Dissertations / Theses on the topic 'Epidemiology Case studies'

Case-noncase studies, also known as case-control studies, are ubiquitous in epidemiology, where a common goal is to estimate the effect of an exposure on an outcome of interest. In many areas of application, such as policy-informing drug utilization research, this effect is inherently causal. Although logistic regression, the predominant method for analysis of case-noncase data, and other traditional methodologies, may provide associative insights, they are generally inappropriate for causal conclusions. As such, they fail to address the very essence of many epidemiological investigations that employ them. In addition, these methodologies do not allow for outcome-free design (Rubin, 2007) of case-noncase data, which compromises the objectivity of resulting inferences. This thesis is directed at exploring what can be done to preserve objectivity in the causal analysis of case-noncase study data. It is structured as follows. In Chapter 1 we introduce a formal framework for studying causal effects from case-noncase data, which builds upon the well-established Rubin Causal Model for prospective studies. In Chapter 2 we propose a two-party, three-step methodology — PrepDA — for objective causal inference with case-noncase data. We illustrate the application of our methodology in a simple non-trivial setting. Its operating characteristics are investigated via simulation, and compared to those of logistic and probit regression. Chapter 3 focuses on the re-analysis of a subset of data from a published article, Karkouti et al. (2006). We investigate whether PrepDA and logistic regression, when applied to case-noncase data, can generate estimates that are concordant with those from the causal analysis of prospectively collected data. We introduce tools for covariate balance assessment across multiple imputed datasets. We explore the potential for analyst bias with logistic regression, when said method is used to analyze case-noncase data. In Chapter 4 we discuss our technology’s advantages over, and drawbacks as compared to, traditional approaches.
Statistics

The case-control study is one of the most frequently used study designs in analytical epidemiology. This thesis focuses on some methodological aspects in the analysis of the results from this kind of study.

A population based case-control study was conducted in northern Norway and central Sweden in order to study the associations of several potential risk factors with thyroid cancer. Cases and controls were individually matched and the information on the factors under study was provided by means of a self-completed questionnaire. The analysis was conducted with logistic regression. No association was found with pregnancies, oral contraceptives and hormone replacement after menopause. Early pregnancy and artificial menopause were associated with an increased risk, and cigarette smoking with a decreased risk, of thyroid cancer (paper I). The relation with diet was also examined. High consumption with fat- and starch-rich diet was associated with an increased risk (paper II).

Conditional and unconditional maximum likelihood estimations of the parameters in a logistic regression were compared through a simulation study. Conditional estimation had higher root mean square error but better model fit than unconditional, especially for 1:1 matching, with relatively little effect of the proportion of missing values (paper III). Two common approaches to handle partial non-response in a questionnaire when calculating nutrient intake from diet variables were compared. In many situations it is reasonable to interpret the omitted self-reports of food consumption as indication of "zero-consumption" (paper IV).

The reproducibility of dietary reports was presented and problems for its measurements and analysis discussed. The most advisable approach to measure repeatability is to look at different correlation methods. Among factors affecting reproducibility frequency and homogeneity of consumption are presumably the most important ones (paper V). Nutrient variables can often have a mixed distribution form and therefore transformation to normality will be troublesome. When analysing nutrients we therefore recommend comparing the result from a parametric test with an analogous distribution-free test. Different methods to transform nutrient variables to achieve normality were discussed (paper VI).

Objetivos: Investigar os fatores associados à hospitalização por pneumonia, em crianças menores de cinco anos de idade, no município de Ribeirão Preto - SP. Métodos: Estudo epidemiológico com delineamento do tipo caso-controle de base hospitalar, com alocação de 345 casos e 345 controles. Fatores socioeconômicos, reprodutivos, ambientais, perinatais, nutricionais, relativos ao cuidado à criança e à morbidade prévia foram considerados variáveis explanatórias. Os dados foram coletados por meio da aplicação de um questionário pré-codificado que contemplou o elenco de variáveis do estudo, incluindo-se o Instrumento de Avaliação da APS - PCATool. Odds ratios (OR) brutos e ajustados, com respectivos intervalos de confiança (95%) foram calculados, aplicando-se a regressão logística multivariada e seguindo-se os pressupostos da abordagem hierarquizada, buscando-se um modelo explicativo que contemplasse as relações hierárquicas existentes entre as exposições e o desfecho, sendo as análises desenvolvidas no software STATA, versão 12.0. Resultados: Renda familiar superior a R$700,00 foi responsável por uma redução de 32% na chance de hospitalização das crianças por pneumonia (OR=0,68; IC95%=0,47-0,98). Paridade >=2 representou um expressivo aumento na chance de hospitalização (categoria 2 partos: OR=4,60, IC95%=2,18-9,72; categoria >=3 partos: OR=3,25, IC95%=1,55-6,81), enquanto o intervalo interpartal >=48 meses e o ganho de peso na gestação de 10 Kg ou mais apresentaram efeito protetor para o desfecho (OR=0,28, IC95%=0,14-0,56 e OR=0,68, IC95%=0,47-0,97, respectivamente). Frequência à creche foi responsável por um aumento de 67% na chance de hospitalização por pneumonia (OR=1,67, IC95%=1,16-2,41). As crianças desnutridas apresentam uma chance duas vezes maior de serem hospitalizadas pela doença (OR=2,53; IC=1,06-6,05) enquanto aquelas com excesso de peso apresentam uma redução de 63% nessa chance (OR=0,37; IC=0,14-0,99); no entanto, questiona-se a plausibilidade biológica desse efeito protetor. A situação vacinal não atualizada foi responsável por um aumento de quase 3 vezes na chance de hospitalização por pneumonia (OR=2,81; IC=1,76-4,49). As crianças que fizeram uso pregresso de medicamentos apresentaram uma chance 67% maior de serem hospitalizadas por pneumonia (OR=1,67; IC=1,00-2,78; p=0,049). Crianças com sibilância prévia apresentaram o dobro de chance de serem hospitalizadas pela doença (OR categoria 1 episódio = 2,13; IC95%=1,31-3,47; OR categoria >=3 episódios = 2,37; IC95%=1,35-4,15). A exclusão de pneumonias aspirativas dentre os casos pode ter contribuído para uma maior proporção de crianças com refluxo referido entre os controles, levando a uma associação inversa à esperada (efeito de proteção) entre refluxo gastroesofágico e hospitalização por pneumonia (OR=0,55; IC=0,31-0,99). Escores Essenciais da APS acima de 3,17 foram responsáveis por um efeito protetor em relação à hospitalização por pneumonia, reduzindo as chances de hospitalização em 43% (OR para a categoria >3,41 = 0,57; IC=0,32-0,99) a 50% (OR para a categoria >3,17 e <=3,41 = 0,50; IC=0,28-0,88). Conclusões: O modelo explicativo obtido pelo presente estudo é composto, em grande parte, por variáveis relacionadas ao cuidado à criança ou às características da mãe e da família. Considerando-se os procedimentos referentes ao planejamento do estudo, à execução da coleta de dados e às análises estatísticas empregadas, reitera-se a consecução de validade interna para o estudo, sendo possível afirmar que o modelo obtido é explicativo do fenômeno da hospitalização por pneumonia, na população estudada.
Objectives: To investigate the factors associated with hospitalization due to pneumonia in children under five years of age in the city of Ribeirão Preto - SP, Brazil. Methods: Epidemiological study with a hospital-based case-control design, including 345 cases and 345 controls. Socioeconomic, reproductive, environmental, perinatal, nutritional, childcare and previous morbidity factors were considered as explanatory variables. The data were collected through the application of a pre-coded questionnaire that addressed the study variables and included the Primary Care Assessment Tool - PCATool. Gross and adjusted odds ratios (OR) were calculated with their respective confidence intervals (95%), applying multivariate logistic regression in accordance with the premises of the hierarchized approach, looking for an explanatory model that considered the existing hierarchical relations between the exposures and the outcome. The analyses were developed in STATA software, version 12.0. Results: A family income superior to R$700 was responsible for a 32% reduction in children\'s chance of hospitalization due to pneumonia (OR=0.68; 95%CI=0.47-0.98). Parity>=2 represented a considerable increase in the chance of hospitalization (category 2 births: OR=4.60, 95%CI=2.18-9.72; category >=3 births: OR=3.25, 95%CI=1.55-6.81), while the inter-birth interval >=48 months and the weight gain of 10 Kg or more during pregnancy represented a protective effect against the outcome (OR=0.28, 95%CI=0.14-0.56 and OR=0.68, 95%CI=0.47-0.97, respectively). Attending kindergarten was responsible for a 67% increase in the chance of hospitalization due to pneumonia (OR=1.67, 95%CI=1.16-2.41). Malnourished children present twice as many chances of being hospitalized due to the disease (OR=2.53; CI=1.06-6.05), while children with overweight present a 63% reduction in that chance (OR=0.37; CI=0.14-0.99); the biological plausibility of this protective effect is questioned though. An outdated vaccine situation was responsible for almost three times as many chances of hospitalization due to pneumonia (OR=2.81; CI=1.76-4.49). Children with earlier medication use revealed a 67% higher chance of being hospitalized due to pneumonia (OR=1.67; CI=1.00-2.78; p=0.049). Children with earlier wheezing presented twice as many chances of being hospitalized due to the disease (OR category 1 episode = 2.13; 95%CI=1.31-3.47; OR category >=3 episodes = 2.37; 95%CI=1.35-4.15). The exclusion of aspiration pneumonias from the cases may have contributed to a greater proportion of children with reflux among the control, leading to an inverse association (protective effect) between gastroesophageal reflux and hospitalization due to pneumonia (OR=0.55; CI=0.31-0.99). Essencial Scores of PHC superior to 3.17 were responsible for a protective effect with regard to hospitalization due to pneumonia, reducing the chances of hospitalization by 43% (OR for the category >3.41 = 0.57; CI=0.32-0.99) to 50% (OR for the category >3.17 and <=3.41 = 0.50; CI=0.28-0.88). Conclusions: The explanatory model obtained in this study largely includes variables related to childcare or the mother\'s and family\'s characteristics. In view of the study planning and data collection procedures and the statistical analyses applied, the internal validity of the study is highlighted, based on which it can be affirmed that the obtained model explains the phenomenon of hospitalization due to pneumonia in the study population.

Orientador: Rodney Carlos Bassanezi
Dissertação (mestrado profissional) - Universidade Estadual de Campinas, Instituto de Matemática Estatística e Computação Científica
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Resumo: A modelagem matemática epidemiológica constitui uma ferramenta importante para o estudo do comportamento de doenças, entre outras coisas, ela é capaz de analisar a forma de propagação e apontar meios eficazes para a prevenção e erradicação dessas doenças. Tal modelagem é feita através do estudo de sistemas de equações diferenciais que descrevem a interação entre a população e a doença. Com base nisso este trabalho tem como objetivo determinar modelos matemáticos alternativos para o estudo do número de casos de Meningite ocorridos no Estado do Maranhão nos anos de 2001 a 2012. Este trabalho se divide em duas partes, na primeira delas será feito uma análise qualitativa dos modelos epidemiológicos matemáticos SI (Suscetível-Infectado), SIS (Suscetível-Infectado-Suscetível) e SIR (Suscetível-Infectado-Recuperado). Os modelos estudados foram analisados conforme a presença ou não de dinâmica vital, e ainda conforme os pontos de equilíbrio e o seu número de reprodutividade basal R0. Na segunda parte, os dados foram utilizados para formulação de 5 modelos alternativos para a doença, estes modelos diferenciam-se entre si, principalmente, por não haver uma constância no número de casos confirmados ano a ano; por isso, em alguns deles foram necessários utilizar equações que determinem uma certa periodicidade.Tais modelos propostos tem por objetivo fazer uma análise sobre a real situação da doença no estado e predizer o seu comportamento futuro, afim de que os resultados aqui encontrados sirvam de base para estudos posteriores
Abstract: The mathematical epidemiological modeling is an important tool for the study of behavior of behavior. Among other things, through this modeling we can analyze the form of disease spread and point effective means for its prevention and eradication. Such modeling is done through the study of systems of differential equations that describe the interaction between population and diseases. Based on that, this research aims to determine alternative mathematical models to study the number of cases of meningitis occurred in the state of Maranhão ¿ Brazil from 2001 to 2012. This work is divided into two parts. The first one will be a qualitative analysis of mathematical epidemiological models SI (Susceptible-Infected), SIS (Susceptible-Infected-Susceptible) and SIR (Susceptible-Infected-Recovered). The models were analyzed according to the presence or absence of vital dynamics, and as the points of balance and the number of basal reproducibility R0. In the second part, the data contained in were used for 05 (five) alternative models formulation. They differ from each other mainly because there is no consistency in the number of confirmed cases from year to year, so in some of them it was necessary to use equations to determine a certain periodicity. These proposed models aims to perform an analysis of the actual situation of the disease in the state and predict their future behavior, so that the present results can provide basis for further studies
Mestrado
Matematica Aplicada e Computacional
Mestre em Matemática Aplicada e Computacional

A vigilância de efeitos indesejáveis após a vacinação é complexa. Existem vários actores de confundimento que podem dar origem a associações espúrias, meramente temporais mas que podem provocar uma percepção do risco alterada e uma consequente desconfiança generalizada acerca do uso das vacinas. Com efeito as vacinas são medicamentos complexos com características únicas cuja vigilância necessita de abordagens metodológicas desenvolvidas para esse propósito. Do exposto se entende que, desde o desenvolvimento da farmacovigilância se tem procurado desenvolver novas metodologias que sejam concomitantes aos Sistemas de Notificação Espontânea que já existem. Neste trabalho propusemo-nos a desenvolver e testar um modelo de vigilância de reacções adversas a vacinas, baseado na auto-declaração pelo utente de eventos ocorridos após a vacinação e testar a capacidade de gerar sinais aplicando cálculos de desproporção a datamining. Para esse efeito foi constituída uma coorte não controlada de utentes vacinados em Centros de Saúde que foram seguidos durante quinze dias. A recolha de eventos adversos a vacinas foi efectuada pelos próprios utentes através de um diário de registo. Os dados recolhidos foram objecto de análise descritiva e análise de data-mining utilizando os cálculos Proportional Reporting Ratio e o Information Component. A metodologia utilizada permitiu gerar um corpo de evidência suficiente para a geração de sinais. Tendo sido gerados quatro sinais. No âmbito do data-mining a utilização do Information Component como método de geração de sinais parece aumentar a eficiência científica ao permitir reduzir o número de ocorrências até detecção de sinal. A informação reportada pelos utentes parece válida como indicador de sinais de reacções adversas não graves, o que permitiu o registo de eventos sem incluir o viés da avaliação da relação causal pelo notificador. Os principais eventos reportados foram eventos adversos locais (62,7%) e febre (31,4%).------------------------------------------ABSTRACT: The monitoring of undesirable effects following vaccination is complex. There are several confounding factors that can lead to merely temporal but spurious associations that can cause a change in the risk perception and a consequent generalized distrust about the safe use of vaccines. Indeed, vaccines are complex drugs with unique characteristics so that its monitoring requires specifically designed methodological approaches. From the above-cited it is understandable that since the development of Pharmacovigilance there has been a drive for the development of new methodologies that are concomitant with Spontaneous Reporting Systems already in place. We proposed to develop and test a new model for vaccine adverse reaction monitoring, based on self-report by users of events following vaccination and to test its capability to generate disproportionality signals applying quantitative methods of signal generation to data-mining. For that effect we set up an uncontrolled cohort of users vaccinated in Healthcare Centers,with a follow-up period of fifteen days. Adverse vaccine events we registered by the users themselves in a paper diary The data was analyzed using descriptive statistics and two quantitative methods of signal generation: Proportional Reporting Ratio and Information Component. themselves in a paper diary The data was analyzed using descriptive statistics and two quantitative methods of signal generation: Proportional Reporting Ratio and Information Component. The methodology we used allowed for the generation of a sufficient body of evidence for signal generation. Four signals were generated. Regarding the data-mining, the use of Information Component as a method for generating disproportionality signals seems to increase scientific efficiency by reducing the number of events needed to signal detection. The information reported by users seems valid as an indicator of non serious adverse vaccine reactions, allowing for the registry of events without the bias of the evaluation of the casual relation by the reporter. The main adverse events reported were injection site reactions (62,7%) and fever (31,4%).

