La résistance aux antimicrobiens (RAM) est un problème de santé publique mondial avec des répercussions importantes en médecine vétérinaire et humaine. Elle est classiquement associée à une surutilisation des antimicrobiens. Les bactéries commensales des animaux et des humains, tel Escherichia coli, sont souvent utilisées comme bactéries indicatrices pour surveiller la RAM. Parmi les mécanismes de résistance de E. coli, la production de β-lactamases à spectre étendue (BLSE) ou de type AmpC est particulièrement inquiétante. Ces enzymes peuvent inactiver une classe d’antimicrobien de très haute importance en santé humaine également utilisée en médecine vétérinaire : les céphalosporines de 3e génération. La prévalence générale de la RAM ainsi que la présence de E. coli producteur de BLSE/AmpC dans les troupeaux laitiers québécois sont inconnues. De plus, la transmission de ces bactéries résistantes et les facteurs de risque associés à leurs excrétions par les bovins laitiers sont actuellement peu documentés. L’objectif général de cette thèse était d’explorer la RAM par une étude transversale observationnelle sur des fermes québécoises de bovins laitiers sélectionnées aléatoirement (n = 101). La première étape du projet constituait à décrire la prévalence de cette RAM pour la bactérie E. coli isolée des matières fécales des animaux (vaches en lactation, veaux pré-sevrage) et de l’environnement (fosse à fumier). La prévalence de RAM observée pour les E. coli indicateurs était faible (<5%) pour les antimicrobiens de très haute importance en médecine humaine (céphalosporines de 3e génération et fluoroquinolones). Cependant, il y avait une prévalence élevée (85%) de fermes avec la présence d’au moins un E. coli producteur de BLSE/AmpC. La RAM était particulièrement importante pour les E. coli isolés chez les veaux pré-sevrage. Pour la deuxième étape, cette RAM était analysée au niveau génétique par le séquençage du génome entier des E. coli les plus résistants. La grande majorité de la RAM (>95%) était expliquée par des mutations ou des gènes de résistance. Certains de ceux-ci étaient à proximité l’un de l’autre et leur configuration laissait supposer qu’une partie de ces gènes étaient présents sur des éléments génétiques mobiles. De plus, il y avait une dissémination clonale de E. coli résistant entre les fermes. La dernière étape constituait à déterminer des facteurs de risque (utilisation des antimicrobiens ou pratiques à la ferme) de la RAM. Grâce à des analyses multivariées utilisant l’intelligence artificielle, il a été possible d’observer des facteurs de risque significatifs associés à la taille de la ferme et à la santé des animaux. Bref, un portrait de la situation de la RAM est maintenant établi dans les troupeaux de bovins laitiers du Québec pour 2017. Il s’agit d’un phénomène complexe qui ne se limite pas simplement à un lien direct avec l’utilisation des antimicrobiens. Ces travaux serviront de bases pour suivre l’évolution temporelle de la RAM. De plus, des études prospectives pourraient être réalisées afin de confirmer les impacts des observations notées dans cette thèse. L’ensemble de ces informations seront déterminantes en vue d’établir des mesures concrètes pour tenter de limiter cette importante problématique. / Antimicrobial resistance (AMR) is a global public health problem with major repercussions in both veterinary and human medicine. It is classically associated with the overuse of antimicrobials. Animal and human commensal bacteria, such as Escherichia coli, are often used as indicator bacteria to monitor AMR. Among the resistance mechanisms of E. coli, the production of an extended-spectrum β-lactamase (ESBL) or AmpC-type is of particular concern. These enzymes can inactivate a class of antimicrobials of great importance in human health also used in veterinary medicine: third-generation cephalosporins. The overall prevalence of AMR and the presence of ESBL/AmpC-producing E. coli are unknown in Québec dairy herds. Furthermore, the transmission of these resistant bacteria and the risk factors associated with their excretion by dairy cattle are currently poorly documented. The overall objective of this thesis was to explore AMR through an observational cross-sectional study on randomly selected Québec dairy farms (n = 101). The first step of the project was to describe the prevalence of AMR for E. coli isolated