Dissertations / Theses on the topic 'RDoC'

Due to difficulties in elucidating neurobiological aspects of psychological disorders, the National Institute of Mental Health (NIMH) created the Research Domain Criteria (RDoC), which encourages novel conceptualizations of the relationship between neurobiological circuitry and clinical difficulties. This approach is markedly different from the Diagnostic and Statistical Manual of Mental Disorders (DSM) based approach that has dominated clinical research to date. Thus, RDoC necessitates exploration of novel experimental and statistical approaches. Fear learning paradigms represent a promising methodology for elucidating connections between acute threat (“fear”) circuitry and fear-related clinical difficulties. However, traditional analytical approaches rely on central tendency statistics, which are tethered to a priori categories and assume homogeneity within groups. Growth Mixture Modeling (GMM) methods such as Latent Class Growth Analysis (LCGA) may be uniquely suited for examining fear learning phenotypes. However, just three extant studies have applied GMM to fear learning and only one did so in a human population. Thus, the degree to which classes identified in known studies represent characteristics of the general population and to which GMM methodology is applicable across populations and paradigms is unclear. This preliminary study applied LCGA to a fear learning lab study in an attempt to identify heterogeneity in fear learning patterns based on a posteriori classification. The findings of this investigation may inform efforts to move toward a trans-diagnostic conceptualization of fear learning. Consistent with the goals laid out in RDoC, explication of fear learning phenotypes may eventually provide critical information needed to spur innovation in psychotherapeutic and psychopharmacological treatment.
Master of Science
To date, most clinical psychology research has been based on the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is a catalog of mental health disorders that was originally designed to facilitate communication among clinicians. Many experts contend that this approach has hampered progress in the field of biological clinical psychology research. Thus, the National Institute of Mental Health (NIMH) created a new template for biological clinical psychology research called the Research Domain Criteria (RDoC). Since RDoC calls for a complete overhaul in the conceptualization of clinical dysfunction, this approach requires statistical and experimental innovation. One traditional experimental approach that may be helpful in understanding the RDoC topic of acute threat (“fear”) is called Pavlovian Fear Learning (PFL). However, traditional PFL studies have utilized statistical methods that are based on comparing group averages and require researchers to determine groups of interest based on theory before the study begins. This is problematic because RDoC calls for research that begins with evidence rather than theory. Growth Mixture Modeling (GMM) is a statistical methodology that may allow researchers to analyze fear learning data without having to begin with theoretically determined categories such as DSM disorders. However, little research has tested how well this approach would work. This study is just the second to apply a GMM approach to a human PFL study. The findings from this investigation may inform efforts to develop a statistical technique that is well suited for RDoCian research and may also spur innovation in psychotherapeutic and psychopharmacological treatment.

Mental disorders present difficulties in the research of their mechanisms, considering the high levels of comorbidity and the lack of specific neuroscience data to evaluate them. Estipulating deficit circuits in the disorders and the best treatment is a complex task, given the limited comprehension of the factors that correlate to the disorders. The utilization of biomarkers has proved an efficient and reliable alternative to provide precise diagnosis. Among the biomarkers, the Error-Related Negativity component, an event-related cortical potential, has presented high indexes of stability and validity in correlating to anxiety, obsessive, and mood-related mental disorders. The present dissertation evaluated irritability traits in a community sample, using a Flanker task, that has consistently elicited Error-Related Negativity according to the literature. Our results corroborate literature and found a frontocentral negativity, that peaked around 100ms after the commission of an error in the Flanker Task. However, our manipulation of negative feedback did not support literature, and ERN amplitudes were less enhanced post negative feedback. The relationship between irritability and ERN remains unclear. Future studies should, therefore, address these questionings.

Die Research-Domain-Criteria-Initiative und andere haben vorgeschlagen, zur Konzeption psychischer Störungen dimensionale psychologische Konstrukte zu verwenden. Die vorliegende Arbeit beschreibt mehrere Experimente, in denen mit Augenbewegungsaufgaben das Konstrukt der kognitiven Kontrolle evaluiert wurde. Die Studien sollten klären, welche kognitiven und neuronalen Mechanismen zu den bei Menschen mit Schizophrenie oder Zwangsstörung erhöhten Latenzen volitionaler Sakkaden beitragen. In drei Studien wurden Anforderungen der Antisakkadenaufgabe isoliert und funktionelle Magnetresonanztomographie angewendet. Die Ergebnisse legen nahe, dass die verlangsamte volitionale Sakkadengenerierung bei Schizophrenie durch eine dysfunktionale Aktivierung des lateralen präfrontalen Cortex und der supplementären Augenfelder vermittelt wird, was mit Defiziten in der proaktiven Handlungskontrolle verbunden sein könnte. Fünf weitere Experimente sollten Teilprozesse aufklären und haben gezeigt, dass die Defizite möglicherweise aus einer Beeinträchtigung der volitionalen Loslösung der Fixation und der motorischen Vorbereitung resultieren. Zwei weitere Studien legen nahe, dass auch die Zwangsstörung mit erhöhten Latenzen volitionaler Sakkaden assoziiert ist. Effekte experimenteller Variation haben jedoch gezeigt, dass diesen Defiziten wahrscheinlich eine Verlangsamung der Reaktionsauswahl zugrundeliegt. Die bei beiden Patientengruppen vermutlich betroffenen Mechanismen dienen zielgerichteten Verhaltensweisen. Man kann vermuten, dass die Defizite eine Störung auf der Ebene eines allgemeinen Faktors exekutiver Funktionen widerspiegeln. Die experimentellen Ergebnisse weisen jedoch auch auf störungsspezifische Funktionsbeeinträchtigungen hin. Zukünftige Forschung muss den Zusammenhang zwischen diesen Beeinträchtigungen und Symptomen besser aufzuklären, wenn Konzepte psychischer Störungen, die auf experimentell definierten psychologischen Konstrukten basieren, am Ende erfolgreich sein sollen.
The research domain criteria initiative and others have suggested to conzeptualize mental disorders on the basis of dimensional psychological constructs. The present work describes several experiments using eye movement tasks to evaluate the construct of cognitive control. The studies aimed at uncovering cognitive and neural mechanisms involved in increased latencies of volitional saccades as found in individuals with schizophrenia or obsessive-compulsive disorder. Three studies used functional magnetic resonance imaging and isolated different demands of the antisaccade task. The results suggest that slowed volitional saccade generation in schizophrenia is mediated by dysfunctional activation of the lateral prefrontal cortex and the supplementary eye fields, which may relate to deficits in proactive control of action. Five additional behavioral experiments aimed at specifying sub-processes and showed that the deficits might result from impairments in volitional fixation disengagement and motor preparation. Two studies in individuals with obsessive-compulsive disorder suggest that this disorder is also associated with increased latencies of volitional saccades. However, experimental variation revealed that these deficits may reflect a slowing in response selection. The mechanisms affected in both groups are serving goal-directed behaviors and may reflect a disturbance on the level of a common executive functions factor. However, the experimental results also suggest disorder specific functional impairment. Future research will have to improve our understanding of the relationship between these impairments and symptoms if concepts based on experimentally defined psychological constructs shall be successful in the end.

Background: Approximately 7% of clinically referred youth exhibit profound impairment in the ability to regulate their affect, behavior, and cognition. This phenotype – often referred to as dysregulation – has been associated with a multitude of negative outcomes. Symptom overlap between dysregulation and other psychological disorders has generated debate regarding whether DP constitutes a distinct syndrome characterized by intense, persistent irritability or is merely the combination of symptoms from disruptive or mood disorders. In order to elucidate this question, the current study examined the transdiagnostic continuities and discontinuities in three RDoC constructs (frustrative non-reward, acute threat, and cognitive control) proposed to be mechanisms of irritability Method: Participants were 294 children ages 7-17 (M=10.94; 67% male). Emotional and behavioral symptoms were measured using the Child Behavior Checklist and the Kiddie Schedule for Affective Disorders and Schizophrenia. Frustrative non-reward was measured using a frustration-induction Go/No-Go paradigm during which heart rate variability was indexed by respiratory sinus arrhythmia (RSA) and pre-ejection period (PEP). Acute threat was measured using an Emotional Faces computer paradigm in conjunction with an eyetracker/pupilometer. Cognitive control was assessed with the Behavioral Rating Inventory of Executive Function (BRIEF), Delis-Kaplan Executive Function System (D-KEFS) and Stop Signal Task (SST). Results: Symptoms of dysregulation and non-episodic irritability were strongly, positively related. Due to a lack of demonstrated construct validity for the hypothesized RDoC constructs of frustrative non-reward, acute threat, and cognitive control, two alternative mechanisms—SNS response and cognitive dyscontrol of emotion—were derived from the data. Results showed that blunted sympathetic responsivity and poor executive control in response to emotion were predictive of more severe irritability symptoms. Finally, moderation analyses showed that among highly dysregulated children, low levels of sympathetic responsiveness were associated with more severe irritability symptoms. Conclusions: Despite phenotypic overlap with other forms of developmental psychopathology, dysregulated children can be distinguished based on the severity of their irritability symptoms. This supports the conceptualization of dysregulation as a unique syndrome characterized by intense and persistent irritability and lends credence to the novel diagnosis of DMDD. Furthermore, cognitive, behavioral and physiological patterns identified in this study suggest that difficulties with processing negative emotion—as opposed to frustration or threat specifically—may constitute a vulnerability for irritability.

This study examined the clinical utility of the recently released National Institute of Mental Health's (NIMH) research domain criteria (RDoC) by replicating and extending earlier work by using a demographically novel sample. Information retrieval and natural language processing of archival clinical records was used to achieve two main objectives: (1) estimate how well the RDoC domains match language used by clinicians by creating domain scores and (2) examine the differences between the DSM's and RDoC's ability to predict treatment outcome using these domain scores and DSM diagnoses. The social systems RDoC category was found to be the strongest predictor of treatment outcome across all diagnostic measures.

The ability to monitor client change in psychotherapy over time is vital to quality assurance in psychotherapy as well as the continuing improvement of psychotherapy research. Currently there is not a free and comprehensive outcome measure for psychotherapy that meets current research and treatment goals. This study took further steps to validate a suite of measures to aid in treatment and research, theoretically based in the research domain criteria (RDoC) and the phase model of change frameworks. Items previously tested in a community sample were further tested in a clinical population in psychotherapy training clinics and a community clinical sample Data was analyzed using bi-factor confirmatory factor analysis and multidimensional item response theory. Additional exploratory analyses were conducted to explore differential item functioning in these samples.

