Os tumores na região de cabeça e pescoço são frequentes ao redor do mundo, estando relacionados a altas taxas de morbidade e mortalidade. Recentemente, alguns estudos propuseram a associação entre doença periodontal, risco de câncer e piora na qualidade de vida de pacientes oncológicos. O objetivo deste estudo é investigar a possível associação clínica entre doença periodontal e neoplasias de cabeça e pescoço antes e após seu tratamento. Para isso, foram incluídos no grupo teste 40 pacientes de ambos os sexos, &#x2265;18 anos e com diagnóstico de câncer de cabeça e pescoço. Estes pacientes foram subdivididos em dois subgrupos: antes (T1; n=20) e após (T2; n=20) o tratamento quimio e/ou radioterápico. O grupo controle foi formado por 40 pacientes sistemicamente saudáveis selecionados aleatoriamente, sem diferenças significativas entre os grupos em relação à idade e sexo. Os pacientes responderam a um questionário de qualidade de vida relacionada à saúde oral (OHIP-14) e foram examinados periodontalmente em boca toda quanto às medidas de profundidade de sondagem (PS), recessão (REC)/hiperplasia (HP), nível de inserção clínica (NIC), índice de sangramento gengival (ISG) e índice de placa (IPl) e número de dentes perdidos. O nível ósseo proximal foi determinado a partir de imagens radiográficas pela distância entre junção cemento-esmalte e crista óssea alveolar (JCE-CA). O desfecho primário foi definido pelo diagnóstico de câncer pela equipe médica responsável, enquanto que a medida de exposição foi a doença periodontal. Houve maior número de dentes perdidos (p= 0.0017; ANOVA pós-teste Tukey) e maior quantidade de placa (p= 0.0003; Kruskal Wallis pós-teste Dunn) no grupo T2 comparativamente ao controle, porém sem diferenças em relação ao grupo T1. Não houve diferença entre os grupos (p> 0.05) quanto ao ISG, PS, REC/HP, NIC e prevalência de doença periodontal. A distância JCE-CA (p= 0.007; teste exato de Fischer) e a extensão da doença periodontal em &#x2265; 50% dos sítios (p= 0.0033; teste exato de Fischer) foram significativamente maiores no grupo teste. Foi observada associação entre câncer na região de cabeça e pescoço, presença de doença periodontal em &#x2265; 50% dos sítios (OR= 5,12; 95% CI: 1,76 14,91) e distância JCE-CA &#x2265; 4 mm (OR= 2.91; 95% CI: 1.14 7.39). Não houve associação entre câncer na região de cabeça e pescoço e exposição prévia ao fumo (p= 0.81; teste exato de Fischer) e etilismo (p= 0.15; teste exato de Fischer). Na análise da qualidade de vida relacionada à saúde oral, o grupo teste apresentou maior impacto do que o controle nas dimensões limitação funcional (p< 0.0001; Mann Whitney), dor física (p= 0.02; Mann Whitney), incapacidade social (p= 0.01; Mann Whitney), desvantagem social (p= 0.03; Mann Whitney) e na somatória das pontuações (p= 0.0092; Mann Whitney). Houve diferenças significantes entre os grupos T1 e T2 apenas no domínio limitação funcional (p= 0.0058; Kruskal Wallis pós-teste Dunn). Estes resultados sugerem que a extensão da doença periodontal em &#x2265; 50% dos sítios e a perda óssea interproximal média, determinada por meio da distância JCE-CA, &#x2265;4 mm estão associadas ao câncer na região de cabeça e pescoço. / Malignant tumors in the head and neck region are frequently observed all around the world, and are related to high morbidity and mortality rates. Recently, some studies have proposed an association among periodontal disease, risk of cancer and worsening of quality of life of oncologic patients. The aim of this study is to investigate the possible clinical association between periodontal disease and neoplastic lesions in head and neck before and after its treatment. It was included in the test group 40 patients, both genders, &#x2265;18 years old, diagnosed with cancer in the head and neck region. Patients were divided into two subgroups: before (T1; n= 20) and after (T2; n= 20) oncologic treatment. Control group was constituted by 40 systemically healthy patients randomly selected, with no significant differences in age and gender when compared with test group. All patients answered a quality of life questionnaire (OHIP-14) and were periodontally full-mouth examined according to probing depth (PD), recession (REC)/hyperplasia (HP), clinical attachment level (CAL), gingival bleeding index (GBI) and plaque index (PlI) and number of lost teeth. Interproximal bone level was determined from X-ray images as the distance between cementum-enamel junction and alveolar crest (CEJ-AC). Primary outcome was defined by the diagnosis of cancer in the head and neck region by medical staff, and the measure of exposure was periodontal disease. A higher number of missing teeth (p= 0.0017; ANOVA post hoc Tukey) and plaque accumulation (p= 0.0003; Kruskal Wallis post hoc Dunn) was observed at T2 compared to control, but with no differences when compared to T1. No differences between groups (p> 0.05) were found in GBI, PD, REC/HP, CAL and prevalence of periodontal disease. CEJ-AC (p= 0.007; Fischers exact test) and extension of periodontal disease in &#x2265; 50% of sites (p= 0.0033; Fischers exact test) were significantly higher in test than control group. It was observed a significant association between head and neck cancer, presence of periodontal disease in &#x2265; 50% sites (OR= 5,12; 95% CI: 1,76 14,91) and CEJ-AC distance &#x2265; 4 mm (OR= 2.91; 95% CI: 1.14 7.39). There was no association between head and neck cancer and previous exposition to smoking (p= 0.81; Fischers exact test) and alcohol consumption (p= 0.15; Fischers exact test). In the analysis of quality of life related to oral health, test group showed more impact than controls in the domains functional limitation (p< 0.0001; Mann Whitney), physical pain (p= 0.02; Mann Whitney), social disability (p= 0.01; Mann Whitney), handicap (p= 0.03; Mann Whitney) and total score (p= 0.0092; Mann Whitney). Significant differences between T1 and T2 groups were found only at functional limitation domain (p= 0.0058; Kruskal Wallis pós-teste Dunn). These results suggest that extension of periodontal disease in &#x2265; 50% sites and mean interproximal bone loss, determined by the distance CEJ-AC, &#x2265;4 mm are associated to head and neck cancer.