from animal feces (lactating cows, pre-weaned calves) and the environment (manure pit). The prevalence of AMR observed for indicator E. coli was low (<5%) for antimicrobials of very high importance in human medicine (third-generation cephalosporins and fluoroquinolones). However, there was a high prevalence (85%) of farms with at least one ESBL/AmpC-producing E. coli. AMR was particularly high for E. coli isolated from pre-weaned calves. In the second step, AMR was analyzed at the genetic level by whole genome sequencing of the most resistant E. coli isolates. The vast majority of AMR (>95%) was explained by mutations or resistance genes. Some of these were in close proximity to each other, and their configuration suggested that some of these genes were present on mobile genetic elements. In addition, there was clonal dissemination of resistant E. coli between farms. The final step was to identify risk factors (antimicrobial use or farm practices) for AMR. Using artificial intelligence methods for multivariate analyses, it was possible to identify significant risk factors associated with farm size and the health of animals. In summary, our results provide a portrait of the AMR situation in Québec dairy herds. This complex phenomenon is not simply limited to a direct link with antimicrobial use. This work will serve as a baseline for monitoring the temporal evolution of AMR. In addition, prospective studies could be carried out to confirm the impacts of the observations noted in this thesis. All this information will be decisive in establishing concrete measures to try and limit this major problem.

This quantitative, descriptive study investigated risk factors for MDR-TB in Addis Ababa, Ethiopia. A total of 439 medical records belonging to MDR-TB and non MDR-TB patients managed in public health centres from January 2008 to December 2011 were analysed. Data were transcribed from each TB patient‟s medical records using a specifically designed checklist. The findings revealed that male gender, previous history of TB treatment, poor treatment adherence, an outcome of failure after TB re-treatment, previous category of failure, pulmonary involvement of TB infection and HIV infection were associated with MDR-TB. The findings illustrate that efforts should be made to prioritise the development and implementation of effective MDR TB screening and treatment protocols for these high risk groups to improve treatment outcome and minimize the emergence of XDR TB. / Health Studies / M. Public Health

本研究旨在利用風險管控的方式，來協助電子製造業建立一套可有效的維持產品的綠色品質並降低產品的綠色風險的綠色品質風險管控模型，使得企業不致因產品在出貨後，被檢測出違反RoHS指令而使企業被罰以巨額款項並損失商譽。 回顧1997年12月聯合國氣候變化框架公約(UNFCCC)參加國第三次會議在日本京都舉行，並簽定了[京都議定書]之後，各國陸續制定出其各自的環保法令，其中又以歐盟於2003年2月通過並於2006年7月1日起實施限制鉛，鎘，汞，六價鉻，多溴聯苯，多溴聯苯醚等六項有害物質的RoHS指令的影響範圍最大且最為直接的影響到我國的產業，從而引發起了本研究的動機。 本研究透過與訪談個案的合作，實際從分析個案的產品研發生產的作業中，由影響RoHS的角度從作業一直剖析到管控內容，進而找到會影響RoHS品質不良的16個風險因子，並透過建立的監控系統來進行風險因子的資料採樣，最後經由羅吉斯迴歸模型，建立出一套風險計算模型，以連接RoHS風險因子的監控系統而成為一套綠色品質風險管控模型。 / The objective of this research is to help electronic manufacturers to establish a Green Quality Risk Management Model, which can effectively keep green quality and decrease green quality risk of products. Consequently, companies can prevent huge amount of fine and goodwill impairment caused by RoHS violation of their shipments. After the participants of UNFCCC held the third meeting in Kyoto, Japan and ratified the Kyoto Protocol in December 1997, every country created its environmental regulations in secession. Among those regulations, the RoHS directive, which prohibits the usage of Lead, Mercury, Cadmium, Hexavalent chromium (Cr6+), Polybrominated biphenyls (PBB)and Polybrominated diphenyl ether (PBDE), adopted in February 2003 and activated in January 2006 by the European Union resulted in most pervasive and direct impact on Taiwanese industry, consequently creating the incentive for this research. By the cooperation of case interview, this research analyze the research and development operations of interviewees with the perspectives from primary operations to floor control in order to identify sixteen risk factors of RoHS quality, and sample the data of risk factors with established control system. Finally, a green quality risk management model was created by the establishment of a risk computation model in connection with RoHS risk factor control system was established using Logistic Regression model.

