The burden of chronic low back pain in the adult Portuguese population : an epidemiological population-based study under the scope of Epireumapt

RESUMO: Nos países desenvolvidos a lombalgia é a condição músculo-­‐esquelética mais prevalente. Quando evolui para um quadro crónico é responsável por um encargo económico bastante considerável, não só em relação aos indivíduos, mas também para a sociedade. A lombalgia crónica é por isso uma das principais causas de perda de produtividade e de perda de independência económica, nomeadamente através do absenteísmo (ausência do trabalho), do presenteísmo (perda de produtividade no trabalho, devido à capacidade diminuída provocada pela lombalgia) e da incapacidade para trabalhar (invalidez permanente, total ou parcial). Até à data, em Portugal, a prevalência e carga social da lombalgia crónica eram desconhecidas. Até agora não existiam estudos populacionais de grande dimensão sobre este tema. O objetivo principal desta tese foi determinar a prevalência de lombalgia crónica, e também avaliar a carga social que esta tem na população adulta Portuguesa. O trabalho de investigação foi desenvolvido no âmbito do Estudo Epidemiológico de Doenças Reumáticas em Portugal (EpiReumaPt). Este foi o primeiro estudo de larga escala e de base populacional, que determinou a prevalência de doenças reumáticas e músculo-­‐ esqueléticas na população adulta portuguesa. Foi realizado numa amostra aleatória e representativa, de 10.661 indivíduos do Continente, da Região Autónoma dos Açores e da Região Autónoma da Madeira, entre Setembro de 2011 e Dezembro de 2013. Esta tese foi dividida em duas secções. A primeira secção incluiu o detalhe das questões relativas ao desenvolvimento e gestão do EpiReumaPt, constituindo-­‐se como um guia prático sobre como realizar um estudo de base populacional de larga escala, em Portugal. A metodologia detalhada do EpiReumaPt foi também descrita nesta secção e incluiu os objectivos, o desenho do estudo, as características de recrutamento e a preparação de dados para análise. Nesta secção foram ainda descritos os principais resultados do EpiReumaPt. Estes evidenciaram que a lombalgia foi a condição músculo-­‐esquelética com maior prevalência na população adulta portuguesa.A segunda secção desta tese estimou a prevalência da lombalgia crónica ativa na população adulta Portuguesa, e avaliou a carga social esta condição. A lombalgia ativa foi definida com base na dor auto-­‐relatada no dia da entrevista e que persistia há pelo menos 90 dias (independentemente da causa). A lombalgia foi definida como dor na área definida entre a margem inferior das décimas segundas costelas até às pregas glúteas inferiores, com ou sem dor nos membros inferiores. A carga social foi medida tendo em conta os seguintes parâmetros: qualidade de vida, função, consumo de recursos de saúde, consumo de analgésicos e outros fármacos usados no alívio da dor, sintomas de ansiedade e sintomas de depressão. Os resultados mostraram que o consumo de recursos em saúde e a carga social da lombalgia crónica na população adulta Português é significativa. Também a incapacidade causada pela lombalgia crónica,nos indivíduos com idade ativa, é responsável por elevadas taxas de absenteísmo e má qualidade de vida, aos quais acresce o consequente ónus socioeconómico. Esta tese também concluiu que o consumo de analgésicos e outros medicamentos para alívio da dor, na população adulta portuguesa com lombalgia crónica ativa, é relativamente baixa. A maioria destes indivíduos não tomava nenhum medicamento analgésico, independentemente da intensidade da dor. Mesmo os indivíduos que reportaram dor intensa, apenas 4.0% estavam no primeiro degrau da escada analgésica da Organização Mundial de Saúde; 2.3% usavam opióides fracos e 0.03% usavam opióides fortes para controlar a dor (segundo e terceiro degrau da escada analgésica da Organização Mundial da Saúde). O trabalho de investigação também confirmou que a prevalência de sintomas de ansiedade e depressão entre os indivíduos adultos portugueses com lombalgia crónica ativa é elevada. Nestes indivíduos, registou-­‐se um consumo mais elevado de analgésicos e outros medicamentos para alívio da dor, quando comparados com os indivíduos com lombalgia crónica activa sem esses sintomas psicológicos. Os grupos terapêuticos mais utilizados foram os ansiolíticos, sedativos e hipnóticos, os antidepressivos e os anti-­‐inflamatórios não esteróides. A intensidade média da dor reportada foi também maior entre os indivíduos com lombalgia ativa e sintomas de ansiedade e/ou depressão. Também nestes, foi reportada pior função e pior estado de saúde. Em relação ao consumo de recursos de saúde foram encontradas diferenças significativas entre as duas populações: os indivíduos com lombalgia ativa e sintomas psicológicos concomitantes registaram maior número de consultas de psiquiatria de outras especialidades médicas, assim como precisaram de mais apoio domiciliário nos 12 meses prévios à entrevista do EpiReumaPt. Foram também identificados os fatores associados a sintomas isolados de ansiedade, a sintomas isolados de depressão e a sintomas de ansiedade e depressão. Resumindo,esta tese permitiu concluir que a lombalgia crónica é um problema de saúde comum na população adulta portuguesa, contribuindo para um elevado grau de incapacidade e que consequentemente afeta o desempenho laboral e o bem-­‐estar dos indivíduos. A lombalgia crónica é também responsável por um consumo considerável de recursos de saúde. Acresce ainda que os sintomas de ansiedade e depressão são comuns, entre os indivíduos com lombalgia crónica, contribuindo com uma carga social adicional.