RESUMO: Contexto: As anomalias congénitas, com particular destaque para as neuploidias , afectam aproximadamente 2% dos recém-nascidos, constituindo causas frequentes de morbilidade e mortalidade. Actualmente, a avaliação do grau de risco para as aneuploidias mais prevalentes (T21, T13, T18) é efectuada através do “Rastreio Combinado do 1º Trimestre”, devendo as grávidas com risco acrescido ser sujeitas a exames invasivos (ex.biópsia das vilosidades coriónicas,amniocentese). Quanto mais qualidade existir num rastreio, menos falsos positivos existirão e menor o número de exames diagnósticos invasivos desnecessários. As doenças autoimunes são doenças inflamatórias crónicas em cuja fisiopatologia se encontram distúrbios da imunidade humoral e celular, dependentes de factores genéticos, hormonais,psicológicos e ambientais. Atingem mais o sexo feminino e durante a idade fértil,podendo influenciar o outcome da gravidez e a saúde neonatal causando significativa morbilidade e mortalidade. O lúpus eritematoso sistémico para além de potencialmente afectado pelas alterações imunoendócrinas fisiológicas da gravidez, associa-se frequentemente a problemas de fertilidade. Recentemente, foi sugerido que as anormalidades ocorridas durante a invasão precoce do sinciciotrofoblasto, resultando em deficiente diferenciação, deficiente maturação e diminuição na produção de hCG, poderão ser o mecanismo fisiopatológico primário para as perdas fetais no primeiro trimestre, nos doentes com SLE. A ocorrência de níveis elevados de hCG total e ß-hCG livre no rastreio para despiste de síndrome de Down do segundo e do primeiro trimestre foi assinalada em grávidas portadoras de lúpus, mas a escassez de estudos comprovativos e a pequena dimensão das amostras estudadas constituiu uma limitação significativa na fidedignidade dos resultados obtidos. Objectivos: O estudo teve como objectivos i. estabelecer valores normativos Portugueses e de distribuição para as MoM’s dos parâmetros séricos do primeiro trimestre, por semana de gestação:(PAPP-A e ß-hCG livre), ii. avaliar a influência que as doenças autoimunes têm sobre as MoM’s individuais dos parâmetros bioquímicos PAPP-A e/ou ß-hCG livre, utilizados no rastreio pré-natal combinado do 1º trimestre, e iii. saber se as doenças autoimunes podem condicionar um aumento da taxa de resultados falsos positivos, com consequente aumento do número de amniocenteses. Metodologia: Estudo longitudinal prospectivo, consistindo num rastreio pré-natal combinado de 1º trimestre para pesquisa de aneuploidias, em duas amostras provenientes do Reino Unido (n= 45,854) e de Portugal (n=3122). Foram avaliados parâmetros socio-demográficos, ecográficos, laboratoriais, e calculados os indicadores de desempenho do rastreio combinado. A execução analítica dos testes bioquímicos séricos (PAPP-A e ß-hCG livre) foi realizada no autoanalisador Brahms Kryptor e no autoanalizador 6000 Delfia Xpress. Compararam-se os grupos autoimune e não autoimune das amostras. Resultados: Relativamente às características populacionais, o grupo auto imune tinha valores significativamente superiores nas variáveis idade materna e idade gestacional. Comparando os grupos com e sem doença autoimune, constatou-se a existência de uma elevação das MoM’s da ß-hCG livre nas grávidas com doença autoimune, nomeadamente nos casos de lúpus eritematoso sistémico. Conclusões: os resultado obtidos reforçam a indicação do rastreio combinado do 1º trimestre certificado pela FMF nas grávidas com doenças autoimunes, nomeadamente para as doentes com LES; no entanto, devem ser calculados e introduzidos factores de correcção no algoritmo de risco, de modo a evitar a subida no número de resultados falso-positivos, e consequentemente a sobre- utilização de métodos invasivos.------------ ABSTRACT: Context: Congenital anomalies, with particular reference to aneuploidias, affect approximately 2% of newborns, and are frequent causes of morbidity and mortality. Currently, the risk evaluation for the most prevalent aneuploidias (T21, T13, T18) is carried out through the “combined first trimester screening”, and pregnant women with increased risk are subjected to invasive tests (e.g. villus biopsy done, amniocentesis). The more quality exists in a screening, less false positives exists and fewer unnecessary invasive diagnostic exams. Autoimmune diseases are chronic inflammatory diseases in whose pathophysiology are immune humoral and cellular disorders, dependent on genetic factors, hormonal, psychological and environmental factors. The disease is more prevalent among females, during the child-bearing age, and may influence the outcome of pregnancy and neonatal health causing significant morbidity and mortality. Lupus Erythematosus in addition to potentially affected by immunoendocrine physiological changes of pregnancy, is often associated with fertility problems. Recently, it has been suggested that the abnormalities that occurred during the early invasion of the syncytiotrophoblast, resulting in insufficient differentiation, deficient maturation and decrease in production of hCG may be the primary pathophysiological mechanism for fetal losses in the first quarter, in patients with SLE. The occurrence of elevated levels of total hCG and free ß-hCG in screening for Down’s syndrome of the second and first trimester was reported in pregnant women with lupus, but the paucity of supporting studies and the small size of the samples studied constituted a significant limitation on the trustworthiness of the results obtained. Objectives: this study aims to i. establish normative values for the serum parameters MoM’s (PAPP-A and free β-hCG) and it’s distribution, in the first trimester, by week of pregnancy; ii. assess the influence that the autoimmune diseases have on the MoM’s of individual biochemical PAPP-A and/or β-hCG, used in antenatal screening combined for the first trimester, and iii. whether the autoimmune diseases may make an increased rate of false positives, with consequent increase in the number of amniocenteses.Methodology: Prospective longitudinal study, consisting of a combined first trimester antenatal screening for aneuploidies lookup in two samples from the United Kingdom (n=45.854) and Portugal (n= 3.122). Socio-demographic, echographic and laboratory parameters were evaluated, and combined screening performance indicators were calculated. The analytical run of serum biochemical tests (PAPP-A and ß-hCG) was held at the Brahms Kryptor and in Delfia Xpress 6000. Comparisons between autoimmune group and non-autoimmune group were made. Results: Relating to population characteristics, the autoimmune group had significantly diferente values in the variables maternal age and gestational age. Comparing the groups with and without autoimmune disease, it was noted that there is an elevation of the MoM’s of free ß-hCG levels in pregnant women with autoimmune disease, particularly in cases of systemic lupus erythematosus. Conclusions: The results obtained reinforce the indication of FMF certified combined screening in pregnant women with autoimmune diseases, notably to the patients with SLE; However, correction factors should be calculated and entered in the risk algorithm, in order to avoid the rise in the number of false positive results, and consequently the over-use of invasive methods.

Background: Androgens are important in prostate cancer development but how circulating levels of androgens affect risk of prostate cancer of different aggressiveness is not clear. Being childless has been associated with a lower risk of prostate cancer, but it is not clear if this association is causal or a result of residual confounding. Fathering of dizygotic twins, a marker of high fertility, has not been studied in relation to risk of prostate cancer. Another marker of life-long hormonal exposure is height, which has been associated with increased risk of cancer and cancer death. However, the association to separate cancer sites has not been consistent. The aims of this thesis were to study hormonal factors (paper I), and proxies of hormonal factors (paper II and III), and risk of prostate cancer; as well as height and risk of cancer and cancer death by separate sites (paper IV). Methods: Study designs were i) case-control studies, nested within the Västerbotten Intervention Project (paper I), and in Prostate Cancer database Sweden 2.0 (PCBaSe 2.0) (paper II and III), and ii) cohort study, in the Metabolic Syndrome and Cancer project (Me-Can) (paper IV). Results, prostate cancer: In paper I, increasing levels of serum androgens were not associated with risk of prostate cancer overall or in tumor risk categories. In paper II, childless men had a lower risk of prostate cancer, overall and in all risk categories, compared to fathers, an association which was in part explained by differences in marital status and educational level.  In paper III, fathers of dizygotic twins did not have an increased risk of prostate cancer, either overall or in risk categories, when compared to fathers of singletons. Results, cancer overall: In paper IV, height was associated with an increased risk of cancer and cancer death overall in both women and men. The strongest association for cancer was to malignant melanoma in both women and men, and for cancer death to post-menopausal breast cancer in women and renal cell carcinoma in men. Conclusions: These studies indicate that hormonal factors, when studied as serum levels or when studied using proxies of fertility, do not have a major impact on the risk of prostate cancer. The association between height and an increased risk of cancer appears robust for total cancer and cancer death, as well as for several separate cancer sites.

The purpose of this thesis is to explore the institutionally shaped response to the introduction of the national guidelines on the Swedish regional health policy arena. The thesis consists of two case studies. Adapting a qualitative approach, the data is based on individual interviews and these were analysed thematically. The first paper explores the response by four Swedish regional health authorities to the introduction of the National Guidelines for Cardiac Care, while the second paper aims to broaden the understanding of how the national guidelines are used for strategic purposes among politicians. As illustrated in this thesis, organizations will respond, adjust and react to external pressure according to conditions shaped by the institutional context. Key findings here are that the national guidelines are a complex policy instrument that, beyond being able to be used in an instrumental fashion by the medical managment, can also serve a legitimizing function for political decision-makers. The goals of the national guidelines, i.e. equal and efficient care, and the uncertainty about who, among multiple stakeholders, is responsible for the guidelines in the regional health authority, is a source of ambiguity and potential conflict. Those who are potentially responsible represent different rationales – a political rationale and a scientific rationale. The dominating scientific rationale of the national guidelines can create instability, when pushing towards the use of explicit priority-setting. Priority-setting in the institutional setting of a regional health authority has strong elements of becoming “wicked problems” since the dilemma of prioritization remains regardless of ambitions to apply a “technocratic fix”. A wicked problem is characterized by high complexity and being persistently hard to solve (Williams et al. 2012). A recurring dilemma is that priority-setting still contains many wicked problems, as social values and political considerations remain important parts of the policy process. One weakness of the national guidelines, identified in this thesis, is that the guidelines discuss each service area separately, and thereby reinforce a silo mentality in the Swedish health policy arena. To sum up, the national guidelines create a multifaceted and complex response in the Swedish health policy arena where different rationalities collide, and where conflicts appear and are dealt with within the regional health authorities.

Os estudos epidemiológicos relativos ao denominado câncer ocupacional têm como objetivo o estudo do câncer em populações trabalhadoras e a identificação de fatores causais. O número de agentes que comprovadamente causam câncer em seres humanos é ainda pequeno, cerca de trinta. A estes fatores podem ser agregados algumas atividades ocupacionais e processos industriais onde agentes potencialmente cancerígenos existem mas não foram ainda identificados. A quase totalidade dos estudos epidemiológicos buscando relacionar ocupação e câncer foram realizados nos países desenvolvidos, com processos de industrialização mais antigos e consolidados. Nesta investigação o objetivo é estudar a relação trabalho e câncer no contexto de um país subdesenvolvido e recentemente industrializado. O estudo explora os riscos ocupacionais determinantes da neoplasia pulmonar na Região Metropolitana de São Paulo (RMSP). O trabalho está dividido em duas partes. Na primeira são discutidos aspectos relativos ao câncer com particular destaque ao carcinoma broncogênico e à aplicação da metodologia epidemiológica na área da saúde do trabalhador, em especial para o estudo do câncer relacionado à ocupação. A segunda parte contempla a descrição do estudo de caso-controle construído para atingir os objetivos definidos. Os dados do estudo foram levantados no período de 1º de julho de 1990 a 31 de janeiro de 1991 em quatorze hospitais que concentram o atendimento a pacientes com câncer de pulmão na RMSP. Um total de 316 casos e 536 controles, emparelhados com os casos por sexo e idade, foram selecionados para análise. Tabagismo, tabagismo passivo, história migratória, outros cânceres na família e estrato sócio-econômico, além de sexo e idade, foram as outras variáveis estudadas. A análise univariada permitiu identificar as variáveis que estavam interferindo na relação principal estudada. Posteriormente, utilizou-se as técnicas de análise estratificada e de regressão logística para controlar as variáveis tabagismo, referência à carcinoma de pulmão na família, sexo e idade. Os resultados revelam que os trabalhadores que estiveram ligados por tempo prolongado aos setores de produção, de ramos de atividades industriais nos quais há maior probabilidade de exposição à substâncias cancerígenas, têm cerca de duas vezes o risco de desenvolverem carcinoma broncogênico em relação aos trabalhadores com menor probabilidade de exposição a substâncias cancerígenas como os que referiram nunca terem trabalhado fora de casa.
Epidemiological studies on occupational cancer have as their objective the study of cancer in working populations and the distribution of causal factors. The number of agents proved to cause cancer in humans is still rather small, about thirty. It could be added some occupational activities and industrial processes where hazardous agents are known to exist, but have not been identified. Almost all epidemiological studies to evaluate the relationship between occupation and cancer were carried out in developed countries, where industrialization process is older and more structured. In this investigation the objective is to study the association between occupation and cancer in a developing and newly industrialized country context. In this sense, the study explores occupational risks for lung cancer in the Metropolitan Region of São Paulo (MRSP). This work is split in two parts. Firstly it was introduced a review of some aspects on cancer, particularly lung cancer, and the use of epidemiologic methodology related to worker\'s health, particularly cancer. In the second part it was described the hospital-based case-control study carried out to reach defined objectives. This research was conducted between 1st July 1990 and 31st January 1991 in fourteen hospitais which concentrate lung cancer cases in the MRSP. It has been selected a total of 316 cases and 536 controls, matched by hospital, sex and age with cases. Smoking, passive smoking, migratory history, cancer in the family and socio-economic status, besides sex and age, were other variables studied. Univariate analysis identified variables that could interfere in the main studied associatian. Through stratification and logistic regression approaches the variables gender and age, smoking and reference to lung neoplasy in family, were controlled. The results showed that workers linked to the production sectors of industries where there are higher risk of exposure to carcinogenic products have about two fold the risk of developing lung cancer rather than those workers with the lowest risk of exposure to carcinogens.

