Predictors of Contralateral Breast Cancer in BRCA Negative Women

Breast cancer is the most common cancer diagnosis and second leading cause of death in women. Risk factors associated with breast cancer include: increased age, alcohol consumption, cigarette smoking, white race, physical inactivity, benign breast conditions, reproductive and hormonal factors, dietary factors, and family history. Hereditary breast and ovarian cancer syndrome (HBOC) is caused by mutations in the BRCA1 and BRCA2 genes. Women carrying a mutation in these genes are at an increased risk to develop a second breast cancer. Contralateral breast cancer is the most common second primary cancer in patients treated for a first breast cancer. Other risk factors for developing contralateral breast cancer include a strong family history of breast cancer, age of onset of first primary breast cancer, and if the first primary was a lobular carcinoma, which has an increased risk of being bilateral. A retrospective chart review was performed on a select cohort of women in an IRB approved database at MD Anderson Cancer Center. The final cohort contained 572 women who tested negative for a BRCA1 or BRCA2 mutation, had their primary invasive breast cancer diagnosed under the age of 50, and had a BRCAPro risk assessment number over 10%. Of the 572 women, 97 women developed contralateral breast cancer. A number of predictors of contralateral breast cancer were looked at between the two groups. Using univariable Cox Proportional Hazard model, thirteen statistically interesting risk factors were found, defined as having a p-value under 0.2. Multivariable stepwise Cox Proportional Hazard model found four statistically significant variables out of the thirteen found in the univariable analysis. In our study population, the incidence of contralateral breast cancer was 17%. Four statistically significant variables were identified. Undergoing a prophylactic mastectomy was found to reduce the risk of developing contralateral breast cancer, while not having a prophylactic mastecomy, a young age at primary diagnosis, having a positive estrogen receptor status of the primary tumor, and having a family history of breast cancer increased a woman’s risk to develop contralateral breast cancer.

EFFECTS OF THE ACTA2 R258C MUTATION ON VASCULAR SMOOTH MUSCLE CELL PHENOTYPE AND PROPERTIES

Thoracic Aortic Aneurysms and Dissections (TAAD) are the fifteenth leading cause of death in the United States. About 15% of TAAD patients have family history of the disease. The most commonly mutated gene in these families is ACTA2, encoding smooth muscle-specific α-actin. ACTA2 missense mutations predispose individuals both to TAAD and to vascular occlusive disease of small, muscular arteries. Mice carrying an Acta2 R258C mutant transgene with a wildtype Acta2 promoter were generated and bred with Acta2-/- mice to decrease the wildtype: mutant Acta2 ratio. Acta2+/+ R258C TGmice have decreased aortic contractility without aortic disease. Acta2+/- R258C TG mice, however, have significant aortic dilatations by 12 weeks of age and a hyperproliferative response to injury. We characterized smooth muscle cells (SMCs) from bothmouse models under the hypothesis that mutant α-actin has a dominant negative effect, leading to impaired contractile filament formation/stability, improper focal adhesion maturation and increased proliferation. Explanted aortic SMCs from Acta2+/+ R258C TG mice are differentiated - they form intact filaments, express higher levels of contractile markers compared to wildtype SMCs and have predominantly nuclear Myocardin-Related Transcription Factor A (MRTF-A) localization. However, ultracentrifugation assays showed large unpolymerized actin fractions, suggesting that the filaments are brittle. In contrast, Acta2+/- R258C TG SMCs are less well-differentiated, with pools of unpolymerized actin, more cytoplasmic MRTF-A and decreased contractile protein expression compared to wildtype cells. Ultracentrifugation assays after treating Acta2+/- R258C TGSMCs with phalloidin showed actin filament fractions, indicating that mutant α-actin can polymerize into filaments. Both Acta2+/+ R258C TGand Acta2+/- R258C TGSMCs have larger and more peripheral focal adhesions compared to wildtype SMCs. Rac1 was more activated in Acta2+/+ R258C TGSMCs; both Rac1 and RhoA were less activated in Acta2+/- R258C TG SMCs, and FAK was more activated in both transgenic SMC lines compared to wildtype. Proliferation in both cell lines was significantly increased compared to wildtype cells and could be partially attenuated by inhibition of FAK or PDGFRβ. These data support a dominant negative effect of the Acta2 R258C mutation on the SMC phenotype, with increasing phenotypic severity when wildtype: mutant α-actin levels are decreased.