Quedas são eventos, acidentais, considerados comuns em todas as fases da vida. No entanto, entre as pessoas idosas são muito preocupantes pois podem ocasionar fraturas, imobilidade e declínio funcional, insegurança em sair ou deambular sozinho com conseqüente isolamento social e possível depressão culminando, muitas vezes, com a necessidade de institucionalização ou mesmo a ocorrência de óbito. Esses eventos resultam de uma combinação de fatores físicos, psicológicos, sociais e ambientais presentes no processo de envelhecimento. Esse estudo tem como objetivos: verificar a prevalência de quedas entre as pessoas idosas do Município de São Paulo nos anos de 2000 e 2006; verificar a incidência de quedas em 2006 e seus fatores determinantes, identificar os idosos denominados \"caidores\" ou seja, pessoas idosas que referiram quedas em 2000 e em 2006 e os fatores associados e verificar o impacto das quedas na ocorrência de óbitos nesse grupo. Este estudo é parte do Estudo SABE - Saúde, Bem estar e Envelhecimento e caracteriza-se como uma pesquisa longitudinal, exploratória, descritiva retrospectiva e com abordagem quantitativa. Para verificar a prevalência fizeram parte da amostra os idosos que referiram quedas nos 12 meses anteriores à entrevista nos dois momentos de coleta de dados, para a incidência, os que não referiram queda em 2000 e a referiram em 2006 e para os \"caidores\" os que referiram quedas nos dois períodos concomitantemente. Para a análise do impacto das quedas sobre a mortalidade, foram considerados os idosos que referiram queda em 2000 e que morreram entre as duas coletas de dados. Verifica-se um aumento na prevalência de quedas de 28,6% para 31,1% em 2000 e 2006 respectivamente. A incidência de quedas em 2006 foi de 19,7% e, dentre as variáveis analisadas, nenhuma foi significante para o sexo feminino e, para o sexo masculino, a idade (70 a 79 anos) e a presença de doenças representaram uma RRR de 2,4 e 3,1 respectivamente. Para os \"caidores\" os fatores determinantes foram velhice avançada (80 anos e mais para ambos os sexos) e a presença de doenças (para as mulheres). As RRR encontradas para idade foram 2,2 para as mulheres e 3,04 para os homens e a presença de doenças obtiveram uma RRR de 5,3 para as mulheres. Verificou-se ainda que as quedas aumentaram o risco de óbito em uma RRR de 1,4. Estes resultados reforçam a necessidade de implementação de políticas públicas voltadas à prevenção deste agravo de forma que possa ser evitado uma vez que esse vem a contribuir não somente para o óbito precoce como para uma pior qualidade de vida entre os idosos mais longevos / Falls are accidental events, considered common in all phases of life. However, when it happens with aged people, these events are worrying because can cause fractures, immobility and functional declining, insecurity in going out or walk alone with consequent social isolation and possible depression, culminating, in most cases, with the need of institutionalization and even occurrence of death. These events results from a combination of physical, psychological, social and environmental factors those are present on aging process. This study aims to: verify the prevalence of falls between elderly in the city of São Paulo in 2000 and 2006, verify the incidence of falls in 2006 and its determinants factors, identify the elderly called \"fallers\", which means, elderly people which referred falls in 2000 and 2006, and its associated factors and to verify the impact of falls on the deaths occurrences in this group. This study is part of SABE Study (Health, Well-being and Aging) and is characterized as a longitudinal, exploratory, descriptive research with quantitative approach. To verify the prevalence, elderly that referred fall during 12 months before the interview at the two moments of data collect were part of the sample, for the incidence, the elderly that not referred fall in 2000, but referred in 2006 and for the \"fallers\" the ones who referred falls in both periods concomitantly. To analyze the impact of falls on the mortality, it was considered the elderly that referred fall in 2000 and died between the two data collection. It was possible to verify the increase of the prevalence of falls from 28.6% to 31.1% in 2000 and 2006 respectively. The incidence of falls in 2006 was 19.7% and, among the analyzed variables, none of them was significant for female sex, and for male sex, the age (70 to 79 years old) and the presence of diseases represented RRR of 2.4 and 3.1 respectively. For the \"fallers\", the determinant factors were advanced old age (80 and more years old for both sexes) and the presence of diseases (for women). The found RRR for age were 2.2 for women and 3.04 for men and the presence of diseases obtained RRR of 5.3 for women. It was yet verified that the falls increases the risk of deaths in a RRR of 1.4. These results reinforces the necessity of implementation of public politics focused on early prevention of this event in order to avoid it, since it can contribute not only with early deaths but to worst quality of life of the aged people