Thesis (MScMedSc)--Stellenbosch University, 2008.
ENGLISH ABSTRACT: Application of molecular fingerprinting highlights transmission as the driving force behind the drug resistant epidemic in South Africa. Different strains dominate within different geographical regions, which is a reflection of micro-epidemics of drug resistance in the different regions. Cluster analysis shows that strains within the same strain family are different. The Beijing drug resistant strain family is the most dominant strain family (31%) in the Western Cape and of particular concern is the highly transmissible Beijing cluster 220 strain in the Western Cape communities. This cluster is widespread in the region and was previously identified in a MDR outbreak in a high school in Cape Town. Results suggest that the spread of Beijing drug resistant cluster 220 in the community was due to a combination of acquisition of drug resistant markers and transmission. This study also indicate that atypical Beijing can acquire drug resistance and become fit amongst HIV infected individuals. This is contrary to believe that atypical Beijing strains are not frequently associated with drug resistance and are attenuated. This implies that HIV levels the playing field for all drug resistant strains. Mechanisms leading to the evolution of MDR-TB and XDR-TB in a mine setting with a wellfunctioning TB control program which exceeds the target for cure rates set by the WHO were investigated. Despite the excellent control program, an alarming increase in the number of drug resistant cases was observed in 2003 and subsequent years. Phylogenetic analysis shows sequential acquisition of resistance to first and second-line anti-TB drugs leading to the development of MDR and XDR-TB. Contact tracing indicate extensive transmission of drug resistant TB in the shafts, hospital and place of residence. This study shows that despite exceeding the WHO cure rate target, it was not possible to control the spread and amplification of drug resistance. In summary, as a top priority, future TB control plans need to address diagnostic delay more vigorously.
AFRIKAANSE OPSOMMING: Molukulêre tegnieke toon transmissie as die hoofrede vir die toename in die anti-tuberkulose middelweerstandigheid epidemie in Suid-Afrika. Die verskillende Mikobakterium tuberkulose rasse wat domineer in verskillende areas is ‘n refleksie van middelweerstandige mikro-epidemies in verskillende gebiede. Analise van identiese rasgroepe demonstreer dat ras families bestaan uit verskillende rasse. Die Beijing middelweerstandige rasfamilie is die mees dominante familie in die Wes-Kaap (31% van monsters van middelweerstandige families) en van spesifieke belang is die hoogs oordraagbare Beijing 220 groep. Hierdie groep is die mees wydverspreide groep in die studie area en was voorheen geïdentifiseer tydens ‘n meervoudige middelweerstandige uitbreking in ‘n hoërskool in Kaapstad. Die resultate dui aan dat die Beijing middelweerstandige groep 220 in die gemeenskap versprei as gevolg van ‘n kombinasie van middelweerstand verwerwing en transmissie. Hierdie studie dui verder aan dat die atipiese Beijing ook middelweerstandigheid kan verwerf en hoogs geskik is vir infeksie veral in MIV geïnfekteerde individue. Hierdie data is in teenstelling met die algemene denke dat atipiese Beijing nie gereeld geassosieer word met middelweerstandigheid nie en dat dit dikwels geattenueer is. Dit beteken dat MIV die hoof faktor is wat alle middelweerstandige rasse kans gee om te versprei. Hierdie studie het die meganisme wat lei tot die evolusie van middelweerstandigheid en “XDRTB” in die myne ondersoek. Die myn besit ‘n goeie funksioneerde tuberkulose kontrole program wat alreeds die Wêreld Gesondheids Organisasie se mikpunt vir tuberkulose genesing oortref. Ten spyte van ‘n uitstekende tuberkulose kontrole program, is daar ‘n bekommerenswaardige toename in die aantal middelweerstandige tuberkulose gevalle waargeneem in 2003 en in die daaropvolgende jare. Filogenetiese analise wys dat opeenvolgende verwerwing van middelweerstandigheid teen eerste en tweede vlak anti-tuberkulose middels gelei het tot die ontwikkeling van meervoudige middelweerstandigheid en “XDR-TB”. Die opsporing van kontakpersone om transmissie te bewys dui aan dat transmissie van middelweerstandige tuberkulose in die werk plek, hospitaal en woon plek plaasvind. Hierdie studie wys dat ongeag die feit dat die Wêreld Gesondheids Organisasie se genesings verwagtinge oortref is, dit steeds onmoontlik was om die verspreiding en amplifisering van middelweerstandigheid te beheer. ‘n Top prioriteit vir tuberkulose kontrole planne in die toekoms behoort die vertraging van diagnose sterk aan te spreek.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado
Background: There are no internationally validated questionnaires to investigate the prevalence of infant wheezing. This study was undertaken to validate a questionnaire for the International Study on the Prevalence of Wheezing in Infants (Estudio Internacional de Sibilancias en Lactantes, EISL). Material and Methods: Construct and criterion validity were tested for the question 'Has your baby had wheezing or whistling in the chest during his/her first 12 months of life?'. Construct validity (i.e. the ability of parents and doctors to refer to the same symptoms with the same words) was tested in a sample of 50 wheezing and 50 non-wheezy infants 12-15 months of age in each of 10 centres from 6 different Spanish- or Portuguese-speaking countries. Criterion validity (i.e. the ability of parents to correctly detect the symptom in the general population) was evaluated in 2 samples (Santiago, Chile and Cartagena, Spain) of 50 wheezing and 50 non-wheezing infants (according to parents) of the same age, randomly selected from the general population, who were later blindly diagnosed by a paediatric pulmonologist. Results: Construct validity was very high (κ test: 0.98-1) in all centres. According to Youden's index, criterion validity was good both in Cartagena (75.5%) and in Santiago (67.0%). Adding questions about asthma medication did not improve diagnosis accuracy. Conclusions: The EISL questionnaire significantly distinguished wheezy infants from healthy ones. This questionnaire has a strong validity and can be employed in large international multicentre studies on wheezing during infancy.
Revisión por pares

Health protection involves the prevention and control of threats to health from both communicable diseases and the environment. I conducted a variety of projects across the breadth of Health Protection within NSW Health between March 2016 and October 2017 to fulfil the requirements of the Masters of Philosophy in Applied Epidemiology (MAE). My first placement was within the Enteric and Zoonotic Diseases division of the Communicable Disease Branch. A large outbreak of Salmonella Saintpaul occurred in Australia between December 2015 and June 2016 with a total of 547 confirmed and probable cases notified. When I commenced in March 2016 this outbreak had been underway since December 2015 with no clear vehicle of infection identified. I conducted a case-control study including 72 confirmed cases and 144 controls from SA and NSW which identified that Mung bean sprout consumption was reported by 40.6% (28/69) of cases and 4.3% (6/140) of controls (OR 14.6, 95% CI 5.9-39.4). This outbreak led to a recall of mung bean sprouts from an implicated sprouter in South Australia and public messaging about the safe preparation and consumption of bean sprouts. In July 2016 six states and territories of Australia were affected by a large outbreak of Salmonella Hvittingfoss with 144 confirmed and suspected cases notified. I led a coordinated multi-jurisdictional investigation to identify the source of infection and control the outbreak, including conducting a case-control study. The epidemiological, microbiological and environmental investigation implicated consumption of rockmelon (OR 7.2, 95%CI 1.87-27.93) from a single producer as a significant risk for infection. The producer initiated a voluntary recall of the product. My second placement was in the Environmental Health Branch of Health Protection. I completed a review of the epidemiology of notifications in NSW to provide a snapshot of elevated blood lead levels in NSW and to inform an evaluation of the NSW elevated blood lead surveillance system. There were 9,486 notifications of elevated blood lead from 1997–2016, with an average annual notification rate of 6.9 per 100,000. I analysed notification data for by age, sex, geographic area, exposure and occupation and compared notification rates over time and between geographic regions. I identified several limitations with the dataset that made it difficult to analyse notification rates, particularly by risk and exposure history and by blood lead level, and made recommendations to improve the data collection system. I also collected qualitative data about the function of the blood lead surveillance system by conducting face-to-face interviews with key stakeholders throughout NSW. Key areas for improvement in the system included changes to the way data is entered into the surveillance system, greater guidance for public health units on following up notifications, a review of the information collected on exposure, and guidance regarding liaising with occupational health regulatory agencies to ensure follow-up of occupational notifications. Through completing these projects, I made valuable contributions to protecting the health of NSW residents.

Non-melanoma skin cancer (NMSC), comprised of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is the most common cancer in Caucasians. Ultraviolet radiation (UVR) exposure is the most important environmental risk factor for both BCC and SCC development. However, the precise relationship between UVR and the risk of NMSC is complex, and the relationship may differ by skin cancer type. It has been hypothesized that intermittent patterns and childhood sunlight exposure are important for BCC while continuous (chronic) and lifelong (i.e. childhood and adulthood) sunlight exposure is important for SCC. Epidemiologic studies have demonstrated that cutaneous human papillomavirus (HPV) infection may also be a risk factor for developing NMSC. However, the pathway by which cutaneous HPV is associated with NMSC remains unclear. It is hypothesized that UVR exposure may interact synergistically with cutaneous HPV in NMSC development. The goal of the research study was to evaluate the relationship between levels of sunlight exposure and BCC and SCC and to investigate differences in sunlight-associated BCC and SCC risk by genus-specific cutaneous HPV serostatus. To address these goals, we conducted a clinic based case-control study of histologically confirmed BCC and SCC cases recruited from a university dermatology clinic and controls with no history of cancer and screened negative for current skin cancer. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for the associations between measures of sunlight exposure and BCC and SCC. Multiplicative interactions were tested by placing an interaction term for the product of genus-specific HPV seroreactivity and sunlight related factors in the logistic regression models. Measures of both intermittent and continuous patterns of sunlight exposure were associated with both types of skin cancer (i.e. BCC and SCC). Specifically, history of blistering sunburn (a marker of intermittent sunlight exposure) and occupational sunlight exposure (i.e. having a job in the sun for at least 3 months for >10 years) were both associated with BCC and SCC. The major differences in patterns of sunlight exposure between BCC and SCC were observed for sunlight exposure in one's thirties. Additionally, sunlight exposure in one's twenties was associated with SCC, regardless of pattern of exposure; similar associations were not observed for BCC. Measures of timing of sunlight exposure consistently demonstrated that childhood/adolescent sunlight exposure was more important for SCC than BCC. These included number of moles on the forearms and entire body (measure of increased childhood sunlight exposure), and younger age at first and tanning bed use. Younger age at first blistering sunburn was statistically significantly associated with both BCC and SCC. NMSC cases were more likely to be seropositive for cutaneous HPV antibodies compared to controls. Compared to tanning, having a propensity to sun burn (p=0.006), or poor tanning ability (p=0.003) were significantly associated with a higher seroprevalence to genus beta HPV types within SCC cases. Statistically significant interactions were observed between poor tanning ability and genus-specific seropositivity with NMSC. Specifically, the associations between poor tanning ability and BCC (p interaction=0.02) and SCC (p interaction=0.01) were significantly stronger among individuals that were seropositive for antibodies to genus alpha HPV types. Similarly, the association between poor tanning ability and SCC was stronger among those seropositive for genus beta HPV types (p interaction=0.001). No additional significant interactions were observed for BCC or SCC between cutaneous sensitivity, history of blistering sunburn, or cumulative sunlight exposure and genus-specific seroreactivity. In conclusion, associations with patterns of sunlight exposure appeared to be similar between BCC and SCC cases. With the exception of age at first blistering sunburn, factors measuring timing of sunlight exposure demonstrated stronger and statistically significant relationships with SCC. Additionally, of the sunlight related factors measured, only the associations between poor tanning ability and BCC and SCC were significantly modified by HPV seropositivity to types in genera alpha or beta.

Le cancer du sein est le cancer le plus fréquent chez la femme dans le monde. Au Maroc, comme dans de nombreux pays en voie de développement, l'incidence du cancer du sein a considérablement augmenté ces dernières années. Le rôle des facteurs de risque reconnus et suspectés dans la survenue du cancer du sein est peu étudié au Maroc. L'objectif principal de cette thèse était de déterminer les principaux facteurs de risque du cancer du sein chez les femmes marocaines dans la région de Fès- Maroc. Méthodes : Ce travail porte sur les données de deux études cas-témoins réalisées dans la région de Fès- Maroc : l'étude "Fez Breast Cancer Study" (2014-2015) incluant 237 cas et 237 témoins appariés sur l'âge, et l'étude "BreCaFez Study " (2016-2017) incluant 300 cas et 300 témoins appariés sur l'âge et le milieu de résidence. Des informations détaillées sur les facteurs de risque du cancer du sein ont été recueillies au cours d'entretiens en face-à-face. Les odds ratios et leurs intervalles de confiance à 95% ont été estimés à partir de régressions logistiques, en ajustant sur les variables de confusion. Résultats : Nos résultats montrent que (1) l'âge précoce de la ménarche et la nulliparité étaient significativement associés à une augmentation de risque de cancer du sein, tandis que l'âge précoce à la première grossesse à terme est associé à une diminution de ce risque ; (2) un score de mode de vie sain élevé était associé significativement à une réduction du risque de cancer du sein chez les femmes de notre population ; (3) un excès d'adiposité abdominale et une forte évolution de trajectoire de la silhouette étaient associés à une augmentation de risque du cancer de sein chez les femmes en pré- et en postménopause. En revanche, une large silhouette à l'enfance (6–11 ans) était associée à une diminution significative de risque de cancer du sein chez les femmes en préménopause et à la limite de la signification statistique chez les femmes en postménopause ; (4) les femmes ayant travaillées dans certaines professions du secteur de l'agriculture, en particulier celles employées comme ouvrière agricole, avaient un risque élevé de cancer du sein, une augmentation significative de ce risque en fonction de la durée de l'emploi a été également observée. Conclusion : Ce travail suggère l'existence d'associations entre certains facteurs de risque et la survenue de cancer du sein chez les femmes de notre région. Les résultats de nos études peuvent orienter les mesures et les activités de prévention de cancer du sein dans notre pays. Par ailleurs, des études à plus grande échelle sont nécessaires pour confirmer et compléter nos résultats
Introduction Breast cancer is the most common cancer among women worldwide. In Morocco, as in many countries that are either developing or in epidemiological transition, breast cancer incidence rates have clearly risen. Numerous risk factors for female breast cancer have been identified in the literature, but their role in breast cancer among Moroccan women remains poorly documented. The purpose of this doctoral work was to investigate the association between several risk factors and breast cancer among Moroccan women in the Fez region, Morocco. Methods Our analyses were based on data from two case controls studies conducted in the Fez region, Morocco: "Fez Breast Cancer Study" (2014-2015) including 237 cases and 237 age-matched controls, and the "BreCaFez Study" (2016-2017) including 300 cases and 300 controls matched by age and area of residence. Detailed information on various risk factors of breast cancer were collected through face-to face interviews. Odds ratios and 95% confidence intervals, adjusted for potential confounders were estimated by using logistic regression models. Results Our findings suggest that (1) Early menarche and nulliparity were significantly associated with an increased risk of breast cancer among women of our population, whereas an early age at first full-term pregnancy was associated with a significantly decreased risk of breast cancer. (2) High healthy lifestyle index scores were associated with decreased risk of breast cancer in Moroccan women included in our study. (3) Central adiposity and body shape trajectory were positively associated with breast cancer risk in both pre- and post-menopausal women; whereas, a significant inverse association was observed between silhouette at young ages (6- 11 years) and BC risk for premenopausal women and a borderline significant inverse association for postmenopausal women. (4) Women employed in specific agricultural occupations, particularly those who worked as crop farm laborers, had an elevated risk of breast cancer compared to those who never worked in these occupations and the risk increased with duration of employment. Conclusion Our results showed the association between some risk factors and breast cancer among women in our region. It identified some susceptible groups at high risk of breast cancer. Preventive interventions and screening should focus on these groups as a priority. However, our findings should be confirmed in larger, multicenter studies

