<p>Uvod: Iz rezultata brojnih randomiziranih kliničkih studija proizi&scaron;le su smernice u koijma se navodi da je upotreba neinvazivne ventilacije (NIV), uz farmakolo&scaron;ku terapiju, indikovana kod svih bolesnika sa te&scaron;kom egzacerbacijom hronične opstruktivne bolesti pluća (HOBP), i to sa najvi&scaron;im nivoom preporuke. Dokazano je da se upotrebom NIV-a smanjuje broj intubacija, uz smanjenje mortaliteta ali i skraćenje dužine bolničkog lečenja. S obzirom da je nekada ventilatorna potpora bila pružana isključivo u jedinicama intenzivne nege, a da je kapacitet ovakvih odeljenja gotovo stalno popunjen, postavlja se pitanje adekvatnog okruženja unutar bolnice gde se bezbedno i efikasno može primeniti neinvazivna ventilacija, ali gde se i na vreme mogu prepoznati rani znakovi njene neuspe&scaron;ne primene, nakon čega trebaobezbediti pravovremenu endotrahealnu intubaciju. Stoga su rađene brojne studije u cilju izdvajanja ranih prediktora ishoda neinvazivne ventilacije - kako u cilju ranog prepoznavanja neuspeha NIV-a i omogućavanja pravovremene intubacije, tako i u cilju stratifikacije pacijenata sa različitim stepenom rizika za neuspeh, uz obezbeđivanje adekvatnog nivoa nege i monitoringa za sve bolesnike. Ciljevi: Ciljevi istraživanja su da se utvrdi koji pokazatelji koreliraju sa neuspe&scaron;nim ishodom primene neinvazivne mehaničke ventilacije kod bolesnika sa te&scaron;kom egzacerbacijom hronične opstruktivne bolesti pluća, kako bi se kreirao prognostički model ishoda lečenja, te da se se na osnovu prognostičkog modela stratifikuju bolesnici prema stepenu rizika za neuspeh NIV-a i u skladu sa njim predloži adekvatan stepen monitoringa, odnosno kliničko okruženje za bezbedno i efikasno pružanje ventilatorne potpore. Metodologija: U Institutu za plućne bolesti Vojvodine u Sremskoj Kamenici sprovedeno je prospektivno opservaciono istraživanje u trajanju od 39 meseci, u koje je uključeno 250 konsekutivnih bolesnika hospitalizovanih zbog te&scaron;ke egzacerbacije HOBP-a sa respiratornom acidozom. NIV je primenjen u modu pritiskom podržane ventilacije ventilatorima marke Covidien tipa Airox Supportair, uz upotrebu oronazalne maske. Početni parametri su podrazumevali upotrebu ekspiratornog pozitivnog pritiska u disajnim putevima - EPAP-a od 5 cm H2O i inspiratornog pozitivnog pritiska u disajnim putevima IPAPa od 12 cm H20, koji su u potom titrirani ka ciljnim vrednostima IPAPa od 15-20 cmH2O, a u skladu sa kliničkim odgovorom. Za svakog bolesnika evidentirani su: pol, starost, ranija primena dugotrajne oksigenoterapije u kućnim uslovima, primena NIV-a tokom prethodnih hospitalizacija, komorbiditeti preko Charlson indeksa, vreme proteklo od početka hospitalizacije do započinjanja NIV-a, vrednosti pH, bikarbonata, PaCO2 i PaO2 u gasnim analizama arterijske krvi pre započinjanja NIV-a, inicijalna SpO2 i odnos PaO2/FiO2, zatim promena vrednosti pH, PaCO2 i PaO2 u gasnim analizama arterijske krvi sat vremena nakon početka primene NIV-a, inicijalni vitalni parametri - srčana frekvenca, respiratorna frekvenca, stanje svesti procenjeno Glazgov koma skalom (GCS), telesna temperatura, sistolni arterijski pritisak, diureza, a potom zbirni modifikovani ranoupozoravajući bodovni skor (MEWS-modified early warning score), prisustvo i opseg konsolidacija na radiogramu grudnog ko&scaron;a, saradnja bolesnika, te mesto primene NIV-a. Kao primarni ishod istraživanja definisan je neuspeh neinvazivne mehaničke ventilacije: intubacija ili smrtni ishod u toku hospitalizacije uzrokovan respiratornom insuficijencijom. Svaki potencijalni prediktor neuspeha je prvo evaluiran uz pomoć univarijantne analize, a potom su svi faktori rizika za koje je univarijantnom analizom utvrdjena statistička značajnost analizirani uz pomoć multivarijantne logističke regresije, u cilju utvrdjivanja adekvatnih statističkih modela. Rezultati: Od ukupno 250 bolesnika NIV je uspe&scaron;no primenjen kod 164 bolesnika (65.6%). Ukupno 139 (59.3%) bolesnika bilo je mu&scaron;kog pola, a prosečna starost svih ispitanika bila je 67 godina. Bolesnici sa neuspe&scaron;nim ishodom NIV-a imaju, prema univarijantnoj analizi: statistički značajno veće vrednosti Charlson indexa (p=0.002, OR 1.293, 95%CI 1.103-1.516), konsolidacije u &ge;2 kvadranata (p=0.000, OR 5.384, 95%CI 2.487-11.655), duže vreme od početka hospitalizacije do započinjanja NIV-a (p=0.0034, OR 1.005, 95%CI 1.000-1.009), tahikardiju (p=0.031, OR 2.292, 95%CI 1.080-4.864), vrednost GCS &le;11 (p=0.042, OR 1.000, 95%CI 0.165-0.969), veći MEWS skor (p=0.000, OR 1.708, 95%CI 1.410-2.068), niže vrednosti inicijalnog pH (p=0.004, OR 0.002, 95%CI 0.000-0.147), slabiju saradnju (p=0.000, OR 2.102, 95%CI 0.145-0.339). Mesto gde je sprovedena NIV je značajno uticalo na ishod &ndash; &scaron;anse za neuspe&scaron;an ishod su bile dvostruko veće kod bolesnika ventiliranih na op&scaron;tem odeljenju (p=0.006, OR 2.102, 95%CI 1.236-3.574). Kao nezavisni prediktori neuspeha nakon multivarijantne logističke regresije pokazali su se vrednosti Charlson-ovog indexa (p=0.043, OR 1.246, 95%CI 1.007-1.541), MEWS skora (p=0.010, OR 1.394, 95%CI 1.083-1.795), inicijalne vrednosti pH (p=0.030, OR 0.642, 95%CI 0.430-0.958) i stepena saradnje (p=0.000, OR 0.230, 95%CI 0.141-0.376). Zaključci: Bolesnici sa visokim vrednostima Charlson-ovog indeksa (preko 6 bodova) i MEWS-ovog skora (preko 4 boda), te niskom inicijalnom pH vredno&scaron;ću arterijske krvi (ispod 7.29) i niskim stepenom saradnje (manjim od 4) su bolesnici koji imaju povi&scaron;en stepen rizika za neuspe&scaron;an ishod primene neinvazivne ventilacije. Bolesnici visokog stepena rizika treba da se zbrinjavaju i neinvazivno ventiliraju na odeljenjima poluintenzivne i intenzivne nege, dok se bolesnici sa manjim stepenom rizika mogu inicijalno neinvazivno ventilirati i na op&scaron;tim odeljenjima, uz adekvatan monitoring i nadzor obučenog osoblja.