La Fièvre de la Vallée du Rift (VFVR) est une arbovirose zoonotique affectant principalement les ruminants et les humains. Son éco-épidémiologie complexe implique de nombreuses espèces de vecteurs, d'hôtes et de voies de transmission. Ainsi, différents mécanismes de transmission et d'émergence sont impliqués dans la circulation du virus de la FVR (VFVR) et ceux-ci dans des écosystèmes contrastés d'Afrique, de la Péninsule Arabique et des îles du sud-ouest de l'Océan Indien, dont l'île de Madagascar.Par sa superficie, sa grande diversité éco-climatique et sa faune et flore endémique, Madagascar est considérée comme une île continent. On y retrouve, en effet, des écosystèmes variés plus ou moins favorables aux moustiques : semi-arides dans le sud-ouest, humides et froids sur les hautes terres centrales, per-humide dans l'est et humides et chaud dans le nord-ouest. Madagascar a été affectée par deux épidémies de FVR en 1990-91 puis 2008-09. Une étude menée lors de la dernière épidémie a montré que le virus avait largement diffusé dans l'île de façon hétérogène.Compte tenu de la complexité des mécanismes de transmission de la FVR et de la diversité des écosystèmes de Madagascar, nous avons supposé que cette hétérogénéité spatiale était due à des mécanismes de transmission et d'émergence qui variaient en fonction des écosystèmes de l'île. Ainsi, le premier objectif de ce travail de thèse étaient de déterminer les mécanismes et les dynamiques de transmission de la FVR inhérents aux différents écosystèmes de Madagascar. Le second objectif a été d'identifier les mécanismes d'émergence de la FVR à Madagascar et de déterminer s'il sera possible, et nécessaire, de prédire cette émergence à l'échelle des écosystèmes.Dans le cadre de ce travail de thèse deux enquêtes sérologiques nationales, l'une bovine (2008) et l'autre humaine (2011-13) ont, premièrement, été analysées par un modèle linéaire mixte généralisé afin d'identifier les facteurs environnementaux et comportementaux favorables à la circulation du virus chez les bovins et les humains. Deuxièmement, deux enquêtes sérologiques bovines, l'une réalisée en 2008 et l'autre en 2014, ont été analysées pour reconstruire la dynamique de transmission de la FVR dans les différents écosystèmes de l'île. Cette reconstruction a été réalisée à partir de données de séroprévalence et d'âge inclues dans un modèle Bayésien hiérarchique pour estimer la force d'infection annuelle de 1992 à 2014. Enfin, afin de faire le lien biologique avec les résultats des travaux menés à une échelle nationale et de décrire les mécanismes de transmission à une échelle fine, des enquêtes longitudinales entomologiques et sérologiques ont été réalisées entre 2015 et 2016 dans un écosystème à risque. Et ceci, afin de décrire la transmission saisonnière du VFVR chez les ruminants associée à la dynamique de transmission des vecteurs potentiels.Nos résultats ont montré que la région du nord-ouest de l'île est une région à risque de transmission. D'une part, elle est constituée d'environnements associant une forte densité de bovins à des zones humides, inondables et irriguées, favorables aux espèces d'Anopheles et Culex. D'autre part, le VFVR semble avoir circulé de façon relativement intense lors de la période inter-épizootique de 1992 à 2007, puis sa transmission a soudainement augmenté en 2007-2008, ce qui est concomitant avec l'apparition des foyers de FVR en 2008. Pour finir, 6 ans après l'épidémie de FVR à Madagascar, le virus semble toujours circuler à bas bruit dans la région. Cette circulation étant probablement due à une transmission vectorielle favorisée par l'abondance de vecteurs potentiels dans la région.Les résultats de ces différents travaux nous ont permis de présenter des hypothèses de transmission dans les différents écosystèmes de l'île et ainsi de proposer des stratégies de surveillance, de prévention et de lutte contre la FVR adaptées au contexte de Madagascar. / Rift Valley fever (RVF) is a zoonotic vector-borne disease affecting ruminants and humans. Its complex eco-epidemiology involves several species of vectors, hosts and transmission routes. These particularities allowed the circulation of RVF virus (RVFV) in a variety of ecosystems involving different transmission and emergence mechanisms. Indeed, the RVFV has affected contrasted eco-regions in Africa, Arabian Peninsula and South-West Indian Ocean islands, including Madagascar.Madagascar is considered as a continent island due to its ecological diversity and its endemicity level of the flora and the fauna. In particular, the variation of the Malagasy ecosystems (semi-arid in the south, humid and cold in the highlands, humid and warm in the north-west and per-humid in the east) has an impact in their presence and /or the relative abundance of some mosquito species. Madagascar was heavily affected by RVF in 1990-91 and 2008-2009, with evidence of a large and heterogeneous spread of the disease.Thus considering the diversity of RVF eco-epidemiological cycles and the variety of Malagasy ecosystems, we hypothesized that, in Madagascar, the mechanisms of transmission would be different according to these ecosystems. Therefore, the first objective of this thesis was to understand the mechanisms and the dynamics of transmission of RVFV in the different ecosystems. The second objective was to determine the mechanisms of emergence of RVFV and if it would be necessary and possible to predict the emergence of RVFV outbreaks according to the ecosystems.Firstly, we analyzed both cattle and human serological data performed at the national level using generalized linear mixed models to identify the environmental and behavioral factors associated with RVF transmission in both cattle and human. Secondly, we