Dissertations / Theses on the topic 'Life years lost'

Made available in DSpace on 2016-12-12T17:32:59Z (GMT). No. of bitstreams: 1 RESUMO KADINE.pdf: 15853 bytes, checksum: bfa11d3fee681ef7c30a44a0738800d9 (MD5) Previous issue date: 2015-12-10
Coordenação de Aperfeiçoamento de Pessoal de Nível Superior
Os estudos de Carga Global da Doença (GBD) alertam que idosos com doenças crônicas irão viver mais, porém com incapacidades como é o caso das amputações de membros inferiores atribuíveis ao diabetes mellitus (DM). O objetivo deste estudo foi estimar a GBD para as amputações de membros inferiores atribuíveis ao DM no Estado de Santa Catarina, no período de 2008 a 2013. Realizou-se um estudo epidemiológico descritivo de base hospitalar, utilizando o cálculo de DALY (disability adjusted life years). A partir das Autorizações de Internação Hospitalar no período de 2008 a 2013, foram incluídas pessoas submetidas à cirurgia de amputação nos hospitais públicos do Estado de Santa Catarina e a prevalência do óbito por DM registrados no sistema de informação de mortalidade nesse período. Ocorreram 1.183 amputações de membros inferiores em pessoas com DM nos últimos 6 anos considerando-se todas as microrregiões do Estado de Santa Catarina. A carga revelou-se elevada e a morbidade foi a principal responsável por mais de 8 mil anos de vida sadia perdidos (93% do DALY), em homens e mulheres acima de 60 anos de idade com maior impacto na expectativa de vida de homens. Estimamos a GBD de uma população majoritariamente idosa que envelhecerá com a amputação de membro Inferior. Assim, há necessidade de assistência planejada a partir de intervenções reabilitadoras em tempo real, levando em consideração que as distribuições das taxas de DALY nas 20 microrregiões do estado não mostraram distribuição homogênea. Alerta-se para a criação de equipes multidisciplinares para a identificação precoce do pé diabético, além da necessidade de capacitação das equipes na atenção especializada e ampliação da atuação do fisioterapeuta na reabilitação pré e pós-protetização.

Climate change is expected to be one of the biggest global health threats in the 21st century. In response to changes in climate and associated extreme events, public health adaptation has become imperative. This thesis examined several key issues in this emerging research field. The thesis aimed to identify the climate-health (particularly temperature-health) relationships, then develop quantitative models that can be used to project future health impacts of climate change, and therefore help formulate adaptation strategies for dealing with climate-related health risks and reducing vulnerability. The research questions addressed by this thesis were: (1) What are the barriers to public health adaptation to climate change? What are the research priorities in this emerging field? (2) What models and frameworks can be used to project future temperature-related mortality under different climate change scenarios? (3) What is the actual burden of temperature-related mortality? What are the impacts of climate change on future burden of disease? and (4) Can we develop public health adaptation strategies to manage the health effects of temperature in response to climate change? Using a literature review, I discussed how public health organisations should implement and manage the process of planned adaptation. This review showed that public health adaptation can operate at two levels: building adaptive capacity and implementing adaptation actions. However, there are constraints and barriers to adaptation arising from uncertainty, cost, technologic limits, institutional arrangements, deficits of social capital, and individual perception of risks. The opportunities for planning and implementing public health adaptation are reliant on effective strategies to overcome likely barriers. I proposed that high priorities should be given to multidisciplinary research on the assessment of potential health effects of climate change, projections of future health impacts under different climate and socio-economic scenarios, identification of health cobenefits of climate change policies, and evaluation of cost-effective public health adaptation options. Heat-related mortality is the most direct and highly-significant potential climate change impact on human health. I thus conducted a systematic review of research and methods for projecting future heat-related mortality under different climate change scenarios. The review showed that climate change is likely to