Introduction : La mortalité associée à l’insuffisance rénale aiguë (acute kidney injury ‘’AKI’’) aux soins intensifs pédiatriques (SIP) dépasse les 50%. Des études antérieures sur la thérapie de remplacement rénal (TRR) ont fait ressortir plusieurs facteurs de risque de mortalité dont le syndrome de défaillance multiviscérale (SDMV) et la surcharge liquidienne ≥ 10 à 20% avant l’initiation de la TRR. L’objectif de cette étude était d’identifier les principaux facteurs de risque de mortalité à 28 jours après l’initiation de la TRR chez les patients atteints d’AKI aux SIP. Méthode : Il s’agit d’une étude de cohorte rétrospective aux SIP d’un centre tertiaire. Tous les enfants ayant reçus de la TRR continue ou de l’hémodialyse intermittente pour AKI, entre janvier 1998 et décembre 2014, ont été inclus. Les facteurs de risque de mortalité ont été préalablement identifiés par quatre intensivistes et deux néphrologues pédiatres et analysés à l’aide d’une régression logistique multivariée. Résultats : Quatre-vingt-dix patients ont été inclus. L’âge médian était de 9 [2-14] ans. La principale indication d’initiation de la TRR était la surcharge liquidienne (64,2%). La durée médiane d’hospitalisation aux SIP était de 18,5 [8,0-31,0] jours. Quarante patients (44,4%) sont décédés dans les 28 jours suivant l’initiation de la TRR et quarante-cinq (50,0%) avant la sortie des SIP. Le score de PELOD ≥ 20 (OR 4,66 ; 95%CI 1,68-12,92) et la surcharge liquidienne ≥ 15% (OR 9,31; 95%CI 2,16-40,11) à l’initiation de la TRR étaient associés de façon indépendante à la mortalité. Conclusion : Cette étude a permis de faire ressortir deux facteurs de risque de mortalité à 28 jours à l’initiation de la TRR : la surcharge liquidienne et la sévérité du SDMV mesurée par le score de PELOD. / Introduction: Mortality rate associated with acute kidney injury (AKI) in pediatric intensive care units (PICU) exceeds 50%. Prior studies on renal replacement therapy (RRT) have highlighted different mortality risk factors including the presence of a multiple organ dysfunction syndrome (MODS) and fluid overload ≥ 10 to 20% before starting RRT. The aim of this study was to identify most important risk factors of 28-day mortality in patients with AKI at RRT initiation in PICU. Methods: We conducted a retrospective cohort study in a tertiary care pediatric center. All critically ill children who underwent acute continuous RRT or intermittent hemodialysis for AKI between January 1998 and December 2014 were included. A case report form was developed and specific risk factors were identified by a panel of four pediatric intensivists and two nephrologists. Risk factors analysis was made using logistic regression in SPSS and SAS software. Results: Ninety patients were included. The median age was 9 [2-14] years. The most common indication for RRT initiation was fluid overload (FO) (64.2%). The median PICU length of stay was 18.5 [8.0-31.0] days. Forty of the 90 patients (44.4%) died within 28 days after RRT initiation and forty-five (50.0%) died before PICU discharge. In a multivariate logistic regression analysis, a PELOD score ≥ 20 (OR 4.66; 95%CI 1.68-12.92) and percentage of FO ≥ 15% (OR 9.31; 95%CI 2.16-40.11) at RRT initiation were independently associated with mortality. Conclusion: This study suggests that fluid overload and severity of MODS measured by PELOD score are two risk factors of 28-day mortality in PICU patients on RRT.