</p> / <p>Introduction: Clinical guidelines that have evolved from the results of numerous randomized clinical trials state that the use of non-invasive ventilation (NIV), in addition to pharmacological therapy, is necessary in all patients wih severe exacerbation of chronic obstructive pulmonary disease (COPD) - at the highest level of recommendation. It has been proven that the use of NIV leeds to reduction in mortality, intubation rates, and the length of stay in hospitals. Since ventilatory support in past was only delivered in intensive care units, and bearing in mind that their capacities are limited, there is a question of an adequate setting within a hospital where NIV can be used safely and efficiently, and where potential early signs of failure will be timely recognized and patient intubated, if necessary. Consequently, the studies were performed in order to identify early predictors of NIV outcome &ndash; in order to recognize NIV failure and necessity for transition towards invasive ventilation, but also in order to stratify the patients according to the level of risk, which will then dictate the necessary level of care and monitoring. Goals: This research is aimed at identification of parameters that correlate with failure of non-invasive ventilation in patients with severe exacerbation of COPD, in order to create prognostic model of outcome, which will then enable stratification of patients according to the risk of NIV failure. The model is to be used in order to determine adequate level of care and monitoring, that is, a setting within a hospital, for provision of efficent and safe ventilatory support for all patients. Methods: This 39-month prospective observational study was performed at the Institute for Pulmonary Diseases of Vojvodina in Sremska Kamenica, which included 250 consecutive patients hospitalized due to severe exacerbation of COPD with respiratory acidosis. NIV was applied as pressure support mode of ventilation with the ventilators brand Covidien, type Airox Supportair, with oro-nasal mask. Initial parameters were: expiratory positive airway pressure &ndash; EPAPof 5 cm H2O and inspiratory positive airway pressure - IPAP of 12 cm H20, which were further adjusted towards the IPAP of 15-20 cmH2O, or according to the clinical response. The following data were recorded for each patient: sex, age, earlier longterm oxygen therapy, NIV episode during the previous hospitalizations, co-morbidities through Charlson index, time elapsed from admission to NIV initiation, initial blood gas values: pH, bicarbonates, PaCO2 and PaO2, initial SpO2 and PaO2/FiO2, the subsequent changes inthe blood gas values after one hour: pH, PaCO2 and PaO2, initial vital signs - heart rate, respiratory rate, consciousness level by Glasgow coma scale (GCS), body temperature, sistolic blood pressure, urine output, and then modified early warning score - MEWS, presence of consolidation on chest X-ray, tolerance, setting where NIV was applied. Primary outcome was NIV failure defined as endotracheal intubation or death during hospitalization caused by respiratory failure. All variables were first tested with univariate analysis, and those with statistical significance were further subjected to multivariate logistic regression, in order to generate an adequate statistical model. Results: Amongst the total of 250 patients, NIV was successfully applied in 164 patients (65.6 %). There were 139 (59.3%) male patients, and average age was 67. According to the univariate analysis, patients with NIV failure had: higher Charlson index (p=0.002, OR 1.293, 95%CI 1.103-1.516), consolidation in &ge;2 quadrants (p=0.000, OR 5.384, 95%CI 2.487-11.655), longer time from admission to NIV initiation (p=0.0034, OR 1.005, 95%CI 1.000-1.009), increased heart rate (p=0.031, OR 2.292, 95%CI 1.080-4.864), GCS &le;11 (p=0.042, OR 1.000, 95%CI 0.165-0.969), higher MEWS score (p=0.000, OR 1.708, 95%CI 1.410-2.068), lower initial pH (p=0.004, OR 0.002, 95%CI 0.000-0.147), poorer tolerance (p=0.000, OR 2.102, 95%CI 0.145-0.339). The setting were NIV was applied influenced the outcome &ndash; odds for NIV failure were twice as high for the patients on general wards (p=0.006, OR 2.102, 95%CI 1.236-3.574). After the multivariate logistic regression, the following variables were identified as independent predictors of outcome: Charlson index (p=0.043, OR 1.246, 95%CI 1.007- 1.541), MEWS score (p=0.010, OR 1.394, 95%CI 1.083-1.795), initial pH (p=0.030, OR 0.642, 95%CI 0.430-0.958) and tolerance (p=0.000, OR 0.230, 95%CI 0.141-0.376). Conclusions: Patients with higher Charlson index (&gt; 6 points) and MEWS score (&gt;4 points), lower initial pH (&lt;7.29) and tolerance (&lt;4) are at a higher risk for nonivasive ventilation failure. High-risk patients should be admitted and ventilated at high dependency or intensive care units, while the low-risk patients may receive non-invasive ventilatory support on general wards, with adequate monitoring and under the trained staff supervision.</p>