result in a substantial increase in heatrelated mortality. Projecting heat-related mortality requires understanding of historical temperature-mortality relationships, and consideration of future changes in climate, population and acclimatisation. Further research is needed to provide a stronger theoretical framework for mortality projections, including a better understanding of socioeconomic development, adaptation strategies, land-use patterns, air pollution and mortality displacement. Most previous studies were designed to examine temperature-related excess deaths or mortality risks. However, if most temperature-related deaths occur in the very elderly who had only a short life expectancy, then the burden of temperature on mortality would have less public health importance. To guide policy decisions and resource allocation, it is desirable to know the actual burden of temperature-related mortality. To achieve this, I used years of life lost to provide a new measure of health effects of temperature. I conducted a time-series analysis to estimate years of life lost associated with changes in season and temperature in Brisbane, Australia. I also projected the future temperaturerelated years of life lost attributable to climate change. This study showed that the association between temperature and years of life lost was U-shaped, with increased years of life lost on cold and hot days. The temperature-related years of life lost will worsen greatly if future climate change goes beyond a 2 °C increase and without any adaptation to higher temperatures. The excess mortality during prolonged extreme temperatures is often greater than the predicted using smoothed temperature-mortality association. This is because sustained period of extreme temperatures produce an extra effect beyond that predicted by daily temperatures. To better estimate the burden of extreme temperatures, I estimated their effects on years of life lost due to cardiovascular disease using data from Brisbane, Australia. The results showed that the association between daily mean temperature and years of life lost due to cardiovascular disease was U-shaped, with the lowest years of life lost at 24 °C (the 75th percentile of daily mean temperature in Brisbane), rising progressively as temperatures become hotter or colder. There were significant added effects of heat waves, but no added effects of cold spells. Finally, public health adaptation to hot weather is necessary and pressing. I discussed how to manage the health effects of temperature, especially with the context of climate change. Strategies to minimise the health effects of high temperatures and climate change can fall into two categories: reducing the heat exposure and managing the health effects of high temperatures. However, policy decisions need information on specific adaptations, together with their expected costs and benefits. Therefore, more research is needed to evaluate cost-effective adaptation options. In summary, this thesis adds to the large body of literature on the impacts of temperature and climate change on human health. It improves our understanding of the temperaturehealth relationship, and how this relationship will change as temperatures increase. Although the research is limited to one city, which restricts the generalisability of the findings, the methods and approaches developed in this thesis will be useful to other researchers studying temperature-health relationships and climate change impacts. The results may be helpful for decision-makers who develop public health adaptation strategies to minimise the health effects of extreme temperatures and climate change.

Ainda que limitadas enquanto expressão dos eventos ligados à saúde e apesar das deficiências em relação à cobertura e à qualidade dos dados, as estatísticas de mortalidade constituem um dos mais importantes subsídios para o planejamento e avaliação dos serviços de saúde. Tradicionalmente, a mortalidade de uma determinada população tem sido aferida por meio das taxas brutas e específicas de mortalidade. Porém, esses índices consideram apenas a magnitude das causas de óbito, sem qualificar o peso resultante dessas mortes para a sociedade. Neste sentido, tem-se enfatizado cada vez mais a importância da mortalidade prematura enquanto expressão social do valor da morte, pois esta, quando ocorre numa idade de altas criatividade e produtividade não só afeta o indivíduo e o grupo social que convive diretamente com ele, mas a sociedade como um todo, que é privada do seu potencial