Submitted by JÚLIO HEBER SILVA (julioheber@yahoo.com.br) on 2016-12-07T18:56:59Z No. of bitstreams: 2 Dissertação - Taizy Leda Tavares - 2016.pdf: 1902946 bytes, checksum: dc7d3e16c692d2980b305fcdf07c397f (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Jaqueline Silva (jtas29@gmail.com) on 2016-12-13T15:41:24Z (GMT) No. of bitstreams: 2 Dissertação - Taizy Leda Tavares - 2016.pdf: 1902946 bytes, checksum: dc7d3e16c692d2980b305fcdf07c397f (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2016-12-13T15:41:25Z (GMT). No. of bitstreams: 2 Dissertação - Taizy Leda Tavares - 2016.pdf: 1902946 bytes, checksum: dc7d3e16c692d2980b305fcdf07c397f (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2016-05-16 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Malaria is a parasitic disease caused by protozoa of the genus Plasmodium. In 2014 was registered 214 million new cases in worldwide with approximately 480,000 deaths. Brazil is responsible for about half of malaria cases that occur in America, where the main etiological agent is P. vivax. The absence of effective vaccines against malaria parasites is a serious obstacle to controlling the disease. In this context, this study aimed to identify peptides that may be candidates for the development of a vaccine against P. vivax through a immunoinformatics strategy called the Reverse Vaccinology (RV). Primarily, we track the P. falciparum proteome in search of proteins that presented predicted epitopes and were orthologs between species P. vivax and the species of malaria rodents, P. yoelli. The similarity between proteins and epitopes of the three species was quantified for excluding those that exhibited low similarity. Among this proteins, we sought in the literature which had been extensively studied and / or whether they had been vaccine candidates in previous research. For proteins that had been little studied or not evaluated, the prediction of B and T lymphocytes epitopes. Were thus identified 357 proteins of P. falciparum with predicted epitopes, among which 270 have orthologs in P. vivax and P. yoelli. Of these, fifty proteins were found to be highly similar between the three species under study, and 12 had little or no previous study. These 12 proteins were examined to Immunology Epitope Database program (IEDB) in order to implement the prediction of epitopes. Through a combinatorial analysis of the different immunoinformatics prediction methods, 7 proteins were selected as vaccine candidates, based on their function and / or location, such as export protein (EXP1), proteins expressed on the surface of the membrane (SERA) or transmembrane domain (MAEBL), or participate in processes essential for the survival of the parasite (CLAG). These proteins may be evaluated in the future biological assay constituents such as antigens in a vaccine against P. vivax parasite. / A malária é uma doença parasitária causada por protozoários do gênero Plasmodium. Em 2014 foram registrados 214 milhões de novos casos mundiais com aproximadamente 480.000 óbitos. O Brasil é responsável por cerca de metade dos casos de malária que ocorrem nas Américas, onde o principal agente etiológico é P. vivax. A ausência de vacinas eficazes contra parasitos de malária representa um sério obstáculo ao controle da doença. Nesse contexto, o presente trabalho identificou peptídeos que possam ser candidatos ao desenvolvimento de uma vacina contra P. vivax, através de uma estratégia de imunoinformática denominada de Vacinologia Reversa (VR). Primariamente, rastreamos o proteoma de P. falciparum em busca de proteínas que apresentassem epítopos preditos e fossem ortólogas entre as espécies P. vivax e a espécie de malária de roedores P. yoelli. A similaridade entre as proteínas e os epítopos das três espécies foi quantificada, visando excluir aquelas que exibissem baixa similaridade. Entre as proteínas restantes, buscamos na literatura quais já haviam sido extensivamente estudadas e/ou se já haviam sido candidatas vacinais em pesquisas anteriores. Para as proteínas que haviam sido pouco estudadas ou não avaliadas, foi realizada a predição de epítopos de linfócitos B e T. Foram assim identificadas 357 proteínas de P. falciparum com epítopos previstos, entre as quais, 270 possuíam ortólogos em P. vivax e P. yoelli. Destas, cinquenta proteínas revelaram ser altamente similares entre as três espécies em estudo, e 12 tinham poucos ou nenhum estudo anterior. Essas 12 proteínas foram submetidas ao programa Imunology Epitope Database (IEDB) no intuito de realizar a previsão de epítopos. Através de uma análise combinatória entre os diferentes métodos imunoinformáticos de previsão, 7 proteínas foram selecionadas como candidatas vacinais, com base em suas funções e/ou localização, como a proteína exportada (EXP1), proteínas expressas na superfície da membrana (SERA) ou com domínio transmembrana (MAEBL), ou ainda participam de processos essenciais para a sobrevivência do parasito (CLAG). Estas proteínas poderão ser avaliadas no futuro em ensaios biológicos como antígenos constituintes de uma vacina contra o parasito P. vivax.