Genetic Predictors of Clinical Outcomes in Non-Small Cell Lung Cancer Patients

Lung cancer is the leading cause of cancer-related mortality in the US. Emerging evidence has shown that host genetic factors can interact with environmental exposures to influence patient susceptibility to the diseases as well as clinical outcomes, such as survival and recurrence. We aimed to identify genetic prognostic markers for non-small cell lung cancer (NSCLC), a major (85%) subtype of lung cancer, and also in other subgroups. With the fast evolution of genotyping technology, genetic association studies have went through candidate gene approach, to pathway-based approach, to the genome wide association study (GWAS). Even in the era of GWAS, pathway-based approach has its own advantages on studying cancer clinical outcomes: it is cost-effective, requiring a smaller sample size than GWAS easier to identify a validation population and explore gene-gene interactions. In the current study, we adopted pathway-based approach focusing on two critical pathways - miRNA and inflammation pathways. MicroRNAs (miRNA) post-transcriptionally regulate around 30% of human genes. Polymorphisms within miRNA processing pathways and binding sites may influence patients’ prognosis through altered gene regulation. Inflammation plays an important role in cancer initiation and progression, and also has shown to impact patients’ clinical outcomes. We first evaluated 240 single nucleotide polymorphisms (SNPs) in miRNA biogenesis genes and predicted binding sites in NSCLC patients to determine associations with clinical outcomes in early-stage (stage I and II) and late-stage (stage III and IV) lung cancer patients, respectively. First, in 535 early-stage patients, after correcting multiple comparisons, FZD4:rs713065 (hazard ratio [HR]:0.46, 95% confidence interval [CI]:0.32-0.65) showed a significant inverse association with survival in early stage surgery-only patients. SP1:rs17695156 (HR:2.22, 95% CI:1.44-3.41) and DROSHA:rs6886834 (HR:6.38, 95% CI:2.49-16.31) conferred increased risk of progression in the all patients and surgery-only populations, respectively. FAS:rs2234978 was significantly associated with improved survival in all patients (HR:0.59, 95% CI:0.44-0.77) and in the surgery plus chemotherapy populations (HR:0.19, 95% CI:0.07-0.46).. Functional genomics analysis demonstrated that this variant creates a miR-651 binding site resulting in altered miRNA regulation of FAS, providing biological plausibility for the observed association. We then analyzed these associations in 598 late-stage patients. After multiple comparison corrections, no SNPs remained significant in the late stage group, while the top SNP NAT1:rs15561 (HR=1.98, 96%CI=1.32-2.94) conferred a significantly increased risk of death in the chemotherapy subgroup. To test the hypothesis that genetic variants in the inflammation-related pathways may be associated with survival in NSCLC patients, we first conducted a three-stage study. In the discovery phase, we investigated a comprehensive panel of 11,930 inflammation-related SNPs in three independent lung cancer populations. A missense SNP (rs2071554) in HLA-DOB was significantly associated with poor survival in the discovery population (HR: 1.46, 95% CI: 1.02-2.09), internal validation population (HR: 1.51, 95% CI: 1.02-2.25), and external validation (HR: 1.52, 95% CI: 1.01-2.29) population. Rs2900420 in KLRK1 was significantly associated with a reduced risk for death in the discovery (HR: 0.76, 95% CI: 0.60-0.96) and internal validation (HR: 0.77, 95% CI: 0.61-0.99) populations, and the association reached borderline significance in the external validation population (HR: 0.80, 95% CI: 0.63-1.02). We also evaluated these inflammation-related SNPs in NSCLC patients in never smokers. Lung cancer in never smokers has been increasingly recognized as distinct disease from that in ever-smokers. A two-stage study was performed using a discovery population from MD Anderson (411 patients) and a validation population from Mayo Clinic (311 patients). Three SNPs (IL17RA:rs879576, BMP8A:rs698141, and STK:rs290229) that were significantly associated with survival were validated (pCD74:rs1056400 and CD38:rs10805347) were borderline significant (p=0.08) in the Mayo Clinic population. In the combined analysis, IL17RA:rs879576 resulted in a 40% reduction in the risk for death (p=4.1 × 10-5 [p=0.61, heterogeneity test]). We also validated a survival tree created in MD Anderson population in the Mayo Clinic population. In conclusion, our results provided strong evidence that genetic variations in specific pathways that examined (miRNA and inflammation pathways) influenced clinical outcomes in NSCLC patients, and with further functional studies, the novel loci have potential to be translated into clinical use.

A cross-sectional analysis of the association between polycyclic aromatic hydrocarbons and diesel particulate matter exposures and hypertension among individuals of Mexican origin residing in Houston, TX

Background. Research has shown that elevations of only 10 mmHg diastolic blood pressure (BP) and 5 mmHg systolic BP are associated with substantial (as large as 50%) increases in risks for cardiovascular disease, a leading cause of death, worldwide. Epidemiological studies have found that particulate matter (PM) increases blood pressure (BP) and many biological mechanisms which may suggest that the organic matter of PM contributes to the increase in BP. To understand components of PM which may contribute to the increase in BP, this study focuses on diesel particulate matter (DPM) and polycyclic aromatic hydrocarbons (PAHs). To our knowledge, there have been only four epidemiological studies on BP and DPM, and no epidemiological studies on BP and PAHs. ^ Objective. Our objective was to evaluate the association between prevalent hypertension and two ambient exposures: DPM and PAHs amongst the Mano a Mano cohort. ^ Methods. The Mano a Mano cohort which was established by the M.D. Anderson Cancer Center in 2001, is comprised of individuals of Mexican origin residing in Houston, TX. Using geographical information systems, we linked modeled annual estimates of PAHs and DPM at the census track level from the U.S. Environmental Protection Agency's National-Scale Air Toxics Assessment to residential addresses of cohort members. Mixed-effects logistic regression models were applied to determine associations between DPM and PAHs and hypertension while adjusting for confounders. ^ Results. Ambient levels of DPM, categorized into quartiles, were not statistically associated with hypertension and did not indicate a dose response relationship. Ambient levels of PAHs, categorized into quartiles, were not associated with hypertension, but did indicate a dose response relationship in multiple models (for example: Q2: OR = 0.98; 95% CI, 0.73–1.31, Q3: OR = 1.08; 95% CI, 0.82–1.41, Q4: OR = 1.26; 95% CI, 0.94–1.70). ^ Conclusion. This is the first assessment to analyze the relationship between ambient levels of PAHs and hypertension and it is amongst a few studies investigating the association between ambient levels of DPM and hypertension. Future analyses are warranted to explore the effects DPM and PAHs using different categorizations in order to clarify their relationships with hypertension.^

Systematic review of current trends of cardiovascular disease (CVD) and association between health insurance coverage and CVD mortality among women aged 60--65 in Texas in 2000--2011

Cardiovascular disease (CVD) is highly preventable, yet it is a leading cause of death among women in Texas. The primary goals of this research were to examine past and current trends of CVD, as well as identify whether there is an association between the insurance coverage and mortality from CVD among women aged 60–65 in Texas between 2000 and 2011. ^ The systematic review of the research is based on the guidelines and recommendations set by the Centre for Reviews and Dissemination for conducting reviews in health care. Over 47 citations of peer-reviewed articles from Ovid MEDLINE and PubMed databases and five websites were identified, of which 7 studies met inclusion criteria for the first systematic review to examine the trends of CVD in Texas. Ten citations of peer-reviewed articles from Ovid MEDLINE and PubMed databases and five web sites were reviewed for the second systematic review (to study the association between insurance coverage and cardiovascular health among Texas women 60–64 years of age), of which 3 studies met inclusion criteria and were included in the research. The results of the study highlighted key gaps in the existing literature and important areas for the further research, as well as determined directions for future public health CVD prevention programs in Texas. ^ Based on the conducted research, the major determinants of premature mortality among women attributed to cardiovascular disease are based on individual level characteristics, more specifically sex, age, race/ethnicity, and education. The results indicate that African American and non-Hispanic white women are more likely to have higher CVD mortality rates than Hispanic women due to higher prevalence of cardiac risk factors. The data also shows higher levels of mortality from CVD in the southeastern United States, with Texas ranking as the third state with the highest prevalence of CVD among women. According to the Texas Department of State Health Services, there are approximately 56,000 deaths caused by CVD annually in Texas, which represents about one death every ten minutes. Coronary artery disease and stroke were the causes of 31.2 percent of all female deaths in Texas in 2009, meaning that approximately 68 women die from any form of cardiac disease in Texas each day. ^ The data of the reviewed studies indicate that women' lack of health insurance was significantly associated with a higher prevalence of cardiovascular disease. The uninsured women were more likely to be unaware of their risk factors and more likely to have undiagnosed diabetes—a co-morbidity factor of CVD. One of the studies also reports strong correlation between state rates of uninsured and lower rates of preventive care. Given these strong correlations, those who were chronically uninsured were at a higher risk of mortality than the insured, due to prolonged periods of time without basic access to preventive and medical care. ^ Suggested recommendations to decrease CVD mortality rates in Texas are consistent with the existing literature and include state policy development that addresses elimination of health disparities, consideration of potential benefits of universal health coverage by the legislative policymakers, and maintenance of solid partnerships between public health agencies and hospitals to educate on, diagnose, and treat CVD among the female population in Texas. ^

