The Application of Near Infrared Spectroscopy for the Assessment of Avocado Quality Attributes, Infrared Spectroscopy. Chapter 14

Quality and safety evaluation of agricultural products has become an increasingly important consideration in market/commercial viability and systems for such evaluations are now demanded by customers, including distributors and retailers. Unfortunately, most horticultural products struggle with delivering adequate and consistent quality to the consumer. Removing inconsistencies and providing what the consumer expects is a key factor for retaining and expanding both domestic and international markets. Most commercial quality classification systems for fruit and vegetables are based on external features of the product, for example: shape, colour, size, weight and blemishes. However, the external appearance of most fruit is generally not an accurate guide to the internal or eating quality of the fruit. Internal quality of fruit is currently subjectively judged on attributes such as volatiles, firmness, and appearance. Destructive subjective measures such as internal flesh colour, or objective measures such as extraction of juice to measure sweetness (oBrix) or assessment of dry matter (DM) content are also used, although obviously not for every fruit – just a sample to represent the whole consignment. For avocado fruit, external colour is not a maturity characteristic, and its smell is too weak and appears later in its maturity stage (Gaete-Garreton et al., 2005). Since maturity is a major component of avocado quality and palatability, it is important to harvest mature fruit, so as to ensure that fruit will ripen properly and have acceptable eating quality. Currently, commercial avocado maturity estimation is based on destructive assessment of the %DM, and sometimes percent oil, both of which are highly correlated with maturity (Clark et al., 2003; Mizrach & Flitsanov, 1999). Avocados Australia Limited (AAL (2008)) recommend a minimum maturity standard for its growers of 23 %DM (greater than 10% oil content) for the ‘Hass’ cultivar, although consumer studies indicate a preference for at least 25 %DM (Harker et al., 2007).

Adesão e sobrevida de pacientes em um programa de assistência medicamentosa para doença de Alzheimer no Rio de Janeiro: um estudo baseado em relacionamento de bases de dados

A doença de Alzheimer (DA) afeta mais de um milhão de habitantes no Brasil com grande impacto tanto na saúde como social e financeiro. O uso adequado de medicamentos e os programas de cuidado integrado são recomendados como as melhores práticas nesta doença. Em 2002, o Ministério da Saúde criou o Programa de Assistência Farmacêutica aos Portadores de doença de Alzheimer que garante aos portadores desta patologia acesso à avaliação por especialistas e tratamento medicamentoso de alto custo. Mas, para um melhor planejamento das ações relacionadas ao programa, é importante entender os padrões de morbi-mortalidade da população alvo, qualidade da assistência oferecida e o seu impacto. Com foco nesse cenário, esta tese teve como objetivo o estudo da adesão, mortalidade e sobrevida em uma população portadora de doença de Alzheimer assistida nesse programa de assistência farmacêutica. Para apresentação dessa pesquisa, dividiram-se os resultados em três artigos. No primeiro artigo, o objetivo foi avaliar a viabilidade de se utilizar as informações de reabastecimento de receitas coletadas por esse programa na construção de medidas de adesão, uma metodologia já explorada na literatura internacional, mas com experiência limitada no Brasil. Os dados foram acessados nos formulários de Autorização de Procedimentos de Alto Custo (APAC) armazenados na base de dados do programa de acesso de medicamentos excepcionais do Sistema de Informação Ambulatorial (SIA). Como resultado, foram criadas várias medidas de adesão com potencial aplicação no campo da farmacoepidemiologia e planejamento em saúde. No segundo artigo, o foco foi entender que fatores individuais, terapêuticos ou relacionados à assistência, poderiam estar relacionados com um aumento do risco de abandono do programa. Fatores como o sexo feminino, o número de comorbidades na APAC, o tipo de inibidor de colinesterase iniciado e a irregularidade nos reabastecimentos foram associados a um maior risco de abandono do programa. No terceiro artigo, pelas técnicas de relacionamento probabilístico de base de dados, agregaram-se os dados presentes no Sistema de Informação sobre Mortalidade (SIM) para avaliação dos padrões de mortalidade desta patologia. Cerca de 40% dos pacientes foram a óbito durante todo o período de seguimento e principal causa básica de mortalidade foi a doença de Alzheimer (19%). Idade mais avançada e sexo masculino foram as únicas variáveis associadas com uma menor sobrevida. A persistência no programa em seis meses e os diferentes níveis de adesão, medidos pela proporção de posse da medicação, não mostraram associação com a sobrevida. Conclui-se que os dados disponíveis nas bases possibilitaram a investigação do padrão de mortalidade e utilização de um programa de assistência na doença de Alzheimer. E, a possibilidade de analisar grandes populações, em caráter contínuo, com medidas objetivas e com um custo relativamente baixo suplanta o caráter limitado das informações individuais e da doença. Políticas que suportem o aumento na disponibilidade, qualidade e escopo da informação e o avanço nas metodologias de pesquisa em bases de dados devem ser uma prioridade da saúde, pois contribuem com a criação de informações relevantes para um uso racional de recursos e melhora nas práticas de cuidado.