Os objetivos deste estudo foram identificar os fatores de risco para complicações pulmonares pós-operatórias em pacientes laringectomizados por carcinoma espinocelular de laringe, assim como os fatores de risco para apresentação de metástases pulmonares e os fatores de risco para apresentação de segundo tumores primários em pulmão destes pacientes no período de 1985 a 1996. O estudo consistiu em uma análise retrospectiva de 291 pacientes admitidos no Hospital do Câncer A. C. Camargo, no período de 1985 a 1996, portadores de carcinoma espinocelular de laringe, submetidos a tratamento cirúrgico com intenção curativa seguido ou não de radioterapia. Foram analisados as variáveis demográficas, as comorbidades, a localização do sítio primário, o estadiamento clínico, o tratamento do tumor primário e do pescoço, o tratamento radioterápico, a diferenciação celular, as margens cirúrgicas, as recidivas locais, as recidivas regionais, a presença de complicações maiores, de complicações menores, as metástases pulmonares e a presença de múltiplos tumores primários pulmonares. O teste de associação do qui-quadrado foi utilizado para análise univariada descritiva das diversas variáveis comparando-se os grupos com complicação pulmonar e sem complicação pulmonar. A análise multivariada através da regressão logística foi utilizada na determinação dos fatores de risco para apresentação de metástases pulmonares e múltiplos tumores primário pulmonares. A incidência de complicações pulmonares foi de 31,3%, foram identificados como fatores de risco para complicações pulmonares somente a epiglote (p=0,004; RR 2,1), tendo a variável gênero associação marginal (p=0,081; RR 2,8). As metástases pulmonares tiveram incidência de 7,2%, na análise univariada foram identificados como fatores de risco o estadiamento N (p=0,032), diferenciação histológica (p=0,004), margens cirúrgicas (p=0,017) e recidivas locoregionais (0,002). Os múltiplos tumores primários pulmonares apresentaram incidência de 3,1% e na análise univariada foram identificados como fatores de risco o estadiamento N (p=0,048) e sítio aritenóide (p=0,001). Na análise multivariada foram significativos somente a diferenciação histológica: moderamente diferenciado (p=0,007; RR 2,9) e pouco diferenciado (p=0,032; RR 4,0); e as margens cirúrgicas: exíguas (p=0,003; RR 6,4) para apresentação de metástases pulmonares e múltiplos tumores pulmonares. Este estudo demonstra a importância do estadiamento clínico como fator de risco para complicações pulmonares, metástases à distância e múltiplos tumores primário em pulmão. Os fatores de risco determinantes para aparecimento de metástases pulmonares e múltiplos tumores primários pulmonares foram a diferenciação histológica e as margens cirúrgicas / Objective: To identify the risk factors to postoperative pulmonary complications in laryngeal cancer patients submitted to surgical treatment, the risk factors to development of lung metastasis and second lung primary tumor. Patients and Methods: Retrospective study of a cohort of 291 patients admitted at Hospital do Câncer A.C.Camargo from January, 1985 to December 1996. All patients were submitted to some kind of laryngectomy with curative intent as part of treatment of a proven laryngeal cancer, followed or not by radiotherapy. The following variables were analized: demographic, comorbidities, primary site, clinical stage, primary and neck surgical treatment, histopathologic differentiation grade, surgical margins, recurrences, postoperative pulmonary complications, lung metastasis and second lung primary tumor. The univariate and multivariate analysis were utilized to built the model to predict the risks factors and the factors of prognostic significance. Results: The overall pulmonary complications incidence were 31,3%, epiglottis were identified as significant single risk factor to pulmonary complications (p=0.004; RR 2,1). Lung metastasis had 7,2% incidence to this, the risk factors were N stage (p=0.032 ), histopathologic differentiation grade (p=0.004), surgical margins (p=0.017) and locoregional recurrence (p=0.002). The second lung primary tumor incidence were 3,1%, univariate analysis showed N stage (p=0,048) and arithenoid site (p=0,001) as significant risk factors. The multivariate analysis showed the histopathologic differentiation: moderate grade (p=0.007 RR 2,9) and poor grade (p=0.032 RR 4,0) and surgical margins: close (p=0.003 RR 6,4) as prognostic factors to deveopment of lung metastasis and second lung primary tumor. Conclusions: This study showed the clinical stage importance as risk factor to development of postoperative pulmonary complication, lung metastasis and second lung primary tumor in laryngectomy cancer patients. The prognostic factors associated with lung metastasis and second lung primary tumor were the histopathologic differentiation and the surgical margins