Systematic reviews of the effect of foster care on mental-health outcomes have consistently indicated a zero-sum game, which makes it unclear whether the intervention is suitable for children in need of out-of-home placements. This thesis took on a meta-analytical approach to examine sources of heterogeneity between studies evaluating the effect of foster care on adaptive functioning, cognitive functioning, externalizing behavior, internalizing behavior, and total problems behavior. The bulk of studies came from two recently published systematic reviews. The searches were replicated to cover studies published until March 31, 2018. From 2943 studies assessed for eligibility, 240 were selected for the analysis covering 25 085 children. A choice of study-related covariates was abstracted, and potential sources of heterogeneity were hypothesized and tested by means of meta-regression. The findings indicated that both the choice of study design and measurement instrument were significantly associated with the variation in effect sizes. These associations were even stronger in child protection-oriented welfare regimes while insignificant in family service-oriented regimes, which instead showed significant associations for outcome type and publication year. The results imply a need to standardize effect studies of foster care, and to further research on sources of heterogeneity in different child welfare regimes.

OBJECTIVES: The integrin α4β7 is the gut-homing receptor for lymphocytes. It also is an important co-receptor for human immunodeficiency virus (HIV) via glycoprotein (gp)120 binding. Depletion of gut cluster of differentiation (CD)4 T cells is linked to chronic inflammation in patients with HIV; however, measuring CD4 cells in the gut is invasive and not routine. As such, establishing a peripheral marker for CD4 depletion of the gut is needed. We hypothesized that α4β7 CD4 T cells are depleted in the peripheral blood of treatment-naïve patients with HIV compared with healthy controls. METHODS: The study groups were treatment-naïve patients with HIV and uninfected controls. Subjects were included if they were 18 years or older with no history of opportunistic infections, active tuberculosis, or cancer. We collected peripheral blood and examined on whole blood using flow cytometry for the following cell surface markers: CD4, CD45RO, chemokine receptor type 5, C-X-C chemokine receptor type 4 (CXCR4), and the integrin β7. We collected demographic information, including age, sex, and ethnicity, as well as viral load (VL) and CD4 count. Two-samplettests and Fisher exact tests were used to compare the differences between the two groups. Spearman correlation coefficients were calculated between CD4 count and log10-VL and percentage of CD4+/CD45RO+/β7+and log10-VL in patients. RESULTS: Twenty-two subjects were enrolled in the study (12 patients with HIV and 10 controls). There were no differences in age or sex between the two groups. There were more Hispanics and fewer Asians in the group comprising patients with HIV compared with the control group (7 vs 2 and 0 vs 4,P= 0.05, respectively). Patients infected with HIV had significantly lower frequencies of CD4+/CD45RO+/β7+cells (median 12%, range 5-18 compared with uninfected controls: median 20%, range 11-26,P= 0.0007). There was a statistically significant difference in the percentage of CD4+/CD45RO+/C-X-C chemokine receptor type 4+cells between patients (72%, range 60%-91%) compared with controls (79%, range 72%-94%,P= 0.04). The percentage of CD4+/CD45RO+/chemokine receptor type 5+did not differ between the group of patients with HIV and the control groups (22%, range 11%-57% vs 27%, range 14%-31%;P= 0.8, respectively). There was no correlation between percentage of CD4+/CD45RO+/β+cells and log10-VL as measured by the Spearman correlation coefficient (r= 0.05,P= 0.88) in patients infected with HIV. CONCLUSIONS: Memory CD4 β7+cells are reduced significantly in the peripheral blood of untreated patients infected with HIV, which could be used as a noninvasive indicator of intestinal CD4 T cell loss and recovery. Further studies are needed to examine whether depletion of these CD4+/CD45RO+/β7+cells in the peripheral blood parallels depletion in the gut of treatment-naïve patients with HIV and whether levels return to control levels after treatment.

In Deutschland fehlen bislang belastbare epidemiologische Daten über sowohl die Häufigkeit nikotinabhängiger Raucher im primärärztlichen Versorgungsbereich als auch das Ausmaß der von Hausärzten angebotenen Raucherentwöhnungsmaßnahmen. Die Ziele in der "Smoking and Nicotine Dependence Awareness and Screening (SNICAS)"-Studie waren/sind: (1) die Ermittlung repräsentativer Daten zur Prävalenz des Rauchens und der Nikotinabhängigkeit in Deutschland, (2) die Beschreibung des Rauchverhaltens und der Aufhörmotivation von Rauchern in der primärärztlichen Versorgung sowie (3) die Feststellung von Einstellungen, Fertigkeiten und Erfahrungen von Hausärzten im Zusammenhang mit der Raucherentwöhnung. SNICAS basierte auf einem zweistufigen epidemiologischen Studiendesign, woran sich eine derzeit noch laufende, klinische Interventionskomponente anschloss. In Stufe I (Vorstudien-Fragebogen) wurde eine repräsentative Auswahl von 889 Ärzten (Allgemeinärzte, praktische Ärzte, Internisten) hinsichtlich Erfahrungen und Einstellungen zu Raucherentwöhnungsmethoden charakterisiert. In Stufe II wurde an einem Stichtag (7. Mai 2002) in diesen Praxen n = 28 707 unausgelesene, konsekutive Patienten zunächst mittels eines Patientenfragebogens untersucht (konservative Ausschöpfungsrate: 52,8%). Daran schloss sich für jeden einzelnen Patienten eine unabhängige, standardisierte Arztbeurteilung (Erhebung des Rauchstatus, des Gesundheitszustands, vergangener und aktueller Interventionen u.ä.) an. Der Beitrag enthält eine Darstellung von Design und Methode der SNICAS-Studie und berichtet über die Gewinnung, Ausschöpfung und Repräsentativität der Arzt- und Patientenstichprobe. Auf der Grundlage ausgewählter Daten des Vorstudien- Fragebogens, aus denen eine geringe Anzahl (17,6%) an sich intensiv mit der Raucherentwöhnung befassenden Ärzten hervorgeht, werden ärztliche Interventionsstrategien, aber auch Einstellungs- und Strukturbarrieren vorgestellt
Aims, Design and Methods of the "Smoking and Nicotine Dependence Awareness and Screening" (SNICAS) Study Germany lacks robust epidemiological data on the prevalence of smoking and nicotine dependence in primary care patients as it does on smoking cessation interventions provided by primary care physicians. Objectives of the "Smoking and Nicotine Dependence Awareness and Screening" (SNICAS) study are (1) to provide nationally representative data on the frequency of smoking and nicotine dependence among primary care patients in Germany, (2) to describe their smoking behaviour and motivation to quit as well as (3) attitudes, skills and experiences of physicians regarding smoking cessation. SNICAS is based on a 2-stage epidemiological design, supplemented by a subsequently conducted clinical intervention trial still ongoing. Stage I consists of a prestudy characterization of a nationwide sample of 889 primary care doctors (general practitioners, family doctors and internists with primary care functions). Stage II consists of a target day assessment (May 7th 2002) of n=28,707 unselected consecutive patients by means of a patient questionnaire (conservative response rate: 52.8%). For each patient a structured clinical appraisal form (screening of the patients' smoking status, physical and mental health, current and past interventions etc. ) was accomplished by the doctor. This article presents design and methods of the SNICAS study and describes its sampling strategy, its response rates and the representativity of primary care doctors and patients. By means of selected pre-study data, showing that only a small proportion of physician is extensively involved in smoking cessation (17.6%), intervention strategies of the doctors are presented as well as obstacles for smoking cessation (e.g. structures, attitudes)

Bakgrund: Primärvården har en viktig preventiv och kurativ funktion där många av befolkningens hälsobehov kan tillgodoses. Med sin breda kompetens har primärvården bäst förutsättningar att tillgodose patienters vårdbehov ur ett helhetsperspektiv. En tillgänglig och välfungerande primärvård för hela befolkningen kan bidra till en mer jämlik hälso-och sjukvård på befolkningsnivå. Syfte: Studiens syfte var att undersöka tillgängligheten till läkare på vårdcentraler i Landstinget Dalarna under en tidsperiod som inkluderade förändringar av primärvården motiverad av ekonomiska svårigheter inom landstinget. Metod: Studien hade en icke-experimentell kvantitativ design som undersökte geografisk jämlikhet utifrån tillgänglighet till läkare, samt eventuella samband mellan socioekonomisk sammansättning och tillgänglighet till läkare över en femårsperiod. Statistiska analyser med oberoende t-test, Mann-Whitney U-test och Kruskal-Wallis test användes för att utforska geografisk jämlikhet ur flera aspekter (p<,05). Eventuella samband mellan socioekonomisk sammansättning och tillgänglighet till läkare undersöktes med Spearmans rangkorrelationskoefficient. Resultat: Tillgängligheten till läkare inom primärvården i Landstinget Dalarna visade stora procentuella skillnader inom och mellan vårdcentraler. Under femårsperioden hade Landstinget Dalarna generellt lägre tillgänglighet än riksgenomsnittet och jämförelselandsting. Resultatet visade signifikanta skillnader (p<,05) gällande tillgänglighet på kommunnivå, men studien hittade inget geografiskt mönster för tillgänglighet. Tillgänglighet utifrån vårdcentralernas socioekonomiska sammansättningar mätt via CNI (Care Need Index) kunde inte påvisa samvariation mellan tillgänglighet till läkare inom primärvården och CNI, vilket kan bero på att CNI kompenserar för socioekonomiska skillnader. Slutsats: Studiens resultat visade varierande tillgänglighet till läkare inom primärvården i Landstinget Dalarna. För att uppnå en mer tillgänglig och jämlik primärvård för samtliga invånare i Dalarnas län bör regionala skillnader reduceras och tillgängligheten till läkare i landstinget bör förbättras generellt.
Background: Primary health care has an important preventative and curative role, where many of the population's health needs can be met. An accessible and well-functioning primary health care can reduce health inequities in the population. Objective: The purpose of the study was to investigate accessibility for medical consultations in primary health care centres in Dalarna County Council. The study explored accessibility during a period of time when changes were made in primary health care due to financial difficulties in the county council. Methods: The study had a non-experimental, quantitative design that examined geographic equality based on accessibility to medical consultations, and relationships between socioeconomic composition and accessibility of medical consultations over a five-year period. Statistical analysis with independent t-test, Mann-Whitney U-test and Kruskal-Wallis test examined geographic equality from several aspects (p<,05). Associations between socioeconomic composition and accessibility of medical consultations was investigated using Spearman's rank correlation coefficient. Results: Accessibility to medical consultations in Dalarna County Council varied within and between primary health care centres. During the five-year period, Dalarna County Council generally had lower accessibility than the national average and a comparative county council. The result showed significant differences (p<,05) regarding accessibility at the municipal level, but no geographic pattern for accessibility was found. This study did not find correlations between socioeconomic composition and accessibility to medical consultations, which may be because CNI compensates for socioeconomic differences. Conclusion: This study found variations regarding accessibility to medical consultations within Dalarna County Council. In order to achieve a more accessible and equal primary health care for all residents in Dalarna, regional differences should be reduced and accessibility to medical consultations should be improved in general.

Bakgrund: Distriktssköterskan triagerar dagligen patienter med psykisk ohälsa i primärvården. Psykisk ohälsa är mångfacetterat och till viss del tabubelagt i samhället. Detta kräver att distriktssköterskan har god kännedom om psykisk ohälsa och hur den kan uttrycka sig hos olika patienter. Distriktssköterskan behöver även ha ett holistiskt synsätt med personcentrerad vård i fokus. Syfte: Syftet med studien var att belysa distriktssköterskans erfarenheter av triagering av patienter med psykisk ohälsa inom primärvården. Metod: En kvalitativ intervjustudie med åtta distriktssköterskor/sjuksköterskor verksamma i primärvården. Analysmetoden var kvalitativ innehållsanalys. Resultat: Resultatet var tre kategorier och tio underkategorier. De tre kategorierna var: Brister i utbildning, Utmaningar vid triagering samt Brister i samverkan. Resultatet visade att distriktssköterskan behöver ha mer kunskap om psykisk ohälsa samt ha de förutsättningar som krävs för att genomföra en bra triagering såsom stödverktyg och trygghet i dialog om självmordstankar hos patienten. Distriktssköterskan behöver vara medveten om somatisering och dess påverkan i triageringen. Samarbetet mellan primärvården och öppen psykiatriska mottagningen behöver förbättras. Konklusion: För att triagering av psykisk ohälsa ska bli bättre behöver distriktssköterskan erhålla mer utbildning av psykisk ohälsa. Där har både arbetsgivare och utbildningsansvariga ett ansvar att påverka möjligheterna till triagering av psykisk ohälsa i primärvården. Distriktssköterskan behöver även ha stödverktyg för att säkerhetsställa likvärdig triagering av psykisk ohälsa i primärvården.
Background: The district nurse triage daily patients with mental illness in primary care. Mental illness is multifaceted and to some extent taboo in society. This requires that the district nurse has a good knowledge of mental illness and how it can express itself in different patients. The district nurse also needs to take a holistic approach with person-centred care in focus. Aim: The aim was the district nurse experiences with triage of patients with mental illness in primary care. Method: A qualitative research approach based on interviews with eight district nurse/nurse active in primary care. Qualitative content analysis. Result: The result was three categories and ten subcategories. The three categories were: Deficiencies in education, Challenges in triage and Deficiencies in collaboration. The results showed that the district nurse needs to have more knowledge about mental illness and have the conditions required to carry out a good triage, such as support tools and security in dialogue about suicidal thoughts in the patient. The district nurse needs to be aware of somatization and its impact on triage. The collaboration between primary care and the open psychiatric clinic needs to be improved. Conclusion: In order for triage of mental illness to improve, the district nurse needs to receive more training in mental illness. There, both employers and education managers have a responsibility to influence the opportunities for triage of mental illness in primary care. The district nurse also needs support tools to ensure equivalent triage of mental illness in primary care.