Entre as principais demandas da agricultura brasileira nos últimos anos, destaca-se a necessidade de cultivares de soja com elevado potencial produtivo, resistentes/tolerantes a doenças, em especial à ferrugem asiática da soja e com ciclo reduzido. O trabalho teve como objetivo principal avaliar cruzamentos de soja em diferentes gerações de endogamia e seleção, com ênfase nos caracteres produtividade de grãos, resistência/tolerância à ferrugem e ciclo (precocidade). Os 49 cruzamentos foram obtidos em um dialelo parcial 7x7, avaliados nas gerações F2 e F2:3 por Oliveira (2011) e, neste trabalho, nas gerações F2:4, F2:5, F5:6 e F5:7. Um total de dez experimentos (combinações de anos agrícolas, locais e manejos de doenças) foram realizados em blocos aumentados e ou blocos casualizados. Os dois manejos de doenças compreenderam um experimento com controle das doenças de fim de ciclo (DFC) e da ferrugem, enquanto que no segundo experimento envolveu somente o controle das DFC. Os caracteres avaliados foram: produtividade de grãos (PG), peso de cem sementes (PCS, representando o tamanho das sementes), número de dias para a maturidade (NDM), altura da planta na maturidade (APM), acamamento (AC), valor agronômico (VA), notas de severidade da ferrugem (NF) e taxas de reação à ferrugem (TRF). As TRFs foram estimadas para cada caráter por meio da diferença entre as médias ajustadas de cada genótipo nos dois experimentos com manejos de doenças. Foram realizadas análises de variância, estimativas de herdabilidade, capacidades médias de combinação (CMC), correlações das CMC entre as gerações, correlações entre caracteres, seleção de linhagens experimentais superiores e estimativas dos ganhos com a seleção. As metodologias de avaliação da resistência (NF) e da tolerância (TRF) possibilitaram a discriminação de genótipos superiores quanto à reação à ferrugem, demonstrando evidências de serem complementares e úteis para uso em conjunto. Observou-se maior tendência de haver correlações das CMC entre as gerações para caracteres de alta herdabilidade. A magnitude da variabilidade dentro de cruzamentos oscilou em consequência da seleção e da abertura de progênies e ou linhagens para a maior parte dos caracteres. Apesar das correlações entre os caracteres (NDM x PG e NDM x NF), foram observados ganhos na seleção de genótipos superiores. Os genitores que mais contribuíram para a obtenção de linhagens experimentais com alta produtividade de grãos, resistentes/tolerantes à ferrugem e precoces foram M-Soy 8001 e IAC 100 no Grupo I e USP 70.080 e USP 70.123 no Grupo II do dialelo. / Among the main demands of Brazilian agriculture in recent years highlights the need for soybean cultivars with high yield potential, resistance / tolerance to diseases, mainly Asian soybean rust (FAS) and reduced cycle. The research aimed to study the genetic relationships of soybean crosses in different generations of inbreeding and selection, with an emphasis on the seed yield, resistance/tolerance to rust and cycle (earliness). The 49 crosses was obtained in a partial diallel 7x7, researching the generations F2 and F2: 3 by Oliveira (2011) and, in this work, the generations F2:4, F2:5, F5:6 and F5:7. A total of ten experiments (combinations of agricultural years, locations and disease managements) were performed in augmented block and or randomized complete-block designs. The two managements involved one experiment with control of the late season leaf diseases (DFC) and rust, whereas the second experiment only involved the control of the DFC. The following traits were evaluated : seed yield (PG), one hundred seed weight (PCS, representing the seed size), number of days to maturity (NDM), plant height at maturity (APM), lodging (AC), agronomic value (VA), notes of rust severity (NF) and the rust reaction rates (TRF). The TRFs for each trait were estimated by the difference between the adjusted means of each genotype in the two experiments with diseases managements. There were obtained analyses of variance and estimates of heritability, average combining ability (CMC), the CMC correlations between generations, correlations between traits, selection of superior experimental lines and the selection gains. The methodologies for measuring the rust resistance by severity notes (NF) and the rust tolerance (TRF) allowed the discrimination of genotypes and showed evidences of being complementary and with benefits for use together. Higher evidences of CMC correlations between generations were observed in the high heritability traits. The magnitude of the variability within crosses oscillated due the selection and the progeny/line opening, for most of the traits. Even with negative correlations between traits ( NDM x PG and NDM x NF), there were observed gains in the selection of superior genotypes. The parents who contributed most to obtain experimental lines with high seed yield, rust resistance / tolerance and earliness were M-Soy 8001 and IAC 100 in the Group I, and USP 70.080 and USP 70.123 in the Group II of the diallel.

