155577 bytes, checksum: aa80e4897484ab3c60b5f04c4cd45b14 (MD5) Previous issue date: 2017-02-14 / Fundação de Ensino e Pesquisa em Ciências da Saúde (FEPECS) / O objetivo geral deste estudo foi verificar os fatores socioeconômicos, clínicos e relacionados à organização dos serviços associados ao tempo para acesso aos tratamentos do câncer de mama. Foi realizado um estudo de coorte com 600 mulheres com diagnóstico de câncer de mama internadas para tratamento clínico e/ou cirúrgico dessa doença que realizaram o primeiro tratamento em nove hospitais públicos do Distrito Federal. Não foram incluídos casos prevalentes de câncer de mama e casos que apresentavam doença metastática identificada em exames de estadiamento antes do início do tratamento. Todas as participantes foram entrevistadas entre setembro de 2012 e setembro de 2014. Os dados clínicos foram preenchidos com dados do prontuário. Em um segundo momento, realizou-se nova revisão do prontuário e/ou contato telefônico para obter informações sobre os tratamentos após a cirurgia e evolução clínica. O seguimento das mulheres ocorreu até fevereiro de 2016. Esta pesquisa foi aprovada pelo Comitê de Ética em Pesquisa da Secretaria de Estado de Saúde do Distrito Federal pelo parecer nº 99.313. As mulheres apresentavam, em média, 53,3 anos (± 12,5) ao diagnóstico e a maioria se declarou com a cor da pele parda (46,4%), referiu ter em média 7,9 anos de estudo (± 4,6), renda familiar média de R$ 2.079,01 (± R$ 2.489,23), residir no Distrito Federal (65,8%). Dentre as mulheres que buscaram os serviços de saúde a partir da autoidentificação dos sintomas sugestivos de câncer de mama, o intervalo de tempo entre o início do sintoma e a primeira consulta apresentou mediana de 39 dias (intervalo interquartílico: 14-123 dias). Na análise multivariada, esse intervalo de tempo > 90 dias apresentou associação estatisticamente significativa com anos de estudo (OR: 0,95; IC 95%: 0,91-0,99), não realização de mamografia e/ou ultrassonografia mamária nos dois anos anteriores ao diagnóstico de câncer de mama (OR: 1,95; IC 95%: 1,25-3,03) e estadiamento mais avançado (OR: 1,74; IC 95%: 1,10-2,75). Em relação ao itinerário terapêutico percorrido nos serviços de saúde e o intervalo de tempo entre a primeira consulta e o início do tratamento (mediana 160 dias), verificou-se que esse período foi maior entre mulheres com a cor da pele parda ou negra (p<0,001), menor escolaridade (p=0,001), menor renda familiar (p=0,045); que realizaram a primeira consulta na atenção primária quando comparado às que realizaram em serviços de saúde suplementar (p<0,001); e aquelas atendidas em mais de dois serviços de saúde (p=0,003). A implementação do agendamento de consulta com especialista, através da regulação assistencial, proporcionou redução do tempo para início do tratamento (p<0,001). Em relação à evolução clínica da doença, após um seguimento médio de 30,6 meses, não se observou associação estatisticamente significativa da recidiva do câncer de mama com os intervalos de tempo estudados. Conclui-se que os intervalos de tempo para acesso aos serviços de saúde para diagnóstico e tratamento do câncer de mama no Distrito Federal foram associados a características socioeconômicas, clínicas e relacionados à organização dos serviços, porém não apresentaram associação com a evolução clínica da doença. / The main objective of this study was to verify the socioeconomic, clinical and related factors related to the organization of the services associated with the time to access breast cancer treatments. A cohort study was conducted with 600 women with breast cancer admitted for clinical and/or surgical treatment in nine public hospitals in