---------------------------------- ABSTRACT:Low Back Pain(LBP) is the most prevalent of musculoskeletal condition in developed countries.When it becomes chronic, LBP causesan enormous economic burden on individuals and society -­‐ it is one of the leading causes of loss of productivity and economic independence through absenteeism (time off work), presenteeism (lost productivity because of diminished capacity while at work) and work disability (permanent, partial or complete disablement for work purposes). In Portugal the prevalence and burden of LBP and chronic LBP (CLBP) were poorly defined. Until now no large population-­‐based studies have focused on this. The main aim of this thesis was to determine the prevalence of LBP and CLBP, and also to assess the burden of CLBP in the adult rtuguese population. The research work was developed under the scope of EpiReumaPt (the Portuguese Epidemiologic Study of Rheumatic Diseases). EpiReumaPt was the first national large population-­‐based and prevalence study of rheumatic and musculoskeletal diseases (RMD). It was performed among a randomized and representative sample of 10,661 adult Portuguese subjects recruited in Mainland, Azores and Madeira Islands, from September 2011 to December 2013. The first section of this thesis included detailed issues regarding the development and management of EpiReumaPt, and provided a practical guide on how to set-­‐up a large population-­‐based study in Portugal. The detailed methodology of EpiReumaPt, including its objectives,study design,recruitment features,and data preparation for analyses were also described. The main results from EpiReumaPt study were provided in this section and showed that LBP was the musculoskeletal condition with highest prevalence among Portuguese population. The second section of this thesis estimated the prevalence of active CLBP among adult Portuguese population, and assessed the social burden of this condition. Active CLBP was defined based on self-­‐reported pain on the day of the interview, and for most of the time for at least 90 days (independently from cause). LBP was defined as pain in the back area from the lower margin of the twelfth ribs to he lower gluteal folds, with or without pain referred to the lower limbs. Social burden was measured taking into account the following outcomes: quality of life, function, healthcare resources consumption, analgesic and other pain relief drugs intake, anxiety and depression symptoms. Results showed that the healthcare consumption and social burden of CLBP among adult Portuguese population were enormous, and the disability caused by CLBP among subjects in a working age provides high rates of absenteeism (work loss) and poor quality of life, with a consequent socioeconomic burden. This thesis also concluded that analgesic and other pain relief drugs untake among adult Portuguese population with active CLBP was very low. Most of the subjects with active CLBP did not take any analgesic drug regardless pain severity. Even when subjects self-­‐reported severe pain, only 24.0% were in the 1st step of the analgesic ladder,2.3% used weak analgesic opioids and 0.03% used strong opioids (2nd and 3rd step of WHO analgesic ladder, respectively) to control pain . The research work also confirmed that the prevalence of anxiety and depression symptoms among adult Portuguese subjects with active CLBP was high. Regarding pharmacological therapy, the intake of analgesic and other pain relief drugs was higher among subjects with anxiety and/or depression symptoms, when compared with subjects without these psychological symptoms. Anxiolytics, sedatives and hypnotics, antidepressants and NSAIDs intake had higher usage rates among these subjects. The pain severity mean was also higher among this subjects and function and health status was worse. Regarding healthcare resources consumption,significant differences between the two populations were found. Subjects with ctive CLBP and concomitant psychological symptoms had a higher number of psychiatrist and other physician visits. They also needed more home care in the previous 12 months. Factors associated with isolated symptoms of anxiety, depression,and concomitant anxiety and depression symptoms were also identified. Summarizing, we concluded that CLBP is a common health problem among adult Portuguese population contributing to disability and affecting labor performance, and the well being of subjects. it is also responsible for considerable healthcare resource consumption. Anxiety and depression symptoms are common among subjects with CLBP and provided an additional burden among them.