econômico e intelectual (REICHENHEIM; WERNECK, 1994). \"O indicador Anos Potenciais de Vida Perdidos (APVP), ao combinar a magnitude das mortes com a idade em que ocorreram os óbitos, qualifica essas mortes\" (KERR-PONTES; ROUQUAYROL, 1999 apud SAUER; WAGNER, 2003, p. 1520). Este estudo pretendeu avaliar a evolução dos APVPs nos municípios e regionais de saúde do Estado de São Paulo, no período de 2003 a 2013, para a população total. Pretendeu, também, analisar a evolução retrospectiva das 15 causas de óbito com as maiores taxas de APVP em 2013, para a população total do Estado de São Paulo. Para tanto, foi elaborada uma base de dados a partir dos óbitos de residentes do Estado de São Paulo ocorridos no período de 2003 a 2013 e processados pelo SIM (Sistema de Informação sobre Mortalidade), sendo as causas de morte classificadas de acordo com a Décima Revisão da Classificação Internacional de Doenças (CID 10). O cálculo dos APVPs foi realizado com base numa proposta feita por Romeder e McWhinnie (1988) e, após elaborados os dados, foram confeccionados cartogramas utilizando o programa Tabwin para visualização da evolução dos APVPs nas regionais de saúde do Estado. Foram construídos gráficos de linha para a observação da evolução das 15 causas de óbito com as maiores taxas de APVP de 2003 a 2013. Posteriormente, foram analisadas as Taxa de Mortalidade Geral (TMG), Taxa de Mortalidade Infantil (TMI) e Taxa de Mortalidade Materna (TMM) para os anos de 7 2003 a 2013 para o Estado de São Paulo. E, finalmente, foram avaliados: as dimensões escolaridade, longevidade e riqueza do Índice Paulista de Responsabilidade Social (IPRS) em cada um de seus grupos; frequência absoluta e relativa do IPRS em cada um de seus grupos; relação do IPRS segundo Redes Regionais de Atenção à Saúde (RRAS); relação IPRS segundo Grupos Populacionais; TAPVP por grupos de IPRS; TAPVP por Grupos Populacionais; TAPVP por RRAS; IPRS na sua dimensão Riqueza por TAPVP; IPRS na sua dimensão Longevidade por TAPVP; IPRS na sua dimensão Escolaridade por TAPVP; Correlação entre as dimensões do IPRS e TAPVP. Todas estas avaliações são válidas para o Estado de São Paulo para o ano de 2012 e foram obtidas utilizando-se o aplicativo Stata 9.0. A Taxa de Mortalidade Geral (TMG) para o Estado de São Paulo para o período de 2003 a 2013 em comparação com a do Brasil mostrou-se desfavorável, o mesmo acontecendo com a Taxa de Mortalidade Infantil (TMI), cujo predomínio, no Estado, foi do componente Pós-Neonatal. Já a Taxa de Mortalidade Materna (TMM) demonstrou boa assistência ao pré-natal, parto e puerpério no Estado no período citado. Observando-se a evolução das TAPVP nos cartogramas do Estado de São Paulo no período de 2003 a 2013 as RRAS onde as TAPVP foram maiores foram: 6, 7, 9, 10, 11, 12, 13 e 17. Das quinze maiores causas de óbito segundo TAPVP para o Estado no período, nove são passíveis de prevenção na atenção primária. Citou-se ainda o subregistro e a tripla carga de doenças. A maioria dos 645 municípios do Estado de São Paulo, no ano de 2012 apresentaram um IPRS de grupo 4. Houve 95% de probabilidade de que a maior TAPVP ocorreu para o IPRS 4 com um IC de 17.325,04 a 18.424,20. O Teste de Anova, com 4 gl mostrou diferença significativa (p<0,05) na TAPVP por grupos de IPRS. Com 5 graus de liberdade, o Teste de Kruskal-Wallis foi significativo (p<0,05) indicando que houve diferença entre os Grupos Populacionais quanto à TAPVP. Com 16 graus de liberdade, o Teste de Kruskal-Wallis foi significativo (p<0,05) indicando que existiu diferença entre as RRAS quanto às TAPVP. À medida que aumentou a riqueza do IPRS, diminuiu, ainda que discretamente, a TAPVP. Longevidade e TAPVP mantiveram-se estáveis. Conforme aumentou a escolaridade, aumentou a TAPVP. Por existir uma correlação positiva entre riqueza e longevidade e escolaridade, à medida que aumentou a riqueza, aumentaram a longevidade e escolaridade. Com relação a TAPVP e riqueza e longevidade, o coeficiente de correlação foi negativo, significando que à medida que aumentaram a riqueza e 8 longevidade, diminuiu a TAPVP. Porém, com relação à escolaridade, o coeficiente de correlação entre o mesmo e a TAPVP foi positivo, indicando que à medida que aumentou a escolaridade, aumentou a TAPVP. Por fim, essa dissertação poderia ser apresentada às autoridades de saúde do Estado como um projeto para redução da mortalidade prematura, com foco em melhoria da educação básica, instalação de mais serviços de saúde de qualidade e adequação dos serviços de segurança pública.