Associations between BMI and home, school and route environmental exposures estimated using GPS and GIS: do we see evidence of selective daily mobility bias in children?

BACKGROUND: This study examined whether objective measures of food, physical activity and built environment exposures, in home and non-home settings, contribute to children's body weight. Further, comparing GPS and GIS measures of environmental exposures along routes to and from school, we tested for evidence of selective daily mobility bias when using GPS data. METHODS: This study is a cross-sectional analysis, using objective assessments of body weight in relation to multiple environmental exposures. Data presented are from a sample of 94 school-aged children, aged 5-11 years. Children's heights and weights were measured by trained researchers, and used to calculate BMI z-scores. Participants wore a GPS device for one full week. Environmental exposures were estimated within home and school neighbourhoods, and along GIS (modelled) and GPS (actual) routes from home to school. We directly compared associations between BMI and GIS-modelled versus GPS-derived environmental exposures. The study was conducted in Mebane and Mount Airy, North Carolina, USA, in 2011. RESULTS: In adjusted regression models, greater school walkability was associated with significantly lower mean BMI. Greater home walkability was associated with increased BMI, as was greater school access to green space. Adjusted associations between BMI and route exposure characteristics were null. The use of GPS-actual route exposures did not appear to confound associations between environmental exposures and BMI in this sample. CONCLUSIONS: This study found few associations between environmental exposures in home, school and commuting domains and body weight in children. However, walkability of the school neighbourhood may be important. Of the other significant associations observed, some were in unexpected directions. Importantly, we found no evidence of selective daily mobility bias in this sample, although our study design is in need of replication in a free-living adult sample.

Assessing the sensitivity of seagrass bed biotopes to pressures associated with marine activities.