reconstructed the dynamic of transmission of RVF in the different Malagasy ecosystems. Seroprevalence data of cattle of known age were fitted using Bayesian hierarchical models to estimate the annual force of infection from 1992 to 2014. Thirdly, to understand the biological process link to the mechanisms of transmission at the national scale, we investigated the fine scale mechanisms of transmission of RVFV in pilot area of an at-risk region. We, thus, performed both longitudinal entomological and serological surveys between 2015 and 2016, in order to describe the seasonal transmission of RVFV among ruminants and its association with the dynamics of RVFV potential vectors.Our results showed that the northwestern part of Madagascar is an at-risk region for RVFV transmission. On one hand, it is characterized by high cattle densities associated with humid, floodplain and irrigated areas suitable for RVFV potential vector like Anopheles and Culex species. On the other hand, RVFV had probably circulated intensively in the region during the 1992-2007 inter-epizootic period and its transmission increased suddenly in 2007-08, almost concomitantly with the first outbreaks recorded in 2008. Finally, RVFV was still circulated in the northwestern region at low level, 6 years after the last epidemic. This circulation is likely due to vectorial transmission favoring by the abundance of several potential vectors of RVFV in this pilot region.Finally, our better understanding of the mechanisms of transmission of RVFV throughout Madagascar allowed us to propose hypothesis of transmission in different ecosystems of Madagascar and consequently refine strategies for RVF surveillance and prevention.

In der Literatur finden sich zahlreiche Hinweise dafür, daß die hämorheologischen Meßgrößen wie Hämatokrit, Erythrozytenaggregation und Erythrozytenrigidität, sowie Vollblut- und Plasmaviskosität bei Patienten mit Atherosklerose bzw. bereits bei Personen mit kardiovaskulären Risikofaktoren pathologisch verändert sind. Offen ist dagegen derzeit die Frage, ob derartige Veränderungen reversibel sind. Die vorliegende Arbeit sollte deshalb der Frage nachgehen, ob sich im Verlauf einer stationären Anschlußheilbehandlung (AHB) neben einer Normalisierung klassisch kardiovaskulärer Risikofaktoren auch positive Veränderungen rheologischer Parameter beobachten lassen. Dazu wurden 64 männliche und weibliche Patienten zu Beginn und am Ende ihrer vierwöchigen kardiologischen AHB untersucht. Es wurden der Blutdruck, Gewicht und Gesamtcholesterin, sowie die hämorheologischen Parameter Plasmaviskosität, Hämatokrit und Fibrinogen bestimmt. Bis auf geschlechtsspezifische Hämatokritwertunterschiede wurden keine statistisch signifikanten Differenzen der rheologischen Werte im Gruppenvergleich der verschiedenen Patientengruppen gefunden. Im Verlauf der AHB kam es neben einer statistisch signifikanten Reduktion klassisch kardiovaskulärer Risikofaktoren zu einer statistisch signifikanten, von koronarer Herzkrankheit und Risikofaktoren unabhängigen Verminderung der Plasmaviskosität und des Hämatokrits. Keine statistisch signifikanten Änderungen zeigten sich diesbezüglich des Fibrinogenspiegels. Desweiteren wurden einige schwach positive Korrelationen zwischen der Änderung klassischer Risikofaktoren und der Änderung hämorheologischer Faktoren aufgezeigt. Diese Ergebnisse bestätigen Zusammenhänge zwischen kardiovaskulären Risikofaktoren und hämorheologischen Meßgrößen. Sie implizieren weiterhin, daß es im Verlauf einer kardiovaskulären Rehabilitation nicht nur zu der erhofften Reduktion diverser Risikofaktoren kommt, sondern daß auch hämorheologische Kenngrößen günstig beeinflußt werden. / The fact that hemorheological variables such as hematocrit, red cell flexibility and aggregability, plasma and blood viscosity are pathologically altered in the presence of cardiovascular risk factors and diseases is evidenced by a large and growing amount of data. The question whether and how such abnormalities might be reversible is still largely unanswered. This investigation was therefore aimed at determining the hemorheological effects of a 4-week cardiovascular rehabilitation programme in 64 male and female patients with cardiovascular disease and/or risk factors. Blood pressure, body weight and total cholesterol were measured together with hemorheological parameters such as plasma viscosity, hematocrit and fibrinogen. With the exception of gender-specific hematocrit differences, no significant differences were found regarding rheological values between various groups. In the course of the rehabilitation programme, a reduction of conventional cardiovascular risk factors was noted and a statistically significant reductions of plasma viscosity and hematocrit were found which were independent of coronary heart disease. No significant changes were seen in fibrinogen levels. Moreover, a weak positive correlation was observed between conventional risk factors and changes in hemorheological variables. These results confirm the links between conventional risk factors and hemorheological measurements. They also imply that, during a rehabilitation programme, a reduction of various risk factors may be associated with positive changes in hemorheological variables. In conclusion, this study has demonstrated a change in some hemorheological variables in the course of a complex rehabilitation programme for cardiac patients.