the Brazilian Federal District. Breast cancer prevalent cases and patients with metastatic disease identified by staging tests before treatment were excluded. All participants were interviewed between September 2012 and September 2014. Clinical data were abstracted from the medical records during hospital admission. In a second moment, further review of the medical records and / or telephone contact was made to get information about treatments after surgery and clinical outcome. Patients were follow-up until February 2016. This study was approved by the Ethics Committee of the Brazilian Federal District Secretary of Health (Approval number 99,313). The mean age at diagnosis was 53.3 years (± 12,5) and the great majority self-declared with mixed heritage (46.4%). The average years of study was 7.9 (± 4.6) years, their family income average was R$ 2,079.01 (± R$ 2,489.23) and were living in the Brazilian Federal District (65.8%). Among women who self-identified suggestive symptoms of breast cancer, the time interval between onset of symptom and the first medical visit presented a median of 39 days (interquartile range: 14-123 days). In the multivariate analysis, this time interval longer than 90 days were significantly associated with years of education (OR: 0.95; 95% CI: 0.91-0.99), those who did not performe mammography and/or breast ultrasound in the two years prior breast cancer diagnosis (OR: 1.95; 95% CI: 1.25 - 3.03) and patients with more advanced stages (OR: 1.74; 95% CI: 1.10 - 2.75). Regarding the treatment pathways in health care system and the interval between the first medical visit and the first treatment (median 160 days), we observed that this interval was longer among women with mixed heritage (p <0.001), lower level of education (p = 0.001), lower family income (p = 0.045); those who had the first medical visit in the primary care compared to those that used private health services (p <0.001); and those that used more than two health services (p = 0.003). The introduction of the scheduled consultation with a medical expert in the area provided a reduction of time to treatment (p <0.001). Regarding the clinical course of the disease, after a mean follow-up of 30.6 months, we did not observe significant association of breast cancer recurrence with the time intervals. In conclusion, the time intervals for access to health services for diagnosis and treatment of breast cancer in the Federal District were associated with socioeconomic, clinical and organizational characteristics of the services; however they were not associated with clinical evolution. / FEPECS: 064.000.455/2013

Delayed auditory feedback (DAF) is known to produce speech disruptions in fluent speakers. The present study examined the relationship between individuals' susceptibility to DAF and their auditory processing skills. Forty participants (20 males and 20 females) read and produced monologue at no delay and 3 different delay levels of 100, 200, and 400 ms. Auditory processing skills were evaluated using dichotic digits test (DDT) and staggered spondaic word (SSW) test. Males produced significantly more Stuttering-Like Disfluencies (SLDs) under DAF than females. Significantly more SLDs were observed during conversation compared to reading. Overall, there was significant correlation between the frequency of SLDs and auditory performance on SSW test. Females scored significantly better on both SSW test and DDT compared to males. Scores on attention regulation questionnaire were not significantly different between genders. Fewer SLDs observed in females under DAF could be attributed to their superior control of auditory processing resources compared to males.