Although limited as an expression of health-related events and despite problems concerning the coverage and quality of available data, mortality estimates are among the most important foundations for the planning and evaluation of health services. Traditionally, mortality has been estimated according to the gross and specific mortality rates in a given population. However, these indicators consider the impact of death causes alone, without qualifying the burden resulting from deaths to society. The importance of premature mortality as a social expression of the burden of death has therefore received increasing attention, as it occurs at an age range of high creativity and productivity and affects not only the individual and his direct social group, but society as a whole, whose economic and intellectual potential is affected (REICHENHEIM; WERNECK, 1994). The estimate of potential years of life lost (PYLL) provides a more detailed assessment of mortality by combining death rates and the age when death occurs (KERR-PONTES; ROUQUAYROL, 1999 apud SAUER; WAGNER, 2003, p. 1520). Our study was aimed at assessing the evolution of PYLL rates in the total population of cities and health districts in the State of São Paulo, Brazil, between 2003 and 2013. We also assessed the retrospective evolution of the 15 death causes with the greatest PYLL rates in 2013 for the total population of the State of São Paulo. In order to achieve this, we created a database with information on deaths occurred in the state between 2003 and 2013 which were processed by the Mortality Information System (MIS), with death causes classified according to the 10th revision of the International Classification of Diseases (ICD-10). PYLL rates were calculated according to the method proposed by Romeder and McWhinnie (1988) and data charts 9 were created in TabWin to display the evolution of PYLL rates in the health districts of the state. Line graphs were created to display the evolution of the 15 death causes with the highest PYLL rates between 2003 and 2013. We further assessed the general mortality rate (GMR), child mortality rates (CMR), and mother mortality rates (MMR). Finally, we assessed the education, longevity, and wealth dimensions of the São Paulo Index of Social Responsibility (SPISR) in each of its groups; absolute and relative frequency of the SPISR in each of its groups; relationship of the SPISR according to the Regional Health Care Networks (RHCN); SPISR relationship according to population groups; PYLL rates by SPISR group; PYLL rates by population groups; PYLL rates by RHCN; SPISR dimension \'wealth\' by PYLL rates; SPISR dimension \'longevity\' by PYLL rates; SPISR dimension \'education\' by PYLL rates; and correlations between SPISR dimensions and PYLL rates. All the analyses are valid for the State of São Paulo in the year of 2012 and were made using the Stata 9.0 software. The GMR in the State of São Paulo for the period of 2003-2013 was worse compared to Brazil, and so was the CMR, with a predominance of the post-neonatal component in the State. The MMR indicated the availability of adequate prenatal, delivery, and postpartum assistance in the State during the period. The data charts displaying the evolution of PYLL rates in the State of São Paulo show that the RHCNs with the highest PYLL rates were 6, 7, 9, 10, 11, 12, 13, and 17. From the main 15 death causes according to PYLL rates in the period, 9 can be prevented in primary care. Under-recording and the triple load of diseases were also detected. The SPISR of most of the 645 municipalities in the State of São Paulo in the year 2012 was 4. The probability that the highest PYLL rate was associated with a SPISR of 4 was 95%, with a confidence interval between 17325.04 and 18424.20. An ANOVA with 4 degrees of freedom showed significant differences (p<0.05) in PYLL rates by SPISR group. With 5 degrees of freedom, the test of Kruskal-Wallis provided significant results (p<0.05), indicating the existence of differences between population groups in respect to PYLL rates. With 16 degrees of freedom, the Kruskal-Wallis test indicated the existence of significant differences between the RHCNs in terms of PYLL rates. PYLL rates decreased, although subtly, with the increase of wealth in the SPISR. Longevity and PYLL rates remained stable. As education increased, PYLL rates also increased. Since there was a positive correlation between wealth, longevity, and education, increased wealth was associated 10 with increased longevity and education as well. Concerning the relationship between PYLL rates and wealth and longevity, we found a negative correlation coefficient, indicating that as wealth and longevity increased, PYLL rates decreased. In respect to education, however, the correlation with PYLL rates was positive, indicating that increases in education were associated with increases in PYLL rates. Finally, this dissertation could be presented to the health authorities of the State of São Paulo as a project to reduce early mortality, focused on improvements in basic education, expansion of high-quality health services, and improvements in public security

En un contexto de envejecimiento de la población activa y de implantación de medidas de retraso de la jubilación, la presente tesis estudia la relación entre las condiciones de empleo a través de las trayectorias laborales y la salida prematura del mercado de trabajo por incapacidad permanente (IP). La IP es un fenómeno que pone en crisis la sostenibilidad del sistema de protección social y debilita el mercado de trabajo. Los resultados, basados en el análisis de la Muestra Continua de Vidas Laborales (MCVL), muestran que factores como la ocupación y las características de las trayectorias laborales en términos de flexibilidad e inseguridad influyen en el abandono definitivo de la vida laboral activa. Las categorías de trabajadores no cualificadas (en especial las manuales) y las trayectorias laborales caracterizadas por una alta inseguridad y una alta flexibilidad, presentan en mayor medida un abandono prematuro del mercado de trabajo, medido en términos de Años Potenciales de Vida laboral perdidos (APVLP). Sin embargo, hemos observado que en términos de estos APVLP, las trayectorias caracterizadas por una alta flexibilidad, compensada con una baja inseguridad, suponen un retraso en la salida prematura del mercado de trabajo por IP. Una política de relaciones laborales que favorezca la flexiseguridad puede ayudar a retrasar la salida prematura del mercado de trabajo.