Quedas são eventos, acidentais, considerados comuns em todas as fases da vida. No entanto, entre as pessoas idosas são muito preocupantes pois podem ocasionar fraturas, imobilidade e declínio funcional, insegurança em sair ou deambular sozinho com conseqüente isolamento social e possível depressão culminando, muitas vezes, com a necessidade de institucionalização ou mesmo a ocorrência de óbito. Esses eventos resultam de uma combinação de fatores físicos, psicológicos, sociais e ambientais presentes no processo de envelhecimento. Esse estudo tem como objetivos: verificar a prevalência de quedas entre as pessoas idosas do Município de São Paulo nos anos de 2000 e 2006; verificar a incidência de quedas em 2006 e seus fatores determinantes, identificar os idosos denominados \"caidores\" ou seja, pessoas idosas que referiram quedas em 2000 e em 2006 e os fatores associados e verificar o impacto das quedas na ocorrência de óbitos nesse grupo. Este estudo é parte do Estudo SABE - Saúde, Bem estar e Envelhecimento e caracteriza-se como uma pesquisa longitudinal, exploratória, descritiva retrospectiva e com abordagem quantitativa. Para verificar a prevalência fizeram parte da amostra os idosos que referiram quedas nos 12 meses anteriores à entrevista nos dois momentos de coleta de dados, para a incidência, os que não referiram queda em 2000 e a referiram em 2006 e para os \"caidores\" os que referiram quedas nos dois períodos concomitantemente. Para a análise do impacto das quedas sobre a mortalidade, foram considerados os idosos que referiram queda em 2000 e que morreram entre as duas coletas de dados. Verifica-se um aumento na prevalência de quedas de 28,6% para 31,1% em 2000 e 2006 respectivamente. A incidência de quedas em 2006 foi de 19,7% e, dentre as variáveis analisadas, nenhuma foi significante para o sexo feminino e, para o sexo masculino, a idade (70 a 79 anos) e a presença de doenças representaram uma RRR de 2,4 e 3,1 respectivamente. Para os \"caidores\" os fatores determinantes foram velhice avançada (80 anos e mais para ambos os sexos) e a presença de doenças (para as mulheres). As RRR encontradas para idade foram 2,2 para as mulheres e 3,04 para os homens e a presença de doenças obtiveram uma RRR de 5,3 para as mulheres. Verificou-se ainda que as quedas aumentaram o risco de óbito em uma RRR de 1,4. Estes resultados reforçam a necessidade de implementação de políticas públicas voltadas à prevenção deste agravo de forma que possa ser evitado uma vez que esse vem a contribuir não somente para o óbito precoce como para uma pior qualidade de vida entre os idosos mais longevos / Falls are accidental events, considered common in all phases of life. However, when it happens with aged people, these events are worrying because can cause fractures, immobility and functional declining, insecurity in going out or walk alone with consequent social isolation and possible depression, culminating, in most cases, with the need of institutionalization and even occurrence of death. These events results from a combination of physical, psychological, social and environmental factors those are present on aging process. This study aims to: verify the prevalence of falls between elderly in the city of São Paulo in 2000 and 2006, verify the incidence of falls in 2006 and its determinants factors, identify the elderly called \"fallers\", which means, elderly people which referred falls in 2000 and 2006, and its associated factors and to verify the impact of falls on the deaths occurrences in this group. This study is part of SABE Study (Health, Well-being and Aging) and is characterized as a longitudinal, exploratory, descriptive research with quantitative approach. To verify the prevalence, elderly that referred fall during 12 months before the interview at the two moments of data collect were part of the sample, for the incidence, the elderly that not referred fall in 2000, but referred in 2006 and for the \"fallers\" the ones who referred falls in both periods concomitantly. To analyze the impact of falls on the mortality, it was considered the elderly that referred fall in 2000 and died between the two data collection. It was possible to verify the increase of the prevalence of falls from 28.6% to 31.1% in 2000 and 2006 respectively. The incidence of falls in 2006 was 19.7% and, among the analyzed variables, none of them was significant for female sex, and for male sex, the age (70 to 79 years old) and the presence of diseases represented RRR of 2.4 and 3.1 respectively. For the \"fallers\", the determinant factors were advanced old age (80 and more years old for both sexes) and the presence of diseases (for women). The found RRR for age were 2.2 for women and 3.04 for men and the presence of diseases obtained RRR of 5.3 for women. It was yet verified that the falls increases the risk of deaths in a RRR of 1.4. These results reinforces the necessity of implementation of public politics focused on early prevention of this event in order to avoid it, since it can contribute not only with early deaths but to worst quality of life of the aged people