O desenvolvimento de novas tecnologias vem contribuindo para um conhecimento mais aprofundado da fisiopatologia dos transtornos psiquiátricos, mas os resultados ainda são controversos e não parecem ser específicos para cada diagnóstico. As altas taxas de comorbidade também questionam as características principais de um diagnóstico específico. Em 2009, o Instituto Nacional de Saúde Mental dos EUA iniciou um projeto chamado Research Domain Criteria (RDoC) com o objetivo de desenvolver novas classificações para a pesquisa baseadas em dimensões de comportamentos observáveis associadas a medidas neurobiológicas. Para o estudo da fisiopatologia da comorbidade entre duas doenças mentais, esta proposta sugere que se execute o estudo de sintomas compartilhados e não partir de dois grupos diagnósticos distintos. Na psiquiatria infantil, as altas taxas de comorbidade entre o transtorno do humor bipolar (THB) e o transtorno de déficit de atenção e hiperatividade (TDAH) são um tema controverso. O prejuízo na atenção é um forte candidato para um estudo com a metodologia proposta pelo RDoC visto que os poucos estudos que avaliaram concomitantemente a atenção em jovens com THB e TDAH apresentaram resultados contraditórios. Um dos testes mais utilizados para o estudo da atenção em THB e TDAH é o Continuous Performance Test (CPT). Nossos objetivos foram: 1.Verificar qual é o melhor agrupamento dos sujeitos através dos resultados do Conner\'s Continuous Performance Test (CPT II) independentemente do grupo de origem (THB, TDAH, THB+TDAH, controles); 2. Construir um classificador baseado nos resultados do CPT II; 3com THB+TDAH e 18 controles com idades entre 12 e 17 anos. A melhor divisão dos sujeitos, baseada nos resultados do CPT II, foi em dois novos subgrupos. Grupo A com 35 sujeitos composto de: 30% THB, 52,2% TDAH, 51,5% THB+TDAH, e 16,7% controles. Grupo B com 49 sujeitos: 70% THB, 47,8% TDAH, 48,5% THB+TDAH, e 83,3% controles. O grupo A comparado com o B apresentou um prejuízo funcional maior evidenciado por médias significativamente mais altas no CPT II, com uma diferença significativa em oito das 12 variáveis do CPT II: omissão (p=0,0003), comissão (p=0,00000002), erro padrão (EP) do tempo de reação (TR) (p=1,7x10-20), variabilidade do EP (p=4,3x10-22), detectabilidade (p=0,000008), perseveração (p=0,0000001), TR por intervalo interestímulo (IIE) (p=4,7x10-10) e TR(EP)IIE (p= 1,5x10 -13). Foi possível construir um classificador baseado nas doze variáveis do CPT II, sendo sua acurácia de 98,8% em relação a nossa amostra e 95,2% em relação à validação cruzada confirmando a consistência desses novos grupos. As principais variáveis do CPT II usadas na função discriminante desses novos agrupamentos foram: variabilidade do erro padrão, erro padrão de TR e erro padrão de TR por intervalo interestímulo. Não houve diferença estatística em nenhuma das variáveis do CPT II quando realizamos a comparação tradicional entre THB, TDAH, THB+TDAH, e controles; e a acurácia do classificador para esses grupos foi mais baixa, de 40,5% na nossa amostra e 23,8% na validação cruzada. Discussão: Esses resultados evidenciam a heterogeneidade encontrada nas respostas do CPT II pelos grupos THB, TDAH, THB+TDAH, e controles. As três medidas que mais influenciaram a diferenciação entre os novos agrupamentos A e B foram as que medem a variação no tempo de resposta, que é um dos prejuízos mais replicados no TDAH e também está associada com THB. Essa variabilidade de resposta aumentada é sugerida como um marcador endofenotípico inespecífico de psicopatologia. Conclusão: Nossos achados refletem a heterogeneidade encontrada em pacientes classificados através de categorias diagnósticas vigentes e sugerem que a abordagem da metodologia do RDoC pode ser de grande valia para a melhor compreensão dos transtornos psiquiátricos que acometem crianças e adolescentes. Essa metodologia pode identificar subgrupos com diferenças relevantes do ponto de visto neurobiológico contribuindo para a melhor compreensão da fisiopatologia dos transtornos e promovendo caminhos nos quais a pesquisa pode trazer benefícios para decisões clínicas
The better understanding of psychiatric disorders\' pathophysiology is undeniable. Yet, the results are still replete of controversy and are not diagnostic specific. Categorical approach analysis implicitly involves the notion of a unitary entity, not taking into account the acknowledged heterogeneity present in clinical diagnoses. High comorbidity rates also raises questions about the core features of a specific diagnosis. For this purpose, the National Institute of Mental Health has initiated the Research Domain Criteria (RDoC) project. Instead of using disorders categories as the basis for grouping individuals, RDoC suggests to find relevant dimensions that can cut across traditional disorders. The starting point suggested to study comorbid disorders should be shared symptoms and behaviors, instead of two distinct diagnostic groups. One of the strongest controversies in child psychiatry is the high comorbidity rate between bipolar disorder (BD) and attention-deficit/hyperactivity disorder (ADHD). Distractibility, one of the most common symptoms in BD and ADHD could be a good candidate for an RDoC unit of analysis. Our aim was first to study the patterns of attention based on the Conners\' Continuous Performance Test (CPTII) results in youth with BD, ADHD, BD+ADHD and controls; followed by developing a classifier to compare the classification accuracy of this new formed groups and the original diagnostic ones. Results: 18 healthy controls, 23 patients with ADHD, 33 BD+ADHD and 10 BD were assessed. Using cluster analysis, the entire sample was best clustered in two new groups, A and B, based on the twelve CPT II variables performance, independently of the original diagnoses. 35 subjects in group A: 30% BD, 52.2% ADHD, 51.5% BD+ADHD and 16.7% controls. 49 individuals in group B: 70% BD, 47.8% ADHD, 48.5% BD+ADHD and 83.3% controls. Group A presented a greater impairment exhibited by higher means in all CPTII variables, SNAP-IV means, and lower CGAS means. When we compared the CPT II variables performance between the new clustered groups A and B we found eight out of the twelve CPT II measures that were statistically significant: omission (p=0.0003), commission (p=0.00000002), standard error (SE) of hit reaction time (RT) (p=1.7x10-20), variability of SE (p=4.3x10 -22), detectability (p=0.000008), perseveration (p=0.0000001), hit RT by interstimulus interval (ISI) (p=4.7x10 - 10) and hit RT SE ISI. We found high cross-validated classification accuracy for A and B groups: 95.2%. The stronger CPT II variables in the discriminative pattern were: variability of standard error ranking first, followed by hit RT SE, hit RT SE ISI. There were no statistically significant differences in any of the CPT II measures when comparing the four original groups (BD, ADHD, BD+ADHD, controls). The cross-validated classification accuracy based on the CPT II measures performance in order to classify subjects in the original four groups was much lower (23.8%). Discussion: These results highlight the heterogeneity of CPT II responses among each of the four original groups: BD, ADHD, BD+ADHD and controls. The three variables that most influenced the new clustered groups were the ones that measure and adolescents may share this attentional trait marker. Conclusion: In summary, our findings highlighted the heterogeneity of patients clustered by categorical diagnostic classification. In addition, our classificatory exercise supports the concept behind new approaches like the RDoC framework for child and adolescent psychiatry. It can define meaningful clinical subgroups for the purpose of pathophysiological studies and treatment selection, and provide a pathway by which research findings can be translated into changes in clinical decision making

A Ruminação tem sido um importante campo de investigação para estudar os mecanismos cognitivos e alteração dos estados emocionais associados ao processo do desenvolvimento de condições de saúde mental. A presente dissertação, cujo relatório de pesquisa deriva nessa produção, busca elucidar as relações entre ruminação e disforia de gênero. Dessa forma, a dissertação apresentará dois estudos de delineamento transversal que, no entanto, sofrem adaptações na disposição dos indivíduos da amostra para testar hipóteses específicas. Em ambos os estudos foram recrutadas 39 mulheres transexuais, no período de 2014 a 2015, que atenderam aos critérios do DSM 5 para diagnóstico de Disforia de Gênero (DG). O primeiro estudo teve como objetivo analisar os níveis de ruminação em pacientes com disforia de gênero antes e depois da Cirurgia de Redesignação Sexual (CRS), o que contribui com a literatura que investiga marcadores de desfecho positivo para CRS. O primeiro subgrupo (T0) foi constituído por participantes com diagnósticos confirmados para DG e com, no máximo, um ano de acompanhamento em grupoterapia. O T1, por pacientes que atenderam os pré-requisitos em relação à frequência aos atendimentos dos grupos psicoterapêuticos de, no mínimo, um ano, e no máximo dois anos, sem contra-indicação para realização da CRS. E o T2, constituído por pacientes pós-cirúrgicos em um período superior a seis meses. O segundo estudo teve como objetivo tanto analisar a relação entre abuso emocional na infância e ruminação em mulheres transexuais quanto identificar, entre os indivíduos da amostra, quais ruminam em nível p[baixo] = (33) ≤18 e p[alto] = (67) ≥23. Essa classificação entre dois subtipos do pensamento ruminativo pode elucidar diferenças entre os fatores protetivos e os desfechos nocivos na saúde mental e física dessa população. No primeiro estudo, a ruminação diminuiu entre os pacientes no T2 e os escores em ruminação foram ainda gradualmente menores a cada procedimento realizado nas características sexuais secundárias por pacientes deste grupo. Esse achado contribui para pesquisas do paradigma Research Domain Criteria (RDoC), que almeja demonstrar marcadores psicológicos para condições de saúde mental. Nesse caso, a ruminação parece se mostrar como um marcador importante para o desfecho positivo em pacientes com disforia de gênero pós-CRS. No segundo estudo, nosso principal achado reside na prevalência em até 15 vezes (IC95%: 2,25-99,63) de maior chance para engajamento em ruminação elevada ou comportamento disfórico entre os indivíduos que foram expostos ao abuso emocional, sobretudo, entre aqueles que o vivenciaram no intervalo da tipologia que variou de moderado – grave a grave – extremo se comparado aos indivíduos com gravidade entre mínimo a moderado na escala Childhood Trauma Questionnaire (CTQ). O abuso emocional está relacionado com engajamento em ruminação, sobretudo, ao subtipo elevada, o que contribui para aumento em comportamentos disfóricos, e ao estar associado à desregulação da emoção, que contribui para os desfechos nocivos na saúde física e mental desta população.
The Rumination has recently become an important field of study to better understand cognitive mechanisms and emotional status associated to the development of mental health conditions. The current work aims to shine a light upon the relation between rumination and gender dysphoria (GD). In this sense, this work presents two cross-sectional studies, each testing two specific hypotheses. Therefore, they have suffered adaptations in the disposition of the sample. In both studies, 39 transexual women, who fulfilled the DSM 5 diagnostic criteria for GD, were recruited within the years of 2014 and 2015. The first study aimed to analyse how much GD patients have rumination processes before and after sex reassignment surgery (SRS), which contributes to the body of literature seeking for positive outcome markers for SRS. The first group (T0) was made of participants who had a confirmed DG diagnostic and participated of group therapy for up to one year (between 0 and 12 months). The second group (T1) was composed by participants who had a confirmed DG diagnostic and attended from one up to two years of group therapy and had no contraindications for SRS. The third group (T2) was comprised of patients who have gone through SRS surgery at least six months prior to the data collection. The second study aimed to analyse the relation between emotional abuse during childhood and rumination in transexual women and to identify, amongst sample individuals, those who ruminate at a low or high levels. This classification into two subsets of ruminative thinking might clarify diferences between protective factors and poor mental and physical health outcomes in this specific population. In the first study, patients of the T2 group ruminate significantly less than their counterparts; moreover, scores of the ruminative thinking process seems to fall gradually with each alteration in the secondary sex characteristics. This finding contributes to the researches of the Research Domain Criteria (RDoC) paradigm, which seeks to find physiological markers for mental health conditions. In this case, rumination seems to be an important marker for positive outcomes in post-SRS GD patients. In the second study, the main result is the higher (up to 15 fold) prevalence for likeliness to engane in high level of ruminative thinking or dysphoric behaviour amongst the individuals who were exposed to emotional abuse. Above all, the engagement in ruminative thinking process is even higher amongst those who lived through emotional abuse in the moderated - severe and the severe - extreme categories of the Childhood Trauma Questionnaire (CTQ) scale than those in the light - moderate category. Emotional abuse is related to ruminative engagement, specially to the high level subtype of rumination. This contributes to the increase in dysphoric behaviours and to the bad health and mental outcomes in this population, probably associated with emotional dysregulation.

The ability to monitor client change in psychotherapy over time is vital to quality assurance in service delivery as well as the continuing improvement of psychotherapy research. Unfortunately, there is not currently a comprehensive, affordable, and easily utilized outcome measure for psychotherapy specifically normed and standardized for use in psychology training clinics. The current study took the first steps in creating such an outcome measure. Following development of an item bank, factor analysis and item-response theory analyses were applied to data gathered from a stratified sample of university (n = 101) and community (n = 261) participants. The factor structure did not support a phase model conceptualization, but did reveal a structure consistent with the theoretical framework of the research domain criteria (RDoC). Suggestions for next steps in the measure development process are provided and implications discussed.

Introdução: Ruminação é a perseveração mal-adaptativa de pensamentos auto-centrados. Evidências sinalizam que ela está associada com início e manutenção de episódios depressivos, e ocorre em múltiplos transtornos mentais. A ruminação está associada com marcadores de desenvolvimento psicopatológico, como volumetria cerebral, memória, genes do BDNF e serotonina. É necessário aprofundar o conhecimento da ruminação enquanto traço dimensional, e conhecer melhor sua associação com variáveis sóciodemográficas, biológicas e clínicas para entender quando passa a ser um sintoma. Entretanto, aferi-la é um desafio, considerando que só existem escalas psicométricas. A mais utilizada, Ruminative Response Scale (RRS), foi validada em amostras não-clínicas. Objetivos: Avaliar ruminação transdiagnosticamente e determinar a validade de constructo da RRS em amostra clínica, buscando determinar fatores sócio-demográficos, clínicos e neurobiológicos associados a maiores escores de ruminação. Métodos: Estudo transversal, amostra não-probabilística. Foram convidados a participar 944 pacientes em atendimento psiquiátrico ambulatorial no HCPA entre março/2015 e junho/2016, maiores de 18 anos, que soubessem ler e escrever, e portadores de transtornos bipolares, depressão, esquizofrenia, esquizoafetivo, ansiedade generalizada, pânico, fobia específica e obsessivocompulsivo. Foram excluídos 373 com doenças que alteram resposta inflamatória, dependência química, gravidez, lactação, doenças neurológicas, vasculares e degenerativas. Recusaram-se a participar 254. Foram incluídos 317 pacientes, e 200 completaram a coleta de dados, que foi realizada em 4 etapas: 1) perfil sócio-demográfico e escalas auto-aplicáveis: ruminação, preocupação e funcionalidade; 2) amostras de sangue e entrevista clínica para aplicação das escalas de sintomas: depressão, mania, ansiedade e gravidade; 3) confirmação diagnóstica; e 4) processamento, armazenamento e análises bioquímicas das amostras de sangue. No primeiro artigo, revisamos sistematicamente a literatura sobre ruminação nos transtornos bipolares. No segundo, determinamos as validades de construto e externa da RRS. No terceiro, usamos machine learning para encontrar padrões de ruminação e determinar quais variáveis associadas preveem ruminação. Resultados: Ruminação está presente em todas as fases do transtorno bipolar, e é um sintoma estável independente do estado de humor, apesar de ter relação estreia com ele. Verificou-se também que mulheres ruminam mais que homens. Os escores de ruminação foram menores nos portadores de esquizofrenia que nos com depressão maior, bipolaridade e ansiedade. RRS apresentou boa confiabilidade, com 2-fatores correlacionados, brooding e ponderação, que apresentaram similaridade nas correlações com medidas clínicas, confirmando a validade externa transdiagnóstica. Por fim, encontrou-se que as variáveis associadas aos pacientes que mais ruminam são preocupação, sintomas de ansiedade generalizada e depressão, gravidade, nível socioeconômico e diagnóstico atual de pânico, sinalizando que ruminação pode ser um marcador de maior sensibilidade à ansiedade. Discussão: Ruminação parece ser um sintoma transdiagnóstico marcador de sofrimento. Os resultados desta tese contribuem para ampliar a discussão sobre diagnóstico psiquiátrico, agregando evidências para aprimorar as definições de limites e sobreposições diagnósticas entre as doenças mentais em que a ruminação ocorre. Por fim, conhecer melhor os mecanismos bioquímicos e clínicos envolvidos na ruminação contribuem na compreensão sobre quando ela deixa de ser um traço normal e vira um sintoma que necessita de tratamento.
Introduction: Rumination has been described as maladaptive perseveration of self-centered thoughts. Evidence indicates that rumination is associated with onset and maintenance of depressive episodes, it’s present in several mental disorders. Rumination is associated with markers of development of psychopathology, such as cerebral volumetry, memory, BDNF and serotonin genes. Measuring rumination is a challenge, considering that are available only psychometric scales. The most used, the Ruminative Responses Scale (RRS), was validated on non-clinical samples. Objectives: To evaluate transdiagnostically the rumination and to determine construct validity of the RRS in outpatients, in order to determine which associated factors lead the patients to ruminate. Methods: Cross-sectional study, non-probabilistic sample. A total of 944 patients in psychiatric outpatient treatment at HCPA between March / 2015 and June / 2016, major than 18 years old, knowing read and write, presenting bipolar disorder, schizophrenia, schizoaffective disorder, generalized anxiety disorder, panic disorder, phobia specific and obsessive-compulsive disorder were invited to participate. We excluded 373 patients with diseases that alter inflammatory response, chemical dependence, pregnancy, lactation, neurological, vascular and degenerative diseases. Two hundred fifty four refused to participate, 317 were included, and 200 completed the data collection, which was performed in 4 stages: 1) socio-demographic profile and self-applicable scales: rumination, worry and functionality; 2) blood samples and clinical interview for the application of symptom scales: depression, mania, anxiety and severity; 3) diagnostic confirmation; and 4) processing, storage and biochemical analyzes of blood samples. In the first article, we systematically reviewed the literature on rumination in bipolar disorders. In the second, we evaluated construct and external validity of RRS. In the third, we used machine learning algorithms to find patterns of rumination and to determine which associated variables predict rumination. Results: Rumination is present in all phases of bipolar disorder, it is a stable symptom, independent of mood, despite it has close relationship with it. It has also been found that women ruminate more than men. Rumination scores were lower in patients with schizophrenia than in major depression, bipolarity and anxiety patients. RRS presented good reliability, with correlated 2-factors, brooding and pondering, which presented similar correlations with clinical measures, confirming the external transdiagnostic validity. Finally, it was found that the variables associated with the greater scores of rumination are worry, symptoms of generalized anxiety and depression, severity of symptoms, socioeconomic level and current diagnosis of panic, signaling that rumination may be a marker of greater sensitivity to anxiety. Discussion: Rumination seems to be a transdiagnostic symptom of suffering. The results of this thesis contribute to broadening the discussion about psychiatric diagnostic, adding evidence to improve the definitions of limits and diagnostic overlaps between mental illnesses in which rumination occurs. Finally, a better understanding of the biochemical and clinical mechanisms involved in rumination may contribute to understanding of when rumination ceases to be a normal trait and becomes a symptom that requires treatment.