INDUCTION OF STRONGER AND LONG LASTING VACCINE IMMUNITY TO TUBERCULOSIS

Tuberculosis is a major cause of death due to an infection in mankind. BCG vaccine protects against childhood tuberculosis although, it fails to protect against adult tuberculosis. BCG vaccine localizes to immature phagosomes of macrophages, and avoids lysosomal fusion, which decreases peptide antigen production. Peptides are essential for macrophage-mediated priming of CD4 and CD8 T cells respectively through MHC-II and MHC-I pathways. Furthermore, BCG reduces the expression of MHC-II in macrophages of mice after infection, through Toll-like receptor-1/2 (TLR-1/2) mediated signaling. In my first aim, I hypothesized that BCG-induced reduction of MHC-II levels in macrophages can decrease CD4 T cell function, while activation of other surface Toll-like receptors (TLR) can enhance CD4 T cell function. An in vitro antigen presentation model was used where, TLR activated macrophages presented an epitope of Ag85B, a major immunogen of BCG to CD4 T cells, and T cell derived IL-2 was quantitated as a measure of antigen presentation. Macrophages with BCG were poor presenters of Ag85B while, TLR-7/9/5/4 and 1/2 activation led to an enhanced antigen presentation. Furthermore, TLR-7/9 activation was found to down-regulate the degradation of MHC-II through ubiquitin ligase MARCH1, and also stimulate MHC-II expression through activation of AP-1 and CREB transcription elements via p38 and ERK1/2 MAP kinases. I conclude from Aim-I studies that TLR-7/9 ligands can be used as more effective ‘adjuvants’ for BCG vaccine. In Aim-II, I evaluated the poor CD8 T cell function in BCG vaccinated mice thought to be due to a decreased leak of antigens into cytosol from immature phagosomes, which reduces the MHC-I mediated activation of CD8 T cells. I hypothesized that rapamycin co-treatment could boost CD8 T cell function since it was known to sort BCG vaccine into lysosomes increasing peptide generation, and it also enhanced the longevity of CD8 T cells. Since CD8 T cell function is a dynamic event better measurable in vivo, mice were given BCG vaccine with or without rapamycin injections and challenged with virulent Mycobacterium tuberculosis. Organs were analysed for tetramer or surface marker stained CD8 T cells using flow cytometry, and bacterial counts of organisms for evaluation of BCG-induced protection. Co-administration of rapamycin with BCG significantly increased the numbers of CD8 T cells in mice which developed into both short living effector- SLEC type of CD8 T cells, and memory precursor effector-MPEC type of longer-living CD8 T cells. Increased levels of tetramer specific-CD8 T cells correlated with a better protection against tuberculosis in rapamycin-BCG group compared to BCG vaccinated mice. When rapamycin-BCG mice were rested and re-challenged with M.tuberculosis, MPECs underwent stronger recall expansion and protected better against re-infection than mice vaccinated with BCG alone. Since BCG induced immunity wanes with time in humans, we made two novel observations in this study that adjuvant activation of BCG vaccine and rapamycin co-treatment both lead to a stronger and longer vaccine-mediated immunity to tuberculosis.

Influenza vaccination as a primary or secondary prevention for cardiovascular diseases: A systematic review of the literature

Background: Cardiovascular diseases (CVD) are the leading cause of morbidity and mortality worldwide. CVD mainly comprise of coronary heart disease and stroke and were ranked first and fourth respectively amongst leading causes of death in the United States. Influenza (flu) causes annual outbreaks and pandemics and is increasingly recognized as an important trigger for acute coronary syndromes and stroke. Influenza vaccination is an inexpensive and effective strategy for prevention of influenza related complications in high risk individuals. Though it is recommended for all CVD patients, Influenza vaccine is still used at suboptimal levels in these patients owing to prevailing controversy related to its effectiveness in preventing CVD. This review was undertaken to critically assess the effectiveness of influenza vaccination as a primary or secondary prevention method for CVD. ^ Methods: A systematic review was conducted using electronic databases OVID MEDLINE, PUBMED (National Library of Medicine), EMBASE, GOOGLE SCHOLAR and TRIP (Turning Research into Practice). The study search was limited to peer-reviewed articles published in English language from January 1970 through May 2012. The case control studies, cohort studies and randomized controlled trials related to influenza vaccination and CVD, with data on at least one of the outcomes were identified. In the review, only population-based epidemiologic studies in all ethnic groups and of either sex and with age limitation of 30 yrs or above, with clinical CVD outcomes of interest were included. ^ Results: Of the 16 studies (8 case control studies, 6 cohort studies and 2 randomized controlled trials) that met the inclusion criteria, 14 studies reported that there was a significant benefit in u influenza vaccination as primary or secondary prevention method for preventing new cardiovascular events. In contrary to the above findings, two studies mentioned that there was no significant benefit of vaccination in CVD prevention. ^ Conclusion: The available body of evidence in the review elucidates that vaccination against influenza is associated with reduction in the risk of new CVD events, hospitalization for coronary heart disease and stroke and as well as the risk of death. The study findings disclose that the influenza vaccination is very effective in CVD prevention and should be encouraged for the high risk population. However, larger and more future studies like randomized control trials are needed to further evaluate and confirm these findings. ^

Identification of genes associated with quantitative traits involved in cardiovascular disease and lipoprotein metabolism

Cardiovascular disease (CVD) is a threat to public health. It has been reported to be the leading cause of death in United States. The invention of next generation sequencing (NGS) technology has revolutionized the biomedical research. To investigate NGS data of CVD related quantitative traits would contribute to address the unknown etiology and disease mechanism of CVD. NHLBI's Exome Sequencing Project (ESP) contains CVD related phenotypes and their associated NGS exomes sequence data. Initially, a subset of next generation sequencing data consisting of 13 CVD-related quantitative traits was investigated. Only 6 traits, systolic blood pressure (SBP), diastolic blood pressure (DBP), height, platelet counts, waist circumference, and weight, were analyzed by functional linear model (FLM) and 7 currently existing methods. FLM outperformed all currently existing methods by identifying the highest number of significant genes and had identified 96, 139, 756, 1162, 1106, and 298 genes associated with SBP, DBP, Height, Platelet, Waist, and Weight respectively. ^