Submitted by Luciana Ferreira (lucgeral@gmail.com) on 2016-02-18T10:53:24Z No. of bitstreams: 2 Tese - Maria das Graças Nunes Brasil - 2015.pdf: 3301450 bytes, checksum: e7bbf1d8f5625149fa80de27803d15ee (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2016-02-18T10:56:53Z (GMT) No. of bitstreams: 2 Tese - Maria das Graças Nunes Brasil - 2015.pdf: 3301450 bytes, checksum: e7bbf1d8f5625149fa80de27803d15ee (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2016-02-18T10:56:53Z (GMT). No. of bitstreams: 2 Tese - Maria das Graças Nunes Brasil - 2015.pdf: 3301450 bytes, checksum: e7bbf1d8f5625149fa80de27803d15ee (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2015-04-15 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Poor school performance is a frequent complaint in pediatric clinics and represents a menace for the student’s future. Goal: To identify risk factors for poor school performance in children and teenagers and situate the executive dysfunction among them. Method: The present thesis was constructed in the model of a scientific paper. Initially, an introduction of the theme was made. In the first paper, titled “The modern view of the Executive Function and the legacy of Aleksandr Romanovich Luria”, we compared Luria’s thinking with the contemporary theoretical models that underlie the concept of executive function. In the second paper titled “Executive Function and school performance in children and teenagers” we revised the association between executive function and school performance. We used the PubMed database (United States National Library of Medicine), between the period of 2000 and 2013. In the third paper titled “The executive dysfunction as a risk factor for poor school performance: case-control study” we reported a case-control study paired by sex and age, involving children and teenagers from a public school of Goiânia, Goiás. We selected 30 students retained in their previous classes, in 2011 (cases), and compared them to 30 students of the same sex, same school, similar age and who were approved (control). The school assessed school performance while the executive function was assessed through a neuropsychological protocol and a neuropsychiatric clinic evaluation performed by trained professionals with clinical experience. For data analysis we used the bivariate comparison technique and logistic regression in order to determinate associations for non-parametrical data in the two groups assessed. Results: The first paper showed that Luria described the executive function in his Functional Systems Theory. The second study evidenced associations between executive function and school performance found in ten research papers. In the third, the multivariate model of logistic regression pointed to an injury on planning and in mental flexibility, which are components of the executive function (p=0,025; O.R.=15,60) as a significant predictive variable. Conclusion: Injuries on the executive Abstract xv function, especially in planning and mental flexibility, are presented as risk factors for poor school performance in children and teenagers. / O baixo desempenho escolar é queixa frequente nos ambulatórios pediátricos e pode representar uma ameaça para o futuro do estudante. Objetivo: Identificar os fatores de risco para o baixo desempenho escolar em crianças e adolescentes e situar a disfunção executiva entre eles. Método: A presente tese foi construída no modelo de artigos científicos. Inicialmente, fez-se uma introdução sobre o tema. No primeiro artigo com o título “A visão moderna da Função Executiva e o legado de Aleksandr Romanovich Luria”, comparou-se o pensamento de Luria aos modelos teóricos atuais para fundamentar o conceito de função executiva. No segundo artigo denominado: “Função Executiva e desempenho escolar em crianças e adolescentes” foi feita revisão sobre a associação entre função executiva e desempenho escolar. Utilizou-se a base de dados PubMed (United States National Library of Medicine), compreendendo o período entre 2000 e 2013. No terceiro artigo intitulado “A disfunção executiva como fator de risco para baixo desempenho escolar: estudo caso-controle” foi relatado um estudo tipo caso-controle pareado por sexo e idade, envolvendo crianças e adolescentes de uma escola pública de Goiânia, Goiás. Foram selecionados 30 escolares retidos na série, no ano de 2011 (casos) e comparados a 30 estudantes do mesmo sexo, mesma escola, idade próxima e que foram aprovados (controles). O rendimento escolar foi avaliado pela escola e a função executiva através de protocolo neuropsicológico e avaliação clínica neuropsiquiátrica, realizados por profissionais treinados e com experiência clinica. Na análise dos dados, utilizou-se comparações bivariadas e regressão logística a fim de determinar associações para dados não paramétricos nos dois grupos avaliados. Resultados: O primeiro artigo mostrou que Luria descreveu a função executiva na Teoria dos Resumo xiii Sistemas Funcionais. O segundo estudo evidenciou associações entre função executiva e rendimento escolar em dez pesquisas selecionadas. No terceiro, o modelo multivariado de regressão logística apontou prejuízo no planejamento e na flexibilidade mental, componentes da função executiva (p=0,025; O.R.=15,60) como variável previsora significativa. Conclusão: Prejuízos na função executiva, especialmente no planejamento e na flexibilidade mental, se apresentaram como fatores de risco para baixo rendimento escolar em crianças e adolescentes.