Os tumores carcinóides típicos broncopulmonares são proliferações de células neuroendócrinas. Foram consideradas como adenomas e acreditava-se que não tinham potencial para disseminação hematogênica e linfática. Porém, a ocorrência de metástase linfática e hematogênica acontece em um quinto dos indivíduos acometidos por essa patologia. A variação no comportamento clínico dos carcinóides broncopulmonares torna imperativa a realização de pesquisas que visem à melhor compreensão dessa doença. É fundamental determinar a agressividade e o risco individual da ocorrência de metástase linfática e hematogênica para que se possa oferecer um tratamento individualizado para cada binômio doente-doença. A classificação atual divide os tumores carcinóides, conforme o grau histológico de malignidade em típico e atípico, agrupando as neoplasias de acordo com o índice mitótico, relação volumétrica núcleo/citoplasma, presença ou ausência de necrose, pleomorfismo nuclear e invasão vascular. Esta análise, porém, é realizada em espécimes histológicos corados pela hematoxilina-eosina, técnica tradicional consagrada, mas que não permite avaliar processos biomoleculares relacionados ao potencial maligno das células que já podem estar presentes e não serem detectados pelo método. Em tumores carcinóides vários estudos já foram realizados na tentativa de identificar o potencial proliferativo de células que ainda não apresentam figuras de mitose, como PCNA, p53, Ki-67, o processo apoptótico (Bcl-2, Bax e Bak), fibras do sistema colágeno e elástico e angiogênese. Entretanto, a linfangiogênese nunca foi estudada. Na última década várias moléculas funcionais e constitucionais que são expressas especificamente nas células do endotélio ou nos podócitos dos vasos linfáticos foram identificadas, como o VEGF-C, VEGFR-3 e o LYVE-1, possibilitando a melhor compreensão da linfangiogênese. Estudamos a imunomarcação dessas estruturas no carcinóide típico. Pela primeira vez no Brasil, a quantificação de vasos linfáticos foi realizada usando o LYVE1 como marcador. Apesar do uso de vários bloqueios de sítios inespecíficos não foi possível quantificar a expressão do VEGF-C e VEGFR-3 em carcinóides típicos, pois não encontramos controle interno negativo. Houve diferença significante entre as médias da idade em relação ao gênero. Não houve diferença significante entre as médias do diâmetro e número de linfonodos acometidos em relação ao gênero. Em relação ao grupo com e sem metástase encontramos difenca significante em relação ao diâmetro e ao comprometimento da margem. Não houve diferença da mediana do número de vasos linfáticos corados por mil células entre os grupos sem e com metástase linfática. Por regressão logística identificamos o diâmetro do tumor primário como uma variável independente preditiva do risco de metástase hematogênica e o diâmetro do tumor primário e a localização central ou periférica como variáveis independentes preditivas do risco de qualquer metástase (linfática ou hematogênica). O número de vasos linfáticos corados por mil células não foi identificado pelo modelo de regressão logistica como uma variável independente preditiva do risco individual de metástase linfática. Conclui-se que há correlação do diâmetro do tumor com o potencial de metástase hematogênica e há correlação entre diâmetro e localização do tumor primário e a ocorrência de metástase linfática ou hematogênica. A quantificação da imunoexpressão do LYVE-1 não demonstrou correlação. Outras técnicas devem ser estudadas e empregadas para identificar a importância da linfangiogênese no carcinóide típico. / Typical pulmonary carcinoids are neuroendocrine cells proliferations and they were former considered lung adenomas with no hematogenic or lymphatic metastatic potential. However, it is known that up to 20% of patients develop metastatic disease. It is mandatory that new studies be developed due to the variation in clinical presentation of these patients. It is also required that the individual risk of lymphatic and hematogenic metastasis be determined in order to individualize the patients treatment. Pulmonary carcinoids are classified according to hystologic grade. The current classification includes hystologic grade, presence or absence of necrosis, nuclear pleomorphism, and vascular invasion. This classification is based on Hematoxylin and Eosin stain and this technique can not assess biomolecular processes related to malignant potential. Trying to identify the malignant potential of the carcinoid tumors some studies have already been designed to identify some proteins as PCNA, p53, Ki-67, apoptosis proteins (Bcl-2, Bax and Bak), collagen and elastic fibers as well as angiogenic process. However, the lymphangiogenic mechanism has never been evaluated in typical pulmonary carcinoid tumors. Recently some molecules (VEGF-C, VEGFR-3 and LYVE-1) that are specifically