Classification of cellular malignancy associated changes in cervical cancer

Cervical cancer is the leading cause of death and disease from malignant neoplasms among women in developing countries. Even though the Pap smear has significantly decreased the number of deaths from cervical cancer in the past years, it has its limitations. Researchers have developed an automated screening machine which can potentially detect abnormal cases that are overlooked by conventional screening. The goal of quantitative cytology is to classify the patient's tissue sample based on quantitative measurements of the individual cells. It is also much cheaper and potentially can take less time. One of the major challenges of collecting cells with a cytobrush is the possibility of not sampling any existing dysplastic cells on the cervix. Being able to correctly classify patients who have disease without the presence of dysplastic cells could improve the accuracy of quantitative cytology algorithms. Subtle morphologic changes in normal-appearing tissues adjacent to or distant from malignant tumors have been shown to exist, but a comparison of various statistical methods, including many recent advances in the statistical learning field, has not previously been done. The objective of this thesis is to use different classification methods applied to quantitative cytology data for the detection of malignancy associated changes (MACs). In this thesis, Elastic Net is the best algorithm. When we applied the Elastic Net algorithm to the test set, we combined the training set and validation set as "training" set and used 5-fold cross validation to choose the parameter for Elastic Net. It has a sensitivity of 47% at 80% specificity, an AUC 0.52, and a partial AUC 0.10 (95% CI 0.09-0.11).^

Genetic integration of a nuclear -encoded mitochondrial gene with cardiac function

Cardiovascular disease (CVD) is the leading cause of death in the United States. One manifestation of CVD known to increase mortality is an enlarged, or hypertrophic heart. Hypertrophic cardiomyocytes adapt to increased contractile demand at the genetic level with a re-emergence of the fetal gene program and a downregulation of fatty acid oxidation genes with concomitant increased reliance on glucose-based metabolism. To understand the transcriptional regulatory pathways that implement hypertrophic directives we analyzed the upstream promoter region of the muscle specific isoform of the nuclear-encoded mitochondrial gene, carnitine palmitoyltransferase-1β (CPT-1β) in cultured rat neonatal cardiac myocytes. This enzyme catalyzes the rate-limiting step of fatty acid entry into β-oxidation and is downregulated in cardiac hypertrophy and failure, making it an attractive model for the study of hypertrophic gene regulation and metabolic adaptations. We demonstrate that the muscle-enriched transcription factors GATA-4 and SRF synergistically activate CPT-1β; moreover, DNA binding to cognate sites and intact protein structure are required. This mechanism coordinates upregulation of energy generating processes with activation of the energy consuming contractile promoter for cardiac α-actin. We hypothesized that fatty acid or glucose responsive transcription factors may also regulate CPT-1β. Oleate weakly stimulates CPT-1β activity; in contrast, the glucose responsive Upstream Stimulatory Factors (USF) dramatically depresses the CPT-1β reporter. USF regulates CPT-1β through a novel physical interaction with the cofactor PGC-1 and abrogation of MEF2A/PGC-1 synergistic stimulation. In this way, USF can inversely regulate metabolic gene programs and may play a role in the shift of metabolic substrate preference seen in hypertrophy. Failing hearts have elevated expression of the nuclear hormone receptor COUP-TF. We report that COUP-TF significantly suppresses reporter transcription independent of DNA binding and specific interactions with GATA-4, Nkx2.5 or USF. In summary, CPT-1β transcriptional regulation integrates mitochondrial gene expression with two essential cardiac functions: contraction and metabolic substrate oxidation. ^

The effects of omega -3 fatty acid -enriched fish on C -reactive protein levels in postmenopausal women

Coronary heart disease (CHD) is the leading cause of death in women and rates markedly increase among women after 65 years of age. C-reactive protein (CRP) is a new clinical indicator of atherosclerotic-related inflammation with a direct pathogenic role. Studies show lifestyle factors can modulate CRP. Omega-3 fatty acids have anti-inflammatory properties and studies suggest that eating fish high in omega-3 fatty acids may lower CHD risk in women. This study sought to assess the possible role of omega-3 fatty acids in the reduction of CHD-related inflammation by investigating the effect of fish consumption on CRP levels. Methods. Twenty-four healthy postmenopausal women were randomly assigned to a fish group (usual diet plus two servings per week of enriched fish) or control group (usual diet with no fatty fish) for eight weeks. Omega-3 fatty acid-enriched fish developed by the West Virginia University Aquaculture Division was used. Serum CRP, serum interleukin-6 (IL-6), and the fatty acid content of red blood cells (RBC) were measured before and after the study. Women also completed food records. RESULTS: Baseline levels of CRP were low (85% of the fish group had normal levels) and few changes in CRP risk category were observed. Mean IL-6 levels were reduced by 27% and 35% in the fish and control groups, respectively (p for between-group difference = 0.60). Changes in RBC fatty acid composition were not statistically significant. Compared to control women, women in the fish group had greater reductions in mean triglycerides (p = 0.08), total cholesterol (P = 0.04), and LDL cholesterol levels (p = 0.06). Baseline dietary intake of total and monounsaturated fatty acids tended to be positively associated with baseline CRP, while vitamin E intake was inversely related. Saturated fat intake tended to have a positive association with IL-6. Conclusions. Findings regarding the effect of two servings of fish on CRP and IL-6 levels are inconclusive due to low baseline levels of CRP and IL-6. However, results indicate two servings of fatty fish have favorable effects on blood lipids. The relationship of dietary components with CRP and IL-6 is complex and further research is needed to determine the varying roles of diet on the inflammatory process. ^

(Table 1) Concentrations of persistant organic pollutants in brain and liver of glaucous gulls, Bjørnøya, Svalbard archipelago

Dead and dying glaucous gulls (Larus hyperboreus) were collected on Bjornoya in the Barents Sea in 2003, 2004 and 2005. Autopsies of the seabirds only explained a clear cause of death for three (14%) of the 21 birds. A total of 71% of the birds were emaciated. Liver and brain samples were analysed for organochlorine pesticides (OCPs), polychlorinated biphenyls (PCBs), polybrominated diphenyl ether (PBDEs), hexabromo-cyclododecanes (HBCDs) and mercury (Hg). High levels of OCPs, PCBs, PBDEs and alpha-HBCD were found in liver and brain. Compared to the dead and dying glaucous gulls found 1989, the congeners' composition tended to change toward more persistent compounds in the 2003-2005 samples. The brain levels of OCPs and PCBs did not differ between 1989 and 2003-2005, while the liver levels were significantly lower. The brain/liver ratio for PCB and PBDE significantly decreased with halogenations of the molecule, indicating a clear discrimination of highly halogenated PCBs and PBDEs entering the brain. There was further a clear negative correlation between contaminant concentrations and body condition. The brain levels were not as high as earlier published lethal levels of p,p'-DDE or PCB. However, more recent studies reported a range of sub-lethal OCP- and PCB-related effects in randomly sampled glaucous gulls. An additional elevation of pollutants due to emaciation may increase the stress of the already affected birds. The high brain levels of OCP, PCB and PBDE of present study might therefore have contributed to the death of weakened individuals of glaucous gull.