The influence of sports events endorsement on children’s perceptions of healthy food products and brands

Field lab in marketing: Children consumer behaviour

The influence of low-frequency noise pollution on the quality of life and place in sustainable cities: a case study from northern Portugal

Discussing urban planning requires rethinking sustainability in cities and building healthy environments. Historically, some aspects of advancing the urban way of life have not been considered important in city planning. This is particularly the case where technological advances have led to conflicting land use, as with the installation of power poles and building electrical substations near residential areas. This research aims to discuss and rethink sustainability in cities, focusing on the environmental impact of low-frequency noise and electromagnetic radiation on human health. It presents data from a case study in an urban space in northern Portugal, and focuses on four guiding questions: Can power poles and power lines cause noise? Do power poles and power lines cause discomfort? Do power poles and power lines cause discomfort due to noise? Can power poles and power lines affect human health? To answer these questions, we undertook research between 2014 and 2015 that was comprised of two approaches. The first approach consisted of evaluating the noise of nine points divided into two groups â near the sourceâ (e.g., up to 50 m from power poles) and â away from the sourceâ (e.g., more than 250 m away from the source). In the second approach, noise levels were measured for 72 h in houses located up to 20 m from the source. The groups consist of residents living within the distance range specified for each group. The measurement values were compared with the proposed criteria for assessing low-frequency noise using the DEFRA Guidance (University of Salford). In the first approach, the noise caused discomfort, regardless of the group. In the second approach, the noise had fluctuating characteristics, which led us to conclude that the noise caused discomfort.

The influence of climatic parameters in the haematophagic daily activity of Cerqueirellum argentiscutum (Shelley & Luna Dias) (Diptera: Simuliidae) in Amazonas, Brazil

We studied the influence of climatic parameters in the daily haematophagic activity of Cerqueirellum argentiscutum from September/1999 to August/2000. The bite activity observed was different according to the annual rain precipitation (dry and rainy seasons). Humidity and temperature were the factors that most influenced it in both periods. During the dry season, it was greater in the beginning of the morning, showing a positive association with the humidity. However, during the rainy season, it was negatively related to that same factor. When wind speed was higher than 10 Km.h-1, it was reduced abruptly. Light intensity, atmospheric pressure and cloudiness seemed to act as secondary factors in the daily abundance of C. argentiscutum.