Este estudo foi realizado com os seguintes objetivos: identificar a frequência e os preditores de disfagia em pacientes com Acidente Vascular Cerebral (AVC); avaliar o impacto da disfagia quanto aos desfechos dependência funcional e óbito em três meses após o AVC; e validar o teste de rastreio para disfagia Toronto Bedside Swallowing Screening Test (TOR-BSST©) em pacientes com AVC de um hospital público no Brasil. Participaram do estudo pacientes admitidos na Unidade de Emergência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP) e incluídos no Registro de Acidente Vascular Encefálico (REAVER) no período de abril de 2015 a setembro de 2016, maiores de 18 anos, com diagnóstico de AVC agudo (<10 dias entre o AVC e a admissão hospitalar) confirmado por exames de neuroimagem. Foram excluídos pacientes com ataque isquêmico transitório, hemorragia subaracnóidea, trombose venosa cerebral, ictus antigo, AVC hemorrágico de causa secundária ou aqueles que não concordaram em participar do estudo. As características demográficas e clínicas foram coletadas de forma prospectiva pelos coordenadores de pesquisa do REAVER. A deglutição foi avaliada na primeira semana da admissão hospitalar à beira do leito, por três fonoaudiólogas, com um protocolo de avaliação clínica utilizando as consistências pastosa e líquida. Os pacientes foram avaliados com o teste TORBSST© e com a videofluoroscopia após a alta hospitalar. A escala modificada de Rankin, o Índice de Barthel e a Medida de Independência Funcional (MIF) foram utilizados para avaliar os desfechos funcionais de três meses após o AVC. No período do estudo foram admitidos 831 pacientes com AVC, sendo que 353 pacientes foram excluídos de acordo com os critérios de inclusão e exclusão. Dos pacientes elegíveis, 53 foram removidos das análises por receberem alta antes da avaliação da deglutição, portanto, foram incluídos 425 pacientes. Dentre os pacientes incluídos, 28,2% não apresentaram condições para avaliação clínica da deglutição e foram considerados no grupo de disfagia presumida. Desta forma, foram examinados com avaliação clínica da deglutição 305 pacientes, sendo que 45,2% foram diagnosticados com disfagia. Idade (p=0,017), história médica conhecida de apneia obstrutiva do sono (p=0,003) e gravidade do AVC na admissão hospitalar (p<0,001) se associaram independentemente com disfagia. Os pacientes disfágicos apresentaram maior tempo de internação (p=0,001), maior frequência de reabilitação (p<0,001) e uso de sonda para alimentação (p<0,001) dentro de três meses após o AVC. A presença de disfagia detectada na avaliação clínica da deglutição foi independentemente associada com dependência funcional ou óbito em três meses após o AVC (p<0,001). O teste TORBSST© apresentou sensibilidade de 85% para detectar disfagia comparado a videofluoroscopia, e concordância moderada entre os avaliadores (K=0,44). Portanto, neste estudo, disfagia foi diagnosticada em quase metade dos pacientes (45,2%). Idade, história médica conhecida de apneia obstrutiva do sono e gravidade do AVC foram preditores de disfagia, sendo esta independentemente associada com morte ou dependência funcional em três meses após o AVC. O teste de rastreio para disfagia TOR-BSST© apresentou alta sensibilidade para detectar disfagia em pacientes com AVC comparado ao padrão ouro. / This study was carried out with the following objectives: to identify the frequency and the predictors of dysphagia in stroke patients; to assess the impact of dysphagia on outcomes functional dependence and death at three months post-stroke; and to validate the Toronto Bedside Swallowing Screening Test (TOR-BSST©) screening test in stroke patients from a public hospital in Brazil. All consecutive eligible patients newly admitted to the Emergency Unit of the Hospital Clinics of School of Medicine of Ribeirao Preto - University of São Paulo (HCFMRP-USP) and captured by REAVER (an institution