Entre as principais demandas da agricultura brasileira nos últimos anos, destaca-se a necessidade de cultivares de soja com elevado potencial produtivo, resistentes/tolerantes a doenças, em especial à ferrugem asiática da soja e com ciclo reduzido. O trabalho teve como objetivo principal avaliar cruzamentos de soja em diferentes gerações de endogamia e seleção, com ênfase nos caracteres produtividade de grãos, resistência/tolerância à ferrugem e ciclo (precocidade). Os 49 cruzamentos foram obtidos em um dialelo parcial 7x7, avaliados nas gerações F2 e F2:3 por Oliveira (2011) e, neste trabalho, nas gerações F2:4, F2:5, F5:6 e F5:7. Um total de dez experimentos (combinações de anos agrícolas, locais e manejos de doenças) foram realizados em blocos aumentados e ou blocos casualizados. Os dois manejos de doenças compreenderam um experimento com controle das doenças de fim de ciclo (DFC) e da ferrugem, enquanto que no segundo experimento envolveu somente o controle das DFC. Os caracteres avaliados foram: produtividade de grãos (PG), peso de cem sementes (PCS, representando o tamanho das sementes), número de dias para a maturidade (NDM), altura da planta na maturidade (APM), acamamento (AC), valor agronômico (VA), notas de severidade da ferrugem (NF) e taxas de reação à ferrugem (TRF). As TRFs foram estimadas para cada caráter por meio da diferença entre as médias ajustadas de cada genótipo nos dois experimentos com manejos de doenças. Foram realizadas análises de variância, estimativas de herdabilidade, capacidades médias de combinação (CMC), correlações das CMC entre as gerações, correlações entre caracteres, seleção de linhagens experimentais superiores e estimativas dos ganhos com a seleção. As metodologias de avaliação da resistência (NF) e da tolerância (TRF) possibilitaram a discriminação de genótipos superiores quanto à reação à ferrugem, demonstrando evidências de serem complementares e úteis para uso em conjunto. Observou-se maior tendência de haver correlações das CMC entre as gerações para caracteres de alta herdabilidade. A magnitude da variabilidade dentro de cruzamentos oscilou em consequência da seleção e da abertura de progênies e ou linhagens para a maior parte dos caracteres. Apesar das correlações entre os caracteres (NDM x PG e NDM x NF), foram observados ganhos na seleção de genótipos superiores. Os genitores que mais contribuíram para a obtenção de linhagens experimentais com alta produtividade de grãos, resistentes/tolerantes à ferrugem e precoces foram M-Soy 8001 e IAC 100 no Grupo I e USP 70.080 e USP 70.123 no Grupo II do dialelo. / Among the main demands of Brazilian agriculture in recent years highlights the need for soybean cultivars with high yield potential, resistance / tolerance to diseases, mainly Asian soybean rust (FAS) and reduced cycle. The research aimed to study the genetic relationships of soybean crosses in different generations of inbreeding and selection, with an emphasis on the seed yield, resistance/tolerance to rust and cycle (earliness). The 49 crosses was obtained in a partial diallel 7x7, researching the generations F2 and F2: 3 by Oliveira (2011) and, in this work, the generations F2:4, F2:5, F5:6 and F5:7. A total of ten experiments (combinations of agricultural years, locations and disease managements) were performed in augmented block and or randomized complete-block designs. The two managements involved one experiment with control of the late season leaf diseases (DFC) and rust, whereas the second experiment only involved the control of the DFC. The following traits were evaluated : seed yield (PG), one hundred seed weight (PCS, representing the seed size), number of days to maturity (NDM), plant height at maturity (APM), lodging (AC), agronomic value (VA), notes of rust severity (NF) and the rust reaction rates (TRF). The TRFs for each trait were estimated by the difference between the adjusted means of each genotype in the two experiments with diseases managements. There were obtained analyses of variance and estimates of heritability, average combining ability (CMC), the CMC correlations between generations, correlations between traits, selection of superior experimental lines and the selection gains. The methodologies for measuring the rust resistance by severity notes (NF) and the rust tolerance (TRF) allowed the discrimination of genotypes and showed evidences of being complementary and with benefits for use together. Higher evidences of CMC correlations between generations were observed in the high heritability traits. The magnitude of the variability within crosses oscillated due the selection and the progeny/line opening, for most of the traits. Even with negative correlations between traits ( NDM x PG and NDM x NF), there were observed gains in the selection of superior genotypes. The parents who contributed most to obtain experimental lines with high seed yield, rust resistance / tolerance and earliness were M-Soy 8001 and IAC 100 in the Group I, and USP 70.080 and USP 70.123 in the Group II of the diallel.

Le syndrome des ovaires polykystiques (SOPK) est le désordre endocrinien le plus répandu chez la femme en âge de procréer. Ayant un impact significatif sur la qualité de vie, il est l’une des causes majeures d’infertilité et est associé à des conditions chroniques sérieuses comme le diabète de type 2, des cancers hormono-dépendants, et les maladies cardiovasculaires. Bien qu’il soit prévalent et ait des conséquences importantes, l’expérience des soins vécue par les femmes traduit des dimensions problématiques : manque de sensibilisation et d’information, délais de diagnostic, insensibilité, inattention et banalisation. Selon certaines recherches, les femmes ne sont pas satisfaites des traitements habituellement prescrits, comme la pilule contraceptive. Elles considèrent manquer d’options de traitement et seraient intéressées par d’autres modalités de soin. D’autres travaux mettent également l’accent sur l’importance du mode de vie (ex. nutrition et gestion du stress) qui peut améliorer le profil métabolique et endocrinien, ainsi que se répercuter de manière favorable sur la fonction reproductive. Le manque général d'attention à cette condition représente dès lors une étude de cas intéressante, reflétant des injustices systémiques en médecine. L’objectif de cette thèse est d’examiner les enjeux en lien avec l’autonomie des femmes affectées par le SOPK dans le cadre des soins de santé et de fertilité, et de proposer des pistes de solution visant à favoriser son expression. Ces enjeux sont analysés dans le contexte de la maladie chronique, où l’accent est surtout mis sur le traitement visant à soulager l'infertilité, mais qui néglige les approches restauratives en regard de la santé, notamment par des changements de mode de vie. L’analyse des enjeux est faite selon une approche relationnelle de l’autonomie en considérant deux modes d’expression : épisodique et programmatique. La mise en évidence de ces enjeux rend possible une réflexion sur ce que pourrait apporter une vision globale dans le soin du SOPK, s’articulant