Made available in DSpace on 2016-04-28T20:17:29Z (GMT). No. of bitstreams: 1 2009 - Nadia Rossi de Almeida.pdf: 1219567 bytes, checksum: 83793b5f3d79ab19c2fe40b41ba26f70 (MD5) Previous issue date: 2009-02-05 / The present study had the aim to make a survey of the Feline Leukemia Virus infection in domestic cats of Rio de Janeiro city and Baixada Fluminense region and to analyze risk factors involved in this infection. For this purpose, peripheral blood smears of 1094 cats had been submitted to indirect immunofluorescence for viral antigen detection and data relative to the animals surveyed, such as sex, age, race, access to the street, sexual life, housing, number of contactants and symptoms and/or clinical signals had been registered in individual files. Among the analyzed samples, 11,52% were positive for the test, corresponding to 11,49% of the animals collected at the Rio de Janeiro city and 11,62% of the collected samples at Baixada Fluminense region. The qui-square test was used for the descriptive analysis of all the selected variables, where only the significant variable had been included in multivariate analysis, by logistic regression. In accordance to these analysis, the access to the street, the age range between 1 and 5 years old and the cohabitation with too much cats in groups among 6 to15 cats and above of 15 cats had been considered risk factors for FeLV infection. / O presente estudo teve como objetivo pesquisar a ocorr?ncia da infec??o pelo V?rus da Leucemia Felina (FeLV) em gatos dom?sticos do munic?pio do Rio de Janeiro e Baixada Fluminense e tamb?m analisar fatores de risco envolvidos na infec??o por este retrov?rus. Para esta finalidade, esfrega?os de sangue perif?rico de 1.094 gatos foram submetidos ao teste de imunofluoresc?ncia indireta para pesquisa de ant?geno viral e os dados relativos aos animais, tais como o sexo, idade, ra?a, acesso ? rua, vida sexual, moradia, n?mero de contactantes e sintomas e/ou sinais cl?nicos foram registrados em fichas individuais. Do total de amostras analisadas, 11,52% apresentaram positividade para o teste, correspondendo a 11,49% de ocorr?ncia da infec??o em animais do munic?pio do Rio de Janeiro e 11,62% da Baixada Fluminense. O teste de qui-quadrado foi utilizado para a an?lise descritiva de todas as vari?veis levantadas, onde apenas as vari?veis que apresentaram signific?ncia foram inclu?das na an?lise multivariada, atrav?s da regress?o log?stica. De acordo com estas an?lises, o acesso ? rua, a faixa et?ria entre 1 e 5 anos de idade e a conviv?ncia com demais gatos na faixa entre 6 e 15 gatos e acima de 15 gatos foram fatores de risco para a infec??o pelo FeLV.

La thèse porte sur les Tests Génétiques vendus en Accès Libre (TGAL), notamment sur l’Internet, et qui sont dédiés à la santé ou à la physiologie, aux performances ou aux comportements. En pleine expansion depuis la fin des années 1990, ce marché va à l’encontre de certaines législations nationales et génère des controverses. Il se construit en l'absence de prescription médicale lors de la vente, et d'accompagnement par un professionnel de santé lors de l’accès aux résultats. Pour autant, les auto-tests relèvent-ils d’une médicalisation sans médecin ? Pour comprendre la dynamique socio-économique de ce marché sur une dizaine d'années, nous avons répertorié 130 sites web (contre une soixantaine dans la littérature académique existante) et identifié 155 entrepreneurs, pour ensuite étudier l’évolution de leurs caractéristiques. La localisation du marché évolue, les sites web européens étant au final aussi nombreux que leurs homologues nord-américains. Que ce soit en matière de conception comme de distribution des dispositifs techniques, les TGAL marquent une progression de l’autonomie des outsiders du champ médical, voire leur intrusion dans ce champ. La distribution médicale se développe en parallèle des ventes en accès libre, entre autres via le recrutement de médecins en interne aux entreprises (i.e. ventes via une hotline). En outre, certains outsiders sont relativement nouveaux puisqu’il faut noter la présence de fonds d’investissement spécialisés en science, et plus ou moins indépendants des traditionnels groupes industriels. Il faut par ailleurs constater la présence de firmes de l’informatique et de l'Internet qui, jusqu'à présent, ne s'étaient pas vraiment intéressées au champ de la santé. Au final, les TGAL amènent à parler également de biomédicalisation et d’auto-médicalisation. / The thesis deals with Direct-To-Consumers Genetic Testing (DTCGTs) sold on the Internet, and more specifically with the ones for health, physiology, performance and behaviour. This market is booming since the end of the 90’s, and is sparking off controversies which are rooted in multiples scientific and medical uncertainties (“missing heritability”, informed consent, third parties, etc.). It doesn’t require for medical prescription, and health professional consultancy for test data and results is not systematically needed, which is not allowed by some national legislations. For all that, is it a medicalisation phenomenon without physician ?To understand the socio-economic dynamic of this market, we had listed 130 websites (for 60 in the academic literature) and identified 155 entrepreneurs, then we studied the evolution of theirs characteristics. The territorial localisation of the market changed, and european websites are finally as numerous as theirs north-american counterparts. Either in technical devices conception, or in commercialisation, DTCGTs are a sign of the autonomy progression of outsiders from the medical field, if not of their intrusion in this field. Medical dispensing systems are growing alongside of DTC selling, notably through the physician hiring by the DTCGT companies (i.e. hotline selling). Furthermore, some outsiders are relatively new, for they are related to investment funds which are specialized in science and more or less independent from industrial groups. Furthermore, one must notice the presence of informatics and Internet companies which, till now, didn’t really explore the health field. Finally, DTCGT relate also to biomedicalisation and automedicalisation.