In a context of active population ageing and implementation of policies to postpone retirement, this thesis examines the relationship between employment conditions through labor market trajectories and early retirement due to permanent disability (PD). This phenomenon puts a strain on the sustainability of the social protection system and weakens the labor market. Results based on the Continuous Working Life Sample (CWLS) show that factors, as the occupation and labor market trajectories characteristics in terms of flexibility and insecurity, influence on the definitive cessation of active working life. Non qualified occupational categories (especially manual categories) and those labor market trajectories characterized by high insecurity and high flexibility show to a greatest extent an early retirement measured by potential years of working life lost (PYWLL). However, we have observed that in terms of these PYWLL, labor market trajectories characterized by high flexibility, compensated by low insecurity, involve a delay in the early retirement due to PD. Labor relations policies that promote flexicurity can help to delay early retirement from the labor market.

Purpose: This critical interpretive and historical case study of Australian Red Cross extends from the organisation’s beginning in 1914 through to the present day. The overarching purpose is to reveal and analyse the annual reporting practices of one of Australia’s oldest and most important humanitarian organisations in the discharge of accountability over the course of a century. Design/methodology/approach: A Political Economy of Accounting theoretical framework guides the content analysis and interpretation of findings. Background: While the review of literature acknowledges the annual report as a crucial element in the discharge of accountability, studies investigating the evolution of annual reports of International nongovernmental development and humanitarian aid organisations (INGDHOs) over extended periods of time appear to be absent from the literature. Findings: The annual reports were found to be responsive to the changing social, political, economic and institutional environment, casting doubt on any claims to objectivity in organisational management’s disclosures, including assertions regarding unadulterated adherence to its Fundamental Principles. Furthermore, sources of pressure from the wider environmental context impacted upon the development of accountability regimes and shaped the way in which organisational management reported to stakeholders. These regimes evidence the alignment of mission preservation and emotive disclosures with strategic priorities. Implications: This study extends understandings of how INGDHOs discharge accountability through annual reporting practices. It provides a more holistic framework for understanding the role of accountability in organisational management reporting, the development of accountability regimes and the implications for organisational and social functioning. Originality/value (significance): The contribution is distinctive not only for the context and extensive period covered, but also for the significant institutional setting of Australian Red Cross – encompassing deep social, political, economic and institutional changes. This adds to the extant literature and provides significant insights into the contested interplay between annual reporting practices and accountability regimes.
Doctor of Philosophy

Le taux de survie à 5 ans des cancers de l'enfant atteint aujourd'hui 80 %. Les survivants à 5 ans de cancer pédiatrique (CCS) ont cependant un risque accru d'occurrence de nombreux évènements. Beaucoup d'études ont été réalisé pour comprendre les liens entre ces évènements iatrogènes et les traitements pédiatriques, et un taux élevé d'évènements iatrogènes multiples a été observé. Cependant, ce taux d'évènements iatrogènes multiples est méconnu. Ce projet de thèse avait pour objectif d'étudier les causes et conséquences de ce taux élevé.La recherche présentée dans cette thèse est basée sur les données de la French Childhood Cancer Survivors Study, une cohorte rétrospective à suivi prospectif de 7670 CCS diagnostiqués avant l'âge de 21 ans entre 1945 et 2000 en France. La cohorte contient des données détaillées sur les traitements des cancers pédiatriques, et un important travail de validation des évènements iatrogènes a été réalisé.Nous avons utilisé la méthode de landmark combiné avec des pseudo-observations, afin de pouvoir étudier les effets des seconds cancers sur l'incidence cumulée d'évènement cardiaque et les années de vie perdues des patients.Nous avons constanté une augmentation de risque instantanné (csHR: 2.1, 95% CI: 1,5-2,9) et de l'incidence cumulée d'évènement cardiaque (CD) (+3,8%, 95% CI: 0,5-7,1) après un second cancer. Nous avons aussi constaté un impact de la radiothérapie, des seconds cancers, et des CD sur l'espérance de vie des patients, avec respectivement 6, 10,5 et 7,7 années de vie perdues à 16 ans. Nous avons trouvé un effet nul de l'interaction entre second cancer et CD, mais notre analyse de simulation a montré que ce résultat est biaisé par la corrélation entre seconds cancers et CD.En conclusion, dans cette thèse nous avons démontré que le risque accru de multi-morbidité chez les CCS est partiellement attribuable à l'occurrence d'un premier évènements iatrogène. Nous avons aussi montré un fort impact des seconds cancers et évènements cardiaques sur l'espérance de vie des patients. Ces résultats nous ammènent à recommander une forte surveillance des patients dévelopant l'une de ces maladies, et de poursuivre la recherche sur la multi-morbidité chez les CCS qui apapraît complexe et forte de conséquences pour les patients