Syftet med studien är att undersöka unga vuxna invandrares erfarenheter av primärvården. En kvalitativ ansats tillämpas för att söka en djupare förståelse för ämnet och fem semistrukturerade intervjuer har genomförts. Genom ett snöbollsurval har informanter, bosatta i Mälardalsregionen, valts ut till studien. Informanterna är i åldrarna 24 och 26 år samt har varit bosatta i Sverige i omkring sex år. Resultatet innehåller redogörelser av informanternas erfarenheter av primärvården samt interaktionen med vårdpersonal. Informanterna upplever att deras redogörelser inte blir tagna på allvar och att de inte blir lyssnade till, vilket har lett till upplevelser av att de inte får tillräcklig vård. Vidare framkommer det att språket är en betydande faktor för hur information överförs samt att kontaktmöjligheterna upplevs vara goda. Person-centred care [PCC] kan användas som modell i arbetet om att förbättra möten i primärvården mellan patienter och vårdpersonal. Vidare bidrar modellen till ökad kunskap bland patienter när de får engagera sig i sin egen vård som kan resultera i ökad folkhälsa. PCC kan minska skillnader i hälsa, detta blir av vikt för studiens målgrupp som påvisats ha sämre hälsa än resterande befolkning. Studien påvisar behov av att förbättra möten i primärvården.
The aim of this study is to examine young immigrant adults’ experiences of primary care. The study uses a qualitative approach to seek a deeper understanding of the selected subject, five semi-structured interviews have been made. A snowball sampling was made to find participants living in regions around Mälardalen. The participants are between the ages of 24 and 26 years old and have lived in Sweden for six years. The results contain statements of the informants’ perceptions of the primary care and interactions with the healthcare professionals. The informants experience their statements not being taken seriously and not being listened to, which has led to the experience of not receiving adequate care. Furthermore, the importance of language, when information transfers between patients and healthcare professionals, emerges. The contact opportunities are positively experienced. Person-centred care [PCC] can be used as a model to improve the meetings in primary-care between patients and healthcare professionals. The model can contribute to increased knowledge for patients when they engage in their own care which can contribute to increased public health. For the study’s target group, who are shown to have poorer health, the PCC model becomes important to reduce differences in health. The study shows a need of improving meetings in the primary care.

Type 1 diabetes (T1D) is an autoimmune disease that destroys the bodies’ insulin producing beta-cells. The disease is understood to be triggered in genetically susceptible individuals by environmental factors. While the genetic side of the etiological model has to some degree been uncovered, there is no clear understanding of which environmental factors play a role in the disease process. Several hypotheses claim to explain the development of T1D, of which enteroviral infections show the most promise. According to this hypothesis high prevalence of enteroviral infections would also mean high incidence rates of T1D. This study focused on four Nordic countries (Denmark, Finland, Norway and Sweden) that as late as 2017 were found in the top 10 countries for incidence rate of childhood-onset T1D in the world. Incidence rates of T1D and prevalence of enteroviruses were mapped and geographically analyzed according to the principles of spatial epidemiology, after which correlation coefficients were calculated. In doing so the study tried to answer to which extent the prevalence of enteroviruses could explain the regional variations in T1D. For all countries no significant correlation was found, but increasing sample size, by grouping countries, showed considerably different outcomes with a small positive correlation in the case of Norway and Finland.

Background: The challenges of research in economically stunted countries’ settings remains a profound concern and is linked to socioeconomic development of these countries. More research is needed regarding psychiatric morbidity in rural areas of the developing and poverty stricken countries. The present studies were undertaken within the framework of a broader ongoing community-based project on the course and outcome of major psychiatric disorders in the rural Butajira district located in Ethiopia. This thesis treats the course and outcome of bipolar I disorder in the district. Objectives: Through appraising mental health and population based research in a rural Ethiopian district, to evaluate the utility of modern research instruments, and to obtain baseline information relating to bipolar I disorder in the poverty stricken rural Butajira district of Ethiopia. The specific objectives were: 1. Evaluating and comparing two different screening methods of case detection and identification for schizophrenia and bipolar I disorder in the adult population of Butajira district. 2. Assesing the prevalence and clinical characteristics of of bipolar I disorder in Butajira at the community level. 3. Evaluating short-term outcome at follow-up of bipolar I disorder in the Butajira district. 4. Determining Neurological Soft Signs in community-identified cases of bipolar I disorder in Butajira district in comparison with healthy controls. 5. Assessing the burden of care among caregivers of those affected by bipolar I disorder identified in the Butajira Study. Methods: The district’s entire adult population aged 15-49 was identified through a double-sampling design. In the first stage of screening, door-to-door interviews were conducted by lay trained high school completed individuals who knew the culture of the people. Females interviewed females whereas males interviewed males. Additionally, the key-informants method was used to identify cases that would be missed by the CIDI or otherwise. The final confirmatory diagnostic interview was conducted by clinicians using the SCAN on door-to-door basis as well. The probable cases that fulfilled the lifetime DSM-IV diagnosis of bipolar I disorder were assigned for assessment by other baseline research instruments such as Neurological Evaluation vii Scale (NES), Young Mania Rating Scale, Hamilton Rating Scale for Depression, LCSS, PANS and SANS, BISS, BII, FIS and so on. Cases so identified with bipolar I disorder were subject to a follow-up for upto 2.5 years on the average (range 1 to 4 years). Two of the main clinical outcomes assessed were relapse to a mood episode, and remission from a mood episode. Outcomes were assessed annually by the instruments, and were further assessed monthly by trained psychiatric nurses. We also did a cross-sectional study of caregivers of bipolar I disorder cases, and assessed objective burden on the caregivers as considered from social, family strain, occupational and financial domains. Results: Information provided by the key informants was better at detecting schizophrenia or chronic psychiatric disease, whereas the CIDI was better at detecting affective disorders. Of the around 100 000 adults living in Butajira, 83.3% were found by the project’s census, of which 82% (68,378 subjects) were successfully screened by the CIDI, yielding 2,161 CIDI positive. These, together with 719 cases identified by the key informants, were invited for the SCAN interview, of which 74.7% agreed. This yielded 315 SCAN positive cases for bipolar I disorder, and complete information could be collected on 295 of these. Lifetime prevalence was estimated as 0.6% for males and 0.3% for females. The mean age of onset of the manic phase was 22.0 years and that of the depressive phase was 23.4 years. For 22.7% of the cases the illness started with a depressive episode and for the remaining 77.3% it started with a manic episode. Over half of the cases (55.9%) had never sought help from modern health care sector, and only 13.2% had ever been admitted to psychiatric hospital. At follow-up, 65.9% had exprerienced a relapse and 31.1% had persistent illness, while only 5% of the patients were in remission for most of the follow-up time. The bipolar I cases, as compared with healthy controls, performed worse on several items of NES, thus having more neurological dysfunction compared to controls. Caregives were largely (80.3%) first-degree relatives and spouses. Overall, 84% of the caregivers reported difficulties in at least one of the domains of family burden. Of these, 58.7% reported a severe degree of difficulties. Caregivers reported a high level of difficulties in intrafamilial relationships and social restrictions, disruption in earning a livelihood, and financial difficulties. Conclusions: The prevalence of bipolar I disorder is comparable to the prevalences reported from other countries, and our findings support the cross-cultural validity of the concept of bipolar I disorder. Majority of the cases are not treated in contrast to that in the developed countries. The burden of care for the caregivers is substantial in the population studied.

In Deutschland fehlen bislang belastbare epidemiologische Daten über sowohl die Häufigkeit nikotinabhängiger Raucher im primärärztlichen Versorgungsbereich als auch das Ausmaß der von Hausärzten angebotenen Raucherentwöhnungsmaßnahmen. Die Ziele in der "Smoking and Nicotine Dependence Awareness and Screening (SNICAS)"-Studie waren/sind: (1) die Ermittlung repräsentativer Daten zur Prävalenz des Rauchens und der Nikotinabhängigkeit in Deutschland, (2) die Beschreibung des Rauchverhaltens und der Aufhörmotivation von Rauchern in der primärärztlichen Versorgung sowie (3) die Feststellung von Einstellungen, Fertigkeiten und Erfahrungen von Hausärzten im Zusammenhang mit der Raucherentwöhnung. SNICAS basierte auf einem zweistufigen epidemiologischen Studiendesign, woran sich eine derzeit noch laufende, klinische Interventionskomponente anschloss. In Stufe I (Vorstudien-Fragebogen) wurde eine repräsentative Auswahl von 889 Ärzten (Allgemeinärzte, praktische Ärzte, Internisten) hinsichtlich Erfahrungen und Einstellungen zu Raucherentwöhnungsmethoden charakterisiert. In Stufe II wurde an einem Stichtag (7. Mai 2002) in diesen Praxen n = 28 707 unausgelesene, konsekutive Patienten zunächst mittels eines Patientenfragebogens untersucht (konservative Ausschöpfungsrate: 52,8%). Daran schloss sich für jeden einzelnen Patienten eine unabhängige, standardisierte Arztbeurteilung (Erhebung des Rauchstatus, des Gesundheitszustands, vergangener und aktueller Interventionen u.ä.) an. Der Beitrag enthält eine Darstellung von Design und Methode der SNICAS-Studie und berichtet über die Gewinnung, Ausschöpfung und Repräsentativität der Arzt- und Patientenstichprobe. Auf der Grundlage ausgewählter Daten des Vorstudien- Fragebogens, aus denen eine geringe Anzahl (17,6%) an sich intensiv mit der Raucherentwöhnung befassenden Ärzten hervorgeht, werden ärztliche Interventionsstrategien, aber auch Einstellungs- und Strukturbarrieren vorgestellt.
Aims, Design and Methods of the "Smoking and Nicotine Dependence Awareness and Screening" (SNICAS) Study Germany lacks robust epidemiological data on the prevalence of smoking and nicotine dependence in primary care patients as it does on smoking cessation interventions provided by primary care physicians. Objectives of the "Smoking and Nicotine Dependence Awareness and Screening" (SNICAS) study are (1) to provide nationally representative data on the frequency of smoking and nicotine dependence among primary care patients in Germany, (2) to describe their smoking behaviour and motivation to quit as well as (3) attitudes, skills and experiences of physicians regarding smoking cessation. SNICAS is based on a 2-stage epidemiological design, supplemented by a subsequently conducted clinical intervention trial still ongoing. Stage I consists of a prestudy characterization of a nationwide sample of 889 primary care doctors (general practitioners, family doctors and internists with primary care functions). Stage II consists of a target day assessment (May 7th 2002) of n=28,707 unselected consecutive patients by means of a patient questionnaire (conservative response rate: 52.8%). For each patient a structured clinical appraisal form (screening of the patients' smoking status, physical and mental health, current and past interventions etc. ) was accomplished by the doctor. This article presents design and methods of the SNICAS study and describes its sampling strategy, its response rates and the representativity of primary care doctors and patients. By means of selected pre-study data, showing that only a small proportion of physician is extensively involved in smoking cessation (17.6%), intervention strategies of the doctors are presented as well as obstacles for smoking cessation (e.g. structures, attitudes).

Background: As the world becomes more urban and slums continue to grow in developing countries, research is needed to measure utilization of health services, health outcomes, and access to health care providers among urban slum residents. Estimating trends in urban health among slum residents relative to other urban inhabitants provides evidence of health disparities for priority-setting by program implementers and policy-makers. Research on the negative effects of slum environments on human health has started to emerge, yet there remains a paucity of evidence on morbidity trends over time and inequalities between slum residents and other urban residents. The goal of this study is to quantify maternal and child health care access, utilization and outcomes among urban slum dwellers in selected countries in sub-Saharan Africa and South Asia over time. These three areas are addressed in three separate dissertation manuscripts.

Methods: This dissertation offers an in-depth analysis of household and health facility data to measure trends in maternal and child health care utilization and health outcomes among slum residents over time, as well as inequalities in access, utilization and outcomes between other urban and rural populations. Manuscripts 1 and 2 apply a unique spatial inequality approach to existing population-based household data from the Demographic and Health Surveys (DHS) to identify a sample of slum residents. Manuscript 1 assesses trends in maternal and child health care (MCH) utilization and health outcomes using DHS data in Bangladesh, Ethiopia, Kenya, Malawi, Nepal, Nigeria and Tanzania between 2003 and 2011. In Manuscript 2, a trend analysis is performed in Kenya to examine diarrheal disease and acute respiratory infection (ARI) in children under-five in both slums and other urban and rural areas during the roll-out of a national slum upgrading program. Manuscript 3 further explores local-level dimensions of health care access from two slums in Kenya, generating evidence on service availability and readiness in slums. In this section, we analyze health facility data collected using a modified version of the World Health Organization’s (WHO) Service Availability and Readiness Assessment (SARA).

Results: Manuscript 1 reports significant disparities between slum dwellers and other urban residents’ utilization of key maternal health interventions—appropriate antenatal care (ANC), tetanus toxoid vaccination, and skilled delivery—in Bangladesh, Ethiopia, Kenya and Nigeria. In addition, child health outcomes examined in Manuscript 1 suggest that the prevalence of diarrheal disease in children under-five is declining among other urban and rural residents, but not significantly among slum residents. Nigeria was the only exception, with significant declines in diarrheal disease prevalence in slums over the study period. Because ARI improvements are found across populations, the data suggests this condition is not unique to slum settings. The trend analysis in Manuscript 2 supports these findings—ARI is declining steadily over time not only among slum residents, but also among other urban and rural residents as well. Diarrheal disease prevalence, on the other hand, has not changed significantly over time, with stable levels among slum dwellers between 1993 and 2014. In Manuscript 3, analysis of general service availability and readiness in two locations—the Nyalenda slum of Kisumu and the Langas slum of Eldoret—reveals that slums perform far below recommended benchmarks set by WHO. When we compare service availability and readiness indicators with regional, urban, and national averages, in general slums in Kisumu and Eldoret perform poorly. However, there were some instances—typically involving standard precautions for infection control—where Kenyan slums actually performed better than comparison sites.

Conclusions: This research provides a comprehensive view of health systems dimensions in urban slums in sub-Saharan Africa and South Asia. Manuscript 1 confirms evidence of an urban penalty and emphasizes a need to focus on maternal health care utilization in slums. Manuscript 2 detects little improvement in child health outcomes among slum dwellers in Kenya during the roll-out of the country’s national slum upgrading program. An integrated approach to health and urban policy development is recommended based on these results. Manuscript 3 identifies areas of service availability and readiness in two Kenyan slums that fall below global targets and are in need of improvement in order to achieve desired health outcomes. Taken together, this study makes a significant contribution to the crucial demand for research on growing marginalized urban populations in developing countries.