expressed in the endothelium of the lymphatic vessels have been identified. These findings have improved the lymphangiogenic mechanism comprehension. This study used the immunohistochemical technique to identify VEGF-C, VEGFR-3 and LYVE-1 in 182 patients submitted to surgical procedures to treat Typical pulmonary carcinoid tumors. Lymphatic metastasis were diagnosed in 23 of 182 patients and 17 of 182 patients were identified with hematogenic metastasis. Futhermore, this study was the first reported one which has tried to quantify the lymphatic vessels using the LYVE-1 as an immunohistochemical marker. This study could not assess VEGF-C and VEGFR-e expression in Typical pulmonary carcinoids since an internal negative control could not be determined. There was a statistical difference between the median age and gender. There was no statistical difference between the median diameter and the number of positive lymph nodes related to the gender. This study demonstrated a statistical difference between the diameter and positive margins related to the group of patients that have developed metastatic disease and the group of patients with no metatastatic disease. There was no difference between the group of patients that have developed metastatic disease and the group of patients with no metatastatic disease according to the median number of lymphatic vessels stained. Based on logistic regression this study demonstrated that there is a predictive risk of developing hematogenic metastasis related to the diameter of the tumor. The predictive risk of the lymphatic metastasis was not improved by the number of the immunohistochemical stained lymphatic vessels, according to the logistic regression model. The immunohistochemical expression of LYVE-1 has not demonstrated statistical correlation between the parameters studied. Other than immnuhistochemical techniques are required to improve the comprehension of the lymphangiogenic mechanism involved in the Typical pulmonary carcinoid tumor

Os objetivos deste estudo foram identificar os fatores de risco para complicações pulmonares pós-operatórias em pacientes laringectomizados por carcinoma espinocelular de laringe, assim como os fatores de risco para apresentação de metástases pulmonares e os fatores de risco para apresentação de segundo tumores primários em pulmão destes pacientes no período de 1985 a 1996. O estudo consistiu em uma análise retrospectiva de 291 pacientes admitidos no Hospital do Câncer A. C. Camargo, no período de 1985 a 1996, portadores de carcinoma espinocelular de laringe, submetidos a tratamento cirúrgico com intenção curativa seguido ou não de radioterapia. Foram analisados as variáveis demográficas, as comorbidades, a localização do sítio primário, o estadiamento clínico, o tratamento do tumor primário e do pescoço, o tratamento radioterápico, a diferenciação celular, as margens cirúrgicas, as recidivas locais, as recidivas regionais, a presença de complicações maiores, de complicações menores, as metástases pulmonares e a presença de múltiplos tumores primários pulmonares. O teste de associação do qui-quadrado foi utilizado para análise univariada descritiva das diversas variáveis comparando-se os grupos com complicação pulmonar e sem complicação pulmonar. A análise multivariada através da regressão logística foi utilizada na determinação dos fatores de risco para apresentação de metástases pulmonares e múltiplos tumores primário pulmonares. A incidência de complicações pulmonares foi de 31,3%, foram identificados como fatores de risco para complicações pulmonares somente a epiglote (p=0,004; RR 2,1), tendo a variável gênero associação marginal (p=0,081; RR 2,8). As metástases pulmonares tiveram incidência de 7,2%, na análise univariada foram identificados como fatores de risco o estadiamento N (p=0,032), diferenciação histológica (p=0,004), margens cirúrgicas (p=0,017) e recidivas locoregionais (0,002). Os múltiplos tumores primários pulmonares apresentaram incidência de 3,1% e na análise univariada foram identificados como fatores de risco o estadiamento N (p=0,048) e sítio aritenóide (p=0,001). Na análise multivariada foram significativos somente a diferenciação histológica: moderamente diferenciado (p=0,007; RR 2,9) e pouco diferenciado (p=0,032; RR 4,0); e as margens cirúrgicas: exíguas (p=0,003; RR 6,4) para apresentação de metástases pulmonares e múltiplos tumores pulmonares. Este estudo demonstra a importância do estadiamento clínico como fator de risco para complicações pulmonares, metástases à distância e múltiplos tumores primário em pulmão. Os fatores de risco determinantes para aparecimento de metástases pulmonares e múltiplos tumores primários pulmonares foram a diferenciação histológica e as margens cirúrgicas / Objective: To identify the risk factors to postoperative pulmonary complications in laryngeal cancer patients submitted