This project was commissioned to generate an improved understanding of the sensitivities of seagrass habitats to pressures associated with human activities in the marine environment - to provide an evidence base to facilitate and support management advice for Marine Protected Areas; development of UK marine monitoring and assessment, and conservation advice to offshore marine industries. Seagrass bed habitats are identified as a Priority Marine Feature (PMF) under the Marine (Scotland) Act 2010, they are also included on the OSPAR list of threatened and declining species and habitats, and are a Habitat of Principle Importance (HPI) under the Natural Environment and Rural Communities (NERC) Act 2006, in England and Wales. The purpose of this project was to produce sensitivity assessments with supporting evidence for the HPI, OSPAR and PMF seagrass/Zostera bed habitat definitions, clearly documenting the evidence behind the assessments and any differences between assessments. Nineteen pressures, falling in five categories - biological, hydrological, physical damage, physical loss, and pollution and other chemical changes - were assessed in this report. Assessments were based on the three British seagrasses Zostera marina, Z. noltei and Ruppia maritima. Z. marina var. angustifolia was considered to be a subspecies of Z. marina but it was specified where studies had considered it as a species in its own rights. Where possible other components of the community were investigated but the basis of the assessment focused on seagrass species. To develop each sensitivity assessment, the resistance and resilience of the key elements were assessed against the pressure benchmark using the available evidence. The benchmarks were designed to provide a ‘standard’ level of pressure against which to assess sensitivity. Overall, seagrass beds were highly sensitive to a number of human activities: • penetration or disturbance of the substratum below the surface; • habitat structure changes – removal of substratum; • physical change to another sediment type; • physical loss of habitat; • siltation rate changes including and smothering; and • changes in suspended solids. High sensitivity was recorded for pressures which directly impacted the factors that limit seagrass growth and health such as light availability. Physical pressures that caused mechanical modification of the sediment, and hence damage to roots and leaves, also resulted in high sensitivity. Seagrass beds were assessed as ‘not sensitive’ to microbial pathogens or ‘removal of target species’. These assessments were based on the benchmarks used. Z. marina is known to be sensitive to Labyrinthula zosterae but this was not included in the benchmark used. Similarly, ‘removal of target species’ addresses only the biological effects of removal and not the physical effects of the process used. For example, seagrass beds are probably not sensitive to the removal of scallops found within the bed but are highly sensitive to the effects of dredging for scallops, as assessed under the pressure penetration or disturbance of the substratum below the surface‘. This is also an example of a synergistic effect Assessing the sensitivity of seagrass bed biotopes to pressures associated with marine activities between pressures. Where possible, synergistic effects were highlighted but synergistic and cumulative effects are outside the scope off this study. The report found that no distinct differences in sensitivity exist between the HPI, PMF and OSPAR definitions. Individual biotopes do however have different sensitivities to pressures. These differences were determined by the species affected, the position of the habitat on the shore and the sediment type. For instance evidence showed that beds growing in soft and muddy sand were more vulnerable to physical damage than beds on harder, more compact substratum. Temporal effects can also influence the sensitivity of seagrass beds. On a seasonal time frame, physical damage to roots and leaves occurring in the reproductive season (summer months) will have a greater impact than damage in winter. On a daily basis, the tidal regime could accentuate or attenuate the effects of pressures depending on high and low tide. A variety of factors must therefore be taken into account in order to assess the sensitivity of a particular seagrass habitat at any location. No clear difference in resilience was established across the three seagrass definitions assessed in this report. The resilience of seagrass beds and the ability to recover from human induced pressures is a combination of the environmental conditions of the site, growth rates of the seagrass, the frequency and the intensity of the disturbance. This highlights the importance of considering the species affected as well as the ecology of the seagrass bed, the environmental conditions and the types and nature of activities giving rise to the pressure and the effects of that pressure. For example, pressures that result in sediment modification (e.g. pitting or erosion), sediment change or removal, prolong recovery. Therefore, the resilience of each biotope and habitat definitions is discussed for each pressure. Using a clearly documented, evidence based approach to create sensitivity assessments allows the assessment and any subsequent decision making or management plans to be readily communicated, transparent and justifiable. The assessments can be replicated and updated where new evidence becomes available ensuring the longevity of the sensitivity assessment tool. The evidence review has reduced the uncertainty around assessments previously undertaken in the MB0102 project (Tillin et al 2010) by assigning a single sensitivity score to the pressures as opposed to a range. Finally, as seagrass habitats may also contribute to ecosystem function and the delivery of ecosystem services, understanding the sensitivity of these biotopes may also support assessment and management in regard to these. Whatever objective measures are applied to data to assess sensitivity, the final sensitivity assessment is indicative. The evidence, the benchmarks, the confidence in the assessments and the limitations of the process, require a sense-check by experienced marine ecologists before the outcome is used in management decisions.

Assessing the sensitivity of Sabellaria spinulosa to pressures associated with marine activities.

The Joint Nature Conservation Committee (JNCC) commissioned this project to generate an improved understanding of the sensitivities of Sabellaria spinulosa reefs based on the OSPAR habitat definition. This work aimed to provide an evidence base to facilitate and support management advice for Marine Protected Areas, development of UK marine monitoring and assessment, and conservation advice to offshore marine industries. The OSPAR list of threatened and declining species and habitats refers to subtidal S. spinulosa reefs on hard or mixed substratum. S. spinulosa may also occur as thin crusts or individual worms but these are not the focus of conservation. The purpose of this project was to produce sensitivity assessments with supporting evidence for S. spinulosa reefs, clearly documenting the evidence behind the assessments and the confidence in these assessments. Sixteen pressures, falling in five categories - biological, hydrological, physical damage, physical loss, and pollution and other chemical changes - were assessed in this report. To develop each sensitivity assessment, the resistance and resilience of the key elements of the habitat were assessed against the pressure benchmark using the available evidence. The benchmarks were designed to provide a ‘standard’ level of pressure against which to assess sensitivity. The highest sensitivity (‘medium’) was recorded for physical pressures which directly impact the reefs including: • habitat structure changes – removal of substratum; • abrasion and penetration and sub-surface disturbance; • physical loss of habitat and change to habitat; and • siltation rate changes including and smothering. The report found that no evidence for differences in the sensitivity of the three EUNIS S. spinulosa biotopes that comprise the OSPAR definition. However, this evidence review has identified significant information gaps regarding sensitivity, ecological interactions with other species and resilience. No clear difference in resilience was established across the OSPAR S. spinulosa biotopes that were assessed in this report. Using a clearly documented, evidence based approach to create sensitivity assessments allows the assessment and any subsequent decision making or management plans to be readily communicated, transparent and justifiable. The assessments can be replicated and updated where new evidence becomes available ensuring the longevity of the sensitivity assessment tool. Finally, as S. spinulosa habitats may also contribute to ecosystem function and the delivery of ecosystem services, understanding the sensitivity of these biotopes may also support assessment and management in regard to these. Whatever objective measures are applied to data to assess sensitivity, the final sensitivity assessment is indicative. The evidence, the benchmarks, the confidence in the assessments and the limitations of the process, require a sense-check by experienced marine ecologists before the outcome is used in management decisions.