based prospective registry for stroke patients) between April 2015 and September 2016 were approached and consented. Eligible patients were those that met the following criteria: age>18 years and medical diagnosis of acute stroke (<10 days between stroke and hospital admission) confirmed from neuroimage exams. Patients with transient ischemic attack, subarachnoid hemorrhage, cerebral venous thrombosis, not acute stroke, hemorrhagic stroke with secondary cause or those who did not agree to participate in the study were excluded. The demographic and clinical characteristics were prospectively collected by REAVER research coordinators. Swallowing was evaluated by three Speech and Language Pathologists in the first week of hospital admission at the bedside with clinical assessment using paste and liquid consistency. Patients were assessed with TOR-BSST© and with videofluoroscopy after discharge from hospital. Modified Rankin scale, Barthel Index and Functional Independence Measure (FIM) were used to assess functional outcomes three months after stroke. In the period of the study, 831 stroke patients were admitted, 353 patients were excluded according to the inclusion and exclusion criteria. Of the eligible patients, 53 were removed because they were discharged before clinical assessment of swallowing, therefore 425 patients were included in this study. Among the included patients, 28.2% did not present conditions for clinical swallowing assessment and were considered in the presumed dysphagia group. Thus, 305 patients were examined with clinical swallowing assessment and 45.2% of them had dysphagia. Age (p=0.017), known medical history of obstructive sleep apnea (p=0.003) and stroke severity at hospital admission (p<0.001) were independently associated with dysphagia. Dysphagic patients had longer length of stay (p=0.001), higher frequency of rehabilitation (p<0.001) and higher frequency of use of tube feeding (p<0.001) within three months after stroke. The presence of dysphagia detected in clinical swallowing assessment was independently associated with functional dependence or death within three months after stroke (p<0.001). The TORBSST© showed sensitivity of 85% to detect dysphagia compared to videofluoroscopy and moderate agreement among the screeners (K=0.44). Therefore, in this study, dysphagia was diagnosed in almost half of the patients (45.2%). Age, known medical history of obstructive sleep apnea and stroke severity were predictors of dysphagia, which was independently associated with death or functional dependence at three months post-stroke. The TOR-BSST© presented high sensitivity to detect dysphagia in stroke patients compared to the gold standard.

Since the release of the new iPad in 2010, few studies have explored the idea of tablet- based menus in restaurants. Since this is a new topic in the hospitality industry, there has not been literature that explores how personal traits influence the adoption intention of tablet-based menus. This study aims to explain the impact of innovation characteristics and individual differences on customer intentions to adopt tablet-based menus in restaurants of different service levels. With a random sample of 430 participants collected via Amazon’s Mechanical Turk, a regression analysis and an ANOVA test were performed. The results confirmed that only three variables (relative advantage, compatibility, and restaurant type) make a statistically significant contribution to predicting the adoption intention of tablet-based menus. It was also found that adoption intention of tablet-based menus differs across three restaurant types (quick-service restaurant, midscale restaurant, and upscale restaurant). The findings of this study provide an important insight to restaurant managers who may consider implementing tablet-based menus at their establishments. Limitations and ideas for future research are discussed.