tout autant autour de la gestion de la maladie que d’une approche restaurative de la santé. Afin d’analyser les enjeux éthiques particuliers que pose le soin du SOPK, cette thèse utilise une perspective à la fois conceptuelle-normative et empirique. Ces deux perspectives permettent 6 de mieux comprendre les lacunes de l'approche médicale actuelle et de formuler des recommandations éclairées sur les meilleures façons d’y faire face. Par la reconnaissance de la nécessité d’une approche du soin intégrant tant les aspects relatifs à la prévention et à la gestion du SOPK qu’une visée restaurative à l’égard de la santé, cette thèse amène des retombées importantes pour les professionnels de la santé et les femmes affectées par le SOPK. Ce faisant elle présente des pistes permettant de soutenir tant l’autonomie épisodique que programmatique, ainsi que l’empowerment de ces femmes. / Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of childbearing age. It has a significant impact on quality of life and is one of the major causes of infertility. It is also associated with serious chronic conditions such as type 2 diabetes, hormonedependent cancers, and cardiovascular disease. While it is prevalent and has serious consequences, women's experience of care reflects problematic dimensions: lack of awareness and information, delays in diagnosis, insensitivity, inattention, and trivialization. Research shows that women are dissatisfied with commonly prescribed treatments such as the contraceptive pill. They report lacking treatment options and would be interested in other modalities of care. Research on PCOS also emphasizes the importance of lifestyle (e.g. nutrition and stress management) that can improve the metabolic and endocrine profile and have a positive impact on reproductive function. The general lack of attention to this condition is thus an interesting case study, reflecting systemic injustices in medicine. The objective of this thesis is to examine issues related to the autonomy of women affected by PCOS in the context of health care and fertility, and to propose ways to promote the expression of autonomy. The thesis analyzes these issues in the context of chronic disease, whereby treatment focuses on alleviating infertility and neglects restorative approaches to health, particularly through effective lifestyle changes. The analysis is based on the conceptual framework of relational autonomy, and considers two possible modes of autonomy expression: episodic and programmatic. Awareness of these issues makes it possible to reflect on what a holistic approach could bring to PCOS care, considering both disease management and a restorative approach to health. To consider the ethical challenges related to the care of PCOS, this thesis employs both a conceptual-normative and an empirical perspective. Both allow a better understanding of the shortcomings of the current medical approach and an informed recommendation for better ways of responding to these challenges. By recognizing the need for prevention and management of PCOS, as well as a restorative approach to health, this thesis has substantial implications for healthcare professionals and women, suggesting ways of supporting both episodic and programmatic autonomy and empowerment of affected women.

L’aglio è coltivato a livello mondiale nelle regioni temperate, secondo la FAO nel 2016 1.5 milioni di ettari sono stati destinati a questa coltura. A partire dal 2002 Fusarium proliferatum è stato segnalato come principale agente causale del marciume secco dell’aglio in post raccolta. I sintomi sono identificabili come macchie necrotiche sui bulbilli e in presenza di forti infezioni è possibile osservare la presenza di micelio bianco. F. proliferatum è un patogeno in grado di produrre Fumonisina B1 e B2, micotossine che potrebbero accumularsi all’interno dei bulbi ed essere tossiche per il consumatore. In Italia nel 2012 il 30% del raccolto è stato perso a causa di questo patogeno. Essendo la Fusariosi una malattia emergente a livello mondiale in letteratura si trovano ancora scarse informazioni sul suo sviluppo a livello di campo e sulle strategie di contenimento. 1. Allo scopo di verificare la quantità di inoculo fungino presente nell’ambiente si è proceduto all’analisi dei suoli in presemina con specifica attenzione alla quantificazione e all’identificazione delle specie fungine presenti. A tale scopo è stata eseguita: la conta delle Unità Formanti Colonia per grammo di terreno (UFC/g) su terreni specifici per l’isolamento del genere Fusarium spp. per grammo di terreno. Le identificazioni sono state eseguite al microscopio ottico e confermate successivamente con metodi molecolari. 2. Per seguire l’avanzamento della malattia durante la stagione colturale, invece, si è proceduto al campionamento in tre fasi fenologiche (inizio formazione dei bulbilli BBCH 15, ingrossamento dei bulbilli BBCH 45, maturazione di raccolta BBCH 49) con caratterizzazione dei sintomi, isolamento e riconoscimento dei funghi associati al marciume. 3. Per verificare la correlazione tra andamento meteo e incidenza delle specie fungine associate al marciume secco, sono stati raccolti i dati di meteorologici relativi al totale delle piogge, ai gradi giorno, all’umidità relativa media e alla temperatura media nei quadrati corrispondenti alle aziende agricole oggetto di studio. I dati sono stati correlati attraverso il coefficiente di correlazione di Pearson con i valori di gravità e incidenza della malattia stimati a fine stagione colturale. 4. Per verificare l’insorgenza dalla malattia nella fase di post raccolta si è proceduto con campionamenti di bulbi in conservazione, posa in piastra di bulbilli sintomatici e asintomatici e calcolo dell’incidenza delle specie fungine associate ai sintomi del marciume. 5. Al fine di verificare la possibile presenza di fumonisine nei campioni analizzati durante la stagione colturale e nel post raccolta, si è proceduto all’analisi attraverso HPLC di estratti di aglio. 6. Per individuare possibili strategie di controllo della malattia durante la stagione colturale sono stati eseguiti test di efficacia di prodotti chimici e biologici in vitro e in campo. I prodotti chimici sono stati provati su PDA modificato inoculato centralmente con F. proliferatum, mentre per gli agenti di biocontrollo sono state allestite prove di coltura duale. La prova in campo, invece, è stata eseguita all’interno di un campo sperimentale a strip plot. L’aglio delle diverse tesi è stato conservato in cella frigorifera per 9 mesi, per valutare la persistenza dei prodotti utilizzati alla concia. I risultati ottenuti hanno dimostrato che F. proliferatum e F. oxysporum sono le specie maggiormente associate al marciume dell’aglio durante la stagione colturale. L’andamento delle due specie è complementare e varia a seconda dell’andamento meteorologico della stagione colturale. F. proliferatum è correlato positivamente con l’aumento della temperatura e delle piogge, mentre F. oxysporum sembra prevalere nelle stagioni meno piovose ed ha mostrato correlazione positiva