Background: Subarachnoid haemorrhage (SAH) is a severe stroke that in 85% of all cases is caused by the rupture of a cerebral aneurysm. The median age at onset is 50-55 years and the overall mortality is approximately 45%.Sufficient cortisol levels are important for survival. After SAH hypothalamic/pituitary blood flow may be hampered this could result in inadequate secretion of cortisol. SAH is also associated with a substantial inflammatory response. Asymmetric dimethyl arginine (ADMA), an endogenous inhibitor of nitric oxide synthase, mediates vasoconstriction and increased ADMA levels may be involved in inflammation and endothelial dysfunction. Continuous electroencephalogram (EEG) monitoring can be used to detect non-convulsive seizures, leading to ischemic insults in sedated SAH patients. Elevated ADMA levels are risk factors for vascular diseases. Vascular disease has been linked to stress, inflammation and endothelial dysfunction. SAH possesses all those clinical features and theoretically SAH could thus induce vascular disease. Aims: 1. Assess cortisol levels after SAH, and evaluate associations between cortisol and clinical parameters. 2. Assess ADMA levels and arginine/ADMA ratios after SAH and evaluate associations between ADMA levels and arginine/ADMA ratios with severity of disease, co-morbidities, sex, age and clinical parameters. 3. Investigate occurrence of subclinical seizures in sedated SAH patients. 4. Evaluate if patients that survive a SAH ≥ one year have an increased risk of vascular causes of death compared to a normal population. Results: Continuous infusion of sedative drugs was the strongest predictor for a low (<200 nmol/L) serum cortisol. The odds ratio for a sedated patient to have a serum cortisol < 200 nmol/L was 18.0 times higher compared to an un-sedated patient (p < 0.001). Compared to admission values, 0-48 hours after SAH, CRP increased significantly already in the time-interval 49-72 hours (p<0.05), peaked in the time-interval 97-120 hours after SAH and thereafter decreased. ADMA started to increase in the time-interval 97-120 hours (p<0.05). ADMA and CRP levels were significantly higher, and arginine/ADMA ratios were significantly lower in patients with a more severe condition (p<0.05). Epileptic seizure activity, in sedated SAH patients, was recorded in 2/28 (7.1%) patients during 5/5468 (0.09%) hours of continuous EEG monitoring. Cerebrovascular disease was significantly more common as a cause of death in patients that had survived a SAH ≥ one year, compared to the population from the same area (p<0.0001). Conclusions: Continuous infusion of sedative drugs was associated with low (<200 nmol/L) cortisol levels. ADMA increased significantly after SAH, after CRP had peaked, indicating that endothelial dysfunction, with ADMA as a marker, is induced by a systemic inflammation. Patients with a more severe condition had significantly higher ADMA and CRP levels, and significantly lower arginine/ADMA ratio. Continuous sedation in sedated SAH patients seems to be beneficial in protecting from subclinical seizures. Cerebrovascular causes of death are more common in SAH survivors.

Funding: The Swedish Society of Medicine, the Faculty of Medicine at Umeå University, The Kempe Foundations and The Stroke Foundation of Northern Sweden supported this study financially.

Durch eine stärkere Einbeziehung deutscher Hausärzte in die Raucherentwöhnung soll die Versorgung von Rauchern flächendeckend verbessert werden. Inwiefern dieser Anspruch realisierbar ist, wird im Rahmen der "Smoking and Nicotine Dependent Awareness and Screening" (SNICAS) Studie überprüft. SNICAS ist eine zweistufige epidemiologische Punktprävalenzstudie [Stufe I (Vorstudie): Charakterisierung einer repräsentativen, bundesweiten Stichprobe von n = 889 Hausärzten; Stufe II: Stichtagserhebung an n = 28 707 unselektierten konsekutiven Patienten], an die sich eine regionale klinische Interventionskomponente anschließt. In diesem Beitrag werden Prävalenzraten des Rauchens, Aufhörmotivation und bisherige Aufhörversuche von Primärarztpatienten berichtet. Dargestellt werden Erkennens- und Interventionsraten von Rauchern durch Hausärzte, das ärztliche Interventionsverhalten sowie deren Einschätzung der Chancen und Barrieren von Raucherentwöhnung im Praxisalltag. Die Ergebnisse der Studie belegen ein großes Interesse der Hausärzte am Thema Raucherentwöhnung. Dennoch weisen niedrige hausärztliche Interventionsraten bei gleichzeitig hohen Prävalenzraten von Rauchen und Nikotinabhängigkeit auf ein beträchtliches Versorgungsdefizit. Als Ursachen hierfür werden neben ambivalenter Aufhörmotivation der Patienten strukturelle Barrieren diskutiert. Die Autoren fordern neue klinische Versorgungsmodelle, die ein abgestimmtes Zusammenspiel von Hausärzten mit anderen, auf Raucherentwöhnung spezialisierte Berufsgruppen fokussieren.
Through smoking cessation interventions, primary care physicians could play an important part in the treatment of smokers in Germany. In the "Smoking and Nicotine Dependent Awareness and Screening" (SNICAS) study, we examined whether this increased involvement of primary care physicians might be implemented. SNICAS is a two-stage epidemiological point prevalence study. In stage I (pre-study), a nationwide sample of 889 primary care doctors was characterized; in stage II, 28 707 unselected consecutive patients were assessed on the target day. The investigation was followed by regional clinical interventions. The present article contains our findings on the prevalence of smoking, the motivation to quit, and the history of quit attempts among primary care patients. Information will be provided on how frequently physicians recognize and treat smokers; what kind of interventions they offer; as well as how they judge the opportunities and obstacles for smoking cessation in routine care. Despite the high prevalence of smoking and nicotine dependence and the primary care doctors’ interest in treating smokers, insufficient interventions are provided. Reasons for this situation include, but are not limited to the patients’ ambivalent motivation to quit and structural barriers. Hence, new clinical models of health care with an improved cooperation between primary care physicians and other specialists in the field of smoking cessation seem necessary.

The path to controlling the global HIV/AIDS epidemic and achieving the UNAIDS goals of 90-90-90 is hampered by the need to identifying people living with HIV (PLHIV) through HIV testing and counseling (HTC) services. Improving access to HTC services is important because the early identification of HIV-positive individuals can facilitate their access to and enrollment in life-long HIV prevention and treatment services, which can lead to significant reductions in morbidity and mortality. HTC is also a cornerstone of prevention of mother-to-child (PMTCT) programs and can protect the health of pregnant women and their babies. Yet gaps remain in the uptake of HTC, particularly in sub-Saharan Africa where the more than 50% of PLHIV reside. Compounding this problem, there is a dearth of evidence on key operational challenges and the quality of services administered to people in low- and middle-income countries that may impede the delivery of HTC at health care facilities. This dissertation, which is comprised of two analyses, seeks to help fill that gap.

I examined the association between the regional HTC service environment and recent HIV testing behaviors among adults and the determinants of routine HIV testing in antenatal care (ANC) settings using nationally-representative datasets from East Africa. The first objective of this dissertation was to examine the association between HTC service readiness and HTC standard precautions and uptake in HIV testing and counseling by linking data from the Demographic and Health Survey (DHS) and Service Provision Assessments (SPA) from Kenya, Tanzania and Uganda from 2004-2010. The second objective was to determine the frequency of health care providers routinely offering HTC to pregnant women during ANC visits and the facility- and individual-level characteristics of health care providers offering the HIV test, using data from the Kenya 2010 SPA. These population-based analyses provide insight on the degree and extent of HTC program and policy implementation in East Africa, identify how the service readiness of HTC provided at facilities is associated with health-seeking behaviors on an individual level and help to fill an important knowledge gap in HIV implementation research.

Durch eine stärkere Einbeziehung deutscher Hausärzte in die Raucherentwöhnung soll die Versorgung von Rauchern flächendeckend verbessert werden. Inwiefern dieser Anspruch realisierbar ist, wird im Rahmen der "Smoking and Nicotine Dependent Awareness and Screening" (SNICAS) Studie überprüft. SNICAS ist eine zweistufige epidemiologische Punktprävalenzstudie [Stufe I (Vorstudie): Charakterisierung einer repräsentativen, bundesweiten Stichprobe von n = 889 Hausärzten; Stufe II: Stichtagserhebung an n = 28 707 unselektierten konsekutiven Patienten], an die sich eine regionale klinische Interventionskomponente anschließt. In diesem Beitrag werden Prävalenzraten des Rauchens, Aufhörmotivation und bisherige Aufhörversuche von Primärarztpatienten berichtet. Dargestellt werden Erkennens- und Interventionsraten von Rauchern durch Hausärzte, das ärztliche Interventionsverhalten sowie deren Einschätzung der Chancen und Barrieren von Raucherentwöhnung im Praxisalltag. Die Ergebnisse der Studie belegen ein großes Interesse der Hausärzte am Thema Raucherentwöhnung. Dennoch weisen niedrige hausärztliche Interventionsraten bei gleichzeitig hohen Prävalenzraten von Rauchen und Nikotinabhängigkeit auf ein beträchtliches Versorgungsdefizit. Als Ursachen hierfür werden neben ambivalenter Aufhörmotivation der Patienten strukturelle Barrieren diskutiert. Die Autoren fordern neue klinische Versorgungsmodelle, die ein abgestimmtes Zusammenspiel von Hausärzten mit anderen, auf Raucherentwöhnung spezialisierte Berufsgruppen fokussieren
Through smoking cessation interventions, primary care physicians could play an important part in the treatment of smokers in Germany. In the "Smoking and Nicotine Dependent Awareness and Screening" (SNICAS) study, we examined whether this increased involvement of primary care physicians might be implemented. SNICAS is a two-stage epidemiological point prevalence study. In stage I (pre-study), a nationwide sample of 889 primary care doctors was characterized; in stage II, 28 707 unselected consecutive patients were assessed on the target day. The investigation was followed by regional clinical interventions. The present article contains our findings on the prevalence of smoking, the motivation to quit, and the history of quit attempts among primary care patients. Information will be provided on how frequently physicians recognize and treat smokers; what kind of interventions they offer; as well as how they judge the opportunities and obstacles for smoking cessation in routine care. Despite the high prevalence of smoking and nicotine dependence and the primary care doctors’ interest in treating smokers, insufficient interventions are provided. Reasons for this situation include, but are not limited to the patients’ ambivalent motivation to quit and structural barriers. Hence, new clinical models of health care with an improved cooperation between primary care physicians and other specialists in the field of smoking cessation seem necessary

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A mortalidade neonatal sofre influÃncia de uma complexa relaÃÃo de fatores socioeconÃmicos, assistenciais e biolÃgicos. Nas duas Ãltimas dÃcadas a mortalidade nos perÃodos peri e neonatal nÃo sofreu declÃnio significativo, devido à permanÃncia dos elevados nÃveis de mortalidade por fatores ligados à gestaÃÃo e ao parto. Atualmente, a mortalidade neonatal representa 60% a 70% da mortalidade infantil em todas as regiÃes brasileiras. Estudos desenhados para investigar os fatores determinantes da mortalidade neonatal tÃm sido amplamente desenvolvidos no Brasil, no entanto, estudos do tipo caso controle utilizando dados primÃrios nÃo foram desenvolvidos na cidade de Fortaleza-Ce nos Ãltimos anos. O estudo objetivou determinar os fatores associados aos Ãbitos neonatais em Fortaleza-Ce no ano de 2009. ConstituÃram os objetivos especÃficos dessa casuÃstica: descrever as caracterÃsticas socioeconÃmicas e demogrÃficas das mÃes e dos recÃm-nascidos para os casos (Ãbitos neonatais) e os controles (recÃm-nascidos sobreviventes), identificar as caracterÃsticas relacionadas à assistÃncia prÃ-natal, parto e ao recÃm-nascido dos Ãbitos neonatais e dos recÃm-nascidos sobreviventes e determinar os fatores preditores da mortalidade neonatal utilizando modelagem hierarquizada. Quanto aos aspectos metodolÃgicos, tratou-se de um estudo do tipo caso-controle, com 132 casos de Ãbitos neonatais e 264 controles obtidos entre os sobreviventes ao perÃodo neonatal. Para os casos foram consideradas as crianÃas nascidas vivas e que morreram antes de completar 28 dias de vida e como controles as que permaneceram vivas neste perÃodo, nascidas em Fortaleza-Ce e filhos de mÃes residentes no municÃpio. As informaÃÃes foram obtidas atravÃs de entrevistas domiciliares por meio de questionÃrio estruturado. As variÃveis foram agrupadas em quatro blocos hierÃrquicos de acordo com modelo conceitual: bloco1-caracterÃsticas socioeconÃmicas e demogrÃficas; bloco2-caracterÃsticas maternas, histÃria reprodutiva, morbidade materna, comportamento materno, apoio social e exposiÃÃo à violÃncia; bloco 3-caracterÃsticas da assistÃncia no prÃ-natal e parto; bloco 4-sexo e condiÃÃes de saÃde do recÃm-nascido. O modelo de anÃlise de regressÃo logÃstica hierarquizada identificou como fatores associados ao Ãbito neonatal: bloco 1- raÃa materna com efeito protetor para raÃa parda e negra (OR: 0,23; IC 95% 0,09-0,56); bloco 3- tempo gasto entre o deslocamento de casa ao hospital igual ou superior a 30 minutos (OR: 3,12; IC 95% 1,34-7,25), tempo inferior à 1 hora ou superior ou igual a 10 horas entre a internaÃÃo e o parto (OR: 2,43; IC 95% 1,24-4,76) e prÃ-natal inadequado (OR: 2,03; IC 95% 1,03-3,99); bloco 4- baixo peso ao nascer (OR:14,75; IC 95% 5,26-41,35), prematuridade (OR: 3,41; IC 95% 1,29-8,98 ) e sexo masculino (OR: 2,09; IC 95% 1,09-4,03). Essa casuÃstica revelou aspectos na determinaÃÃo das mortes neonatais relacionados à qualidade da assistÃncia prÃ-natal oferecida Ãs gestantes, à oferta dos leitos hospitalares, indicando a peregrinaÃÃo das gestantes em busca de maternidades, bem como aspectos relacionados à assistÃncia direta ao trabalho de parto, traduzido pelo determinante tempo superior a 10 horas decorrido entre a internaÃÃo da gestante e o parto.
Neonatal mortality is influenced by a complex interplay of socioeconomic, biological and social assistance. In the last two decades the mortality in the perinatal and neonatal periods not suffered significant declines, due to persistent high levels of mortality factors related to pregnancy and childbirth. Currently, neonatal mortality accounts for 60% to 70% of infant mortality in all regions of Brazil. Studies designed to investigate the determinants of neonatal mortality have been widely developed in Brazil, however, case-control studies using primary data have not been developed in the city of Fortaleza-Ce in recent years. The study aimed to determine factors associated with neonatal deaths in Fortaleza in 2009. Were the specific objectives of this series to describe the socioeconomic and demographic characteristics of mothers and newborns in cases (neonatal deaths) and controls (newborn survivors), to identify the features related to prenatal care, childbirth and newborn and neonatal deaths of infants surviving and determine predictors of neonatal mortality using hierarchical modeling. Methodological terms, this was a study of case-control, with 132 cases of neonatal deaths and 264 controls obtained among survivals of the neonatal period. For cases were considered children born alive and died before 28 days of life and how those controls remained alive during this period, born in Fortaleza-Ce and children of mothers living in the city. The information was obtained through home interviews using a structured questionnaire. Variables were grouped into four groups according to hierarchical conceptual model: Block 1-socioeconomic and demographic characteristics; bloco2-maternal characteristics, reproductive history, maternal morbidity, maternal behavior, social support and exposure to violence; 3-block handling characteristics of the pre prenatal and childbirth; block 4-sex and health of the newborn. The model of hierarchical logistic regression analysis identified factors associated with neonatal death: Block 1 - maternal race with a protective effect against brown and black race (OR: 0.23, 95% CI 0.09 to 0.56), block 3 - between the time spent commuting from home to hospital less than 30 minutes (OR: 3.12, 95% CI 1.34 to 7.25), less than 1 hour or greater than or equal to 10 hours between admission and delivery (OR: 2.43, 95% CI 1.24 to 4.76) and inadequate prenatal care (OR: 2.03, 95% CI 1.03 to 3.99) Block 4 - low weight birth (OR: 14.75, 95% CI 5.26 to 41.35), prematurity (OR: 3.41, 95% CI 1.29 to 8.98) and male (OR: 2.09, CI 95% 1.09 to 4.03). This series has revealed aspects of the determination of neonatal deaths related to the quality of prenatal care offered to pregnant women, supply of hospital beds, indicating the pilgrimage of pregnant women seeking maternity, as well as aspects related to direct assistance to labor, translated determining the time over 10 hours elapsed between admission and delivery in pregnant women.