The influence of biofilm formation by Gardnerella vaginalis and other anaerobes on bacterial vaginosis

Bacterial vaginosis (BV) is the worldwide leading vaginal disorder in women of reproductive age. BV is characterized by the replacement of beneficial lactobacilli and the augmentation of anaerobic bacteria. Gardnerella vaginalis is a predominant bacterial species, however, BV is also associated with other numerous anaerobes, such as Atopobium vaginae, Mobiluncus mulieris, Prevotella bivia, Fusobacterium nucleatum and Peptoniphilus sp.. Currently, the role of G. vaginalis in the etiology of BV remains a matter of controversy. It is however known that, in BV patients, a biofilm is usually formed on the vaginal epithelium and G. vaginalis is typically the predominant species. So, the current paradigm is that the establishment of a biofilm plays a key role in the pathogenesis of BV. This review provides background on the influence of biofilm formation by G. vaginalis and other anaerobes in the polymicrobial etiology of BV, through its initial adhesion until biofilm formation and discusses the commensal and synergic interactions established between them to understand the phenotypic shift of G. vaginalis' biofilms into BV establishment.

Characterization of physical, mechanical and chemical properties of quiscal fibres : the influence of atmospheric DBD plasma treatment

This paper reports the first attempt of characterizing various physical, mechanical and chemical properties of Quiscal fibres, used by the native communities in Chile and investigating the influence of atmospheric dielectric barrier discharge plasma treatment on various properties such as diameter and linear density, fat, wax and impurity%, moisture regain, chemical elements and groups, thermal degradation, surface morphology, etc. According to the experimental observations, Quiscal fibre has lower tenacity than most of the technical grade natural fibres such as sisal, hemp, flax, etc., and plasma treatment at optimum dose improved its tenacity to the level of sisal fibres. Plasma treatment also reduced the amount of fat, wax and other foreign impurities present in Quiscal fibres as well as removed lignin and hemicellulose partially from the fibre structure. Plasma treatment led to functionalization of Quiscal fibre surface with chemical groups, as revealed from attenuated total reflection spectroscopy and also confirmed from the elemental analysis using energy dispersive Xray technique and pH and conductivity measurements of fibre aqueous extract. The wetting behavior of Quiscal fibre also improved considerably through plasma treatment. However, untreated and plasma treated Quiscal fibres showed similar thermal degradation behavior, except the final degradation stage, in which plasma treated fibres showed higher stability and incomplete degradation unlike the untreated fibres. The experimental results suggested that the plasma treated Quiscal fibres, like other technical grade natural fibres, can find potential application as reinforcement of composite materials for various industrial applications.

The influence of the conservation status and changes in the rainfall regime on forest-savanna mosaic dynamics in Northern Brazilian Amazonia

Coupled carbon/climate models are predicting changes in Amazon carbon and water cycles for the near future, with conversion of forest into savanna-like vegetation. However, empirical data to support these models are still scarce for Amazon. Facing this scenario, we investigated whether conservation status and changes in rainfall regime have influenced the forest-savanna mosaic over 20 years, from 1986 to 2006, in a transitional area in Northern Amazonia. By applying a spectral linear mixture model to a Landsat-5-TM time series, we identified protected savanna enclaves within a strictly protected nature reserve (Maracá Ecological Station - MES) and non-protected forest islands at its outskirts and compared their areas among 1986/1994/2006. The protected savanna enclaves decreased 26% in the 20-years period at an average rate of 0.131 ha year-1, with a greater reduction rate observed during times of higher precipitation, whereas the non-protected forest islands remained stable throughout the period of study, balancing the encroachment of forests into the savanna during humid periods and savannization during reduced rainfall periods. Thus, keeping favorable climate conditions, the MES conservation status would continue to favor the forest encroachment upon savanna, while the non-protected outskirt areas would remain resilient to disturbance regimes. However, if the increases in the frequency of dry periods predicted by climate models for this region are confirmed, future changes in extension and directions of forest limits will be affected, disrupting ecological services as carbon storage and the maintenance of local biodiversity.