Assessing the sensitivity of blue mussel beds to pressures associated with human activities.

The Joint Nature Conservation Committee (JNCC) commissioned this project to generate an improved understanding of the sensitivities of blue mussel (Mytilus edulis) beds, found in UK waters, to pressures associated with human activities in the marine environment. The work will provide an evidence base that will facilitate and support management advice for Marine Protected Areas, development of UK marine monitoring and assessment, and conservation advice to offshore marine industries. Blue mussel beds are identified as a Habitat of Principle Importance (HPI) under the Natural Environment and Rural Communities (NERC) Act 2006, as a Priority Marine Feature (PMF) under the Marine (Scotland) Act 2010, and included on the OSPAR (Annex V) list of threatened and declining species and habitats. The purpose of this project was to produce sensitivity assessments for the blue mussel biotopes included within the HPI, PMF and OSPAR habitat definitions, and clearly document the supporting evidence behind the assessments and any differences between them. A total of 20 pressures falling in five categories - biological, hydrological, physical damage, physical loss, and pollution and other chemical changes - were assessed in this report. The review examined seven blue mussel bed biotopes found on littoral sediment and sublittoral rock and sediment. The assessments were based on the sensitivity of M. edulis rather than associated species, as M. edulis was considered the most important characteristic species in blue mussel beds. To develop each sensitivity assessment, the resistance and resilience of the key elements are assessed against the pressure benchmark using the available evidence gathered in this review. The benchmarks were designed to provide a ‘standard’ level of pressure against which to assess sensitivity. Blue mussel beds were highly sensitive to a few human activities: • introduction or spread of non-indigenous species (NIS); • habitat structure changes - removal of substratum (extraction); and • physical loss (to land or freshwater habitat). Physical loss of habitat and removal of substratum are particularly damaging pressures, while the sensitivity of blue mussel beds to non-indigenous species depended on the species assessed. Crepidula fornicata and Crassostrea gigas both had the potential to outcompete and replace mussel beds, so resulted in a high sensitivity assessment. Mytilus spp. populations are considered to have a strong ability to recover from environmental disturbance. A good annual recruitment may allow a bed to recovery rapidly, though this cannot always be expected due to the sporadic nature of M. edulis recruitment. Therefore, blue mussel beds were considered to have a 'Medium' resilience (recovery within 2-10 years). As a result, even where the removal or loss of proportion of a mussel bed was expected due to a pressure, a sensitivity of 'Medium' was reported. Hence, most of the sensitivities reported were 'Medium'. It was noted, however, that the recovery rates of blue mussel beds were reported to be anywhere between two years to several decades. In addition, M. edulis is considered very tolerant of a range of physical and chemical conditions. As a result, blue mussel beds were considered to be 'Not sensitive' to changes in temperature, salinity, de-oxygenation, nutrient and organic enrichment, and substratum type, at the benchmark level of pressure. The report found that no distinct differences in overall sensitivity exist between the HPI, PMF and OSPAR definitions. Individual biotopes do however have different sensitivities to pressures, and the OSPAR definition only includes blue mussel beds on sediment. These differences were determined by the position of the habitat on the shore and the sediment type. For example, the infralittoral rock biotope (A3.361) was unlikely to be exposed to pressures that affect sediments. However in the case of increased water flow, mixed sediment biotopes were considered more stable and ‘Not sensitive’ (at the benchmark level) while the remaining biotopes were likely to be affected.