Obesity is presently one of the leading preventable causes of mortality and is an increasing issue that affects the workplace. This pilot study investigates the effects of a multidisciplinary obesity management program on employees within a community hospital setting. The purpose of this study is to assess the outcome factors of the intervention and to detect an association between the participants’ biological factors, psychological status, eating behaviors, and lifestyle components to that of their current body weight status. Methods. An evaluation of a tailored obesity management program was conducted in a corporate setting with employees of a large community hospital. The evaluation sought to determine if this program could be efficiently and effectively implemented in this corporate setting. This program also allowed an exploration of those sociological, biological, and behavioral factors that were associated with weight loss. An employee health outcomes assessment visit was used to identify, recruit and enroll overweight employees into a quasi-experimental study designed to evaluate potential impacts of a tailored weight management program. The 6-month intervention included medical assessments, nutritional coaching, activity counseling, and behavioral therapy. The following specific aims were proposed for this dissertation research: Specific Aim 1 sought to evaluate the effectiveness of the multidisciplinary weight loss program to change a series of modifiable health risk factors, body composition, clinical indicators, and biological markers from baseline to 6 months for overweight participants. Specific Aim 2 evaluated factors associated with achieving weight loss and patterns of attrition from the program. Weight and lifestyle factors included onset of obesity, family history, weight loss history, weight loss goals, self-perceptions, physical activity factors, and eating habits/patterns. Within Specific Aim 3, we determined if body composition measurements [body mass index (BMI), weight, basal metabolic rate, fat mass, percent fat, fat free mass, and total body water] correlated with standing or supine measurements of waist, hip, or thigh circumferences. We also investigated if there was a significant difference between recording measurements made in both positions. This aim sought to determine if both sets of position measurements needed to be included for subsequent weight management studies. Results. Forty-six (46) employees, with a mean age of 48.6 +/- 10.9 years and predominately female (91.3%), consented to participate in the pilot intervention, with 26 participants completing the 6 months (response = 50.9%). Statistically significant changes from baseline were seen at 6 months in the 44 participants that continued in the study after enrollment. In the intent to treat analysis, the participants, regardless of completion status, had a clinically significant (p<.0001) mean percent weight loss of 4.1% and a total weight loss of 9.3 pounds, with a corresponding 5.6% mean weight loss in those participants that completed the program. When analyzing predictors of attrition from the program, models indicated significant associations between overall program attrition and an increase in baseline systolic blood pressure (p=0.02), along with decreased compliance with eating three meals per day (p=0.04). Primary attrition (dropout < 3 months) was statistically associated with an increase in baseline systolic blood pressure (p=0.02) and decreased compliance with eating three meals per day (p=0.01). Secondary attrition (dropout between 3-6 months) was associated with decreased compliance with eating three meals per day (p=0.05) and an increase in weight loss expectations during the intervention (p=0.05). The mean absolute difference between the two techniques (standing vs. supine) was 4.14 inches for waist, hip, and thigh measurements combined. An increase in body mass index was associated with a greater magnitude of discrepancy in the measurement between the two techniques for waist circumference (p=0.02). Conclusions. The changes seen following this multidisciplinary intervention were clinically significant and advantageous for the participants. These substantial results suggest that the use of multidisciplinary weight management programs merits further investigation in larger, randomized, controlled trials.

The present study attempted to identify demographic and psychological variables predictive of adolescent suicidal ideations and attempts. Data from 90 adolescents, who completed an intake form at a university community mental health clinic or were student volunteers, were utilized. Two judges tabulated information regarding age, gender, number of siblings, ethnicity, parental marital status, drug use, depression, suicidal ideation, and previous suicidal attempts. A multiple regression analysis was performed to identify which variables had predictive significance. Depression was the best predictor of both suicidal ideations and attempts. Ethnicity was also predictive; white adolescents were found to be at higher risk for suicide than individuals from other ethnic groups. It is suggested that additional studies be done exploring other predictors of suicide among adolescents.