con la gravità dei sintomi rilevati in campo sulle corone. La carica micotica di Fusarium nel terreno rimane costante negli anni di analisi, facendo presupporre un maggiore ruolo del seme nella trasmissione della malattia. Per quanto riguarda il post raccolta, invece, F. proliferatum risulta la specie isolata con maggiore frequenza dai bulbilli e si correla positivamente ai sintomi rilevati sugli spicchi, confermando il suo ruolo come agente causale del marciume secco durante lo stoccaggio. F. oxysporum, invece, colonizza in prevalenza le radici e la parte basale della pianta dividendo il patosistema in due subsistemi: F. proliferatum-bulbi; F. oxysporum-radici. F. proliferatum è stato isolato anche dagli spicchi asintomatici con frequenza del 25%, ed è stato possibile rilevare la presenza di fumonisine con l’avanzare del tempo di stoccaggio in cella. Essendo il fungo presente anche sugli spicchi asintomatici maggiori studi saranno necessari per garantire la sicurezza dei consumatori. Infine, dalle prove di concia in campo è emerso che il principio attivo Tebuconazolo, riduce la comparsa dei sintomi da Fusarium, ma non in modo risolutivo. Ciononostante, una volta che il prodotto viene riportato a temperatura ambiente dopo lo stoccaggio in cella refrigerata, l’incidenza di F. proliferatum aumenta nuovamente con possibilità di sviluppo di danni al prodotto da commercializzare. / Since 2002, Fusarium proliferatum has been reported as the main causal agent of garlic dry rot during the postharvest stage, but information on the development of the disease throughout the production chain was nearly absent. Dry rot has caused huge economic losses in the past few years (up to 30 % of the yield), symptoms are visible on bulbs during storage as necrotic spots and in the most severe attacks, white mycelium may become visible on cloves. Few pest management strategies were tested in the recent past, but none were satisfactory. Due to the economic effect that this pathogen can have on local productions, the thesis aimed to deeply investigate the pathosystem with a field to fork approach and to test new strategies to control fungal infections. First of all, the work focused on garlic (Allium sativum L.) cropping season, intending to clarify the role of F. proliferatum in bulb infection as well as the impact of crop growing conditions on the development of the pathogen. A 3-year study was conducted in Piacenza (northern Italy) by sampling six garlic farms with different dry rot history (three highly contaminated and three low contaminated). Soil samples were recovered at sowing time for the counting of fungal colony-forming units (CFU). Plant samples were collected at three relevant growth stages, from April to July, for which disease severity assessment and fungi isolations were performed. Fusarium was the most frequently isolated genus, and F. proliferatum and F. oxysporum the dominant species during the garlic cropping season. F. oxysporum was dominant in the first year of the study, but F. proliferatum registered the highest incidence in all the farms tested. F. oxysporum incidence was correlated with dry weather, whereas F. proliferatum was enhanced in rainy years. To conclude, F. proliferatum is confirmed to be associated with garlic bulbs, even at crop’s early growth stages and symptoms are visible mainly on roots and basal plates at the field stage, related to F. oxysporum. Then, the focus was made in detecting the presence of F. proliferatum on garlic bulbs during prolonged storage, and to identify other fungal species associated with garlic dry rot. Moreover, fumonisin contamination in symptomatic and asymptomatic cloves were detected. Samples of 100 plants were collected over three production seasons in six farms located in Northern Italy at three-time points (at harvest, processing, and 6 months storage at –4° C). Results obtained lead to think that Fusarium–garlic pathosystem is split into two parts: basal plate/root and bulb. F. proliferatum had the highest incidence in infected bulbs and was confirmed as the causal agent of postharvest dry rot in garlic (mean incidence: 35.4%). F. oxysporum co-occurred with F. proliferatum but symptoms were visible only on basal plate/root. Dry rot incidence slightly increased during cold storage (from 14.6% at processing to 18.4% at 6-month storage); although, F. proliferatum incidence was stable during cold storage, fumonisin were produced from harvest through storage. Cloves showing symptoms were more contaminated compared to those asymptomatic, both by the fungus (mean incidence 39% vs 25.3%) and the toxin (287.0 vs 24.4 µg kg-1). Therefore, cold storage limits garlic dry rot, but health concerns related to fumonisin should be seriously considered. Regarding disease management, garlic crop is commonly propagated by plant parts (cloves). To protect garlic crop from early growth stages it is important to find commercial products able to control the pathogen growth on seedlings. The experiment aimed to test in vitro and in vivo the efficacy of triazoles and biocontrol agents (BCAs) against F. proliferatum and F. oxysporum. In in vitro trials, the best performance was achieved by propiconazole+prochloraz (100%), followed by tebuconazole (88.9%). BCAs were less effective but still showed great capacity to control the pathogen with maximum growth inhibition of 80% (Trichoderma harzianum +T. gamsii). In both cases, temperature influenced the capacity to control the pathogen with minimum effect at 25°C compared to lower temperatures. In vivo bacterial BCAs showed a similar capacity to control Fusaria compared to chemical products (mean of severity index 18.6% and 11.7%, respectively) and did not show side effects on root length. In vitro and in vivo results are comparable, except for Trichoderma, with the worst performances in terms of disease severity on plants. Finally, a field trial was designed to verify the efficacy of chemical and biological active ingredients as seed coating both at crop stage and postharvest, simulating the entire production chain, by taking into account visible symptoms and incidence of fungi. All products tested reduced the severity of symptoms on basal plates at the field stage, but none of them was able to reduce Fusarium incidence. A postharvest analysis conducted on bulbs demonstrated the efficacy of Tebuconazole, B. subtilis, and Trichoderma+B. subtilis in reducing the number of cloves showing symptoms per bulb (mean 34.3% vs control 45.8%). Moreover, Tebuconazole was able to reduce the incidence of F. proliferatum by 48% with respect to untreated control. The trial highlighted also that the incidence of F. proliferatum increased by 37% when garlic bulbs were kept for 15 days at room temperature simulating storage at consumers houses. Results obtained in the trial are promising and seed coating had a positive effect on garlic dry rot postharvest; although further studies are needed to test the persistence of seed coating treatments after prolonged storage period, especially when the product is kept outside cold chambers.