Previous studies found that RdgC protein plays a role in the DNA repair system in Escherichia coli. In recBC sbcBC strains, loss of rdgC made growth of the strains dependent upon recombination, hence Recombination Dependent Growth. RdgC was also found to regulate the activity of RecA, a key protein in recombination, both in vivo and in vitro. The function of the protein, however, remains unknown. In this study, I purified and crystallised the RdgC protein. The crystal structure of the protein was then revealed as a homo-dimer, with a head to head, tail to tail organisation, resembling a ring structure. To further investigate how RdgC binds DNA and its in vivo functionality, point mutations and chunk deletions were designed and constructed; and I examined all the mutant proteins in DNA binding shift assays in vitro and in synthetic lethality assays in vivo. A DNA binding model was then proposed based on the results of the DNA binding shift assays. The mutant studies in vivo reinforce the idea that the DNA binding activity is crucial for RdgC’s function in Escherichia coli.

Les Européens (Belges, Grecs et Italiens) du Katanga, dont le nombre s’est considérablement réduit au cours de la période post-coloniale, forment aujourd’hui le groupe le plus puissant de l’économie de la région. Au vu des troubles qui ont marqué l’histoire du Congo depuis l’indépendance, pourquoi sont-ils restés sur place ?Comment ont-ils développé leurs affaires dans une économie sur le déclin, en voie de marginalisation, et dans une structure politique patrimoniale de plus en plus instable ?Et quelle est leur place au sein de la société congolaise ?Telle est la triple question de départ à laquelle tente de répondre cette thèse en abordant de façon successive, au fil des chapitres, leur parcours migratoire, leur insertion dans la société congolaise, la dynamique de leur communauté, leur rôle dans les deux plus gros secteurs de la région, et leurs rapports avec les représentants de l’Etat. Elle prend appui pour ce faire sur une recherche de terrain conduite entre 2003 et 2004.

If the number of Europeans (Belgians, Greeks and Italians) living in Katanga has considerably decreased during the post-colonial period, they represent today the most powerful entrepreneurial group of the local economy. Once considered the troubles they came across since independence, why did they remain in the Congo? How did they develop their business in a declining economy, in process of marginalization, and in a patrimonial political structure, which proves to be more and more unstable? Finally, what is their place and role in Congolese society? These are the three questions this thesis tries to give an answer. Through the chapters, it studies the migration of expatriates in Africa, their relationship with Congolese society, the dynamics of their community, their role in the two most important sectors of Katanga, and the way they interact with the agents of the State. For this purpose, it rests upon a fieldwork research led between 2003 and 2004.

Doctorat en sciences sociales, Orientation anthropologie
info:eu-repo/semantics/nonPublished

Notre recherche a consisté a nous faire une opinion raisonnée sur les interventions des Institutions de Bretton-Woods en République Démocratique de Congo, en nous appuyant sur une analyse de long terme de l’endettement extérieur du pays, et par conséquent à la mise en œuvre des programmes des stabilisations dans les années 70 et d’ajustement structurel depuis les années 80. Cette analyse nous a permis de mettre en lumière les contraintes économiques et sociales, internes et extérieures, auxquelles le pays a dû faire face. Loin de soulager cette économie rentière, les thérapies de choc préconisées par ces Institutions ont provoqué des coûts ou effets secondaires négatifs, délibérément cherché ou non sur d’autres variables (revenu global, niveau des prix, inflation/hyperinflation…). D’autre part, elles ont eu un coût social élevé, et ont contribuées lourdement à une détérioration de la répartition des revenus entre les diverses couches sociales du pays. L’échec des programmes d’ajustement structurel étant aujourd’hui reconnu, il était devenu donc impératif d’imaginer d’autres types d’approches moins superficielles, qui puissent intégrer non-seulement l’équilibre des variables macro et/ou micro-économiques, mais aussi méso-économique ; et donc l’accent doit être désormais mis sur l’amont (discussions des politiques) et sur l’aval (mis au point des projets ou programmes). C’est ainsi que furent mis en place, depuis le milieu des années 90, les mesures d’allègement ou d’annulation de la dette extérieure. L’austérité préconisée aujourd’hui, face à la crise de la dette dans la zone euro, semble ne pas tenir compte des conséquences que les politiques d’inspiration monétariste ont entraînées partout où elles ont été mises en œuvre, et particulièrement en Afrique. Ainsi, nous-nous demandons si le Libéraux ont-ils retenu les leçons des échecs des programmes d’ajustement structurel (PAS) dans les pays ajustés. Pour ce faire, nous-nous sommes permis de proposer quelques perspectives ou voies de sortie afin d’éviter de retomber dans le cycle de la dette que la RD Congo a connut
Our research was to give us a reasoned opinion on the actions of the Bretton-Woods in DR Congo, relying on an analysis of long term external debt of the country, and therefore the implementation of programs stabilization in the 70s and structural adjustment since the 80s. This analysis allowed us to highlight the economic and social constraints, internal and external, that the country faced. Far from alleviating the rentier economy, shock therapies advocated by these institutions have caused costs or negative side effects, deliberately sought or not other variables (total income, inflation/hyperinflation…). On the other hand, they had a high social cost, and contributed heavily to the deterioration of income distribution among different social strata of the country. The failure of structural adjustment programs (SAPs) is regnized today, it has become imperative to imagine other types of less superficial approaches that can integrate not only the balance of macro variables and/or micro-economic, but also meso, and therefore the emphasis should now be placed on the upstream (policy discussion) and downstream (developed projects or programs). Thus were established since the mid 90s, the relief measures or cancellation of the external debt. The austerity advocated today, faced with the debt crisis in the euro area seems to ignore the impact that monetary policies have led to inspiration wherever they have been implemented, particularity in Africa. Thus, we ask whether we Liberals have learned from the failures of adjustment programs (SAPs) in the country originates, the former adjusted. To do this, we have allowed us to propose a few prospects or output channels to avoid failing into the cycle of debt that DR Congo has experienced so far

Orientadores: Walter Esteves e Antonio Jose de Almeida Meirelles
Tese (doutorado) - Universidade Estadula de Campinas, Faculdade de Engenharia de Alimentos
Made available in DSpace on 2018-07-22T03:12:41Z (GMT). No. of bitstreams: 1 Antoniassi_Rosemar_D.pdf: 7487195 bytes, checksum: ef9bf561ee39adfe81d14ee426420e32 (MD5) Previous issue date: 1996
Resumo: O processo contínuo de desacidificação de óleo de milho com etanol foi realizado em um extrator de discos rotativos (RDC), com 74 cm de altura total, 31 cm de altura na região de extração e 5 cm de diâmetro interno. As condições operacionais favoráveis ao processo de desacidificação de óleo de milho no RDC utilizado foram: etanol como fase contínua e óleo como fase dispersa, seis discos na região de extração de 20% de área livre de escoamento, carga total de 40 a 70 gramas/minuto e relação óleo/solvente de 0,5/1 e 1/1. Devido à insolubilização dos fosfatídios no etanol, foi estudado um processo de pré-tratamento do óleo de milho bruto, envolvendo etapas de degomagem e branqueamento. A degomagem do óleo de milho bruto foi conduzida em diversas temperaturas, com agentes de degomagem ácidos, neutros e alcalinos. Maior remoção de fósforo ocorreu na degomagem com água à temperatura de 30°C. Quando a degomagem do óleo de milho bruto foi realizada abaixo de 30°C, independente do agente de degomagem utilizado, ocorreram degomageme winterização simultâneas. O pré-tratamento do óleo de milho bruto com até 400 ppm de fósforo, para alimentação da coluna de discos rotativos, foi realizado através de degomagem com água à temperatura de 30°C. A seguir, o óleo degomado foi tratado com 0,1% de sílica Trysil3000, sob vácuo, às temperaturas de 70 ou 80°C, por 15 minutos, seguido de branqueamento com 1 % de terra branqueadora, à temperatura de 100°C por 30 minutos. O etanol hidratado com 5,83% de água foi selecionado como solvente para o processo contínuo, com base em sua seletividade, coeficiente de distribuição e solubilidade no óleo. O processo de desacidificação do óleo de milho branqueado com conteúdo de ácidos graxos livres de 0,96 a 7,74% e etanol, foi estudado no RDC nas relações alimentação/solvente de 0,5/1 e 1/1, na faixa de temperatura de 24 a 32°C, variando-se a velocidade de agitação até 300 rpm. A eficiência do processo de desacidificação, a fração de ácidos graxos livres e diglicerídios transferida e as perdas de triglicerídios aumentaram com a velocidade de agitação. O aumento da relação óleo/solvente reduziu as perdas de triglicerídios e a transferência de diglicerídios e de ácidos graxos livres. Nas condições utilizadas, ocorreu remoção de até 80% da acidez inicial do óleo. A eficiência do processo foi de até 1,5 estágios de equilíbrio. Os resultados obtidos possibilitaram estabelecer as condições operacionais do RDC na desacidificação de óleo milho com etanol, que se revelou um processo promissor, que se caracteriza pela alta carga processada e alta eficiência.
Abstract: Deacidification of com oil with ethanol by a continuous process was conduded in a perforated rotating-disc-contador (RDC). Since the phosphatides are insoluble in ethanol, different pre-treatments were performed such as degumming and bleahing to reduce the phosphorus content. Water degumming of crude com oil was more efficient than acid degumming with citric acid, at different temperatures varying from 10 to 70°C. The degumming of high acidity com oil was more efficient when neutral degumming agents were used. Samples of oils degummed at temperatures of 30°C and below passed the Cold Test (6 hours at O°C), independently of the degumming agents used. Under these conditions, simultaneous degumming and dewaxing occurred. Therefore, a separate winterization is not necessary at these temperatures. Degummed oil was treated with 0.1 % Silica at 70 or 80°C for 15 minutes under vacuum and bleached with 1 % of bleaching earth at 100°C for 30 minutes under vacuum. The bleached oil was used in the liquid-liquid extradion. The experimental operating conditions used in this study were: temperature ¬ 24 to 32°C; rotating speed - up to 300 rpm; feed/solvent ratio - 0.5/1 and 1/1; feed and solvent flow - 20 to 50 grams/min. The specification of the column was: length of 74 cm, diameter of 5 cm and extradion zone height of 31 cm, with 6 disks with free area of 20%. Azeotropic ethanol was chosen based on its seledivity and its capacity to extrad free fatty acid and diglyceride. The free fatty acid content varied from 0.96 to 7.74% and from 0.37 to 4.68%, for bleached and refined oil, respectively. The redudion of free fatty acid and diglyceride contents depended on the feed/solvent ratio and rotation speed. The perforated rotating disc contador was efficient in the deacidification of bleached com oil with a free fatty acid content of up to 7.80%.
Doutorado
Doutor em Tecnologia de Alimentos

Qu'est-ce que l'intégration? Existe-t-il des personnes intégrées et des personnes non intégrées ou mal intégrées dans la société québécoise? Sur quelles variables pouvons-nous nous baser pour déterminer le niveau d'intégration. Quel est l'impact des politiques d'immigration et d'intégration appliquées par le gouvernement du Québec en vue de promouvoir ou développer et accélérer l'intégration des immigrants d'origine congolaise? Pourquoi le cas des immigrants congolais nécessite-t-il une intervention spéciale de la part de toutes les instances décisionnelles: législatif, financiers et socioculturel? Cette étude tente d'apporter des éléments de réponse à ces questions sur la base d'une enquête qualitative auprès de quelques membres de la communauté congolaise de Montréal.