Characterisation of the operation & maintenance phase in PV rural electrification programmes

Con 1.300 millones de personas en el mundo sin acceso a la electricidad (la mayoría en entornos rurales de países empobrecidos), la energía solar fotovoltaica constituye una solución viable técnica y económicamente para electrificar las zonas más remotas del planeta donde las redes eléctricas convencionales no llegan. Casi todos los países en el mundo han desarrollado algún tipo de programa de electrificación fotovoltaica rural durante los últimos 40 años, principalmente los países más pobres, donde a través de diferentes modelos de financiación, se han instalado millones de sistemas solares domiciliarios (pequeños sistemas fotovoltaicos para uso doméstico). Durante este largo período, se han ido superando muchas barreras, como la mejora de la calidad de los sistemas fotovoltaicos, la reducción de costes, la optimización del diseño y del dimensionado de los sistemas, la disponibilidad financiera para implantar programas de electrificación rural, etc. Gracias a esto, la electrificación rural descentralizada ha experimentado recientemente un salto de escala caracterizada por la implantación de grandes programas con miles de sistemas solares domiciliarios e integrando largos períodos de mantenimiento. Muchos de estos grandes programas se están llevando a cabo con limitado éxito, ya que generalmente parten de supuestos e hipótesis poco contrastadas con la realidad, comprometiendo así un retorno económico que permita el desarrollo de esta actividad a largo plazo. En este escenario surge un nuevo reto: el de cómo garantizar la sostenibilidad de los grandes programas de electrificación rural fotovoltaica. Se argumenta que la principal causa de esta falta de rentabilidad es el imprevisto alto coste de la fase de operación y mantenimiento. Cuestiones clave tales como la estructura de costes de operación y mantenimiento o la fiabilidad de los componentes del sistema fotovoltaico no están bien caracterizados hoy en día. Esta situación limita la capacidad de diseñar estructuras de mantenimiento capaces de asegurar la sostenibilidad y la rentabilidad del servicio de operación y mantenimiento en estos programas. Esta tesis doctoral tiene como objetivo responder a estas cuestiones. Se ha realizado varios estudios sobre la base de un gran programa de electrificación rural fotovoltaica real llevado a cabo en Marruecos con más de 13.000 sistemas solares domiciliarios instalados. Sobre la base de este programa se ha hecho una evaluación en profundidad de la fiabilidad de los sistemas solares a partir de los datos de mantenimiento recogidos durante 5 años con más de 80.000 inputs. Los resultados han permitido establecer las funciones de fiabilidad de los equipos tal y como se comportan en condiciones reales de operación, las tasas de fallos y los tiempos medios hasta el fallo para los principales componentes del sistema, siendo este el primer caso de divulgación de resultados de este tipo en el campo de la electrificación rural fotovoltaica. Los dos principales componentes del sistema solar domiciliario, la batería y el módulo fotovoltaico, han sido analizados en campo a través de una muestra de 41 sistemas trabajando en condiciones reales pertenecientes al programa solar marroquí. Por un lado se ha estudiado la degradación de la capacidad de las baterías y por otro la degradación de potencia de los módulos fotovoltaicos. En el caso de las baterías, los resultados nos han permitido caracterizar la curva de degradación en capacidad llegando a obtener una propuesta de nueva definición del umbral de vida útil de las baterías en electrificación rural. También sobre la base del programa solar de Marruecos se ha llevado a cabo un estudio de caracterización de los costes reales de operación y mantenimiento a partir de la base de datos de contabilidad del programa registrados durante 5 años. Los resultados del estudio han permitido definir cuáles son costes que más incidencia tienen en el coste global. Se han obtenido los costes unitarios por sistema instalado y se han calculado los montantes de las cuotas de mantenimiento de los usuarios para garantizar la rentabilidad de la operación y mantenimiento. Finalmente, se propone un modelo de optimización matemática para diseñar estructuras de mantenimiento basado en los resultados de los estudios anteriores. La herramienta, elaborada mediante programación lineal entera mixta, se ha aplicado al programa marroquí con el fin de validar el modelo propuesto. ABSTRACT With 1,300 million people worldwide deprived of access to electricity (mostly in rural environments), photovoltaic solar energy has proven to be a cost‐effective solution and the only hope for electrifying the most remote inhabitants of the planet, where conventional electric grids do not reach because they are unaffordable. Almost all countries in the world have had some kind of rural photovoltaic electrification programme during the past 40 years, mainly the poorer countries, where through different organizational models, millions of solar home systems (small photovoltaic systems for domestic use) have been installed. During this long period, many barriers have been overcome, such as quality enhancement, cost reduction, the optimization of designing and sizing, financial availability, etc. Thanks to this, decentralized rural electrification has recently experienced a change of scale characterized by new programmes with thousands of solar home systems and long maintenance periods. Many of these large programmes are being developed with limited success, as they have generally been based on assumptions that do not correspond to reality, compromising the economic return that allows long term activity. In this scenario a new challenge emerges, which approaches the sustainability of large programmes. It is argued that the main cause of unprofitability is the unexpected high cost of the operation and maintenance of the solar systems. In fact, the lack of a paradigm in decentralized rural services has led to many private companies to carry out decentralized electrification programmes blindly. Issues such as the operation and maintenance cost structure or the reliability of the solar home system components have still not been characterized. This situation does not allow optimized maintenance structure to be designed to assure the sustainability and profitability of the operation and maintenance service. This PhD thesis aims to respond to these needs. Several studies have been carried out based on a real and large photovoltaic rural electrification programme carried out in Morocco with more than 13,000 solar home systems. An in‐depth reliability assessment has been made from a 5‐year maintenance database with more than 80,000 maintenance inputs. The results have allowed us to establish the real reliability functions, the failure rate and the main time to failure of the main components of the system, reporting these findings for the first time in the field of rural electrification. Both in‐field experiments on the capacity degradation of batteries and power degradation of photovoltaic modules have been carried out. During the experiments both samples of batteries and modules were operating under real conditions integrated into the solar home systems of the Moroccan programme. In the case of the batteries, the results have enabled us to obtain a proposal of definition of death of batteries in rural electrification. A cost assessment of the Moroccan experience based on a 5‐year accounting database has been carried out to characterize the cost structure of the programme. The results have allowed the major costs of the photovoltaic electrification to be defined. The overall cost ratio per installed system has been calculated together with the necessary fees that users would have to pay to make the operation and maintenance affordable. Finally, a mathematical optimization model has been proposed to design maintenance structures based on the previous study results. The tool has been applied to the Moroccan programme with the aim of validating the model.