5-years survival of childhood cancer exceeds 80% today. Nonetheless, 5-year childhood cancer survivors (CCS) are at increased risk of health-related late effects. Many studies have been conducted to investigate the link between those late effects and childhood cancer treatments. Furthermore, an elevated number of patients experiencing multiple iatrogenic event was observed. However, little is known about the causes of this multi-morbidity. This thesis aimed to study the causes et consequences of this elevated multi-morbidity.Research presented in this thesis is based on the French Childhood Cancer Survivors Study, a retrospective cohort with prospective follow-up, following 7,670 CCS diagnosed in France before 21 years old between 1945 and 2000. This cohort contains detailed data regarding childhood cancer treatments, and the iatrogenic event observed were validated by trained professionals.We used the landmark method combined with pseudo-observations to study the consequences of subsequent malignant neoplasm on the cumulative incidence of cardiac disease, and the life years lost by CCS.We found a subsequent malignant neoplasm (SMN) to cause a two-fold increase in the cause-specific hazard of cardiac disease (CD) and a 3.8% increase of its cumulative incidence. We found the use of radiotherapy to treat childhood cancer, the occurrence of SMN, and of CD to impact the life expectancy of CCS, with respectively 6, 10.5, and 7.7 life years lost at 16 years old. We found a nul effect of the interaction of SMN and CD on the life expectancy, although our simulation study suggested this was biased by the correlation between SMN and CD.In conclusion, we demonstrated that the increased risk of multi-morbidity among CCS is partially attributable to the occurrence of a first iatrogenic event. We also showed that subsequent malignant neoplasm and cardiac disease have a strong impact on the life expectancy of CCS. Therefore, we recommend to keep following in details the CCS developing either disease, and to pursue further research on the multi-morbidity among CCS which appears to be complex and consequentful for patients

Rickettsiales-like organisms (RLOs) are thought to be related to bacteria in the order Rickettsiales. They have been reported to occur in the staghorn coral (Acropora cervicornis), and this study investigated trends of infection over time, and in relation to the health of infected corals. This study focuses on tissue samples taken mostly from visibly healthy A. cervicornis thickets in Broward County, Florida, and processed for histological examination. Samples were originally collected and analyzed to document reproduction during years 2001 through 2012, and tissue loss diseases (white-band disease [WBD] types I and II, and rapid tissue loss). The presence of suspect RLOs, the presence of ovoid bacterial aggregates in the basal body wall, and the condition of the coral tissue were examined in hematoxylin and eosin (H&E) and Giemsa-stained sections. Determination was made as to whether suspect RLO infection severity, location, or the presence of bacterial aggregates are correlated with changes in tissue condition associated with WBD. To better understand progression, trends, and periodicity in bacterial presence and coral tissue health, these data were then further analyzed for potential correlation with the month, year, and average monthly nighttime sea surface temperatures (categorized into ranges above, within, or below 24–29°C) when samples were collected. The severity of suspect RLO infections and the presence of bacterial aggregates in A. cervicornis varied over time, with no correlation with the location of suspect RLOs within the polyp. High suspect RLO prevalence was correlated with normal tissue conditions, while low suspect RLO prevalence was correlated with abnormal tissue conditions. However, high prevalence of bacterial aggregates was correlated to abnormal tissue conditions. Epidermal RLO and overall suspect RLO prevalence severity scores were significantly higher among samples collected when monthly average nighttime sea surface temperatures were below 24°C in contrast to samples collected when temperatures were between 24–29°C, suggesting direct or indirect effects of sea surface temperatures on infection severity. The areas of suspect RLO intracellular bodies within infected mucocytes were measured using digital image analysis software and found to be positively correlated with worsening coral tissue condition. Semiquantitative variable scores for histoslides stained with H&E were significantly different from those stained with Giemsa, indicating that these stains cannot be used interchangeably to study the presence of bacteria and the condition of coral tissue. Overall, the results of this study indicate that infection severity of suspect RLOs and the presence of bacterial aggregates are variable and correlated with the incidence of WBD-I in A. cervicornis. However, the exact nature of this relationship remains unclear. Further studies are necessary to interpret trends detected during this analysis to develop a better understanding of what contributes to the severe tissue-loss outbreaks and mortalities of A. cervicornis.