Spatial-temporal variation of dissolved inorganic material in the Amazon basin

The Amazon River basin is important in the contribution of dissolved material to oceans (4% worldwide). The aim of this work was to study the spatial and the temporal variability of dissolved inorganic materials in the main rivers of the Amazon basin. Data from 2003 to 2011 from six gauging stations of the ORE-HYBAM localized in Solimões, Purus, Madeira and Amazon rivers were used for this study. The concentrations of Ca2+, Na+, K+, Mg2+, Cl-, SO4 -2, HCO3 - and SiO2 were analyzed. At the stations of Solimões and Amazon rivers, the concentrations of Ca2+, Mg2+, HCO3 - and SO4 -2 had heterogeneous distribution over the years and did not show seasonality. At the stations of Madeira river, the concentration of these ions had seasonality inversely proportional to water discharge (dilution-concentration effect). Similar behavior was observed for the concentrations of Cl- and Na+ at the stations of the Solimões, Amazon and Madeira rivers, indicating almost constant release of Cl- and Na+ fluxes during the hydrological cycle. K+ and SiO2 showed almost constant concentrations throughout the years and all the stations, indicating that their flows depend on the river discharge variation. Therefore, the temporal variability of the dissolved inorganic material fluxes in the Solimões and Amazon rivers depends on the hydro-climatic factor and on the heterogeneity of the sources. In the Madeira and Purus rivers there is less influence of these factors, indicating that dissolved load fluxes are mainly associated to silicates weathering. As the Solimões basin contributes approximately 84% of the total flux of dissolved materials in the basin and is mainly under the influence of a hydro-climatic factor, we conclude that the temporal variability of this factor controls the temporal variability of the dissolved material fluxes of the Amazon basin.

The influence of kaolin application on key metabolic pathways associated with grape berry quality: a molecular and biochemical analysis

Dissertação de mestrado em Biologia Molecular, Biotecnologia e Bioempreendedorismo em Plantas

The impact of carbon source in Candida albicans virulence: participation of RLM1 in pathogen host interaction

Dissertação de mestrado em Genética Molecular

Characterization of physical, mechanical and chemical properties of quiscal fibres: the influence of atmospheric dbd plasma treatment

This paper reports the first attempt of characterizing several physical, mechanical and chemical properties of Quiscal fibres, usually used by the native communities in Chile and on investigations concerning the influence of atmospheric dielectric barrier discharge (DBD) plasma treatment on various properties such as diameter and linear density, percent of impurity, moisture regain, chemical elements and groups, thermal degradation, surface morphology, among others.

The influence of the Palestinian sociocultural values in shaping the vernacular architecture of Nablus city

Recently, environmental architecture and sustainable construction has been ranked on top of the worldâ s interests. Making use of natural resources helps in reducing energy consumption and costs associated with the operation of buildings. The current architectural approaches and designs in Palestine are far away from environmental concepts, copying and simulating abroad approaches, without taking into account the culture, climate, and inhabitant's needs. On the contrast, vernacular architecture has achieved environmental concepts and has given suitable approaches and samples - without any need to simulate or copy - which come from people and land. This paper discusses how the Palestinian socio-cultural context shaped the residential vernacular architecture in Palestine, taking the old city of Nablus as a case-study. The research concept depends on analysing and trying to understand the effect of the socio-cultural context on vernacular architecture and trying to reach some rules or understandings of how it works in order to reach a modern environmental dwelling that is suitable to this concept. The research method goes through analysing study cases from the traditional architecture models and the Nablus city is selected as a case study. This analytical and qualitative method can lead to deep understanding for how to benefit from vernacular architecture in Palestine in finding the future environmental residential construction. One of the main findings of this research is to set general and special rules for building sustainable buildings in Palestine from the socio-cultural point view, in order to be a reference for designers, stakeholders, ministry of planning, and municipalities.