Background: Intra-articular corticosteroid injections (IACI) are a commonly used treatment for painful knee osteoarthritis (OA). Response to treatment varies the reason for which is unclear. Further there are no data concerning the impact of accuracy of injection and psychological factors including illness perceptions, pain catastrophizing and depression on outcome following IACI.Objectives: i) to undertake a systematic review looking at predictors of response to IACI in patients with symptomatic knee OA and, ii) to determine the role of psychological factors and accuracy of injection in predicting response to IACI.Methods: A systematic review was conducted using electronic databases for randomised trials and observational studies looking at predictors of response to IACI in knee and hip OA. An observational study of 141 consenting patients (105 primary OA and 36 secondary OA in the context of well controlled rheumatoid arthritis) receiving routine IACI as part of clinical care for knee OA was conducted including baseline assessment and outcome assessments at 3 and 9 weeks. Response was defined as at least 40% reduction of pain from baseline, using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Assessment included ultrasound (US) for features of synovial inflammation), radiographs, and assessment of psychological factors including the revised illness perception questionnaire (IPQR). Accuracy of injection was assessed using US. Characteristics of responders and non-responders to IACI at 3 and 9 weeks were determined using univariate statistics and significant factors entered into logistic regression models. Results: The systematic review found no consistent evidence for any disease or non-disease related predictor of response and no systematic exploration of the effects of psychological factors or accuracy of injection on treatment response. In the observational study, 83 (53%) of 141 subjects were responders to IACI at 3 weeks and 56 (44%) at 9 weeks. In univariate analysis, responders to treatment had higher scores for the IPQR domain treatment control and lower scores for IPQR consequences, depression and pain catastrophizing at both 3 and 9 weeks. Physical and patient related factors, including accuracy of injection and US features, were not associated with outcome, with the exceptions of higher baseline pain and previous experience of injection being associated with non-response at 9 weeks. In multiple regression, treatment control was the only independent predictor of response at 3 weeks. At 9 weeks, treatment control, consequences and depression were independent predictors of treatment outcome. Conclusion: In this observational study illness perceptions and depression predicted the outcome of IACI at 3 and 9 weeks. By contrast, physical factors including accuracy of injection did not influence outcome. Further work is needed to replicate these findings and elucidate mechanisms for these effects.

Class of 2013 Abstract / Specific Aims: To assess influence of PCS and FPQ-III on pain tolerance as well as SNPs TRPA1(rs11988795), COMT (rs4646312, rs6269) and FAAH(rs 932816, rs4141964, rs2295633). Methods: A Pain Catastrophizing Scale (PCS) and Fear of Pain Questionnaire (FPQ-III) were completed by a total of 89 healthy adults. A genetic analysis from cheek swabs was performed for single nucleotide polymorphisms(SNPs) within genes: TRPA1, COMT, and FAAH. A cold-pressor test involving the non-dominant hand inserted in circulating water kept at 1-3 degrees Celsius was used and the duration of time subjects were able to leave their hand in the water (pain tolerance) was measured as the primary outcome. Linear regression analysis was used to identify predictors of pain tolerance. Main Results: The subjects were 58% female, the majority were Caucasian (51%) with 26% Asian, 14% Hispanic and 9% other. The mean pain tolerance was 121 ± 66 seconds and regression analysis showed female sex (p=0.001), Asian race (p=0.001), PCS score (<0.001) and FPQ-III score (p=0.014) were associated with decreased pain tolerance while the SNPs were not.      Conclusion: Psychological factors and patient demographics are associated with pain tolerance but the single nucleotide polymorphisms evaluated were not. Future pain studies should utilize a psychological assessment to adjust for this as a confounder.