碩士
長庚大學
醫務管理學研究所
96
Due to the population aging and the epidemiologic transition, decreasing mortality of chronic illness is becoming critical for the continuing lengthening of life expectancy in Taiwan. This study decomposes crude death rate of chronic illness into three parts, which are prevalence rate, fatality rate and age composition. It is shown that crude death rate decreased at any age and the dying time postponed. Moreover, it is found that prevalence of chronic illness expanded and increase fast after 40 years old. This study finds the population aging and the prevalence of chronic disease both increasing to push the crude death rate of chronic disease upward. We apply the idea of cause deleted life table to the elimination of chronic illness, and then compare the differences before and after deducing the crude death rate of chronic illness. In terms of life expectancy, after deducing crude death rate of chronic illness by ordinary life table, we obtained 69.29 years of life at birth in 1971 and 89.75 years of life at birth in 2006. In this found that the chronic illness has resulted in 10.15 life lost years in 1971 and 12.12 life lost years in 2006, producing a gap of 1.97 years.

博士
國立臺灣大學
職業醫學與工業衛生研究所
93
The thesis was comprised of three papers. In the first paper, we assessed the life expectancy lost and potential work life lost resulting from cases of mortality and permanent disability by different types of occupational injuries during 1986-2000 in Taiwan. Databases of occupational mortality and permanent disability during 1986-2000 were retrieved from the Bureau of Labor Insurance, which were linked with the database of national death registry to construct the survival function. Then, a Monte Carlo simulation method was used to extrapolate the survivors up to 600 months to derive the life expectancy for different injury cases with permanent disability (n=81,249). For the mortality cases (n=20,001), the life expectancy lost were estimated by gender-, age-matched based on the life table of each calendar year. For occupational permanent disability, different types of injury showed variations of YPLL (years of potential life lost) ranged from 13.6 years to 7.4 years per case. The overall YPLL of occupational permanent disability is almost the same as that of occupational mortality, with a ratio of 1.04:1. After accounting for permanent impairment of working ability and assuming a uniform retirement age of 65, the YPWLL (years of potential work life lost) due to occupational permanent disability is about 62% of that resulting from occupational mortality. We concluded that permanent disability resulting from occupational injuries has a significant impact on society. Our estimations can provide empirical basis for both the health policy decision and improvement of the equity and efficiency of workmen compensation system in Taiwan and possibly other newly developed countries. In the second paper, the objectives of the study are to estimate the life expectancy and exploring the determinants of survival for workers with occupational permanent disability. Databases of occupational permanent disability during 1986-2000 were retrieved from the Bureau of Labor Insurance and linked with the database of national death registry to construct the survival function. A Monte Carlo simulation method was used to extrapolate the survivors of up to 600 months to derive the life expectancy for different types of occupational injuries with permanent disability (n=81,249). The Cox (proportional hazards) regression was conducted to explore the determinants and estimate the hazard ratios. We included demographic variables including age, gender, insured wage, severity of disability, injury causes, and organ-system disability into the model as the covariates. The results showed that workers with occupational permanent disability survived shorter than the general population after injury, giving estimated years of life loss ranged from 9 to 19 years. After the adjustment of age and gender, we found that a higher severity of disability, impairment of vital organ or lower extremities, and a lower insured wage were significantly associated with shorter survival. Injury types of struck by sliding objects, transportation, trip/slip, and tumble down showed hazard ratios between 1.24 – 1.34 compared with injury by caught in. We concluded that workers with occupational permanent disability survived shorter than general population. Our findings identified major determinants to predict survival for workers with occupational permanent disability, which may be used to improve the equity for workmen compensation system. Finally, within the process of calculating the true costs of illness, physical pain is a component of intangible, or human, costs. One method of estimating the monetary value of such costs is the ‘contingent valuation method’ (CVM), a stated preference method based upon the elicitation of levels of willingness to pay (WTP) facilitated through surveys. This study is amongst the first of its kind to apply CVM to the estimation of the cost of the removal of physical pain resulting from permanently-disabling occupational injuries. We assume that a painkilling drug has been invented to mitigate physical pain with the advantages of validity and instantaneity, and without any side effects. The WTP of each of the respondents is determined by a two-step sequential-bidding process. The maximum WTP under log normal distribution was NT$1,791/day (US$ 65.1), whilst under Weibull distribution it was NT$1,913/day (US$ 69.6). Older respondents, those with higher household income, fall injuries, longer periods of hospitalization, or with a perceived demand for the painkilling drug in excess of one day, displayed a positive independent effect on the eliciting of their WTP. In addition, respondents with higher ‘out of pocket’ expenses, or where the interview took place two years or more after the injury occurred, responded with a lower WTP.