Master of Science
Department of Psychological Sciences
Michael E. Young
Although risky decision-making tasks present some a priori risk (i.e., base-rate), decision makers often have an opportunity to modify this level of risk through their behaviors. Broadly speaking, risk can be modified by assigning additional resources to an ongoing task or by engaging in specific risk-mitigation strategies before or after the risky decision is made. The modification of risk requires ongoing awareness of task demands, resource constraints, and risk-mitigation strategies that can be used to adapt behavior over time. This thesis explores risk modification that occurs during difficult tasks. Difficult tasks hold greater risks because they fall at the edge of the decision maker’s abilities and are likely to require a greater number of resources to overcome. As resources are engaged they become unavailable for other tasks or strategies to cope with changing task demands. I studied how individuals monitor risks and develop risk mitigation strategies using a videogame task designed to mirror contingencies that would be encountered in the real world. Results from two experiments that involve this task suggest that decision-makers adequately monitor and develop active strategies for dealing with risks. These strategies change over time and vary as a function of task difficulty and experience.

Master of Science
Department of Chemical Engineering
Larry E. Erickson
Caprolactam (C₆H₁₁NO) is produced in industry primarily as a monomer to be converted to nylon-6 via a polymerization reaction. More demanding purity requirements for nylon-6 have increased the performance requirements of extraction columns in the purification train of caprolactam production. Caprolactam is produced by performing a Beckmann Rearrangement on cyclohexanone oxime followed by a neutralization of the excess oleum post reaction. The resulting side product is ammonium sulfate in water with a residual amount of caprolactam that has to be extracted with benzene from the aqueous ammonium sulfate solution to reduce product losses. The aqueous caprolactam liquor is extracted in another column into benzene which purifies the product from water soluble impurities. The resulting caprolactam dissolved in benzene is back extracted into water where the final purification steps are completed prior to storage. Rotating disk contactor (RDC) extraction columns were invented by Royal Dutch Shell in the early 1950’s. The columns have a rotor in the center that is driven by an electric motor to rotate equally spaced flat disks inside the column. There are equally spaced annulus shaped stators that serve to provide mixing-separation compartments for each of the mounted disks on the rotor. Of the variables to consider for the optimum performance of the extraction in the RDC extraction column is the rotor speed. Rotor speed curves are generated for the 3 RDC extraction columns of the caprolactam purification as well as calculations of the number of theoretical stages for each of the columns based on actual performance data. Benzene is the solvent of choice in this purification process however recent push by environmental groups and agencies as well as tightening regulations have driven a desire to find a more benign alternative to benzene for this process. A review of the research and literature on potential alternative solvents for caprolactam purification is summarized with positives and drawbacks for each possible alternative.

O presente estudo avaliou a relação dos parâmetros do eixo II dos Critérios de Diagnóstico de Pesquisa das Disfunções Temporomandibulares (RDC/TMD) na resposta terapêutica de pacientes com DTM. Trinta e três pacientes (média de idade de 33,2 anos ± 13,4) com artralgia da articulação temporomandibular (ATM) foram submetidos a três terapêuticas: laser de baixa potência (LBP) + piroxicam (LPi), LBP + placebo de piroxicam (L) e piroxicam + placebo de LBP (Pi). Os pacientes receberam a terapêutica por 10 dias. As avaliações foram feitas na 1a e 4a sessões de tratamento. A presença e intensidade de dor espontânea, dor à palpação e máxima abertura bucal foram mensuradas. A evolução destas foi comparada à classificação dos pacientes de acordo com os parâmetros do eixo II: grau de dor crônica (GDC), depressão e sintomas físicos não específicos (SFNE). Os dados foram analisados usando os testes de Fisher, Wilcoxon, t de Student, Kruskal-Wallis, U de Mann-Whitney e análise de variâncias, adotando-se p<0,05 como nível de significância. Foi possível observar melhora significativa (p<0,05) dos pacientes estudados quanto ao tempo em relação à EVA e dor à palpação tanto muscular quanto articular. Notou-se diferença estatística significante (p<0,05) entre os grupos de GDC e abertura bucal 4ª sessão e dor articular; entre os grupos de SFNE (incluindo e excluindo itens de dor) e palpação muscular 1ª sessão. Entre os grupos de GDC e as variáveis de EVA e palpação muscular foi encontrada diferença marginalmente significativa, apresentando p-valores próximos a 0,05 (p<0,1). Não foi encontrada diferença estatística significante entre os grupos de depressão e as variáveis consideradas. Portanto, foi observada relação entre alta incapacidade e maiores médias dor articular, grau de SFNE incluindo e excluindo itens de dor classificados como severos e palpação muscular inicial. A depressão não apresentou relação com as variáveis estudadas.
The aim of this study was assess the influence of Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis II parameters on treatment outcome of low-level laser therapy (LLLT) associated with piroxicam in patients with TMD. Thirty-two patients (mean age 33.2 years old ± 13.4) with temporomandibular joint (TMJ) arthralgia were enrolled in the study and received three kinds of treatment: LLLT + piroxicam (LPi), LLLT + placebo piroxicam (L) e piroxicam + placebo LLLT (Pi). Patients were managed for ten days. Follow-up evaluations were done at the 1st and 4th consults. The presence and intensity of spontaneous pain through the visual analogue scale (VAS), painful palpation and mandibular maximum vertical opening were measured. The therapeutic outcomes of this population were compared between the classifications of axis II scores: graded chronic pain (GCP), depression and non-specific physical symptoms (NEPS). The data was analyzed using the following statistic models: Fisher\'s test, Student t test, Wilcoxon, Mann-Whitney U test, Kruskal-Wallis test and Analysis of Variance. The statistical significance level set was p<0.05. The variables VAS, painful joint and muscle palpation showed improvement over time. Significant difference was found between GCP groups and maximum mouth opening on the 4th session and painful TMJ palpation; between NEFS (including and excluding pain items) and painful muscle palpation on the 1st consult. Between groups of GCP and VAS\'s variables it was found a marginally significant relation, showing p-values near 0.05 (p<0.1). No statistical difference was found on the comparison between depression and the physical variables considered. Thus, it is possible to conclude that there is an association between high incapacity and higher mean values to painful joint palpation, severe NEPS including and excluding pain items and baseline painful muscle palpation. No relation between depression and the studied variables was observed.

Made available in DSpace on 2011-05-04T12:36:21Z (GMT). No. of bitstreams: 0 Previous issue date: 2010
Trata-se de um estudo que analisa as ações do Órgão Regulador daPropaganda de Medicamentos no período de 2005 a 2009. A propaganda é um instrumento de promoção da comercialização de medicamentos e de acordo com a própria Agência Nacional de Vigilância Sanitária (ANVISA) e estudos acadêmicos 90 por cento das peças publicitárias exibidas contêm irregularidades. O setor regulado, representado pelas agências de publicidade, indústria e comércio varejista farmacêutico, atua como um forte agente influenciador sobreas normas. Isso ocorre em detrimento do que é preconizado como uso racionale da Política Nacional de Medicamentos. O trabalho analisa os debates ocorridos na Câmara Setorial de Propaganda de Produtos Sujeitos à Vigilância Sanitária da ANVISA, as proposições dos setores envolvidos na área da propaganda de medicamentos, informações veiculadas pela própria Agência e estudos acadêmicos sobre o setor. O trabalho também analisa as estratégias empregadas pela ANVISA para fiscalização e monitoração do setor, bem como a transparência na construção da Resolução de Diretoria Colegiada (RDC) 96/2008. Durante os quatro anos de discussão da regulação de propaganda de medicamentos no país, a nova RDC 96/2008, assim como as demais ações da ANVISA não conseguiram registrar avanços. Portanto, é preciso que se aprofunde ainda mais o debate no sentido de um maior controle da propaganda de medicamentos no país.
This is a study that examines the actions of the Regulatory Agency of Drug Advertising in the period 2005 to 2009. The propaganda is an instrument of promotion of the marketing of medicines and in agreement with the Brazilian’s National Health Surveillance Agency (ANVISA) itself and academic studies 90 % of the publicity pretentious pieces contain irregularities. The regulated sector represented by the agencies of publicity, industry and retail pharmaceutical commerce, influence like a strong Influencer agent over the standards. That takes place to the detriment of what it is extolled like rational use and of the National Politics of Medicines. The work analyses the discussions occurred in the Chamber Setorial of Propaganda of Products Subject to the Sanitary Vigilance of the ANVISA, the propositions of the sectors wrapped in the area of medicines propaganda, informations conveyed by the Agency itself and academic studies on the sector. The work also analyses the strategies employed by the ANVISA for inspection and monitoring of sector, as well as the transparency in the construction of the RDC 96/2008. During the four years of discussion on the regulation of drug advertising in the country, the new Anvisa’s Resolution 96/2008, as well as other actions ANVISA failed to record progress. Thus, it is necessary to deepen further the debate to greater control of drug advertising in the country.

La recherche sur la croyance à la sorcellerie d’antan, c’est-à-dire avant la colonisation de l’Afrique subsaharienne. Le savoir de ces données survivait dans la mémoire de certains aînés qui peuvent se rappeler. Nous avons découvert que pour être sorcier (Nkangadoka) chez les Tetela, il faut être initié. On a deux types de sorciers :celui qui vit dans l’anonymat et celui qui se dévoile parce qu’il est à la fois sorcier et devin-thérapeute. Il y a la notion de personne avec les principes spirituels, quatre pour la personne ordinaire, le double, c’est-à-dire 4 x deux, pour le sorcier. Nous avons aussi découvert l’importance que les Tetela apportent à la vie post-morte, donc la réincarnation. La permanence de cette croyance jusqu’aujourd’hui malgré la métamorphose de la société (industrie, médecine, écoles, les églises de réveil…)
Doctorat en Philosophie
info:eu-repo/semantics/nonPublished

A l'interface de la sociologie des migrations et de la sociologie politique, la thèse porte sur les migrations de retour des réfugiés congolais à partir des principaux pays d'acceuil l'afrique centrale. loin d'être regardées dans une perspective linéaire et statique entre deux sédentarités mais analysées à partir d'observation in situ et d'entretiens biographiques réalisés pendant près de seize mois dans les espaces d'accueil et de retour, les migrations de retour son intégrées ici dans un espace migratoire dynamique fait d'oppositions et de transactions entre les dispositifs du flux migratoire qui organisent et réglementent les migrations de retour, et les multiples pratiques formelles et informelles du sujet dont les intenses jeux de tension s'inscrivent dans un contexte soutenu de limitation des flux migratoires et l'accroissement de nouvelles formes de mobilité dans l'espace migratoire d'afrique centrale
In the interface of the sociology of migration and political sociology, the thesis focuses on return migration of Congolese refugees from the main host countries of central Africa. Far from being observed in a linear and static perspective between two sedentarinesses but analyzed starting from in situ observations and from biographical interviews conducted during 16 months in host and return areas, the migrations of return are integrated in a dynamic migratory space constituted by oppositions and transactions between the biopolitic plans of retention of flows and the circulatory practices of the refugees. The accent is particularly focused on negotiating "biographical crossroads" and migratory careers of refugees from the social, spatial and political capital acquired during the refuge time. How, in these intersections between migratory careers and biopolitical plans, the returnees can define and negotiate their installations in the environment of return ?