Eventos adversos (EAs), definidos como complicações não intencionais decorrentes do cuidado prestado, são reconhecidos como um dos maiores problemas na área da saúde. Embora a maior parte dos eventos acarrete incapacitações leves, uma proporção considerável está relacionada à morte de pacientes. O atendimento de urgência é considerado importante fator de risco para o desencadeamento destas complicações. No Brasil, estudos relacionados a este tema não foram publicados até o momento. O presente estudo objetivou identificar a ocorrência de EAs em pacientes admitidos por acidente vascular cerebral (AVC) ao Pronto-Socorro de Clínica Médica (PSM) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) e determinar as categorias de EAs associadas a óbito. Este estudo caso-controle pareado envolveu 468 pacientes admitidos por AVC ao PSM-HCFMUSP no período de março de 1996 a setembro de 1999. O grupo-caso compreendeu 234 óbitos hospitalares consecutivos e o grupo-controle 234 pacientes que receberam alta, pareados pelo diagnóstico provisório e pela época de internação. Eventos adversos, detectados por revisão de prontuários, foram classificados segundo sua gravidade, causas imediatas, sistemas acometidos e categorias profissionais envolvidas no cuidado aos pacientes. A associação com óbito foi analisada por regressão logística multivariada condicional, incluindo variáveis relacionadas a aspectos demográficos, gravidade do quadro inicial e características da assistência. Nos 468 pacientes foram identificados 1.218 EAs: 932 EAs (76,5%) em 170 casos e 286 EAs (23,5%) em 125 controles. Eventos adversos major corresponderam a 54,1% do total de eventos, com 659 episódios: 538 eventos em 143 casos e 121 em 65 controles. Os procedimentos diagnósticos e terapêuticos e os cuidados de enfermagem foram responsáveis em conjunto por 55,2% do total de eventos. Em relação ao tipo de sistema afetado, 46,0% dos EAs identificados ocasionaram manifestações gerais. Eventos adversos relacionados à enfermagem e EAs médicos representaram as categorias profissionais de EAs mais freqüentes (38,4% e 31,0% do total de eventos). Uma associação significante com óbito foi encontrada em relação a EAs major, EAs médicos e infecções hospitalares, com valores de OR ajustado estimados em 3,72 (IC 95% = 1,63-8,48), 3,69 (IC 95% = 1,60-8,50) e 3,20 (IC 95% = 1,20-8,51), respectivamente. Em resumo, eventos adversos, na sua maioria graves, foram freqüentes em casos e controles, determinando predominantemente manifestações gerais. Os procedimentos diagnósticos e terapêuticos e os cuidados de enfermagem corresponderam às principais causas imediatas de EAs. Em relação à categoria profissional envolvida, os EAs relacionados à enfermagem e os eventos médicos predominaram. Eventos adversos major, EAs médicos e as infecções hospitalares associaram-se de maneira significante com óbito em pacientes com AVC admitidos ao Pronto-Socorro de Clínica Médica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
Adverse events (AEs), defined as unintended injuries caused by medical care, are recognized as a major health problem. Although most of them lead to minimal impairments, a considerable proportion is related to patients’ death. Urgent care is considered an important AE risk factor. No related Brazilian studies were published so far. The present study aimed to identify the occurrence of AEs in patients admitted for stroke to the medical emergency department of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) and to determine the AEs’ categories associated to death. This paired case-control study enrolled 468 patients admitted for stroke to the HCFMUSP medical emergency department from March 1996 to September 1999. The cases comprised 234 consecutive deaths and the controls 234 discharged patients, matched for primary diagnosis and admission period. AEs, detected by retrospective chart review, were classified with regard to their severity, immediate causes, affected systems and professional involved in patient care. The association with death was analyzed by multivariate conditional regression including variables related to demographic aspects, clinical severity on admission and care characteristics. A total of 1,218 AEs were identified in 468 patients: 932 AEs (76.5%) in 170 cases and 286 AEs (23.5%) in 125 controls. Major AEs corresponded to 54.1% of all AEs, with 659 episodes: 538 events in 143 cases and 121 in 65 controls. Diagnostic and therapeutic procedures and nursing activities accounted together for 55.2% of all events. Concerning the affected system, 46.0% of the identified AEs lead to general manifestations. Nursing and medical AEs represented the most frequent professional categories involved (38.4% and 31.0% of all events). A significant association with death was found regarding major AEs, medical AEs and nosocomial infections, with adjusted OR estimates of 3.72 (95% IC = 1.63-8.48), 3.69 (95% IC = 1.60-8.50) and 3.20 (95% IC = 1.20-8.51), respectively. In summary, adverse events, most of them severe, were frequent in cases and controls, leading mainly to general manifestations. Diagnostic and therapeutic procedures and nursing activities corresponded to the main AEs’ immediate causes. Regarding the professional involved, AEs related to nurses and physicians predominated. Major AEs, medical AEs and nosocomial infectious were significantly associated to death in stroke patients admitted to the medical emergency department of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

Background: In settings such as rural Bangladesh, where the majority of births occur at home, population-based data are lacking on the burden and risk factors for obstetric complications, as well as care-seeking behavior. This dissertation seeks to describe the prevalence and risk factors for obstetric complications, explore factors affecting care seeking for complications, and describe the availability of obstetric care among health facilities in rural Bangladesh.

Methods: We used extant data from a community-randomized maternal micronutrient supplementation trial which ascertained reported morbidities and care seeking among 42,214 pregnant women between 2007 and 2011 in rural northwest Bangladesh. Multivariate multinomial logistic regression was used to analyze the association of biological, socioeconomic, and psychosocial factors with reported obstetric complications and near misses. Multivariate logistic regression of socioeconomic, demographic, perceived need, and service factors on care seeking was performed. Primary data on availability and readiness to provide obstetric services at 14 health facilities was collected through surveys.

Results: Of the 42,214 married women of reproductive age, 73% (n=30,830) were classified as having non-complicated pregnancies, 25% (n=10,380) as having obstetric complications, and 2% (n=1,004) with reported near misses. In multivariate analysis, women's age less than 18 years (Relative Risk Ratio 1.26 95% CI 1.14-1.39), obstetric history of stillbirth or abortion (RRR 1.15 CI 1.07-1.22), and neither partner wanting the pregnancy (RRR 1.33 CI 1.20-1.46) significantly increased the risk of obstetric complications. Out of 9,576 women with data on care seeking, 77% sought any care, with only 23% seeking at least one formal provider. Socioeconomic factors and service factors, such as facility availability of comprehensive obstetric services (OR 1.25 CI 1.16- 1.34), improved care seeking from formal providers. Average facility readiness for emergency obstetric care was 81% in private clinics compared to 67% in public facilities (p=0.045).

Conclusions: These analyses indicate a high burden of obstetric morbidity, with a quarter of women reporting obstetric complications. Policies to reduce early marriage and unmet need for contraception may address risk factors including adolescent pregnancy and unwanted pregnancies. Improvements in socioeconomic factors, coupled with strategies to increase service availability at health facilities, could increase care seeking from formal providers.

BACKGROUND: Children with Special Health Care Needs (CSHCN) increasingly live into adulthood, and every year approximately 500,000 American youth transition from pediatric to adult health care system. Health Care Transition (HCT) for Youth with Special Health Care Needs (YSHCN) has emerged as a significant event in the life course of this population. The overarching goal for HCT is to provide high quality, coordinated, uninterrupted health care which is responsive to the needs and desires of the patient. Although improvements have been seen in health care quality of the general population, differences still persist in health care quality among CSHCN in racial and ethnic minority groups. Children with Intellectual and Developmental Disabilities (ID-DD) are an important subpopulation of CSHCN because of their increasing prevalence due to autism and attention deficit hyperactivity disorder, high service needs, cost, and societal impact. A few researchers have focused on transition preparation for all YSHCN, but not on racial and ethnic (e.g., African American, Latino) disparities in health care transition and quality for youth ages 12-17 with ID-DD. OBJECTIVE: The purpose of this study was to explore the racial and ethnic disparities in transition to adult health care and quality of care for youth ages 12-17 with ID-DD. METHODS: The 2009–2010 National Survey of Children with Special Health Care Needs is a nationally representative sample with 17, 114 respondents (parents of CSHCN) ranging in age from 12 to 17 years old. They were asked about transitioning to an adult provider, changing health care needs, maintaining insurance needs, and increasing responsibility for self-care. They were also asked about having a personal doctor or nurse, doctors spending enough time with them, doctors listening carefully to the parent, providers showing sensitivity about family values; the parent receiving enough information from the doctor, and the doctor making the parent feel like a partner. The researcher analyzed the association of selected characteristics with successful transition and quality of health care for White, Black, and Latino children ages 12-17 with ID-DD. The study was guided by Andersen’s (1995) Behavioral Model of Health Care Use. Bivariate analyses were conducted and consisted of seven chi-square analyses. For each chi-square analysis, the data split to include only children with ID-DD. RESULTS: The study was comprised of youth with ID-DD ranging in age from 12 to 17 years old, with an average mean age of 14.55 years old (M=14.55, SD=1.74). Results of the chi-square analysis indicated the proportions of children transitioning to adult health care for each ethnic group were not significantly different than expected (χ²(3) = 5.41, p = 0.144). Results also indicated that only four percent of children with ID-DD successfully transitioned to adult health care. Four of the six chi-square analyses related to the quality of health care were indicative of significant deviations from expected responses (doctors and other health care providers spending enough time with the child χ ²(12) = 79.74, p < 0.001; listening carefully (χ²(15) = 63.42, p < 0.001); showing sensitivity to family values (χ²(15) = 34.44, p = 0.003); and making the family feel like a partner in care (χ ²(12) = 33.89, p <0 .001). A multiple linear regression was conducted to determine the relationship between the occurrence of an intellectual or developmental disability and the transition to adult health care, while controlling for predisposing (e.g., race and ethnicity, gender, parents education, and family structure), enabling factors (e.g., family income, health insurance status, and patient-centered medical home). A preliminary F test on the regression indicated a significant model fit (F(12, 10,387) = 67.76, p < 0.001). Furthermore, a multiple linear regression was conducted to determine the relationship between the occurrence of a disability and the quality of health care, while controlling for predisposing and enabling factors. The preliminary F test indicated a significant model (F(12, 17,101) = 328.62, p < .001). CONCLUSIONS: Youth with ID-DD, particularly those who are Latino and Black, face greater challenges in transitioning to adult health care and receiving a quality of care compared to other children with special health care needs in the United States. Addressing specific medical home components might reduce racial and ethnic disparities. Future research that examines the association between the HCT and family/professional partnerships in family-to-family health information centers (ACA 5507(b)) will be needed to ensure quality outcomes for youth with ID-DD.

HIV infections rates for African American females in the United States remain disproportionately high with no significant evidence that the current trend will change in the near future. For 17 consecutive years, HIV related illnesses continues to be the leading cause of death for African American females ages 25-34, creating additional social and economic burdens for families and communities who have been devastated by this epidemic. This qualitative phenomenological heuristic study was conducted using focus group interviews, journal entries, and letters to explore the lived experiences of nine courageous HIV/ positive African American females, ages 39 to 78, living in the Metropolitan area of Orlando, FL. Additionally, over 2 years of the researcher’s journal entries were added to the richness of the collected data. Findings included four core themes that emerged from the data analysis: (a) lack of knowledge about HIV/AIDS and related issues; (b) low self-worth, poor self-acceptance, and lack of responsibility for self; (c) personal, familial, and social conflicts; and (d) stigma, fear, shame, and guilt that contributed to the HIV seroconversion in nine African American females. The following three themes may be used potentially to develop prevention programs for generalized populations throughout the United States: (e) spiritual and faith based initiatives of shared core beliefs; (f) empowerment and advocacy groups based on attributes of women as healers; and (g) peer campaigns strategies.

Bakgrund Förekomsten av diabetes typ-2 har ökat dramatiskt och cirka en halv miljard människor världen över har diabetes. Prediabetes är en av de riskfaktorer som ökar risken för att utveckla diabetes typ-2. Många studier har visat att livsstilsförändringar kan minska risken eller fördröja uppkomsten av diabetes typ-2. Syfte: Diabetessköterskors upplevelser och erfarenheter av att arbeta med metoder och insatser inom primärvården för att förhindra utveckling av diabetes typ-2 hos patienter med prediabetes Metod: Kvalitativ studie med semistrukturerade intervjuer. Resultat: Resultatet visade att screening och remittering till diabetessjuksköterskor för samtal med levnadsvanor och uppföljningar användes. Fem kategorier identifierades utifrån deras erfarenheter av förebyggande arbete: 1-upplevelser av att känna organisatoriskt stöd ger förutsättningar för preventivt arbete. 2-Upplevelser av att ha organisatoriska begränsningar eller hinder i patientarbete. 3-Rådgivning och stöd nämndes som mycket viktig del i deras patientarbete med livsstilsförändringar.4-Att ha verktyg underlättar preventionsarbete. 5-Upplevelser av att ha olika utmaningar och svårigheter i patientkommunikation- och information Slutsatser: Studien visade diabetessjuksköterskor hade olika erfarenheter avseende preventionsarbete utifrån de organisatoriska förutsättningar och förhållande de hade samt hur deras patientklienter såg ut vilket skulle kunna påverka deras preventionsarebete. Resursbrist och avsaknad av rutiner försvårade deras arbete. Därför är det viktigt att diabetessköterskor arbetsförhållande förbättras. Även utbildningar om befintliga rekommendationer eller riktlinjer avseende hälsofrämjande åtgärder är nödvändiga.