Unearthing the roots of degradation of Quercus pyrenaica coppices: an integrative perspective from clonal structure to carbon budgets

Quercus pyrenaica es una especie rebrotadora de raíz intensa e históricamente aprovechada en monte bajo para la obtención de leñas, carbón y pastos. Debido al éxodo rural y a la aparición de nuevas fuentes energéticas, este aprovechamiento fue abandonado en la década de 1970. Desde entonces, las bajas producciones de madera y bellota y el puntisecado de los pies evidencian el generalizado estancamiento de estas masas. Uno de los mayores retos actuales de la selvicultura en el ámbito mediterráneo es encontrar usos alternativos para estos montes abandonados, siendo la conversión a monte alto una de las alternativas preferidas. Se han realizado resalveos de conversión, sin embrago, éstos se aplican sin un conocimiento integral de las causas de la degradación. En esta tesis doctoral, estudiamos un hipotético desequilibrio entre la parte radical y la parte aérea (R:S) de las cepas de rebollo como causa subyacente de su decaimiento. En una parcela experimental, aprovechada al menos desde el siglo XII, se realizaron análisis genéticos a priori para elucidar la estructura genética del rodal, y así estudiar la influencia del tamaño clonal en el funcionamiento de las cepas. Las cepas de mayor tamaño presentaron un menor crecimiento diametral de sus pies, así como mayores tasas de respiración radical, estimadas a partir de flujos internos de CO2 a través del xilema (FT) y de los flujos de CO2 del suelo. Estos resultados sugieren que el desequilibrio R:S aumenta con el tamaño clonal, dado que la eliminación periódica de órganos aéreos, al mismo tiempo que las raíces permanecen intactas, da lugar a un gran desarrollo del sistema radical que consume gran parte de los carbohidratos no estructurales (NSC) en respiración de mantenimiento, comprometiendo así el desarrollo de órganos aéreos. Se excavaron y pesaron dos cepas compuestas por cuatro y ocho pies, las cuales mostraron ratios R:S (0.5 y 1, respectivamente) superiores a los registrados en pies de origen sexual. Al igual que en otras especies rebrotadoras de raíz, se observaron altas concentraciones de NSC en las raíces (> 20% en primavera) y una gran proporción de albura en el sistema radical (52%) que alberga una notable reserva de NSC (87 kg en la cepa de mayor tamaño). En el sistema radical de dicha cepa, estimada mediante dataciones radiocarbónicas en 550 años de edad, se contaron 248 uniones radicales. La persistencia de sistemas radicales grandes, viejos, y altamente interconectados sugiere que la gran cantidad de recursos almacenados y consumidos en las raíces compensan un pobre desarrollo aéreo con una alta resiliencia vegetativa. Para un mejor entendimiento de los balances de carbono y del agotamiento de NSC en las cepas de rebollo, se midieron los flujos internos y externos de CO2 en troncos y los flujos de CO2 del suelo, y se estimó la respiración de órganos aéreos (RS) y subterráneos (RR). Estacionalmente, RS y RR reflejaron las dinámicas de flujo de savia y de crecimiento del tronco, y estuvieron determinadas principalmente por los flujos externos de CO2, dada la escasa contribución de FT a RS y RR (< 10% y < 2%, respectivamente). En una escala circadiana, la contribución de FT a RS aumentó hasta un 25% en momentos de alta transpiración. Las bajas concentraciones de CO2 en el xilema ([CO2] hasta un 0.11%) determinaron comparativamente unos bajos FT, probablemente causados por una limitada respiración del xilema y una baja resistencia a la difusión radial del CO2 impuestos por la sequía estival. Los pulsos de [CO2] observados tras las primeras lluvias de otoño apoyan esta idea. A lo largo del periodo vegetativo, el flujo medio de CO2 procedente del suelo (39 mol CO2 day-1) fue el mayor flujo respiratorio, tres y cuatro veces superior a RS (12 mol CO2 day-1) y RR (8-9 mol CO2 day-1), respectivamente. Ratios RR/RS menores que la unidad evidencian un importante peso de la respiración aérea como sumidero de carbono adicional. Finalmente, se ensayó el zanjado de raíces y el anillamiento de troncos como tratamientos selvícolas alternativos con el objetivo de aumentar las reservas de NSC en los troncos de las cepas. Los resultados preliminares desaconsejan el zanjado de raíces por el alto coste derivado posiblemente de la cicatrización de las heridas. El anillado de troncos imposibilitó el transporte de NSC a las raíces y aumentó la concentración de almidón por encima de la zona anillada, mientras que sistema radical se mantiene por los pies no anillados de la cepa. Son necesarias más mediciones y datos adicionales para comprobar el mantenimiento de esta respuesta positiva a largo plazo. Para concluir, destacamos la necesidad de estudios multidisciplinares que permitan una comprensión integral de la degradación de los rebollares ibéricos para poder aplicar a posteriori una gestión adecuada en estos montes bajos abandonados. ABSTRACT Quercus pyrenaica is a vigorous root-resprouting species intensively and historically coppiced for firewood, charcoal and woody pastures. Due to the rural exodus and the appearance of new energy sources, coppicing was abandoned towards 1970. Since then, tree overaging has resulted in stand stagnation displayed by slow stem growth, branch dieback, and scarce acorn production. The urgent need to find new alternative uses for abandoned coppices is recognized as one of the biggest challenges which currently faces Mediterranean silviculture; conversion into high forest by thinning is one of the preferred alternatives. For this aim, thinning has been broadly applied and seldom tested, although without a comprehensive understanding of the causes of stand stagnation. In this PhD study, we test the hypothesis of an imbalance between above- and below-ground organs, result of long term coppicing, as the underlying cause of Q. pyrenaica decay. In an experimental plot coppiced since at least the 12th century, genetic analyses were performed a priori to elucidate inconspicuous clonal structure of Q. pyrenaica to evaluate how clonal size affects the functioning of these multi-stemmed trees. Clonal size negatively affected diametric stem growth, whereas root respiration rates, measured by internal fluxes of CO2 through xylem (FT) and soil CO2 efflux, increased with clonal size. These results suggest root-to-shoot (R:S) imbalance intensifying with clonal size: periodic removal of aboveground organs whilst belowground organs remain undisturbed may have led to massive root systems which consume a great proportion of non-structural carbohydrates (NSC) for maintenance respiration, thus constraining aboveground performance. Furthermore, excavation of two multi-stemmed trees, composed by four and eight stems, revealed R:S ratios (0.5 and 1, respectively) greater than those reported for sexually regenerated trees. Moreover, as similarly observed in several root-resprouting species, NSC allocation to roots was favored ([NSC] > 20% in spring): a large proportion of sapwood maintained throughout the root system (52%) stored a remarkable NSC pool of 87 kg in the case of the largest clone. In this root system of the eight-stemmed tree, 248 root connections were counted and, by radiocarbon dating, its age was estimated to be 550-years-old. Persistence of massive, old and highly interconnected root systems suggests that enhanced belowground NSC storage and consumption reflects a trade-off between vegetative resilience and aboveground development. For a better understanding of tree carbon budget and the potential role of carbon starvation in Q. pyrenaica decay, internal and external stem CO2 fluxes and soil CO2 effluxes were monitored to evaluate respiratory costs above- and below-ground. On a seasonal scale, stem and root respiration (RS and RR) mirrored sap flow and stem growth dynamics. Respiration was determined to the greatest extent by external fluxes of CO2 to the atmosphere or soil, since FT accounted for a low proportion of RS and RR (< 10% and < 2%, respectively). On a diel scale, the contribution of FT to RS increased up to 25% at high transpiration rates. Comparatively low FT was determined by the low concentration of xylem CO2 registered ([CO2] as low as 0.11%), likely as a consequence of constrained xylem respiration and reduced resistance to CO2 radial diffusion imposed by summer drought. Xylem [CO2] pulses following first autumn rains support this idea. Averaged over the growing season, soil CO2 efflux was the greatest respiratory flux (39 mol CO2 day-1), three and four times greater than RS (12 mol CO2 day-1) and RR (8-9 mol CO2 day-1), respectively. Ratios of RR/RS below one evidence an additional and important weight of aboveground respiration as a tree carbon sink. Finally, root trenching and stem girdling were tested as complimentary treatments to thinning as a means to improve carbon reserves in stems of clonal trees. Preliminary results discouraged root trenching due to the high cost likely incurred for wound closure. Stem girdling successfully blocked NSC translocation downward, increasing starch concentrations above the girdled zone whilst the root system is fed by non-girdled stems within the clone. Further measurements and ancillary data are necessary to verify that this positive effect hold over time. To conclude, the need of multidisciplinary approaches for an integrative understanding on the functioning of abandoned Q pyrenaica coppices is highlighted for an appropriate management of these stands.