to surgical treatment, the risk factors to development of lung metastasis and second lung primary tumor. Patients and Methods: Retrospective study of a cohort of 291 patients admitted at Hospital do Câncer A.C.Camargo from January, 1985 to December 1996. All patients were submitted to some kind of laryngectomy with curative intent as part of treatment of a proven laryngeal cancer, followed or not by radiotherapy. The following variables were analized: demographic, comorbidities, primary site, clinical stage, primary and neck surgical treatment, histopathologic differentiation grade, surgical margins, recurrences, postoperative pulmonary complications, lung metastasis and second lung primary tumor. The univariate and multivariate analysis were utilized to built the model to predict the risks factors and the factors of prognostic significance. Results: The overall pulmonary complications incidence were 31,3%, epiglottis were identified as significant single risk factor to pulmonary complications (p=0.004; RR 2,1). Lung metastasis had 7,2% incidence to this, the risk factors were N stage (p=0.032 ), histopathologic differentiation grade (p=0.004), surgical margins (p=0.017) and locoregional recurrence (p=0.002). The second lung primary tumor incidence were 3,1%, univariate analysis showed N stage (p=0,048) and arithenoid site (p=0,001) as significant risk factors. The multivariate analysis showed the histopathologic differentiation: moderate grade (p=0.007 RR 2,9) and poor grade (p=0.032 RR 4,0) and surgical margins: close (p=0.003 RR 6,4) as prognostic factors to deveopment of lung metastasis and second lung primary tumor. Conclusions: This study showed the clinical stage importance as risk factor to development of postoperative pulmonary complication, lung metastasis and second lung primary tumor in laryngectomy cancer patients. The prognostic factors associated with lung metastasis and second lung primary tumor were the histopathologic differentiation and the surgical margins

Longtemps ignorés ou déniés, des faits de maltraitance sont aujourd’hui régulièrement signalés et reconnus comme avérés dans des institutions qui accueillent des personnes en situation de handicap. Pour les prévenir, il est préconisé de former le personnel et même de rendre cette thématique obligatoire dans la formation initiale des différents accompagnants. Cependant, pratiquement rien n’est dit sur le contenu des formations à dispenser, ni les modalités pédagogiques à mettre en œuvre. Cette thèse analyse un programme de formation et ses retombées. Ce programme a été élaboré dans une perspective de prévention active en prenant en compte l’évolution du concept de maltraitance, la nécessité d’un travail préalable sur ses représentations et l’option d’une vision écosystémique de cette problématique. Il propose trois modalités pédagogiques distinctes afin d’en vérifier les retombées. Il est dispensé à des travailleurs sociaux en dernière année d’une formation initiale. Notre démarche vérifie l’hypothèse que des changements de représentations sur ce qu’est la maltraitance et ses facteurs de protection surviennent en cours de formation et que ces derniers pourront amener le déploiement d’actions spécifiques afin de la prévenir. Elle permet d’une part de dessiner des perspectives méthodologiques pour l’analyse d’une telle formation et d’autre part de faire des recommandations quant aux contenus et aux modalités pédagogiques à prioriser. / Long ignored or denied, incidents of abuse are now regularly reported and recognized as commonplace in institutions catering for people with disabilities. It is widely recommended that staff should receive training in order to help prevent such abuse, and even that such training modules should now be made compulsory in initial training programmes for all staff working directly with residents. However, virtually nothing is said about the content of such courses, nor about the pedagogical approaches that should be adopted. This thesis analyses such a training program and its outcomes. The programme was conceived with a view to improving active prevention, taking into account the evolution of the concept of abuse, the need for prior work on representations of abuse and the option of an eco-systemic approach to the issue. In order to better understand outcomes, three distinct pedagogical approaches were included. The programme is proposed to social workers during the final year of their initial training. Our approach tests the hypothesis that changes in representations of what constitutes abuse and its factors of protection occur during the training course and may result in specific preventive action. It allows us to develop the methodological approaches needed to analyse such a training programme and also to make recommendations regarding the content and the adoption of appropriate pedagogical methods.