Betyg i Ladok  210625.

Bakgrund Förekomsten av diabetes typ-2 har ökat dramatiskt och cirka en halv miljard människor världen över har diabetes. Prediabetes är en av de riskfaktorer som ökar risken för att utveckla diabetes typ-2. Många studier har visat att livsstilsförändringar kan minska risken eller fördröja uppkomsten av diabetes typ-2. Syfte: Diabetessköterskors upplevelser och erfarenheter av att arbeta med metoder och insatser inom primärvården för att förhindra utveckling av diabetes typ-2 hos patienter med prediabetes Metod: Kvalitativ studie med semistrukturerade intervjuer. Resultat: Resultatet visade att screening och remittering till diabetessjuksköterskor för samtal med levnadsvanor och uppföljningar användes. Fem kategorier identifierades utifrån deras erfarenheter av förebyggande arbete: 1-upplevelser av att känna organisatoriskt stöd ger förutsättningar för preventivt arbete. 2-Upplevelser av att ha organisatoriska begränsningar eller hinder i patientarbete. 3-Rådgivning och stöd nämndes som mycket viktig del i deras patientarbete med livsstilsförändringar.4-Att ha verktyg underlättar preventionsarbete. 5-Upplevelser av att ha olika utmaningar och svårigheter i patientkommunikation- och information Slutsatser: Studien visade diabetessjuksköterskor hade olika erfarenheter avseende preventionsarbete utifrån de organisatoriska förutsättningar och förhållande de hade samt hur deras patientklienter såg ut vilket skulle kunna påverka deras preventionsarebete. Resursbrist och avsaknad av rutiner försvårade deras arbete. Därför är det viktigt att diabetessköterskor arbetsförhållande förbättras. Även utbildningar om befintliga rekommendationer eller riktlinjer avseende hälsofrämjande åtgärder är nödvändiga.

Betyg i Ladok  210625.

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O objetivo foi avaliar as condições de processo e de resultado do atendimento às pessoas acima de 20 anos com diagnóstico de diabetes mellitus, residentes na área de cobertura da Unidade Básica de Saúde Vila Gaúcha, Porto Alegre. Avaliou-se a taxa de pacientes controlados com diabetes mellitus referido. A definição de controle foi estabelecida a partir dos valores da pressão arterial, hemoglobina glicada, circunferência abdominal e, ou, IMC. Entre 753 pessoas acima de 20 anos, 37 (4,9%; IC95% 3,4 – 6,5) referiram diabetes mellitus diagnosticado por médico. Foi possível realizar as medidas de controle em 31 (83,8%) pessoas. Os resultados mostraram 24 (77,4%) indivíduos apresentando níveis pressóricos alterados, 25 (80,6%) com IMC igual ou maior que 25 kg/m², 29 (93,5%) com circunferência abdominal acima da normalidade e 18 (58,1%) com hemoglobina glicada igual ou maior que 8%. Quanto aos indicadores de resultado utilizaram-se diagramas para análise dos fatores da taxa de pacientes controlados. Apenas um pacien
This study aimed to assess service condition process and results for people aged over 20 years, diagnosed with diabetes mellitus and living in an area covered by the Unidade Básica de Saúde Vila Gaúcha (Vila Gaúcha Basic Health Unit), in the city of Porto Alegre. Disease control rate of interviewees with self-reported diabetes was assessed. Definition of this rate was established from arterial pressure values, glycosylated hemoglobin, abdominal circumference, and/or BMI. Of the 752 people aged over 20 years, 37 (4.9%; 95% CI 3.4 – 6.5) mentioned diabetes mellitus diagnosed by a doctor. Disease control rate measurements could be performed in 31 (83.8%) people. Results revealed 24 (77.4%) individuals with altered blood pressure levels, 25 (80.6%) with BMI equal to or above 25 kg/m², 29 (93.5%) with abdominal circumference above normal and 18 (58.1%) with glycosylated hemoglobin equal to or above 8%. In terms of result indicators, diagrams were used to analyze disease control rate factors. Only one patient was c

Introdução: A ocorrência das diferentes incontinências e da constipação intestinal (CI), de forma isolada ou concomitante, não é pouco frequente no ambiente hospitalar. Esses problemas de saúde ainda são pouco investigados e os estudos com pacientes hospitalizados são escassos. Conhecer sua prevalência e fatores associados em pacientes hospitalizados é necessário para promover a sensibilização dos profissionais de saúde sobre a importância dessas necessidades passíveis de intervenções durante o período da internação. Objetivo: Identificar e analisar a prevalência das incontinências urinária (IU) e fecal (IF), de forma isolada e combinada, e da CI e as variáveis sociodemográficas e clínicas associadas às suas ocorrências em pacientes hospitalizados. Métodos: Trata-se de um estudo epidemiológico, observacional, transversal, analítico e descritivo, onde a amostra do estudo foi composta de 345 pacientes adultos e idosos hospitalizados no Hospital Universitário da USP. Os dados foram coletados por meio de entrevista, exame físico e registros de prontuários, utilizando-se os seguintes instrumentos: questionário de dados Sociodemograficos e Clínicos, Características das Perdas Urinárias, International Consultation on Incontinence Questionnaire - ICIQ-SF, Hábito Intestinal na População Geral e o Índice de Incontinência Anal IIA. A prevalência dos eventos estudados foi levantada quatro vezes (prevalência-ponto), em um único dia, nos meses de março, abril, maio e junho, sempre no mesmo dia do mês, de forma a atender o tamanho amostral para a análise dos fatores associados. Os dados foram analisados utilizando-se os testes qui-quadrado e Fisher para as variáveis categóricas, os testes t-student e Mann-Whitney para as variáveis numéricas, além de regressão logística (forward stepwise) para a identificação de fatores associados. Resultados: Obtiveram-se as seguintes prevalências: 22,9% para IU (28% para mulheres e 16,1% para homens); 7,9% para IF (9,4% para mulheres e 6% para homens); 4,7% para incontinência combinada (IC) (7,3% para mulheres e 1,4% para homens) e 14,9% para CI (15% para mulheres e 14,7% para homens). Dentre as incontinências, conseguiu-se detectar fatores associados somente para a IU: sexo feminino (OR=3,89; IC95% 1,899-7,991); idade (OR=1,03; IC95% 1,019-1,054); asma (OR=3,66; IC95% 1,302-10,290); estar em uso de laxantes (OR=3,26; IC95% 1,085-9,811); o uso de fralda no momento da avaliação (OR=2,75; IC95% 1,096-6,908); o uso de fralda em casa (OR=10,29; IC95% 1,839-57,606) e o uso de fralda em algum momento da internação (OR=6,74; IC95% 0,496-91,834). Especificamente para o sexo feminino, as variáveis associadas à IU foram: idade (OR=1,03; IC95% 1,017-1056); Diabetes Mellitus (OR=2,59; IC95% 1,039-6,489); asma (OR=4,92; IC95% 1,460-16,588) e número de partos (OR=1,27; IC95% 1,064-1,522). Os fatores que apresentaram associação com a CI foram: anos de estudo (OR=0,91; IC95% 0,856-0,985) e estar em uso de laxantes (OR=8,08; IC95% 3,387-19,282). Conclusão: Os valores de prevalência encontrados no presente estudo, assim como os fatores associados, foram similares aos achados de estudos epidemiológicos nacionais e internacionais realizados com população geral, porém distintos daqueles oriundos da escassa literatura internacional existente sobre o tema para adultos e idosos hospitalizados. Estudos longitudinais fazem-se necessários para a confirmação das relações encontradas entre as variáveis estudadas, contribuindo para o diagnóstico mais acurado da causalidade dessas condições e, portanto, o estabelecimento de medidas mais eficazes de prevenção e tratamento das incontinências e da CI no cenário hospitalar.
Introduction: The occurrence of different incontinences and intestinal constipation (IC), alone or concomitantly, is not uncommon in the hospital setting. These health problems are still poorly investigated and studies of inpatients are scarce. Knowing their prevalence and associated factors in hospitalized patients is necessary to promote the awareness of health professionals about the importance of these possible interventional needs during the period of hospitalization. Objective: To identify and to analyze the prevalence of urinary (UI) and fecal incontinence (FI), in an isolated and combined manner, and IC, and sociodemographic and clinical variables associated with their occurrences in hospitalized patients. Methods: This is an observational, cross-sectional, analytical and descriptive epidemiological study, where the study sample consisted of 345 adult and elderly patients hospitalized at University Hospital of USP. The data were collected through interviews, physical examination and medical records, using the following instruments: Sociodemographic and Clinical Data, Characteristics of Urinary Loss, International Consultation on Incontinence Questionnaire - ICIQ-SF, Intestinal Habit of the General Population and the Anal Incontinence Index - IIA. The prevalence of the events studied was raised four times (point-prevalence) in a single day in March, April, May and June, always on the same day of each month, in order to meet the sample size for the analysis of the factors associated. Data were analyzed using chi-square and Fisher tests for categorical variables, t-student and Mann-Whitney tests for numerical variables, and logistic regression for the identification of associated factors. Results: The following prevalences were obtained: 22.9% for UI (28% for women and 16.1% for men); 7.9% for FI (9.4% for women and 6% for men); 4.7% for combined incontinence (CI) (7.3% for women and 1.4% for men) and 14.9% for IC (15% for women and 14.7% for men). Among the incontinences, it was possible to detect factors associated only for UI: female gender (OR=3.89; IC95% 1,899- 7,991); age (OR=1.03; IC95% 1.019-1.054); asthma (OR=3.66; IC95% 1.302-10.290); being in use of laxatives (OR=3.26; IC95% 1.085-9.811); The use of the diaper at the time of evaluation (OR=2.75; IC95% 1.096-6.908); The use of diapers at home (OR=10.29; IC95% 1,839-57,606) and the use of diapers at some time of hospitalization (OR=6.74; IC95% 0.496- 91.834). Specifically for females, the variables associated with UI were: age (OR=1.03; IC95% 1.017-1056); Diabetes Mellitus (OR=2.59; IC95% 1.039-6.489); asthma (OR=4.92; IC95% 1,460-16,588) and number of deliveries (OR=1.27; IC95% 1.064-1.522). The factors that showed association with IC were: years of study (OR=0,91; IC95% 0,856-0,985) and being in use of laxatives (OR=8,08; IC95% 3,387-19,282). Conclusion: The prevalence values found in the present study as well as the associated factors were similar to the findings of National and International epidemiological studies conducted with the general population. But they were quite different from those of the scarce existing International literature for hospitalized adults and elderly people. Longitudinal studies are necessary to confirm the relationships found between the studied variables, contributing to a more accurate diagnosis of the causality of these conditions and, therefore, the establishment of more effective measures of prevention and treatment of incontinence and IC in the hospital setting.

INTRODUÇÃO: O melanoma cutâneo constitui cerca de 3% de todos os tumores da pele. Atinge indivíduos jovens com média de idade de aparecimento entre 50 e 58 anos. Em torno de 20% dos doentes apresentarão doença avançada e morrerão antes de completar cinco anos de sobrevida. CASUÍSTICA E MÉTODOS: Neste estudo retrospectivo de 364 casos acompanhados de maio de 1993 a janeiro de 2006 descreveram-se as variáveis: sexo, idade, cor, localização da lesão primária, tipo de crescimento, espessura de Breslow, nível de Clark, presença de ulceração, estadiamento e suas correlações. RESULTADOS: Predominou o sexo feminino (58,8%) resultando em uma proporção de 1,4 mulheres para cada homem. A média das idades dos pacientes foi de 58,9 anos e a mediana de 61,0 anos. Pacientes não-brancos constituíram 13,7% da amostra. Para homens e mulheres o melanoma cutâneo localizou-se, predominantemente no tronco (24,3-38,0%) e pés (21,4-23,9%). O melanoma acrolentiginoso representou 22,3% de toda amostra. Os padrões melanoma expansivo superficial e melanoma nodular (p < 0,001) e lesões no tronco (52,8%) predominaram nos indivíduos brancos. O melanoma acrolentiginoso (64%) e a localização nos pés (68,2%)prevaleceram nos pacientes não-brancos. Observou-se minoria de casos com lesão primária in situ (14,6%- EC 0) e alto percentual de melanoma cutâneo espesso (39,7% > 4,0 mm). Presença de ulceração foi observada em 13,4% para tumores finos (= 1,0 mm). Homens apresentaram lesões mais espessas (p = 0,011) e ulceradas (p < 0,001) em relação às mulheres, assim como idosos em relação à não idosos (p = 0,021 para a espessura e p = 0,015 para ulceração). A sobrevida média para os pacientes com doença localizada foi de 97,8 meses e a taxa de sobrevida específica para melanoma cutâneo foi de 85,1% em três anos. CONCLUSÕES: Esta amostra constituiu-se de pacientes com tumores espessos e ulcerados denotando diagnóstico tardio do melanoma cutâneo e pior prognóstico. Caracterizou-se por apresentar predomínio de mulheres, de pacientes não-brancos, de lesões nas extremidades e de melanoma acrolentiginoso.
INTRODUCTION: Cutaneous melanoma represents around 3% of all skin tumors. Affecting young patients, with mean age between 50 and 58 years old. About 20% of the patients will have advanced disease and will die before five years of survival. CASUISTIC AND METHODS: In this retrospective study of 364 cases recorded from May 1993 to January 2006 at the Melanoma Unit of Santa Casa de São Paulo the following variables were described: sex, age, skin color, tumor site, growth pattern, tumor thickness, Clark level, ulceration, staging and their correlations. RESULTS: Female (58,8%) prevailed resulting in 1,4 women for each man. The mean age of the patients was 58,9 years old and the median, 61,0 years old. Non-white patients were 13,7% of the sample. The anatomic site of cutaneous melanoma on men and women prevailed at trunk (24,3 – 38,0%) and feet (21,4 – 23,9%). Acral entiginous melanoma represented 22,3% of the cohort. Superficial expansive melanoma and nodular melanoma patterns (p<0,001) and trunk lesions (52,8%) predominated on white patients. Acral lentiginous melanoma (64%) and feet anatomic site 68,2%) prevailed on non-white patients. In situ primary lesions were observed in few cases (14,6% - EC 0) and there was high percentage of thick cutaneous melanoma (39,7% > 4,0 mm). In thin tumors (=1,0 mm) were found 13,4% of ulceration. Thickener (p = 0,011) and ulcerated lesions (p < 0,001) were found more in male and in elderly patients (p = 0,021 for thickeness and p = 0,015 for ulceration). The mean survival of patients with local disease was 97,8 months and the three-year survival rate for cutaneous melanoma was 85,1%. CONCLUSIONS: The cohort consisted mostly of thick and ulcerated tumors, which meant late diagnosis and bad prognosis. Also distinguished by considerable prevalence of female, non-white patients, limb lesions and acral lentiginous melanoma.