Disfunções Temporomandibulares e Dor Orofacial ou DTM, referem-se a um conjunto de alterações funcionais e/ou estruturais que se manifestam nas articulações temporomandibulares (ATMs), nos músculos da mastigação e nas estruturas associadas que compõem o aparelho mastigatório (Okeson, 2013). A DTM tem o potencial de não só interferir nas atividades funcionais do sistema estomatognático, mas também de afetar o comportamento social e psicológico do indivíduo. Este trabalho avaliou a amplitude dos movimentos mandibulares e a dor a palpação muscular no pré e pós-tratamento de participantes com DTM. Os participantes incluídos na pesquisa responderam ao Research Diagnostic for Temporomandibular Dysfunction (RDC/TMD) para viabilizar a formulação do diagnóstico de DTM e qualificar a dor a palpação dos músculos faciais, e submetidos à análise dos movimentos através de uma análise 3D, o JMA que avalia os movimentos mandibulares por vias ultrassônicas, no pré e póstratamento com placa estabilizadora por 30 e 60 dias. Os participantes foram reavaliados, com o objetivo de saber se haverá uma melhora na amplitude dos movimentos mandibulares pela abertura, lateralidades e protrusão e da movimentação condilar dentro da cavidade articular no plano sagital e frontal. Os resultados demonstraram não ter diferenças estatísticas na maior parte dos movimentos excursivos mandibulares (abertura, lateralidade e protrusão) avaliados tanto pelo sistema de ultrassom JMA quanto pelo exame do RDC/TMD. Na análise descritiva dos resultados obtidos através da palpação dos músculos na aplicação do RDC/TMD observamos uma grande melhora no quadro clinico de dor a palpação após 60 dias de uso da Placa Oclusal estabilizadora. Também não observamos diferenças estatisticamente significantes entre os dados coletados de amplitude dos movimentos pelo sistema informatizado JMA e pelo questionário RDC/TMD, ou seja, podemos afirmar que a avaliação pelo JMA é precisa e confiável.
Temporomandibular Disorders and Orofacial Pain or TMD, refer to a set of functional and / or structural changes that are manifested in the temporomandibular joints (TMJ) in the masticatory muscles and associated structures that make up the masticatory system (Okeson, 2013). The TMD has the potential to not only interfere with the functional activities of the stomatognathic system, but also affect the social and psychological behavior of the individual. This study evaluated the range of mandibular movements and muscle palpation pain in the pre and post-treatment of participants with TMD. Participants included in the study responded to the Research Diagnostic for Temporomandibular Dysfunction (RDC / TMD) to allow the formulation of a diagnosis of TMD and qualify pain palpation of the facial muscles, and subjected to analysis of movement through 3D JMA assessing movements mandibular by ultrasonic means, before and after treatment with stabilizing plate for 30 and 60 days. Participants were reassessed in order to know if there will be an improvement in the range of mandibular movements for opening, laterality and protrusion and condyle movement within the joint cavity in the sagittal and frontal plane. The results showed no statistical differences have in most excursive mandibular movements (opening, lateral and protrusive) assessed both by JMA ultrasound system as the examination of the RDC / TMD. In the descriptive analysis of the results obtained by palpation of the muscles in the application of the RDC / TMD noticed a great improvement in the clinical picture of pain palpation after 60 days of use board stabilizing occlusal. We did not observe statistically significant differences between the data collected from the range of motion by the computerized system JMA and the questionnaire RDC / TMD, other words, we can say that the evaluation by the JMA is accurate and reliable.

Bzhad pa'i rdo rje (1697-1740), the Fifth Sle lung Rin po che, was a religiously and politically controversial figure and an incredibly prolific author, having written or compiled over 46 volumes worth of mainly religious texts. A high-ranking Dge lugs pa sprul sku, Sle lung is seen as having gradually "defected" to the Rnying ma school, although he self-identified as a follower of the "non-sectarian" (ris med) perspective. Sle lung also acted as a spiritual advisor to most of the major central Tibetan rulers during the course of his life, most significantly Mi dbang Pho lha nas (r. 1729-1747). But despite numerous features of fascinating interest, Sle lung and his writings have received very little scholarly attention, and this thesis is intended to fill this unfortunate lacuna. The present study begins with an extended biographical examination of Sle lung's life, and the political and religious unrest in central Tibet at the time in which he was deeply invested. I pay special attention to the controversies that surrounded him, particularly his purported sexual licentiousness and his ecumenical work which was unpopular among his more sectarian Dge lugs pa critics. This opening biography provides critical historical context as I move on to examine two of Sle lung's most important literary works. The first is the sixteen-volume Gsang ba ye shes chos skor, a massive cycle of teachings by Sle lung and his students that integrates tantric theories derived from Sle lung's experience with Gsar ma (specifically Dge lugs pa) teachings. The second work is the Bstan srung rgya mtsho'i rnam thar, a unique text in Tibetan literature which consists of an apparently unprecedented compilation of Tibetan Buddhist protector deity (bstan srung, chos skyong) origin myths. I will make sense of key features of these two works within the larger context of Indo-Tibetan Buddhism, as well as the political and personal concerns of Sle lung himself.

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The aim of this study was to investigate the opinion of specialists in radiology, from different parts of the world, regarding to the proposed criteria for image acquisition and interpretation by Computed Tomography (CT), Cone Beam Computed Tomography (CBCT) and Resonance imaging (MRI) in diagnosing temporomandibular joint disorders (DATM) as part of Diagnostic Criteria for Research of Temporomandibular Disorders (RDC/TMD). Radiology specialists were invited by email to participate as volunteers in the study from three different eligible populations: researchers with publication DATM indexed on PubMed, ORADLIST members and individual contact. The link to access the questionnaire was mailed to volunteers interested in participating who matched the inclusion criteria. The sample was composed of specialists in radiology with experience in the interpretation of sectional images (CT, CBCT and/or MRI) of the temporomandibular joint (TMJ) who answered a questionnaire in English, which was developed and maintained online (LimeSurvey 1.87+). In a three months period, two recalls were sent and a period of 40 days after the last notification was given for responses submission. The questionnaire was divided into three parts with closed and open questions. Part I was related to issues of participant identification (gender, age, country of activity, area of activity, time and experience as a radiologist in the interpretation of sectional images of the TMJ and monthly time dedicated to the activity of interpreting sectional images of ATM). Part II contained questions related to the adequacy of the proposed criteria for the interpretation of sectional images of the ATM as part of the RDC/TMD. The criteria were presented into two columns' tables and the participants were asked whether that set of criteria was considered adequate or not for assessement and diagnosis of TMJ osseous and non-osseous tissues according to each imaging modality. If the respondent not considered criteria appropriate, he/she should indicate what type of suggestion: if insertion of new items, the modification or deletion of existing items. Part III had questions related to the need to include a minimal technical protocol for TMJ CT, CBCT and MRI acquisition as part of the RDC/TMD. If deemed necessary, the respondent should indicate which would be his/her suggestion protocol for acquisition of each imaging technique (CT, CBCT and MRI). Fifty-seven radiologists from different countries completed the questionnaire. The results indicate that 87 to 98% of radiologists considered the criteria adequate and that 81.6% of respondents considered necessary to include a minimal technical protocol for CT, CBCT and MRI acquisition as part of the RDC/TMD. Two to thirteen percent of respondents suggested insertion, modification and deletion of items in the proposed criteria. Ninety percent of respondents considered necessary to include a minimal technical protocol for CT/CBCT and 81.7% for MRI. We conclude that, according to the opinion of the worldwide community of specialists in radiology, the need for adjustments in the criteria for assessment of sectional images of the ATM is minimal, however, the need for the inclusion of a protocol to acquire minimal technical parameters of those images as part of protocol standardization of studies using the RDC/TMD is clear.
O objetivo desse estudo foi investigar a opinião de especialistas em radiologia, de várias partes do mundo, quanto aos critérios propostos para aquisição e interpretação de imagens por Tomografia Computadorizada (TC), Tomografia Computadorizada por Feixe Cônico (TCFC) e Ressonância Magnética (RM) no diagnóstico das desordens da articulação temporomandibular (DATM) como parte dos Critérios de Diagnóstico para Pesquisa das Desordens emporomandibulares (RDC/TMD). Especialistas em radiologia foram convidados por meio de e-mail a participar como voluntários do estudo a partir de três diferentes populações elegíveis: pesquisadores com publicação indexada sobre DATM no PubMed, membros da ORADLIST e contato individual. O link de acesso ao questionário foi enviado por email aos voluntários interessados em participar os quais preencheram os critérios de inclusão. A amostra foi composta por especialistas em radiologia com experiência na interpretação de imagens seccionais (TC, TCFC e/ou RM) da articulação temporomandibular (ATM) que responderam um questionário na língua inglesa, desenvolvido e mantido online (LimeSurvey 1.87+). Num período de três meses, duas notificações foram enviadas e um prazo de 40 dias após a última notificação foi estabelecido para o envio das respostas. O questionário foi dividido em três partes com perguntas fechadas e abertas. A parte I relacionava-se às questões de identificação do participante (gênero, idade, país de atuação, área de atividade, tempo de experiência como radiologista e na interpretação de imagens seccionais da ATM e o tempo de dedicação mensal à atividade de interpretar imagens seccionais da ATM). A parte II continha questões relacionadas à adequação dos critérios propostos para interpretação das imagens seccionais da ATM como parte do RDC/TMD. Os critérios foram apresentados em tabelas de duas colunas e os participantes eram questionados se aquele conjunto de critérios era considerado adequado ou não para a interpretação e diagnóstico dos tecidos ósseos e não-ósseos da ATM de acordo com cada modalidade de imagem. Caso não os considerasse adequado, deveria indicar qual o tipo de sugestão: se inserção de novos items, a modificação ou eliminação de itens existentes. A parte III continha perguntas relacionadas à necessidade de se incluir um protocolo técnico mínimo para a aquisição de TC, TCFC e RM como parte do RDC/TMD. Caso considerasse necessário, deveria indicar qual seria sua sugestão de protocolo para aquisição de cada uma das técnicas de imagem (TC, TCFC e RM). Cinqüenta e sete radiologistas de vários países responderam o questionário. Os resultados indicam que 87 a 98% dos radiologistas consideraram os critérios adequados e que 81,6% dos respondentes consideram necessária a inclusão de um protocolo técnico mínimo para aquisição das imagens por TC, TCFC e RM como parte do RDC/TMD. Dois a treze porcento dos respondentes sugeriram inserção, modificação e eliminação de items nos critérios propostos. Noventa porcento dos respondentes consideram necessária a inclusão de protocolo técnico mínimo para TC/TCFC e 81.7% para a RM. Conclui-se que, de acordo com a opinião da comunidade mundial de especialistas em radiologia, é mínima a necessidade de ajustes nos critérios para interpretação de imagens seccionais da ATM, entretanto, é clara a necessidade da inclusão de um protocolo técnico mínimo para a aquisição das referidas imagens como parte do protocolo de normatização das pesquisas que utilizam o RDC/TMD.

Le phénomène des Combattants dans la diaspora congolaise se révèle comme l’un des printemps chauds de l’histoire de la RDCONGO. Il traite de la réaction d’une diaspora devant l’absurdité de la guerre, de crises multiformes ainsi que de l’insécurité protéiforme dans une mère patrie taxée de scandale géologique à cause d’un sous-sol immensément riche, d’un écosystème diversifié et doté d’une exceptionnelle biodiversité, mais dont la population croupit dans l’indigence. Cette situation misérabiliste et paradoxale s’est traduite par une exaspération croissante qui a pris tout son sens dans la mobilisation des masses au sein de la diaspora qui intervient constamment, avec le fait des transferts d’argent. Depuis dix ans, la mobilisation des Combattants au sein de la communauté congolaise à l’étranger a marqué son empreinte dans les cinq continents. L’aspect visible de la mobilisation soudaine de cette communauté, internationale et originale par sa forme, n’a pas manqué de surprendre. Motivée par ce constat empirique, cette étude analyse ce phénomène inédit dans l’histoire de la République démocratique du Congo, dans la mesure où il met en jeu de nouvelles formes de mobilisations et de contestations qui, à notre avis, constituent une forme originale d’un mouvement contestataire à l’heure de la globalisation. L’étude analyse la mobilisation des Combattants par le prisme de la grille des nouveaux mouvements sociaux transnationaux ou des mouvements altermondialistes. De prime abord, elle propose ainsi un cadre de réflexion et développe une analyse rigoureuse du phénomène des Combattants : comprendre sa morphologie : sa structuration, son mode de fonctionnement, ses stratégies de militance, ses effets, ses causes et sa portée ; ensuite, elle rend compte du contenu de leur mobilisation dont quelques aspects touchent la question de l’humanité, de la dignité, de l’identité « Afropéenne » ou Afro-occidentale, de l’Ubuntu, des antagonismes, de la violence, de la dimension religieuse et de la responsabilité pour les générations futures. Elle saisit enfin à partir des perspectives élaborées par les membres de la diaspora africaine, comment les pratiques de la mobilisation transnationale participent concrètement à la construction du monde commun et dynamique autour des nouveaux acteurs dits « Afropéens » ou afro-occidentaux. Tout cela a permis, ensuite, à faire une lecture analytique de la mobilisation des Combattants à la lumière de théories et caractéristiques des NMST lorsque ces dernières se confrontent à la question des relations transnationales
The phenomenon of congolese combatants in the diaspora is proving to be one of the hot springs in the history of the DR CONGO. Il deals with the reaction of a diaspora faced with the absurdity of wars, multifaceted crises as well as protean insecurity in a country where geological scandals are common because of her rich natural ressources, her diverse ecosystem with an extraordinary biodiversity, but whose population languishes in abject poverty. This miserable and paradoxal situation has resulted in a growing exasperation that has taken on a sense of mobilizing of the masses within the diaspora constantly intervening, resulting in money transfers. Over the past ten years, the mobilization of these combatants within the Congolese community abroad has made its mark on all five continents. The visible aspect of the sudden mobilization of this community, international and original in its form, did not fail to surprise. Motivated by this empirical observation, this current study analyses this original phenomenon in the history of the Democratic Republic of Congo, inasmuch as it involves new forms of mobilization and protest which, in our opinion, constitute a form of an original protest movement in the age of globalization. This present study analyzes the mobilization of combatants through the prism of the grid of new socio-transnational movements or alter-globalization movements. In the first place, it thus proposes a framework for reflection and develops a rigorous analysis of the phenomenon of combatants : understanding its morphology : its structuring, its mode of operation, its strategies of militance, its effects, its causes and its scope; secondly, it takes into consideration the content of their mobilization, which affects some aspects of humanity, human dignity, "Afro-Western" (Afro-european) or Afro-Western identity, antagonisms, violence, religion and responsibility for future generations. Finally, from the perspectives elaborated by members of the African diaspora, it tackles how the practices of transnational mobilization are concretely involved in building the common and dynamic world around the new actors known as "Afropeans" or Afro-Westerns. All of this has allowed, then, to make an analytical reading of the combatants mobilization in the light of theories and NMST characteristics when they confront the issue of transnational relations

Deuxième pays le plus endémique pour le paludisme au monde, la république démocratique du Congo (RDC) a adopté officiellement l’initiative Faire Reculer le Paludisme en 2001 et depuis, aligne sa politique de lutte contre le paludisme sur les directives de l’OMS dont les orientations les plus récentes consistent en 3 stratégies :[1] assurer aux malades un accès rapide à un traitement efficace et abordable, [2] assurer aux personnes exposées au risque, notamment les jeunes enfants et les femmes enceintes, l’association la plus adaptée de mesures de protection au niveau personnel et communautaire et [3] donner l’accès, aux femmes enceintes exposées au risque, à des traitements préventifs.