INTRODUCTION: The study focuses on finding a methodology for evaluating the effectiveness of the nonpharmaceutical intervention in the face of a new pathogen entering the population. Different interventions can have different effectiveness levels in different populations; thus, studying possible correlations and effectiveness among different groups is essential. With better knowledge of the topic, the outbreak management could be done more cost-effectively, reducing the need for antibiotics, vaccines, and possible reduction of infectious diseases caused burden in developing regions. Furthermore, the study aims to determine the ways of using excess mortality as an evaluation technique for nonpharmaceutical interventions used in the Covid-19 pandemic.  METHOD: The variables in time-series format were used to calculate a cross-correlation score alongside other correlation coefficient tests. With the cross-correlation, the lag will be established to estimate how the variables correlate in the timeline. In addition, the study will attempt to establish the connections between different nonpharmaceutical interventions and their strengths and different age groups. RESULTS: The most frequent lag scores identified were 1 with 16 observations and 2 with 9 observations. The highest lag score was 4, which was observed once for the dataset of Hungary. The correlation between excess mortality and different harshness of NPI's was calculated. The correlation coefficient ranges from -0.3 to -0.39, indicating an overall low to medium correlation. The highest correlation was detected with stay-at-home requirements (-0.36), workplace closing (-0.37), and gathering restrictions (-0.39). In the final step, age-based correlations were established. The correlation ranged from 0.26 – 0.36, indicating an overall medium correlation. The lowest correlation can be seen in the youngest age group, 15-64 (correlation coefficient of 0.26), while the highest correlation of 0.36 can be seen in the 75-84 age group. Surprisingly the age group 85+ had a little lower correlation than the 75-84 age group. DISCUSSION AND CONCLUSIONS: A stronger correlation between excess mortality and stringency index was detected in the countries with a higher death per capita. The two groups of intervention effectiveness were established: more effective (school closing, workplace closing, public event limitation, gathering restriction, and stay at home requirement) and less effective (public transport limitation, restriction on internal movement, international travel control, public information campaigns, protection of elderly campaigns). This suggests that NPI effectiveness depends on population size. In the age-group-based analysis, the correlation became stronger with the age increase, indicating nonpharmaceutical intervention effectiveness against high mortality in older adults.

This work deals with effectiveness of coeliac disease management. It is a model case of chronic disease management. The analytical framework of this work is the multilevel Innovative Care for Chronic Conditions Framework. Crucial is the interaction between health care team that represents health care system, community partners and patients with their families. In the case of coeliac disease it is necessary to include also the role of representatives of market with gluten free products. The interaction of these participants takes place in wider political context, whose state influences this interaction fundamentaly and reflects so in final results - state of patients and quality of their live. Using the evaluation of the quality of life tool SF-36, it has been ascertained, that the quality of life of coealiac patients is lower in comparison with European standard of healthy population and that the causes of the problem have to be searched and systematically removed at all levels of the system of chronic health care. The findings validate the theoretic presumption, that the chronic health care is still considerably underestimated and that it does not reply to the needs of chronic ill patients, which reflects just on general quality of life.

In the latter part of the 20th century chronic diseases, especially cardio vascular-related diseases (CVDs) and Type 2 diabetes mellitus (DM) seemed to have emerged as substantial problems. This can be seen in the prevalence and the cost of CVDs in South Africa and worldwide. It was predicted that by the year 2030 more people would be dying from CVDs than from Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/Aids). The reasons for the occurrence of CVDs are linked to biological (i.e. hypertension, hyperlipidemia, obesity, insulin resistance, etc), psychological (i.e. emotional stress), and behavioural or lifestyle risk factors. It is known that physical exercise can aid in the treatment of CVDs. Institutions such as the American College of Sports Medicine (ACSM) recommended an exercise frequency of three times per week for 20 minutes. According to literature, a third of patients in exercise studies do not comply with their exercise protocol, and after three to six months, 50 percent will drop out of organised training groups. Less than a third of South Africans complied with exercising 30 minutes a day on most days of the week. Thus, there has been much interest among health-care providers to manage exercise compliance. Exercise compliance is a complex construct, and thus in the present study the role that behavioural patterns play was also investigated via psychological behavioural models. The major objectives of the study were the following: <ul> <li> Firstly, to determine if exercise compliance or non-compliance had an influence on shifts measured in the clinical parameters (i.e. blood pressure, blood lipid levels, blood glucose levels, body mass index, body fat percentage and cardiac risk percentage) over time.</li> <li> Secondly, to determine whether there were any correlation between the psychological behavioural models and the exercise compliance of the members over the course of the Best Med/Access Health-Disease Management Programme (BM/AH-DM Programme).