碩士
國立成功大學
老年學研究所
100
BACKGROUND: The objective of this study is to quantify the incidence rate, life expectancy (LE), expected years of life lost (EYLL), cost per year and lifetime cost in the elderly with ESRD under maintenance hemodialysis after stratification by age, sex and the presence of diabetes. METHODS: We conducted a population-based study by using National Health Insurance Research Database (NHIRD). We identified all incident ESRD cases aged over 65 and under maintenance hemodialysis from registry files of catastrophic illnesses in Taiwan from July 1, 1997 to December 31, 2005. There were 24,243 cases; the age- and sex-specific incidence rates and cumulative incidence rates of ESRD between age 65 and 84 years (CIR65-84) were calculated. After excluding 3,423 cases with malignancy, their survivals were followed through the end of 2006. The survival function for an age- and sex-matched reference population was generated by using the Monte Carlo method from the life table of the general population; survival ratio between ESRD cohorts and referents was used for lifetime extrapolation after stratification by age, sex, and the presence of diabetes. Cost per year and lifetime cost (including healthcare expenditures of ambulatory care and inpatient care) were further analyzed after stratification by age, sex, and the presence of diabetes. RESULTS: The elderly with diabetes and ESRD seem to have a shorter LE than those without diabetes. The estimated average EYLL were 10.6-5.8, and 12.3-7.3 years for males and females with diabetes aged between 65 and 79. The CIR65-84 of requiring hemodialysis in the elderly with diabetes were 0.078 and 0.099 for males and females, but those without diabetes were 0.017 and 0.020 for males and females. The life years potentially saved by successful prevention of ESRD could be 5,430.1 and 10,177 life years in males and females, respectively. The cost per year was higher in those with diabetes than those without diabetes, and the trend persisted as the age advanced, although the differences between those with and without diabetes narrowed in the oldest old group. CONCLUSION: The likelihood of developing ESRD for the elderly with diabetes in the coming 20 years was nearly 5 times of the risk in the elderly without diabetes. Prevention of ESRD among the elderly is of great importance, especially among the elderly with diabetes.

RESUMO - Introdução: A integração de cuidados de saúde tem sido o modelo organizacional procurado para ajudar os sistemas de saúde a ultrapassar os constantes desafios impostos e para obterem ganhos na qualidade dos cuidados e nos resultados para os utentes. A taxa de mortalidade precoce no ambiente hospitalar é um indicador que permite avaliar a performance dos sistemas de saúde, refletindo os resultados em saúde. Esta é expressa a partir do cálculo dos anos de vida potencialmente perdidos (AVPP). Objetivo: Avaliar o impacto da criação de Unidades Locais de Saúde (ULS) na região Alentejo. Metodologia: Em primeiro lugar determinou-se a taxa de mortalidade precoce em ambiente hospitalar e os respetivos AVPP, analisando os diagnósticos principais associados, entre 2000 e 2011, nas ULS do Norte Alentejano e Baixo Alentejo. Para calcular o impacto da criação das ULS nos AVPP foi realizado o método Difference in Difference. Resultados: Foram analisados 605 825 episódios de internamento, dos quais 5258 (0,87%) resultaram em óbito hospitalar em utentes com <70 anos. Desta análise resultaram 102 270 AVPP para ambos os sexos. Após a criação das ULS do Norte Alentejano e Baixo Alentejo, verificou-se uma diminuição no número de AVPP de – 2, 7% e – 2, 6% respetivamente. Conclusões: Com a criação das ULS na região de saúde do Alentejo, o número de AVPP em ambiente hospitalar diminuiu, no entanto torna-se necessário aumentar a população em estudo e incluir mais variáveis que possam influenciar os AVPP por forma a retirarem-se conclusões mais específicas.
ABSTRACT - Introduction: The organizational model of integration of health care has been applied in order to help the systems overcome challenges, to achieve high quality care and good outcomes for the patients. The rate of premature mortality at hospital environment is an indicator that evaluates the health systems performance. The results in health are expressed by the Years of Potential Life Lost (YPLL). Objective: Evaluate the impact of implementing a Local Health Unit (LHU) in the Alentejo region. Methods: First the rate of premature mortality at hospital environment and the YPLL were determined through the analysis of the main diagnosis associated, between 2000 and 2011, in the LHU of Norte Alentejano and Baixo Alentejo. The method Difference in Difference was used to calculate the impact of the implement of the LHU in the YPLL. Results: From the 605 825 hospital admissions analyses, 5258 (0,87%) resulted in death for patients with <70 years old. This analysis resulted in 102 270 YPLL or both genders. After the implementation of the LHU in the Norte Alentejano and Baixo Alentejo there was a decrease in the number of YPLL, - 2,7% and -2,6% respectively. Conclusions: With the implementation of the LHU at the Alentejo region, the number of YPLL decreased, however it is necessary to increase the population number at study and include more variables that may influence the YPLL in order to achieve specific conclusions.