Persuasive system design methods to deliver a cardio-rehabilitation program of post mi outpatients

Las enfermedades no transmisibles provocan cada ano 38 millones de fallecimientos en el mundo. Entre ellas, tan solo cuatro enfermedades son responsables del 82% de estas muertes: las enfermedades cardiovasculares, las enfermedades crónicas respiratorias, la diabetes, y el cáncer. Se prevé que estas cifras aumenten en los próximos anos, ya que las tendencias indican que en el año 2030 las muertes por esta causa ascenderán a 53 millones de personas. La Organización Mundial de la Salud (OMS) considera importante buscar soluciones para afrontar esta situación y ha solicitado a los gobiernos del mundo la implementación de intervenciones para mejorar los hábitos de vida de las personas y reducir así el riesgo de desarrollo de enfermedades no trasmisibles. Cada año se producen 32 millones de infartos de miocardio y derrames celebrales, de los cuales 12.5 son mortales. En el mundo entre el 40% y 75% de la víctimas de un infarto de miocardio mueren antes de su ingreso en el hospital. En los casos que sobreviven, la adopción de un estilo de vida saludable puede evitar infartos sucesivo, y supone un ahorro potencial de 6 billones de euros al año. La rehabilitación cardiaca es un programa individualizado que aplica un método multidisciplinar para ayudar al paciente a recuperar su condición física, a gestionar la enfermedad cardiovascular y sus comorbilidades, a adoptar hábitos de vida saludables, y a promover su salud mental. La rehabilitación cardiaca requiere la total involucración y motivación del paciente, solo de esta manera se podrán promover hábitos saludables y mejorar la gestión y prevención de su enfermedad. Aunque la participación en los programas de rehabilitación cardiaca es baja, hoy en día existen programas de rehabilitación cardiaca que el paciente puede realizar en su casa. Estos suponen una solución prometedora para aumentar la participación. La rehabilitación cardiaca se considera una intervención integral donde los modelos de psicología de la salud son aplicados para promover un cambio en el estilo de vida de las personas así como para ayudarles a afrontar su propia enfermedad. Existen métodos para implementar cambios de hábitos y de aptitud, y también se considera muy relevante promover no solo el bienestar físico sino también el mental. Existen tecnologías que promueven los cambios de comportamientos en los seres humanos. En concreto, las tecnologías persuasivas y los sistemas de apoyo al cambio de comportamientos modelan las características, las estrategias y los métodos de diseño para promover cambios usando la tecnología. Pero estos modelos tienen algunas limitaciones: todavía no se ha definido que rol tienen las emociones en el cambio de comportamientos y como traducir los métodos de la psicología de la salud en la tecnología. Esta tesis se centra en tres elementos que tienen un rol clave en los cambios de hábitos y actitud: el estado físico, el estado mental, y la tecnología. -Estado de salud: un estado de salud critico puede modificar la actitud del ser humano respecto al cambio. A la vez un buen estado de salud hace que la necesidad del cambio sea menos percibida. -Estado emocional: la actitud tiene un componente afectivo. Los estados emocionales negativos pueden reducir la habilidad de una persona para adoptar nuevos comportamientos. La salud mental es la situación ideal donde los individuos tienen predisposición a los cambios. La tecnología puede ayudar a las personas a adoptar nuevos hábitos, así como a mantener una salud física y mental. Este trabajo de investigación se centra en el diseño de tecnologías para la mejora del estado físico y emocional de las personas. Se ha propuesto un marco de diseño llamado “Well.Be.Sign”. El marco se basa en tres aspectos: El marco teórico: representa los elementos que se tienen que definir para diseñar tecnologías para promover el bienestar de las personas. -El diagrama de influencia: presenta las fuerzas de ‘persuasión’ en el contexto de la salud. El rol de las tecnologías persuasivas ha sido contextualizado en una dimensión donde otros elementos influencian el usuario.  El proceso de diseño: describe el proceso de diseño utilizando una metodología iterativa e incremental que aplica una combinación de métodos de diseño existentes (Diseño Orientado a Objetivos, Diseño de Sistemas Persuasivos) así como elementos originales de este trabajo de investigación. Los métodos se han aplicados para diseñar un sistema que ofrezca un programa de tele-rehabilitación cardiaca. Inicialmente se ha diseñado un prototipo de acuerdo con las necesidades del usuario. En segundo lugar, el prototipo se ha extendido especificando la intervención requerida para al programa de rehabilitación cardiaca. Finalmente el sistema se ha desarrollado y validado en un ensayo clínico con grupo control, donde se observaron las variaciones del estado cardiovascular, el nivel de conocimiento acerca de la enfermedad, la percepción de la enfermedad, la persistencia de hábitos saludables, y la aceptabilidad del sistema. Los resultados muestran que el grupo de intervención tiene una superior capacidad cardiovascular, mejor conocimiento acerca de la enfermedad, y más percepción de control de la enfermedad. Asimismo, en algunos casos se ha registrado persistencia de los hábitos de ejercicios 6 meses después del uso del sistema. Otros dos estudios se han presentado para demonstrar la relevancia del estado emocional del usuario en el diseño de aplicaciones para la promoción del bienestar.  