</li></ul> In the present study, a retrospective data analysis was done on data collected from Best Med Medical Aid members (n = 400) who participated in a chronic disease management programme for three and a half years. The inclusion criteria for participation on the programme were the presence of one or more of the following CVDs namely: hypercholesterolemia, hypertension and DM. The members’ clinical parameters (height, body weight, body fat percentage, blood pressure, finger-prick non-fasting (random) blood cholesterol level, finger-prick non-fasting (random) blood glucose, sub-maximal V02 fitness test) were measured every three months. After a baseline assessment was done, an exercise programme was given to each member and a norm of exercising twice a week was prescribed. If members adhered to the norm they were considered compliant and if they did not adhere to the norm, they were considered as being non-compliant. Their exercise compliance, and relevant clinical parameters were measured over 30 months, although data analysis was only a reflection of the first 12 months’ data. At the beginning of the BM/AH-DM Programme the members’ Level of Readiness (LOR) to make a lifestyle change was measured via a questionnaire and by the end of the programme they completed an Implicit Theory Scale (ITS) questionnaire. Descriptive statistics (means, standard deviation) were used to determine the entire groups’ compliance, and to divide the group into compliant and noncompliant groups. The T-test or the Mann-Whitney Test (an equivalent nonparametric technique) was applied to determine significant differences between groups. Thus did the clinical parameters measured over time (baseline to 3 months, baseline to 6 months and baseline to 12 months), change more in the compliant than in the non-compliant group? And were there correlations between psychological questionnaires answers and the two exercise groups? The results indicated that the group’s exercise compliance trend decreased drastically over time. Statistical significant decreases were demonstrated in systolic (p = 0.007) and diastolic (p = 0.012) blood pressure, BMI (p = 0.072 and p = 0.0003), cardiac risk percentage (p = 0.003), and body weight (p = 0.003 and p = 0.0000). All of these decreases were seen in the exercise compliant group. There were no statistical correlations between the psychological questionnaires and the exercise groups. Limitations were the quality of the clinical data, the exercise compliance data that deteriorated over time, and the LOR and ITS questionnaires was neither valid nor reliable tools in making predictions regarding exercise behaviour/compliance. For future research it is recommended that measurements of blood pressure and cholesterol be done more thoroughly, and dietary fat intake must be monitored. A valid and reliable cardiac risk tool, LOR and ITS questionnaires must be designed. AFRIKAANS : Die voorkoms en kosteïmplikasies van kroniese siektetoestande in Suid–Afrika en wêreldwyd, het in die laaste gedeelte van die 20ste eeu ‘n wesenlike probleem geword. Kardiovaskulêre (KVS) siektes en tipe 2 diabetes mellitus (DM) is veral voorbeelde van sulke siektetoestande. Daar is voorspel dat in die jaar 2030, meer mense wêreldwyd aan KVS sal doodgaan, as aan Menslike Immuniteitsgebrekvirus/Verworwe Immuniteitsgebreksindroom (MIV/Vigs). Die risikofaktore wat met die oorsake van KVS geassosieer word, is die volgende: <ul> <li> Biologiese (met inbegrip van hipertensie, insulienweerstandigheid, hoë bloedcholesteroltellings, ens)</li> <li> Sielkundige (bv emosionele spanning) • Risikofaktore wat verband hou met lewenstyl.</li></ul> Literatuur bevestig dat fisiese oefening help om KVS en diabetes mellitus te behandel. Die American College of Sports Medicine (ACSM) het ‘n oefenriglyn van drie maal per week vir 20 minute lank as ‘n minimumfrekwensie daargestel. Volgens literatuur oefen ‘n derde van pasiënte wat deelneem aan oefeningnavorsingsstudies nie volgens die riglyne wat gestel word nie en binne die eerste drie tot ses maande sal 50% van die pasiënte ophou oefen. Navorsing wat op die Suid-Afrikaanse bevolking gedoen is, toon dat minder as ‘n derde 30 minute lank op meeste dae van die week oefen. Dus is die belangstelling van gesondheidsterapeute rakende die bestuur van gereelde oefeningdeelname geprikkel. Gereelde oefeningdeelname sluit ook die rol van gedragspatrone in en dus is sielkundige gedragsmodelle gebruik om dit ook in die huidige studie te ondersoek. Copyright / Dissertation (MA)--University of Pretoria, 2009 / Biokinetics, Sport and Leisure Sciences / unrestricted

Mortality rates in the United States are higher for men than they are for women as a result of chronic diseases such as heart disease, cancer, and diabetes. Despite these disproportionate rates, few health interventions are targeted to men, and limited knowledge exists regarding the specific components needed to design technology health tools to appeal to men. The purpose of this quantitative study was to examine the relationship between the use of technology health tools and the role of self-efficacy in men and the influence on participation in healthy lifestyle behaviors. A quasi-experimental design was used to analyze data collected from the Health Information National Trends Survey (N = 990). A group of men (n = 323) who used technology health tools were compared to a control group of men (n = 667) who did not use technology health tools. Results from the regression analysis indicated that the use of technology health tools for self-management of health behavior had a significant effect on participation in healthy lifestyle behavior (p = .026). Self-efficacy was also found to mediate the relationship between technology health tools and participation in healthy lifestyle behavior (p = .018). This study supports the United States federal government's Healthy People 2020 objective to increase the proportion of people who use Internet health management tools. The implications for positive social change include knowledge for developing targeted technology health interventions to increase the participation of men in healthy lifestyle behavior, reduce the number of men with chronic diseases, improve chronic disease management, and reduce healthcare costs in the United States.

Introduction: Increased vegetable intake has been shown to protect against metabolic syndrome (MetS) among adults. However, limited studies have examined the association between vegetable consumption and MetS among pediatric Hispanic populations. The objective of this study was to explore the association between vegetable consumption and being at risk for MetS among a pediatric Hispanic population of Northeast Tennessee (TN). Methods: Nutrition, parental, and blood sample data were obtained from 114 Hispanic children aged 2 to 10 years who received care from a community health center in Northeast TN. Being at risk for MetS included having two or more of the following: elevated waist circumference, high blood pressure, elevated triglycerides, and low HDL. Multiple logistic regression analysis was used to examine the association between vegetable consumption and being at risk for MetS while controlling for child age, child sex, and parental marital status. Results: Higher vegetable intake was found to be associated with a 60% decrease in odds of being at risk for MetS (95% Confidence Interval (CI): 0.16-0.99). Children of parents who were not married were 162% more likely to be at risk for MetS compared to children of parents who were married (95% CI: 1.17-5.88). Discussion: Higher vegetable intake was associated with decreased odds of being at risk for MetS among this Hispanic pediatric population. Additional studies with a larger sample size are warranted to further understand the relationship of vegetable consumption and their potential protective effects on the development of MetS among this population.