Afin de contribuer à l’amélioration de la lutte antipaludique en RDC, le travail a été réalisé en 3 parties :une portant sur la pertinence du traitement préventif intermittent à la Sulfadoxine-Pyriméthamine (TPI-SP) chez la femme enceinte en contexte d’augmentation de la résistance du parasite, une 2e sur les facteurs déterminants l’adhésion des prestataires de soins, des vendeurs des médicaments et des patients à association Artesunate-Amodiaquine (AS-AQ) et une 3e décrivant le paludisme sévère chez l’enfant.

La 1ère partie du travail portant sur le TPI-SP a été réalisée en 2 temps. La première approche a consisté en une analyse rétrospective des poids de naissance des nouveau-nés en fonction de la prise du TPI-SP par les mères dans 3 maternités en 2007 où les niveaux de résistance à la SP étaient différents. La deuxième approche, comparait l’effet du traitement préventif intermittent à la Sulfadoxine-Pyriméthamine en 1998/1999 et en 2007 à la prophylaxie à base de chloroquine en 1998/1999 à l’Est de la RDC dans un milieu où la résistance à la Sulfadoxine-Pyriméthamine avait accru considérablement.

Dans les régions où la résistance du parasite était de faible (Mikalayi: 1,6% d’échec thérapeutique chez l’enfant) à modéré (Kisangani: 21,7% d’échec thérapeutique chez l’enfant), le TPI-SP réduit le risque de faible poids à la naissance, à Kisangani (OR ajusté :0,15; IC95%, 0,05-0.46) et à Mikalayi (OR ajusté :0,12; IC95%, 0,01-0,89). Dans ces 2 sites, le poids de naissance moyen des Nouveau-nés était plus élevé pour les mères ayant reçu 2 doses par rapport à celui des Nouveau-nés des mères en ayant reçu une seule ou aucune (P<0.001). A Rutshuru où la résistance était élevée (60,6% d’échec thérapeutique chez l’enfant), l’effet du TPI-SP semble moindre: en 2007 - en comparaison dose-dépendante (2 doses Vs 0-1 dose) du poids à la naissance des nouveau-nés en 2007 pour les mères sous TPI-SP – on observait un effet bénéfique chez les primigestes et non chez les multigestes et une légère régression du gain pondéral [(53,9g ( P=0,027) pour les nouveau-nés des mères sous SP en 2007 Vs 70,2g (P=0,003) pour ceux des mères sous SP en 1998/1999 par rapport à ceux des mères sous chloroquine en 1998/1999. Néanmoins, le TPI-SP reste efficace en 2007 comme en 1998-1999 par rapport à la prophylaxie à base de chloroquine en 1998/1999 (poids moyen supérieur et réduction du risque de PPN pour les 2 groupes sous SP).

La 2e partie, traitait des déterminants de l’adhésion des prestataires et des patients au nouveau médicament recommandé par la politique nationale pour la prise en charge des cas de paludisme simple ( AS-AQ ) en 2 enquêtes transversales :une étude préliminaire qui a été réalisée dans les CS fonctionnels de Kisangani en avril 2008 et une étude étendue à 3 des 10 districts sanitaires de la province Orientale de mars à juin 2009. Ces 2 enquêtes ont ensuite servi à une analyse systémique des facteurs d’adhésion des prestataires de soins à l’AS-AQ basée sur le modèle de diagnostic de Green et Kreuter et les étapes de changement de comportement de PROCHASKA pour la planification des interventions de promotion.

Le recours à l’AS-AQ pour le traitement du paludisme simple progresse (41% et 69% des prescriptions dans les services sanitaires respectivement 3 et 4 ans après le changement de politique national de lutte antipaludique), mais reste inférieur à la cible d’au moins 80% visée par la politique nationale. Malgré la croyance en l’efficacité du nouveau traitement, son utilisation effective rencontre comme principaux obstacles, selon l’avis des prestataires de soins, des vendeurs de médicaments et des patients, sa faible disponibilité, son coût élevé, la présence sur le marché d’antipaludiques retirés du protocole national de traitement et de l’AS-AQ de mauvaise qualité à un coût moindre et la crainte des effets indésirables. Tandis que les facteurs incitatifs à son utilisation sont, l’efficacité thérapeutique perçue de l’AS-AQ, la présence du médicament dans les formations sanitaires, la recommandation de son utilisation par les directives du Ministère de la Santé (notamment sous forme de guides techniques), la formation et la supervision des prestataires, l’intention de prescrire l’AS-AQ aux patients ou d’en prendre soi-même, une plus longue durée de consultation, le fait de fournir des explications aux patients, de travailler dans le milieu rural.

La dernière partie du travail consistait en une étude prospective menée du 1er janvier 2010 au 28 février 2011 décrivant le diagnostic et la prise en charge du paludisme grave chez les enfants admis dans 2 HGR de Kisangani.

Le paludisme constitue un des principaux motifs d’hospitalisation des enfants en RDC (37,0% à Kisangani) dont l’évaluation est souvent incomplète (53,6% avec goutte épaisse négative ou sans, insuffisamment explorés et traités comme paludisme grave) et le traitement parfois inadéquat (outre les affections non palustres probables non traitées, il y avait notamment surutilisation des produits sanguins exposant les enfants aux risques infectieux transfusionnels). Ainsi, les limites du plateau technique des HGR et l’organisation du circuit des malades semblent entraîner une sous-estimation, entre autre, des complications métaboliques du paludisme grave et des autres infections graves du jeune enfant et par conséquent des écarts au protocole de prise en charge préjudiciables aux patients.

Ces résultats mettent en lumière la nécessité :

•d’inscrire parmi les priorités du Programme National de Lutte contre le Paludisme, des recherches pour évaluer une option alternative au traitement préventif intermittent avec 2 doses de SP (traitement préventif intermittent avec d’autres antipaludiques) et à l’est du pays le recours préférentiel à la moustiquaire imprégnée à longue durée, en particulier chez la multigeste.

•de retenir, pour la promotion de l’utilisation de l’AS-AQ pour le traitement du paludisme simple, comme priorités :

o mettre à profit les opportunités actuelles de financement dans le domaine de la lutte antipaludique pour améliorer la disponibilité de l’AS-AQ à un coût accessible et à améliorer l’approvisionnement aussi bien des formations sanitaires publiques et privées que des officines pharmaceutiques ;

o assainir le secteur pharmaceutique de manière à endiguer la circulation d’antipaludique de mauvaise qualité à bas prix qui alimente les habitudes d’automédication courante dans les ménages ;

o élaborer des programmes de promotion de l’utilisation de l’AS-AQ, en élargissant la cible des interventions autant aux prestataires de soins du secteur privé qu’aux vendeurs de médicaments ;

o Adapter les programmes de promotion de l’AS-AQ au stade de changement de comportement auquel se trouve les acteurs après analyse des déterminants de leurs comportements notamment, les facteurs prédisposant (aussi bien les connaissances que les croyances et les intentions des prescripteurs), les facteurs potentialisant (notamment la disponibilité de l’AS-AQ de bonne qualité, son accessibilité financière aux patients) et les facteurs renforçant (supervision, contrats de performance).

•de renforcer le plateau technique des HGR et y améliorer le circuit des patients pour leur permettre de jouer pleinement leur rôle dans la prise en charge des formes graves du paludisme. /

Second most endemic country for malaria in the world, the Democratic Republic of Congo (DRC) has officially adopted the Roll Back Malaria (RBM) in 2001, since then aligns its malaria control policy on WHO guidelines which last orientations are based on three major strategies [1] prompt access to effective treatment and affordable for the patients [2] association of the most appropriate measures to protect the persons at risk both at individual and community level, including young children and pregnant women, [3] and access to preventive treatments to pregnant women at risk.

In order to contribute in improving malaria control in DRC, the study was carried out in three parts: the first one on the relevance of IPT with SP in pregnant women in the context of increased parasite resistance, the second one on the determinants of adherence of healthcare providers, drugs sellers and patients to AS-AQ, the last one describing severe malaria in children.

The first part of the study on IPTp-SP was performed in 2 stages. We had firstly carried out a retrospective analysis of birth weight comparing newborns whom mothers had received 2 SP doses to those whom mothers had received one or none, in three maternity hospitals in 2007 where levels of SP resistance were different. Then we evaluated the effect of IPTp-SP in 1998/1999 and 2007 compared to prophylaxis with chloroquine in 1998/1999 in eastern DRC in a region where resistance to SP was significantly increased.

In areas where parasite resistance was low (Mikalayi: 1.6% of therapeutic failure in children) our moderate (Kisangani: 21.7% of therapeutic failure in children), the IPTp-SP reduced the risk of LBW in Kisangani (OR adjusted 0.15, 95% CI, 0.04-0.58) and Mikalayi (adjusted OR, 0.12, 95% CI, 0.01-0.89). In both sites, the average birth weight was higher for mothers having received two rather than one or no SP doses (P<0.001). While in Rutshuru, where resistance was high (60.6% treatment failure), the effect of IPT-SP seems lower. In 2007, IPTp-SP had an effect only in primigravidae (dose-response comparison: 2 doses vs. 0-1dose). It was also observed in a slight decrease in body weight gain [(53.9 g (P = 0.027) for mothers having received SP in 2007 vs. 70.2 g (P = 0.003) for those mothers who had received SP in 1998/1999 compared to mothers who had received chloroquine in 1998/1999.

In the second part of the thesis, two cross-sectional surveys were carried out to identify determinants of the adherence of healthcare providers, drugs sellers and patients to the new drug recommended by the national policy for the treatment of uncomplicated malaria (AS-AQ). A preliminary survey was conducted in functional health centre in Kisangani in April 2008 and a second survey extended to three out of 10 health districts in the Eastern Province from March to June 2009.

The use of AS-AQ for the treatment of uncomplicated malaria progresses (from 41% to 69% prescriptions in health services between 2008 and 2009, 3 and 4 years respectively after the malaria control policy change), but still below the target of at least 80% pursued by national policy. Despite the perceived efficacy of AS-AQ by both healthcare providers and drugs vendors, its use was limited due to its low availability, high cost, mistrust on the quality of the available product, availability of inexpensive antimalarial drugs withdrew from national politicy and the fear for adverse effects. While the incentives for its use were, the therapeutic efficacy, availability, directives of the ministries of health (technical guidelines), training and supervision of healthcare providers, the intention to prescribe AS-AQ to patients or to use oneself, lengthy consultations, providing explanations to patients, working in rural areas.

The last part of the thesis was a prospective study conducted from January 2010 to February 2011 that included all children admitted for severe malaria with at least one of the criteria for severe malaria according to WHO.

Malaria is one of the main reasons for hospitalization of children in the DRC (37.0% in Kisangani) whose evaluation is often uncompleted (53.6% no or negative blood smear that are insufficiently explored and treated as severe malaria) and sometimes inadequately treated (in addition to non-malarial severe diseases treated as severe malaria, there was overuse of blood products conducting probably to exposition of children to risks of infection through transfusion). Thus, poor technical support and inadequate organization of the patient circuit seem to lead to underestimation, among others, of metabolic complications of severe malaria and in the non-recognition of other serious infections early childhood, problems that are detrimental to the patients, even when effective drugs are available.

These results highlight the need:

•to include among the priorities of the National Malaria Control Program, research to evaluate an alternative option to 2 doses IPTp-SP (IPT using other antimalarial drugs) and in the east of the country preferential use of MILD, especially in multigravidae.

•for the use of AS-AQ for the treatment of uncomplicated malaria primarily promote:

o the use of current funding opportunities in the field of malaria control to improve the availability of the AS-AQ at an affordable cost and to improve the supply of both public and private health facilities as well as pharmacies;

o to clean up the pharmaceutical sector in order to stem the flow of poor quality cheapest antimalarial drugs that feeds the habits of self-medication common in households;

o to develop communication programs, training and supervision of healthcare providers to promote the use of AS-AQ, expanding the target of interventions to both healthcare providers in the private sector and drugs sellers;

o To adapt AS-AQ promoting programs to the stage of behavior change after analysis of determinants of actors behavior, in particular, the predisposing factors (knowledge as well as beliefs and intentions of the prescriber), the potentializing factors (including the availability of the good quality AS-AQ, affordability to patients) and reinforcing factors (supervision, performance contracts).

•to strengthen the technical support of general hospitals and to improve the organization of the patient circuit in order to enable them to play their full role in the management of severe malaria.