Using a clearly documented, evidence-based approach to create sensitivity assessments allows the assessment basis and any subsequent decision making or management plans to be readily communicated, transparent and justifiable. The assessments can be replicated and updated where new evidence becomes available ensuring the longevity of the sensitivity assessment tool. For every pressure where sensitivity was previously assessed as a range of scores in MB0102, the assessments made by the evidence review have supported one of the MB0102 assessments. The evidence review has reduced the uncertainty around assessments previously undertaken in the MB0102 project (Tillin et al., 2010) by assigning a single sensitivity score to the pressures as opposed to a range. Finally, as blue mussel bed habitats also contribute to ecosystem function and the delivery of ecosystem services, understanding the sensitivity of these biotopes may also support assessment and management in regard to these. Whatever objective measures are applied to data to assess sensitivity, the final sensitivity assessment is indicative. The evidence, the benchmarks, the confidence in the assessments and the limitations of the process, require a sense-check by experienced marine ecologists before the outcome is used in management decisions.

Functional and Physiological Determinants of Perceived Disability in Individuals Diagnosed with Osteoarthritis of the Hip

Objectives: The main objective of this pilot study was to investigate which standardized functional and physiological test best predicted perceived disability in a single group of 21 individuals diagnosed with osteoarthritis of the hip. Design: Men and women between 60 and 70 years old with osteoarthritis of the hip were selected. If participants passed study criteria, the Western Ontario McMaster University questionnaire (WOMAC), 6 Minute Walk Test (6MWT) and Timed up and Go (TUG), strength testing and aerobic testing were obtained in one single assessment. Results: Regression analysis revealed that wait time, hip abduction strength of the affected side, Aerobic Capacity (VO2 Peak), hip Extension Peak Torque, hip Flexion Peak Torque, TUG and 6MWT were significantly correlated with the WOMAC. Yet, the 6MWT had the highest significant correlation (r = -0.86, p ≤ 0.0001); R2 = 0.75 or 75% with the WOMAC total scores, (r = -0.82, p ≤ 0.0001); R2 = 0.67 or 67% with the WOMAC function and (r = -0.60, p = .002); R2 = 0.36 or 36% with the WOMAC stiffness. While the VO2 Peak revealed the highest significant correlation (r = 0.76, p ≤ .0001); R2 = 0.57 or 57% with the WOMAC pain. Conclusions: The 6MWT and the VO2 Peak seem to be essential functional and physiological assessment tools to determine perceived disability in individuals with hip OA. The perceived disability may provide new or comprehensive knowledge of the disability problems experienced by individuals with osteoarthritis of the hip, and the association of patient perception with objective measures of functional and physiological capacity might strengthen the clinical value of this knowledge.

Pharmaceutical care of patients with congestive heart failure: Interventions and outcomes

We evaluated a structured pharmaceutical care program for elderly patients (> 65 yrs) with congestive heart failure (CHF) based on objective measures of disease control, quality of life, and use of health care facilities in a randomized, controlled, longitudinal, prospective clinical trial. The 42 patients in group A received education from a pharmacist on the disease and its treatment, and lifestyle changes that could help control symptoms. Patients also were encouraged to monitor their symptoms and comply with prescribed drug therapy. If necessary, dosage regimens were simplified in liaison with hospital physicians. The 41 control patients (group B) received standard care. The following outcome measures were assessed in all patients at baseline (before the start of the trial) and at 3, 6, 9, and 12 months: 2-minute walk test, blood pressure, body weight, pulse, forced vital capacity, quality of life [disease-specific (Minnesota Living with Heart Failure questionnaire) and generic (SF-36)], knowledge of symptoms and drugs, compliance with therapy, and use of health care facilities (hospital admissions, visits to emergency room, emergency calls). Patients in group A showed improved compliance with drug therapy, which in turn improved their exercise capacity compared with those in group B; education on management of symptoms, lifestyle changes, and dietary recommendations were also of benefit. Group A patients significantly improved knowledge of their drug therapy over the 12-month study and had fewer hospital admissions compared with group B patients. They also had improved outcomes compared with group B, despite the small samples. An extension of this trial to other sites with pooling of results would provide additional evidence of the value of this structured program in elderly patients with CHF.