La réaction sulfatique interne (RSI) est une pathologie conduisant au gonflement et à la dégradation du béton de certains ouvrages. En tant que gestionnaire d'ouvrages, VINCI doit assurer la sécurité des usagers et des biens. Pour cela, une évaluation de l'aptitude au service des ouvrages concernés est nécessaire. Ce travail a pour but d'améliorer la modélisation des phénomènes mécaniques induits par la formation d'ettringite différée, notamment sous contrainte. Une campagne expérimentale a été réalisée sur éprouvettes prismatiques en béton réactif libres de contraintes, armées uniaxialement, armées triaxialement et soumises à un chargement uniaxial de compression de 14,5 MPa. Les phénomènes expansifs sont relativement isotropes en l'absence de contraintes et atteignent 0,6 % en fin de réaction. Le bridage induit par la présence des armatures conduit à une diminution importante des déformations dans les directions concernées, sans impact majeur sur le gonflement dans les directions libres : les déformations du béton initiées par la RSI sont de fait anisotropes sous chargement anisotrope. Une fissuration préférentielle est observée parallèlement à la direction gênée. L'application d'un chargement uniaxial de compression à hauteur de 14,5 MPa entraine un raccourcissement du béton dans la direction chargée, les déformations de fluage masquant les éventuelles expansions. La décharge de ces corps d'épreuve après environ 420 jours d'immersion a provoqué une reprise des gonflements de l'ordre de 0,10 % en 3 jours dans la direction chargée, sans effet visible dans les autres directions. Au cours des 200 jours suivants, des gonflements longitudinaux et transversaux similaires en termes de cinétique et d'amplitude ont été observés. Ce phénomène a été attribué au renouvèlement de l'eau de conservation ayant eu lieu au moment de la décharge, en particulier à une réaccélération du lessivage des alcalins. L'endommagement induit par la RSI sur le béton a été caractérisé par le biais d'essais de compression, traction par fendage et mesures de module d'Young avant et après gonflement. [...] / Delayed ettringite formation is a pathology leading to swelling and degradation of the concrete of certain structures. As structure manager, VINCI must ensure the safety of users and goods. To do so, an assessment of the serviceability of affected structures is necessary. This work aims to improve the modeling of mechanical phenomena induced by delayed ettringite formation, especially under stress. An experimental campaign was carried out on prismatic reactive concrete specimens. Some were plain, uniaxially reinforced, triaxially reinforced and subjected to an uniaxial compressive loading of 14.5 MPa. Expansions appeared fairly isotropic in stress-free conditions and reached 0,6 %. Restraint due to reinforcements led to decreased strains in the restrained directions. Expansions were only slightly impacted in transversal free directions. Therefore, DEF expansion under uniaxial stress is anisotropic. Cracks were observed parallel to the restrained direction. For prestressed concrete, creep strains hid possible strains induced by DEF. These specimens were unload after 420 days of immersion in water. It led to a strain increase of about 0,10 % in 3 days in the loaded direction, without any effect on transversal directions. Similar kinetic and range of expansion was measured in both longitudinal and transversal throughout the 200 following days. This phenomenon was understood as the consequence of an alkali leaching acceleration after storage water renewal that occurred during specimens unloading. DEF induced damage on concrete was characterize through compressive tests, brazilian tensile tests and Young modulus measurements before and after expansions. DEF effect on steel-concrete bond behavior was also measured through pull-out tests. Maximal steel-concrete bond stress appears slightly impacted by longitudinal expansions of about 0.25 %, but the bond shear modulus decreases significantly after DEF. All collected experimental data were used to fit a poromechanical model of DEF taking into account all the phenomena involved in the of reinforced concrete behavior (plasticity, damage, creep, shrinkage, distributed reinforcements...). [...]