Philosophiae Doctor - PhD / Aim: To investigate strokes, epidemiology, stroke characteristics, use of care and rehabilitation outcomes, and factors predicting these outcomes in stroke patients in Hebron city, in southern Palestine. Design: A one-year hospital-based, observational, descriptive, case-control, cohort study. Sample: One hundred and thirty nine (139) stroke patients were recruited from two main hospitals in Hebron city (Alia and Al-Ahli hospitals). Procedure: Objective assessment, patient interview, file screening and observation of the recruited cases was performed, risk factors were recorded and impairment, functional activity and participation were captured at baseline (T1), three months (T2), and six months (T3).

Background: Because economic conditions are both a risk factor for disease and may themselves be objectives for health delivery interventions, monitoring changes in economic outcomes has become a routine priority for health and development efforts. However, the lack of formal commerce in poor agrarian communities creates challenges for measuring economic status. Data on household finances, such as income, are ideal but are time-consuming, costly, and less reliable, whereas proxy measures of wealth such as indices of durable assets are easier to measure but relatively coarse and are less sensitive to rapid changes in underlying drivers. Methods: We used data from a cohort of 528 people living with HIV/AIDS (PLHA) enrolled in a food intervention study on household demographics, agricultural production, cash income, in-kind income, household durable assets and health status, including CD4 count. We created a household economic index using principal components analysis (PCA) and compared it with three other economic indicators generated from the data (income, expenditures, poverty score). Through multivariate logistic regression analysis we evaluated the effect of the economic metric on probability of survival within the first year of study. Results: Socioeconomic status determined by PCA of durable assets, weighted by the square root of the household size, was the only consistently significant economic predictor of probability of death. It remained significant even after controlling for direct health indicators such as CD4 count. There was no significant correlation between CD4 count and the economic indicators, which may be attributable to uniform access to ART among study participants. Conclusion: Among people who have HIV and are all enrolled in ART and food programs, household socioeconomic status is an important predictor of mortality rates, even after controlling for direct health measurements such as CD4 count and other health-related covariates. The SES indicator from PCA is also a simple metric to estimate. The study underscores that poverty is a social determinant of mortality even in the context of equal access to health services, and is suggestive of the importance of poverty alleviation activities as an important supplement to clinical interventions.

Emotionally Focused Couple Therapy (EFT; Johnson, 2004) is an empirically validated approach to couple therapy that uses attachment theory to understand the needs and emotions of romantic partners. In EFT, relationship distress is conceptualized as resulting from negative affect, emotional disconnection, and unmet attachment needs. Although EFT is recognized as one of the most researched and effective approaches to couple therapy, little research has examined theoretically related characteristics of couples to changes in marital satisfaction throughout EFT. The present doctoral thesis examined this area of literature. Thirty-two couples were provided approximately 21 sessions of EFT. The goal of the first study was to identify intake characteristics related to change in marital satisfaction over the course of EFT. Couples completed self-report measures of marital satisfaction, attachment security, relationship trust, and emotional control at pre- and post-therapy and after each therapy session. Individuals higher on self-report attachment anxiety and higher levels of emotional control had greater change in marital satisfaction over the course of EFT. The goal of the second study was to examine intake levels of attachment security and its relationship to the occurrence of the blamer-softening event, a key change event in EFT, and changes in marital satisfaction. Results indicated that the occurrence of a blamer-softening event significantly predicted positive changes in marital satisfaction. Results also suggested that the occurrence of a softening event significantly moderated the relationship between attachment avoidance at intake and change in marital satisfaction from pre- to post-therapy. For couples who completed a blamer-softening event, partners with lower levels of attachment avoidance were more likely to have positive changes in marital satisfaction. However, this relationship was not evident for attachment anxiety. Overall, results from this thesis suggest that attachment security is a key characteristic of couple partners for therapists to consider when implementing EFT. Therapists may benefit from assessing attachment security at the start of therapy to help inform them of the emotion regulating strategies used by couple partners. This information may help therapists to tailor specific interventions such that couples may begin to develop more secure attachment bonds.