Comparative study for the identification of myocardial ischemia by contrast ventriculography under the effect of isosorbide mononitrate and by perfusional myocardial scintigraphy in patients with ischemic heart disease

OBJECTIVE: To evaluate and compare the usefulness of cineventriculographies, before and after nitrate use, to technetium-99m sestamibi scintigraphy for the identification of myocardial ischemia. METHODS: Twenty-six patients were studied at basal conditions and 5 minutes after intravenous administration of isosorbide mononitrate (0.3mg/kg), to evaluate the performance and regional wall motion of the left ventricle (LV). The results were compared to those obtained with technetium-99m sestamibi scintigraphy. RESULTS: Before nitrate, contrast ventriculography identified 30 normal segments, 62 hypokinetic segments, 28 dyskinetic segments, and 14 akinetic segments. After drug administration, 99 segments were normal, 11 hypokinetic, 11 dyskinetic, and 13 akinetic. Myocardial scintigraphy revealed 110 ischemic segments and 18 fibrotic segments (p<0.005). After drug administration, the ventriculography showed increase in the velocity of circumferential fiber shortening (p=0.0142), the ejection fraction (p=0.0462), decrease in the end-systolic volume (p=0.0031) and no change in end-diastolic volume. CONCLUSION: Contrast ventriculography using nitrate proved to be similar to perfusional myocardial scintigraphy in the identification of myocardial ischemia.

Antibacterial Ag/a-C nanocomposite coatings: The influence of nano-galvanic a-C and Ag couples on Ag ionization rates

Biofilm formation has been pointed as a major concern in different industrial applications, namely on biomedical implants and surgical instruments, which has prompted the development of new strategies for production of efficient antimicrobial surfaces. In this work, nano âgalvanic couples were created to enhance the antibacterial properties of silver, by embedding it into amorphous carbon (a-C) matrix. The developed Ag/a-C nanocomposite coatings, deposited by magnetron sputtering, revealed an outstanding antibacterial activity against S.epidermidis, promoting a total reduction in biofilm formation with no bacteria counts in all dilution. The open circuit potential (OCP) tests in 0.9% NaCl confirmed that a-C shows a positive \OCP\ value, in contrast to Ag coating, thus enhancing the ionization of biocidal Ag+ due to the nano-galvanic couple activation. This result was confirmed by the inductively coupled plasma-optical emission spectroscopy (ICP-OES), which revealed a higher Ag ionization rate in the nanocomposite coating in comparison with the Ag coating. The surface of Ag/a-C and Ag coatings immersed in 0.9% NaCl were monitored by scanning electron microscopy (SEM) over a period of 24 hours, being found that the Ag ionization determined by ICP-OES was accompanied by an Ag nanoparticles coalescence and agglomeration in Ag/a-C coating.

Production of whey protein-based aggregates under ohmic heating

Formation of whey protein isolate protein aggregates under the influence of moderate electric fields upon ohmic heating (OH) has been monitored through evaluation of molecular protein unfolding, loss of its solubility, and aggregation. To shed more light on the microstructure of the protein aggregates produced by OH, samples were assayed by transmission electron microscopy (TEM). Results show that during early steps of an OH thermal treatment, aggregation of whey proteins can be reduced with a concomitant reduction of the heating chargeby reducing the come-up time (CUT) needed to reach a target temperatureand increase of the electric field applied (from 6 to 12 V cm1). Exposure of reactive free thiol groups involved in molecular unfolding of -lactoglobulin (-lg) can be reduced from 10 to 20 %, when a CUT of 10 s is combined with an electric field of 12 V cm1. Kinetic and multivariate analysis evidenced that the presence of an electric field during heating contributes to a change in the amplitude of aggregation, as well as in the shape of the produced aggregates. TEM discloses the appearance of small fibrillar aggregates upon the influence of OH, which have recognized potential in the functionalization of food protein networks. This study demonstrated that OH technology can be used to tailor denaturation and aggregation behavior of whey proteins due to the presence of a constant electric field together with the ability to provide a very fast heating, thus overcoming heat transfer limitations that naturally occur during conventional thermal treatments.