En personas con una grave enfermedad crónica como la insuficiencia cardiaca, donde se ha presentado las conexiones entre estado de salud y estado emocional. En el estudio se ensena la relaciones que tienen los síntomas y las emociones negativas y como un estado negativo emocional puede empeorar la condición física del paciente. -Personas con trastornos del humor: el estudio muestra como las emociones pueden tener un impacto en la percepción de la tecnología por parte del usuario. ABSTRACT Noncommunicable diseases (NCDs) cause the death of 38 million people every year. Four major NCDs are responsible for 82% of these deaths: cardio vascular disease, chronic respiratory disease, diabetes and cancer. These pandemic numbers are projected to raise to 53 million deaths in 2030, and for this reason the assembly of the World Health Organization (WHO) considers communicable diseases as an urgent need to be addressed. It is also a trend to advocate the adoption of mobile technology to deliver health services and to promote healthy behaviours among citizens, but adopting healthS promoting lifestyle is still a difficult task facing human tendencies. Within this context, there is a promising opportunity: persuasive technologies. These technologies are intentionally designed to change a person’s attitudes or behaviours; when applied in this context, than can be used to change health-related attitudes, beliefs, and behaviours. Each year there are 32 million heart attacks and strokes globally, of which about 12.5 million are fatal. Worldwide between 40 and 75% of all heart-attack victims die before reaching hospital. Avoiding a second heart attack by improving adherence to lifestyle and medication regimens has a cost saving potential of around €6 billion per year. In most of the cases the cardiovascular event has been provoked by unhealthy lifestyle. Furthermore, after an MI event the patient's decision to adopt or not healthier behaviour will influence the progress of the disease. Cardio-rehabilitation is an individualized program that follows a multidisciplinary approach to support the user to recover from the Myocardial Infarction, manage the Cardio Vascular Disease and the comorbidities, adopt healthy habits, and cope with any emotional distress. Cardio- rehabilitation requires patient participation and willingness to perform behavioral modifications and change the attitude toward the management and prevention of the disease. Participation in the Cardio Rehabilitation program is not high; the home-based rehabilitation program is a promising solution to increase participation. Nowadays cardio rehabilitation is considered a comprehensive intervention in which models of health psychology are applied to promote the behaviour change of the individuals. Relevant methods that have been successfully applied to foster healthy habits include the Health Belief Model and the Trans Theoretical Model. Studies also demonstrate the importance to promote not only the physical but also the mental well being of the individuals. The idea of also promoting behaviour change using technologies has been defined by the literature as persuasive technologies or behaviour change support systems, in which the features, the strategies and the design method have been modelled to foster the behaviour change using technology. Limitations have been found in this model: there is still research to be done on the role of the emotions and how psychological health intervention can be translated into computer methods. This research focuses on three elements that could foster behaviour change in individuals: the physical and emotional status of the person, and the technology. Every component can influence the user's attitude and behaviour in the following ways: ' Physical status: bad physical status could change human attitude toward the necessity to adopt health behaviours; at the same time, good health status reduces the need to adopt healthy habits. ' Emotional status: the attitude has an affective component, negative emotional state can reduce the ability of a person to adopt new behaviours, and mental well being is the ideal situation in which individuals have a predisposition to adopt healthy behaviours. ' Technology: it can help users to adopt new behaviours and can also be support to promote physical and emotional status. Following this approach the idea driven in this research is that technology that is designed to improve the physical status and the emotional status of the individual could better foster behaviour change. According to this principle, the Well.Be.Sign framework has been proposed. The framework is based on three views: ' The theoretical framework: it represents the patterns that have to be defined to design the technologies to promote well being. ' The influence diagram: it shows the persuasive forces in the context of health care. The role of the persuasive technologies is contextualized in a wider universe where other factors and persuasive forces influence a patient. ' The design process: it shows the process of design using an iterative, incremental methodology that applies a combination of existing methodologies (Goal Directed Design and Persuasive System Design) and others that are original to this research. The methods have been applied to design a system to deliver cardio rehabilitation at home: first a prototype has been defined according to the user’s needs, then it has been extended with the specific intervention required for the cardio–rehabilitation, finally the system has been developed and validated in a controlled clinical study in which the cardiovascular fitness, the level of knowledge, the perception of the illness, the persistence of healthy habits and the system acceptance (only the intervention group) were measured. The results show that the intervention group increased cardiovascular capacity, knowledge, feeling of control of illness and perceived benefits of exercise at the end of the study. After six months of the study, a followSup of the exercise habits was performed. Some individuals of the intervention group continued to be engaged in the running exercise sessions promoted in the designed system. Two other cases have been presented to demonstrate the foundations of the Well.Be.Sign’s approach to promote both physical and emotional status: ' People affected by Heart Failure, in which a bidirectional connection between health status and emotions has been discussed with patients. Two correlations were demonstrated: the relationship between symptoms and negative emotional response, and that negative emotional status is correlated with worsening of chronic conditions. ' People with mood disorders: the study shows that emotions could also impact how the user perceives the technology.