Diabetes is a major risk factor for the development of cataract [3,14,20,22]. In this thesis, we create a model that allows us to understand the incidence of one disease in the context of another; in particular, cataract in the presence of diabetes. The World Health Organization's Vision 2020 blindness-prevention initiative administers surgeries to remove cataracts, the leading cause of blindness worldwide [24]. One of the geographic areas most impacted by cataract-related blindness is Sub-Saharan Africa. In order to plan the number of surgeries to administer, the World Health Organization uses data on cataract prevalence. However, an estimation of the incidence of cataract is more useful than prevalence data for the purpose of resource planning. In 2012, Dray and Williams developed a method for estimating incidence based on prevalence data [5]. Incidence estimates can be further refined by considering associated risk factors such as diabetes. We therefore extend the Dray and Williams model to include diabetes prevalence when calculating cataract incidence estimates. We explore two possible approaches to our model construction, one a detailed extension, and the other, a simplification of that extension. We provide a discussion comparing the two approaches.

Saskatchewan is the only province in Canada to have routinely tested the antimicrobial susceptibility of all provincially reported human cases of campylobacteriosis. From 1999 to 2006, 1378 human Campylobacter species infections were tested for susceptibility at the Saskatchewan Disease Control Laboratory using the Canadian Integrated Program for Antimicrobial Resistance Surveillance panel and minimum inhibitory concentration (MIC) breakpoints. Of these, 1200 were C. jejuni, 129 were C. coli, with the remaining made up of C. lari, C. laridis, C. upsaliensis and undifferentiated Campylobacter species. Campylobacter coli had significantly higher prevalences of ciprofloxacin resistance (CIPr), erythromycin resistance (ERYr), combined CIPr-ERYr resistance and multidrug resistance (to three or greater drug classes) than C. jejuni. Logistic regression models indicated that CIPr in C. jejuni decreased from 1999 to 2004 and subsequently increased in 2005 and 2006. The risk of CIPr was significantly increased in the winter months (January to March) compared to other seasons. A comparison of logistic regression and Cox proportional hazard survival models found that the latter were better able to detect significant temporal trends in CIPr and tetracycline resistance by directly modeling MICs, but that these trends were more difficult to interpret. Scan statistics detected significant spatial clusters of CIPr C. jejuni infections in urban centers (Saskatoon and Regina) and temporal clusters in the winter months; the space-time permutation model did not detect any space-time clusters. Bernoulli scan tests were computationally the fastest for cluster detection, compared to ordinal MIC and multinomial antibiogram models. eBURST analysis of antibiogram patterns showed a marked distinction between case and non-case isolates from the scan statistic clusters. Multilevel logistic regression models detected significant individual and regional contextual risk factors for infection with CIPr C. jejuni. Patients infected in the winter, that were between the ages of 40-45 years of age, that lived in urban regions and that lived in regions of moderately high poultry density had higher risks of a resistant infection. These results advance the epidemiologic knowledge of CIPr C. jejuni in Saskatchewan and provide novel analytical methods for antimicrobial resistance surveillance data in Canada. / Saskatchewan Disease Control Laboratory (Saskatchewan Ministry of Health); Laboratory for Foodborne Zoonoses (Public Health Agency of Canada); Centre for Foodborne, Environmental and Zoonotic Infectious Diseases (Public Health Agency of Canada); Ontario Veterinary College Blake Graham Fellowship