Doctorat en Sciences de la santé publique
info:eu-repo/semantics/nonPublished

A falta de qualidade das obras públicas no Brasil povoa os noticiários diários. Os exemplos são abundantes, atribuídos a contratos mal elaborados, falhas graves nos projetos ou mesmo à ausência desses, licitações frustradas, obras interrompidas e superfaturadas, desvios de recursos e corrupção. Tentar compreender melhor essa situação é a motivação desta dissertação, que discorre sobre a contratação pública de projetos de edificações e, para isso, estuda o projeto e sua encomenda. A licitação é um procedimento obrigatório para a celebração de qualquer contrato público. Entre outros requisitos, a lei de licitações exige que a proposta seja a “mais vantajosa” para a administração, algo que tem levado à adoção indiscriminada do critério do “menor preço”, sendo incoerente com a doutrina jurídica e contrariando as pesquisas científicas, que consideram o projeto relevante para a qualidade final da obra. O problema de pesquisa questiona exatamente por que a Administração Pública tem contratado por menor preço um serviço que deveria ser contratado por critérios técnicos e de qualidade? O objetivo da dissertação é propor uma explicação para essa situação a partir de revisão bibliográfica, análise da legislação, realização de pesquisa documental com editais de licitação, aplicação de questionários de opinião com arquitetos e outros atores, além de entrevista direta com o autor da lei de licitações. Finalmente, o trabalho comprova a relevância do projeto, mas também desvenda sua irrelevância identificando que o menor preço não é o único problema e, mesmo que “todos” afirmem ser contra o menor preço, o povo segue pagando caro por projetos baratos.
The qualityless of public works in Brazil is currently in the daily news. Examples of it are plentiful, attributed to poorly drafted contracts, serious failures or even absence of projects, frustrated bids, discontinued and overpriced works, waste of resources and corruption. The motivation of this dissertation is trying to better understand this situation, which focuses on the public contracting of building projects and, for this, studies the project itself and its order. Bidding is a mandatory procedure for obtaining any public contract. Among other requirements, the bidding law requires that the proposal be the "most advantageous" for the administration, which ledded to the indiscriminate adoption of the "lowest price" criteria, incoerent with the juridical doctrine and opposite to scientific research, which consider the project relevant to the final quality of the building work. The research problem questions why the Public Administration has contracted for a lower price a service that should be contracted by technical and quality criteria? The objective of the dissertation is to propose an explanation for this situation from a bibliographical review, an analysis of the legislation, a documental research on bid’s documents, an opinion questionaries applying to architects and other actors, as well as direct interview with the author of the bidding law. Finally, the research proves the relevance of the project, but also reveals its irrelevance by identifying that the lowest price is not the only problem, and even if "everyone" claims to be against the lowest price, people continue to pay expensive for cheap projects.

The detonation-based engine has the key advantage of increased thermodynamic efficiency over the traditional constant pressure combustor. These detonation-based engines are also known as Pressure Gain Combustion systems (PGC) and Rotating Detonation Combustor (RDC) is a form of PGC, in which the detonation wave propagates azimuthally around an annular combustor. Prior researchers have performed a high fidelity 3-D numerical simulation of a rotating detonation combustor (RDC) to understand the flow physics such as detonation wave velocity, pressure profile, wave structure; however, performing these 3-D simulations is computationally expensive. 2-D simulations are a potential alternative to reduce computational cost. In most RDCs, fuel and oxidizer are injected discretely from separate plenums, and this discrete fuel/air injection results in inhomogeneous mixing within the domain. Due to the discrete fuel injection locations, fuel/oxidizer will stratify to form localized pockets of rich and lean mixtures. The motivation of the present study is to investigate the impact of unmixedness and stratification length scales on the performance of an RDC using a 2-D numerical approach. Unmixedness, which is defined as the standard deviation of equivalence ratio normalized by the mean global equivalence ratio, is a measure of the degree of fuel-oxidizer inhomogeneity. To model the effect of unmixedness in a 2-D domain, a lognormal distribution of the fuel mass fraction is generated with a mean equivalence ratio of 1 and varying standard deviations at the inlet boundary as a numerical source term. Moreover, to model the effects of stratification length scales, fuel mass fraction at the inlet boundary cells is bundled for a given length scale, and the mass fractions for these bundles are updated based on the lognormal distribution after every three-time steps. Using this methodology, 2-D numerical analyses are carried out to investigate the performance of an RDC for an H2-air mixture with varying unmixedness and stratification length scales. Results show that mean detonation velocity decreases and wave speed variation increases with an increase in unmixedness. However, with an increase in stratification length scale mean velocity remain relatively unchanged but variation in local velocity increases. The detonation wave front corrugation also increases with an increase in mixture inhomogeneity. The mean detonation cell size increases with an increase in unmixedness. The cell shape becomes more distorted and irregular with an increase in stratification length scale and unmixedness. The combined effect of unmixedness and stratification length scale leads to a decrease in pressure gain. Overall, this concept is able to elucidate the effects of varying unmixedness and stratification length scales on the performance of an RDC.
Master of Science
Pressure Gain Combustion (PGC) system has gained significant focus in recent years due to its increased thermodynamic efficiency over a constant pressure Brayton Cycle. Rotating Detonation Combustor (RDC) is a type of PGC system, which is thermodynamically more efficient than the conventional gas turbine combustor. One of the main aspects of the detonation process is the rapid burning of the fuel-oxidizer mixture, which occurs so fast that there is not enough time for pressure to equilibrate. Therefore, the process is thermodynamically closer to a constant volume process rather than a constant pressure process. A constant volume cycle is thermodynamically more efficient than a constant pressure Brayton cycle. In an RDC, a mixture of fuel and air is injected axially, and a detonation wave propagates continuously through the circumferential section. Numerical simulation of an RDC provides additional flexibility over experiments in understanding the flow physics, detonation wave structure, and analyzing the physical and chemical processes involved in the detonation cycle. Prior researchers have utilized a full-scale 3-D numerical simulation for understanding the performance of an RDC. However, the major challenge with 3-D analyses is the computational expense. Thus, to overcome this, an inexpensive 2-D simulation is used to model the flow physics of an RDC. In most RDCs, the fuel and oxidizer are injected discretely from separate plenums. Due to the discrete fuel injection, the fuel/air mixture is never perfectly premixed and results in a stratified flow field. The objective of the current work is to develop a novel approach to independently investigate the effects of varying unmixedness and stratification length scales on RDC performance using a 2-D simulation.

RésuméContexte :Les avortements provoqués sont un problème de santé publique, et cela de par leur fréquence, la survenue de complication, et la mortalité et morbidité qui en découlent. Les décès peuvent ainsi représenter jusqu’à 18% de décès maternels. Très peu des données y relatives sont disponibles pour la RDC, alors que ce pays montre une mortalité maternelle très élevée avec un ratio qui est passé de 546 à 1188 décès maternels pour 100.000 naissances vivantes de 2007 à 2016 malgré l’amélioration de l’accessibilité et de l’utilisation des services de santé maternelle de 2001 à 2014. Objectif :Analyser les complications des avortements provoqués et les effets de l’intégration de la stratégie standard des soins après avortement dans les structures sanitaires de référence de la ville de Kinshasa, capitale de la RDC.Méthodes :L'analyse des complications des avortements provoqués incluait trois études transversales. La première étude a déterminé la prévalence des avortements provoqués et les complications y relatives. La deuxième et la troisième ont analysé les cas de complications des avortements provoqués admis dans les structures sanitaires de référence de Kinshasa du niveau secondaire et tertiaire successivement. Ensuite, l’analyse des effets de l’intégration de la stratégie standard des soins après avortement dans les structures sanitaires de référence de la ville de Kinshasa incluait une étude quasi expérimentale avec un design avant-après-comparatif. En outre, une étude qualitative avait été menée afin de contribuer à produire un modèle des soins après avortement adapté à la ville de Kinshasa.Résultats :Il ressort de nos études que le taux des avortements provoqués en 2015 était de 55 pour 1000 femmes en âge de procréer à Kinshasa, capitale de la RDC, et que la pratique de ces avortements était significativement plus souvent observée chez les femmes célibataires, séparées, ou divorcées, chez celles n’ayant pas étudié ou n’ayant fait que l’école primaire, et chez les consommatrices d'alcool, pour la plupart au moyen de doses élevées de médicaments administrées par les femmes elles-mêmes ou par des agents de santé. Un peu plus de la moitié de ces avortements avaient entraîné des complications, principalement hémorragiques, infectieuses, et traumatiques. Les patientes présentant ces complications représentaient entre 12,4 et 17,3% de l’ensemble des admissions dans les services de gynéco-obstétrique des structures sanitaires de référence du niveau secondaire, et environ 12,2% dans celle du niveau tertiaire. Dans ces structures, la durée médiane d'hospitalisation était de 9 à 10 jours, significativement plus longue pour des patientes ayant subi une intervention chirurgicale pour pelvipéritonite post perforation utérine que pour celles ayant subi une césarienne ou une hystérectomie. De plus, cette durée était significativement plus longue pour des patientes traitées pour d’autres types de complication post-abortive, que celles traitées pour un avortement spontané. Le taux de mortalité lié à ces complications était de 2,3 à 11,3% dans les structures du niveau secondaire, et de 37,8% dans celle du niveau tertiaire.La mise en place de la stratégie standard des soins après avortement dans les structures sanitaires de référence du niveau secondaire de la ville de Kinshasa a significativement amélioré la fréquence de la pratique de l’Aspiration Manuelle Intra-Utérine qui est passée de moins de 25% à 32−82% dans les structures expérimentales (p=0,025) au détriment de dilatation-curetage, ainsi que la durée d’hospitalisation des patientes admises pour une complication d’avortement provoqué (1 jour de moins dans les structures expérimentales, p=0,020). Par contre, elle n’a pas eu d’effets significatifs sur l’utilisation des services relatifs aux complications d’avortement provoqué, la létalité, et l’offre effective de la contraception moderne post avortement.Pour ce qui est des obstacles au succès des interventions qui visent l’amélioration de la prise en charge des complications des avortements provoqués dans les structures sanitaires de référence de la ville de Kinshasa, il y a notamment la culture, les normes sociales préétablies, la défaillance de l’éducation, le manque des moyens financiers, l’automédication, le manque d’un personnel formé, l’indiscrétion dans les structures sanitaires officielles, et les influences des pharmaciens/vendeurs des médicaments, des tradipraticiens, et des certains pasteurs.Conclusion :Les études présentées dans cette thèse ont montré que la pratique des avortements provoqués était fréquente à Kinshasa, capitale de la RDC, et que les complications survenaient dans plus de la moitié des cas, lesquelles complications n’étaient pas correctement prises en charge dans les structures sanitaires de référence et menaient à un décès dans plus de 5% de l’ensemble des cas. Ces études ont, en plus, permis de mettre en évidence une insuffisance des résultats de la stratégie standard des soins après avortement implémentée par le Ministère de la Santé Publique via le Programme National de Santé de la Reproduction, et de proposer une série d’actions de réajustementSummaryContext:Induced abortions are a public health problem because of their frequency, the occurrence of complications, and the resulting mortality and morbidity. Deaths can thus represent up to 18% of maternal deaths. Very little relative data is available for the DRC, although this country shows a very high maternal mortality with a ratio that went from 546 to 1188 maternal deaths per 100,000 live births from 2007 to 2016 despite the improvement in accessibility, and use of maternal health services from 2001 to 2014.Goal:Analyze the complications of induced abortions and the effects of integrating the standard postabortion care strategy into referral health structures in the city of Kinshasa, capital of the DRC.Methods:The analysis of complications from induced abortions included three cross-sectional studies. The first study determined the prevalence of induced abortions and related complications. The second and third analyzed the cases of complications from induced abortions admitted to the referral health structures in Kinshasa at the secondary and tertiary level. Then, the analysis of the effects of integrating the standard postabortion care strategy into referral health facilities in the city of Kinshasa included a quasi-experimental study with a before-after-comparative design. In addition, a qualitative study was carried out to help produce a postabortion care model adapted to the city of Kinshasa.Results:Our studies show that the rate of induced abortions in 2015 was 55 per 1000 women of childbearing age in Kinshasa, the capital of the DRC, and that the practice of these abortions was significantly more observed among single, separated or divorced women, those with no or only primary school education, and among female alcohol users, mostly with high doses of drugs administered by women themselves or by health workers. Just over half of these abortions resulted in complications, mainly hemorrhagic, infectious, and traumatic. Patients with these complications represented between 12.4 and 17.3% of all admissions to the gyneco-obstetrics departments of referral health facilities at the secondary level, and around 12.2% at tertiary level. In these facilities, the median duration of hospitalization was 9-10 days, and this period of time was significantly longer for the patients who underwent surgery for pelvic peritonitis due to uterine perforation compared with the patients who underwent Caesarean section/hysterectomy. Furthermore, it was significantly longer for the patients who were treated for other inducedabortion related complications compared with patients treated for spontaneous abortion. The mortality rate associated with these complications was 2.3-11.3% at secondary level facilities, and 37.8% at tertiary level facilities.The implementation of the standard postabortion care strategy in the referral health facilities at the secondary level of the city of Kinshasa has significantly improved the frequency of the practice of Manual Intrauterine Aspiration, which has gone from less than 25% at 32−82% in the experimental structures (p = 0.025) to the detriment of dilation-curettage, as well as the length of hospitalization of patients admitted for a complication of induced abortion (1 day less in the experimental structures, p = 0.020). However, it did not have a significant effect on the use of services related to induced abortion complications, the lethality, and the effective supply of modern postabortion contraception.Finally, with regard to the obstacles to the success of interventions aimed at improving the management of complications from induced abortions in referral health facilities in the city of Kinshasa, there is in particular the culture, the standards social pre-established, lack of education, lack of financial means, self-medication, lack of trained staff, indiscretion in official health structures, and the influences of pharmacists / drug sellers, traditional healers, and some pastors.Conclusion:The studies presented in this thesis showed that the practice of induced abortions was frequent in Kinshasa, the capital of the DRC, and that complications occurred in more than half of the cases, which complications were not well managed in the referral health facilities and led to death in more than 5% of cases. These studies have, in addition, made it possible to highlight an inadequacy of the results of the standard postabortion care strategy implemented by the Ministry of Public Health via the National Reproductive Health Program, and to propose a series of actions. readjustment
Doctorat en Sciences de la santé Publique
info:eu-repo/semantics/nonPublished