La iatrogénie médicamenteuse à l’hôpital est un problème majeur de santé publique dont les causes sont multiples. Les bilans de médications et le rôle des cohortes de patients pourraient permettre de diminuer ce phénomène. L’objectif de cette thèse d’apporter des éléments utiles à la décision publique sur l’évolution des pratiques pharmaceutiques et l’effet iatrogène des médicaments et d’autre part de fournir des outils directement utiles au pharmacien afin de cibler les patients les plus à risques d’évènements iatrogènes médicamenteux. Ce travail se décline en trois séquences : (i) définition et contexte, (ii) évaluation de l’impact clinique et économique du pharmacien clinicien dans une démarche pro-active de soins pharmaceutiques dans les unités de soins, (iii) facteurs de risque d’événements indésirables médicamenteux à court terme et à long terme. Au vu de ces résultats et des données de la littérature, il apparaît que les bilans de médication est un moyen d’optimisation de la qualité et de l’efficience des soins. / Medication errors in hospital is a major public health problem with multiple reasons. Medication reviews and the role of cohorts of patients could help reduce this phenomenon. The objective of this thesis is to provide useful elements for public decision on the evolution of pharmaceutical practices and the adverse drugs reactions and secondly to provide tools directly useful to the pharmacist to target patients most at risk of adverse drugs events. This work is divided into three parts: (i) definition and context, (ii) evaluation of the clinical and economic impact of the clinical pharmacist in a pro-active approach of pharmaceutical care in the care units, (iii) risk factors adverse drug events in the short and long term. In view of these results and data from the literature, it appears that medication reports are a means of optimizing the quality and efficiency of care.

Background: The epidemic of chronic diseases is largely neglected. Although a threatening burden of chronic diseases is emerging, developing public health efforts for their prevention and control is not yet a priority for trans-national and national health policy makers. Understanding the population burden of risk factors which predict chronic diseases is an important step in reducing the impact of the diseases themselves. Objective: This thesis responds to the increasing burden of chronic diseases worldwide, and aims to illustrate the gap in chronic disease risk factor research in developing countries. The thesis describes and analyses the distribution of chronic disease risk factors in a rural setting in Indonesia. It also describes how smoking, one of the most common risk factors, is viewed by rural Javanese boys. Ultimately, therefore, this thesis aims to contribute to policy and programme recommendations for community interventions in a rural setting in Indonesia Methods: The studies were conducted in Purworejo District, where a Demographic Surveillance System (DSS) has been running since 1994. The Purworejo DSS is part of the INDEPTH network (International Network of field sites for continuous Demographic Evaluation of Populations and Their Health in developing countries). Two representative cross-sectional studies (in 2001 and 2005) were conducted to assess the chronic disease risk factors (including smoking, elevated blood pressure, and overweight and obesity). The first cross-sectional study was followed up in 2002 and 2004. In each study, a total of 3 250 participants (approximately 250 individuals in each sex and age group among 15–74 year olds stratified into 10-year intervals) were randomly selected from the surveillance database from each enumeration area in the surveillance area. Instruments were adopted from the WHO STEPS survey and adapted to local setting. Since many Indonesians start to smoke at an earlier age, a qualitative study using a focus group discussion approach was conducted among school boys aged 13-17 years old to describe and explore beliefs, norms, and values about smoking in a rural setting in Java. Result: Both the rural and urban populations in Purworejo face an unequal distribution of risk factors for chronic diseases. The burden among the most well-off group in the rural area has already reached a level similar to that found in the urban area. Most of the risk factors increased in all age, sex and socioeconomic groups during the period of 2001 to 2005. However, women and the poorest group experienced the greatest increase in risk factor prevalence. The qualitative study showed that cultural resistance against women smoking in Indonesia remains strong. Smoking is being viewed as a culturally internalised habit that signifies transition into maturity and adulthood for boys. Smoking is utilised as a means for socialisation and signifies better socioeconomic status. The use of tobacco in the construction of masculinity underlines the importance of gender specific interventions. National tobacco control policy should emphasise a smoking free society as the norm, especially among boys and men, and regulations regarding the banning of smoking should be enforced at all levels and areas of the community. Within the demographic surveillance setting, it is possible to assess the population and health dynamics. Utilisation of a standardised methodology across sites in INDEPTH will produce comparable population-based data in developing countries. Such comparisons are important in global health. A comparison of smoking transition patterns between a Vietnamese DSS and an Indonesian DSS shows that Indonesian men started smoking regularly earlier and ceased less than Vietnamese men. Compared with Vietnam, which has already signed and ratified the Framework Convention on Tobacco Control, tobacco control activities in Indonesia are still deficient. Conclusion: The thesis concludes that the rural population is not spared from the emerging burden of chronic disease risk factors. The patterning of risks across different socioeconomic groups provides a macro picture of the vicious cycle between poverty and chronic diseases. Understanding of risk factors in a local context through a qualitative study provides insight into cultural aspects relating to risk factor adoption, and will allow the fostering and tailoring of culturally appropriate interventions. Combining data from demographic surveillance sites with the WHO STEP approach to chronic disease risk factor Surveillance addresses basic epidemiological questions on chronic diseases. The use of such data is a powerful advocacy tool in public health decision-making for chronic disease prevention in developing countries. With substantial existing evidence on the effectiveness of chronic disease prevention and intervention programmes, it is vital that Indonesia to starts planning intervention programmes to control the impending chronic disease epidemic, and most importantly, to translate all this evidence into public health action. Keywords: chronic disease, risk factor, demographic surveillance system, smoking, elevated blood pressure, overweight and obesity, population-based intervention