Abstract Distal radius fractures (DRFs) are the most commonly encountered fall-related fracture in clinical practice. Recognised as a typical fragility fractures, the ageing of the population may increase the occurrence of DRFs in the near future. The aims of this thesis were (I) to describe the epidemiology of DRFs in a cohort of adult patients in the city of Oulu during the year 2008 and to study changes in the incidence of DRFs during the last decades in Finland and other northern countries and the relationship between slippery conditions during the winter and the incidence of DRFs, (II) to compare the results of primary nonoperative treatment and early palmar plating of primarily dislocated DRFs in 80 patients &#8805; 50 years old in an randomised controlled study and (III) to investigate the rate and risk factors for plate-related complications after palmar plate fixation of 881 DRFs. The crude incidence rate of DRFs was 258/100 000 person-years in Oulu in 2008, and the age-specific incidence rate in the female population aged &#8805; 70 years was increased compared to previous studies in Finland and in Norway. A clear seasonal variation was observed in fall-related DRFs. The number of DRFs was 2.5 times higher on slippery winter days compared to non-winter days. Early palmar plating of DRFs showed favourable DASH (disabilities of the arm, shoulder and hand) scores at two years compared to primary nonoperative treatment. Delayed surgery in the primary nonoperative treatment group did not provide comparable DASH scores to early plating. The overall complication rate in the cohort of 881 plate-fixated DRFs was 15%. These could be regarded as plate-related in 7% of cases. Operations performed by low-volume surgeons and patient ages &#60; 40 years were independent predictors of plate-related complications. In conclusion, the incidence of DRFs has increased during the last decades in Finland in elderly females, and slippery winter conditions increase the risk of DRFs. Early palmar plating of DRFs produces more consistent results compared to primary nonoperative treatment in patients &#8805; 50 years old. The complication rate after palmar plating of DRFs is significantly influenced by surgeon experience and patient age. / Tiivistelmä Värttinäluun alaosan murtuma (rannemurtuma) on yleisin kaatumistapaturman aiheuttama luunmurtuma, jonka taustalla on monesti ikääntymisestä johtuva luun hauraus. Väestön edelleen ikääntyessä rannemurtumien ilmaantuvuus todennäköisesti lisääntyy. Tämän väitöskirjan tavoitteina oli (1) kuvata rannemurtumien epidemiologiaa ja ilmaantuvuuden muutosta Suomessa ja muissa Pohjoismaissa viimeisten vuosikymmenien aikana, sekä tutkia liukkaiden talvikelien yhteyttä rannemurtumien ilmaantuvuuteen. Lisäksi tavoitteena oli (2) verrata kahden eri hoitokäytännön — varhaisen levykiinnityksen ja ensisijaisen konservatiivisen hoidon — kliinisiä tuloksia ≥ 50-vuotiailla rannemurtumapotilailla. Lopuksi tavoitteena oli (3) selvittää rannemurtuman levytykseen liittyvien komplikaatioiden yleisyys sekä riskitekijät. Rannemurtumien ilmaantuvuus oli oululaisessa aikuisväestössä 258/100 000 henkilövuotta vuonna 2008. Ikä-spesifinen ilmaantuvuus lisääntyi aiempaan suomalaistutkimukseen verrattuna etenkin &#62; 70 vuotiailla naispotilailla ja sama suuntaus todettiin myös aiemmassa norjalaistutkimuksessa. Rannemurtumien ilmaantuvuudessa todettiin selkeä vuodenaikavaihtelu, ja liukkaalla talvikelillä rannemurtuman riski oli 2.5-kertainen verrattuna ei-talvikelin murtumariskiin. Varhaisella rannemurtuman levykiinnityksellä saavutettiin paremmat DASH (Disabilities of the Arm, Shoulder, and Hand) – pisteet kahden vuoden seurannassa verrattuna ensisijaiseen konservatiiviseen hoitoon. Murtuman asennon heikentyessä seurannassa ei myöhäisleikkauksella saavutettu kliinistä hyötyä ensisijaisessa konservatiivisen hoidon ryhmässä. Komplikaatioprosentti 881 levykiinnityksellä hoidetun rannemurtumapotilaan aineistossa oli 15 %. Levytyskomplikaatioita todettiin 7 %:lla potilaista. Itsenäisiä levytyskomplikaatioille altistavia riskitekijöitä olivat kirurgin vähäinen leikkauskokemus ja potilaan matala ikä (&#60; 40 vuotta). Yhteenvetona voidaan todeta, että rannemurtumien ilmaantuvuus on lisääntynyt Suomessa iäkkäillä naispotilailla viimeisten vuosikymmenten aikana ja liukkaudella on selkeä yhteys rannemurtumien ilmaantuvuuteen. Varhaisella leikkaushoidolla saavutetaan yhtenäisemmät hoitotulokset verrattuna ensisijaiseen konservatiiviseen hoitoon ≥ 50-vuotialla rannemurtumapotilailla. Kirurgin leikkauskokemus ja potilaan ikä ovat yhteydessä rannemurtuman levytyskomplikaatioiden riskiin.