Cette thèse a pour but de comprendre et d’analyser les logiques d’émergence, les dynamiques de «fragmegration» ainsi que les mécanismes qui concourent à la perpétuation des mouvements politico-militaires au Congo-RDC. Dès le départ nous avons mis en exergue les trois tendances lourdes qui monopolisent le débat sur les rébellions en RDC. Ces trois tendances qui étaient fondamentalement des éléments accélérant ou amplificateurs, ont été à tort considérées comme les principaux éléments déclencheurs. Afin de lever la confusion conceptuelle entre ces deux principes, nous avons suggéré trois autres pistes de réflexion susceptible de mieux expliquer les phénomènes d’émergence, de fragmégration et de perpétuation. Ces pistes de réflexion sont les éléments déclencheurs majeurs autour desquels se structurent et s’articulent notre hypothèse. Dans cette thèse, nous soutenons l’argument selon lequel les phénomènes d’émergence, de fragmégration et de perpétuation sont une résultante de la militarisation des forces sociales congolaises, l’impossibilité du mouvement régional initié par le tandem rwando-ougandais à remporter une victoire clausewitzienne et l’institutionnalisation d’un partage de pouvoir complexe par la communauté internationale. Cette thèse est un appel au décloisonnement disciplinaire et à une multiplication des points d’entrée sur l’étude des groupes armés. D’où le recours à une approche (combinatoire) interdisciplinaire, mobilisant à la fois des courants critiques au sein des relations internationales (le constructivisme critique, la géopolitique) tout en alliant la sociologie des relations internationales plus particulièrement les acquis de la sociologie politique des mouvements sociaux. Notre approche interdisciplinaire qui est au centre de cette thèse peut aussi être d’une grande utilité dans le renforcement de l’approche polémologique fort utile pour saisir la gouvernance par les groupes politico-militaires.

Cette thèse porte sur l'implantation missionnaire en République démocratique du Congo sous l'administration coloniale belge vers la fin du XIXe siècle. Nous voulons comprendre le phénomène observé de la dépendance financière de cette Église, en situant ses différentes causes ou facteurs exogènes et endogènes notamment son ancrage dans la politique coloniale. Dès le début, elle a bénéficié des subventions de l’État et d'autres avantages importants, dont de vastes étendues de terres. Depuis sa prise en main par la hiérarchie autochtone, période correspondant à la décolonisation, cette Église n'arrive pas à se prendre en charge, obligée de se tourner constamment vers l'extérieur (tes organismes occidentaux de financement) pour assurer ses différents besoins. Or cette politique d'extraversion financière ne rassure plus, vu le contexte socioculturel occidental actuel (diminution des pratiques religieuses, crises financières mondiales, ...). En définitive, il faut à cette Église congolaise longtemps habituée à l'assistance de repenser une nouvelle logique d'action lui permettant de trouver d'autres possibilités pour assurer son autofinancement en vue de sa survie. L'objectif de ce travail est de montrer que des potentialités existent qu'elle peut exploiter: la mobilisation et la gestion rationnelle des ressources humaines et économiques disponibles, la rentabilisation des structures de productions héritées des missionnaires, mais en comptant sur un environnement sociopolitique et économique national favorable et un changement des mentalités des acteurs en présence
This thesis focuses the missionary presence in the Democratic Republic of Congo under the Belgian rule towards the end of the Sixth Century. We seek to understand bow this Church came to be financially dependent by looking at the different causes or exogenous and endogenous as well as the roots of this phenomenon within the context of the colonial policy. From the beginning, it has received State subsidies and enjoyed other significant advantages including large tracts of land. Ever since the native hierarchy has taken over, i.e. as from the decolonization, this Church has been unable to support itself and has been obliged constantly seek external aid from western financial bodies in order to meet its needs. But in the light of the current western sociocultural context (decline of religious practices, financial crises worldwide ... ) such a financial extraversion is no longer comforting. Ali things considered, long accustomed as it was to be assisted, this Congolese Church now needs to develop a new course of action through which it will be able to find other means of self-support for its survival. The objective of this work is to show that there is potential at band, namely the mobilization and the rational management of the human and economic resources available, the cost-effectiveness of the production facilities inherited from the missionaries, but resting on a favourable national sociopolitical and economic environment and a change in the attitude of the parties involved

Face aux préjudices irréparables engendrés par les crimes internationaux, le droit international, hormis les cas de poursuites devant la CPI et la pratique des commissions et fonds d'indemnisation des N.U, fait ponce-Pilate au droit interne pour la mise en oeuvre du droit à réparation des victimes de ces crimes. Une hypocrisie qui s'affirme notamment à travers des pratiques d'assistance humanitaire. Le droit interne des Etats quant à lui, fait un recours systématique à son système classique pour la mise en oeuvre de ce droit. Cet attrait pour le système classique tranche pourtant avec les facteurs matériels du droit en cette matière où le contexte des crimes, l'ampleur des préjudices, la vastitude des victimes et les fluctuations de la qualité des auteurs l'ont presque plongé dans la désuétude. C'est ce qui a fait émerger la quête d'un paradigme d'efficacité dont l'expérience de la justice transitionnelle et de la justice réparatrice constituent « l'essai ». La discussion sur l'efficacité des résultats de cet essai conduit l'observateur averti à la conclusion qu'il y a encore du chemin. Pour la RDC, contre l'aporie du droit classique face aux souffrances des victimes des crimes internationaux, cette étude propose la construction d'une politique criminelle basée sur une approche holistique de la réparation. L'approche holistique impliquant, ici, une réaction globaliste face aux préjudices subis par les victimes des crimes internationaux. Préjudices multiformes pour lesquels les réponses en termes de réparation doivent relever d'une appréhension globale du droit, reposant sur l'interdisciplinarité et l'ouverture à la « technologie sociale »
Faced with the irreparable prejudices arising from international crimes, except for the cases being prosecuted at the ICC and the processes of various Commissions and reparations funds of the UN, international law has been pontius-pilating when it comes implementing under domestic laws the rights of victims to reparations. This hypocrisy is particularly highlighted by the use of humanitarian aid. Domestic laws have systematically resorted to traditional practices to implement this right. This inclination towards traditional approaches is indeed at variance with the material elements of the law on reparations in as much as the context of the crimes, the scope of the damage, the vast number of victims and fluctuations in the types of perpetrators have simply made the traditional systems obsolete. Whence the quest for an efficiency paradigm hinged on «attempts» within transitional justice and reparations justice. Analyses of these attempts by experts reveal that a lot still has to be done. In the case of the DRC, and mindful of the shortcomings of the traditional legal system in mitigating the suffering of victims of international crimes, this study proposes a holistic approach to the development of a criminal reparations policy. This holistic approach requires a global response to the damage suffered by victims of international crimes. The reparations response to these multidimensional prejudices must reflect a global understanding of the law based on interdisciplinary and «social technology» considerations

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O objetivo deste trabalho foi avaliar a acurácia dos Critérios de Diagnóstico para Pesquisa das Desordens Temporomandibulares (RDC/DTM), a partir da comparação com o exame de imagem por ressonância magnética (IRM) no diagnóstico dos deslocamentos de disco da articulação temporomandibular em pacientes que buscaram tratamento para desordem temporomandibular. Vinte pacientes foram avaliados, totalizando 40 articulações examinadas. Para detectar anormalidades na posição do disco clinicamente foi empregado o uso do RDC/DTM, por um único examinador calibrado, “cego” para os exames de IRM. O diagnóstico das IRM obtidas dos pacientes foi realizadas por dois especialistas em radiologia odontológica, “cegos” para o exame clínico. Com base na estatística Kappa, foram observados níveis aceitáveis de confiabilidade intra-examinador na aplicação do RDC/DTM, e intra e interexaminador na avaliação das IRM. Os valores de kappa para a concordância entre o RDC/DTM e IMR foram melhores nos diagnósticos de deslocamento de disco do lado direito (k=0,913). Neste estudo, o RDC/DTM mostrou-se válido para diagnosticar deslocamentos de disco articular da ATM, com acurácia de 95% para a avaliação das ATM do lado direito e 75% do lado esquerdo, evidenciando a necessidade de um exame padronizado realizado por investigadores treinados na avaliação de pacientes com DTM.
The aim of this study was to evaluate the accuracy of the Research Diagnostic Criteria to Temporomandibular Disorders (RDC/TMD), from the comparison with magnetic resonance imaging (MRI) findings in the diagnosis of disc displacements of the temporomandibular joint in patients seeking treatment for temporomandibular disorders. Twenty patients were evaluated in a total of 40 joints examined. To detect abnormalities in disc position was employed clinically using the RDC/TMD, by a single calibrated examiner, “blinded” to the MRI scans. The diagnosis of MRI was obtained from patients performed by two specialists in oral radiology, “blinded” to the clinical examination. Based on the Kappa value, were found acceptable levels of reliability intra examiner in the application of RDC/TM, and intra e inter examiner in the evaluation of MRI. Kappa values for agreement between RDC/TMD and MRI were better in the diagnosis of disc displacement on the right side (k = 0.913). In this study, the RDC/TMD was valid for diagnosing disc displacement of the TMJ, with 95% accuracy for the evaluation of ATM on the right side and 75% of the left side, suggesting the need for a standardized examination conducted by trained investigators in the evaluation of patients with TMD.

Em novembro de 2005, com o guia de Gestão de Riscos à Qualidade (Q9) - a Conferência Internacional de Harmonização (ICH), em conjunto com as agências regulatórias dos Estados Unidos, Japão e Europa, passaram a recomendar que seja aplicado o gerenciamento de riscos para regulação da indústria farmacêutica. Em concordância, a Agência Nacional de Vigilância Sanitária (ANVISA) publicou a Resolução de Diretoria Colegiada - RDC 17/2010 que dispõe sobre as Boas Práticas de Fabricação de Medicamentos que possibilita a comercialização de produtos farmacêuticos. Esta resolução preconiza que a validação de um processo produtivo seja efetuada com base em uma análise de risco. Seguindo as orientações da RDC este trabalho se propôs a aplicar a ferramenta de análise de risco de Estudos de Perigos e Operabilidade HAZOP num sistema de biorreação bacteriana para produção de proteínas recombinantes instalado no Instituto de Tecnologia em Imunobiológicos Bio-Manguinhos/Fiocruz. Este sistema é formado por fermentadores de 100 (FE01) e 600 (FE02) litros, um tanque de colheita de 600 litros (HT01) e um tanque de preparo de meios de cultura de 600 litros (MT01). Através da aplicação desta ferramenta de análise de riscos foi possível classificar os riscos dos sistemas identificando os nós, palavras-guia primárias (parâmetros) e secundárias (desvios), assim como a severidade e frequência dos eventos. Foram identificados 82 riscos associados aos fermentadores FE01 e FE02, sendo 8,5% riscos insignificantes, 65,9% riscos aceitáveis e 25,6% riscos não desejáveis. No tanque de colheita HT01 foram identificados 55 riscos, dos quais 14,5% são insignificantes, 67,3% são aceitáveis e 18,2% não desejáveis. Para o tanque de preparo de meios MT01 foram identificados 66 riscos que estão divididos em 9% de riscos insignificantes, 69,7% de riscos aceitáveis e 21,3% de riscos não desejáveis. Foi percebido que não houve riscos catastróficos que pudessem comprometer os equipamentos fabricados, porém somente com utilização dos mesmos na rotina de produção e o ciclo de melhoria continua dos equipamentos será possível validar este estudo prospectivo
In November 2005, with the guidance of the Quality Risk Management (Q9) the International Conference on Harmonization (ICH) in conjunction with regulatory agencies in the United States, Japan and Europe started recommending applying risk management for regulation of the pharmaceutical industry. Following this argument, the National Health Surveillance Agency (ANVISA) published the Board Resolution RDC 17/2010 which establish the Good Manufacturing Practices in Pharmaceutical Manufacturing, allowing the commercialization of pharmaceutical products. This resolution states to perform the production process validation on a risk analysis basis. Following the guidelines, this work intend to use the risk analysis tool Hazards and Operability Studies HAZOP in a bacterial bioreaction system for recombinant protein installed in Bio-Manguinhos/Fiocruz. This system consists of 100 (FE01) and 600 (FE02) liters fermenters, a harvest tank of 600 Liters (HT01) and a 600 Liters tank for culture media preparation (MT01). By applying, this tool was possible to classify the system risk identifying nodes, primary and secondary (deviations) guidewords, as well as, the severity and frequency of events. Thus, ones identified 82 risks within FE01 and FE02 fermenters, with 8.5% being irrelevant risks, 65.9% acceptable risks and 25.6% undesirable risks. In the harvest tank HT01 were identified 55 risks, which 14.5% are significant, 67.3% are acceptable and 18.2% undesirable. For media preparation tank, MT01 were identified 66 risks divided into 9% negligible risks,69.7% acceptable risks and 21.3% of unwanted risks. With these data, it is possible to ensure that there was not fatal risks that could harm the manufactured equipment, but only operation of this equipment during production routine and continual improvement cycle can validate this prospective study