The subjective numeracy scale as a tool for assessing statistical numeracy in older adult populations

BACKGROUND:
Statistical numeracy, necessary for making informed medical decisions, is reduced among older adults who make more decisions about their medical care and treatment than at any other stage of life. Objective numeracy scales are a source of anxiety among patients, heightened among older adults.
OBJECTIVE:
We investigate the subjective numeracy scale as an alternative tool for measuring statistical numeracy with older adult samples.
METHODS:
Numeracy was assessed using objective measures for 526 adults ranging in age from 18 to 93 years, and all participants provided subjective numeracy ratings.
RESULTS:
Subjective numeracy correlated highly with objective measurements among oldest adults (70+ years; r = 0.51, 95% CI 0.32, 0.66), and for younger age groups. Subjective numeracy explained 33.2% of age differences in objective numeracy.
CONCLUSION:
The subjective numeracy scale provides an effective tool for assessing statistical numeracy for broad age ranges and circumvents problems associated with objective numeracy measures.

Radiological imaging in digital systems: the effect of exposure parameters in diagnostic quality and patient dose

Esta tese pretende contribuir para o estudo e análise dos factores relacionados com as técnicas de aquisição de imagens radiológicas digitais, a qualidade diagnóstica e a gestão da dose de radiação em sistema de radiologia digital. A metodologia encontra-se organizada em duas componentes. A componente observacional, baseada num desenho do estudo de natureza retrospectiva e transversal. Os dados recolhidos a partir de sistemas CR e DR permitiram a avaliação dos parâmetros técnicos de exposição utilizados em radiologia digital, a avaliação da dose absorvida e o índice de exposição no detector. No contexto desta classificação metodológica (retrospectiva e transversal), também foi possível desenvolver estudos da qualidade diagnóstica em sistemas digitais: estudos de observadores a partir de imagens arquivadas no sistema PACS. A componente experimental da tese baseou-se na realização de experiências em fantomas para avaliar a relação entre dose e qualidade de imagem. As experiências efectuadas permitiram caracterizar as propriedades físicas dos sistemas de radiologia digital, através da manipulação das variáveis relacionadas com os parâmetros de exposição e a avaliação da influência destas na dose e na qualidade da imagem. Utilizando um fantoma contrastedetalhe, fantomas antropomórficos e um fantoma de osso animal, foi possível objectivar medidas de quantificação da qualidade diagnóstica e medidas de detectabilidade de objectos. Da investigação efectuada, foi possível salientar algumas conclusões. As medidas quantitativas referentes à performance dos detectores são a base do processo de optimização, permitindo a medição e a determinação dos parâmetros físicos dos sistemas de radiologia digital. Os parâmetros de exposição utilizados na prática clínica mostram que a prática não está em conformidade com o referencial Europeu. Verifica-se a necessidade de avaliar, melhorar e implementar um padrão de referência para o processo de optimização, através de novos referenciais de boa prática ajustados aos sistemas digitais. Os parâmetros de exposição influenciam a dose no paciente, mas a percepção da qualidade de imagem digital não parece afectada com a variação da exposição. Os estudos que se realizaram envolvendo tanto imagens de fantomas como imagens de pacientes mostram que a sobreexposição é um risco potencial em radiologia digital. A avaliação da qualidade diagnóstica das imagens mostrou que com a variação da exposição não se observou degradação substancial da qualidade das imagens quando a redução de dose é efectuada. Propõe-se o estudo e a implementação de novos níveis de referência de diagnóstico ajustados aos sistemas de radiologia digital. Como contributo da tese, é proposto um modelo (STDI) para a optimização de sistemas de radiologia digital.

Incongruence between clinicians’ assessment and self-reported functioning is related with psychopathology among patients diagnosed with gastrointestinal disorders

In a previous exploratory study we observed no relevant differences in psychopathology, personality, and functioning between inpatients diagnosed with gastrointestinal motor disorders (GMDs) or functional gastrointestinal disorders (FGDs) [1]. However, we observed higher levels of incongruence between clinician-assessed performance status and patients’ self-reported levels of functioning among patients diagnosed with FGDs. Likewise, research in other medical conditions has shown incongruences between self-reported and clinician-reported or objective measures [2]. Furthermore, in a study on chronic depression, the authors found that discrepancies between patients’ and physicians’ assessments of medical comorbidities were related to higher levels of depressive symptomatology [3]. In this line, the aim of this study was to explore whether the inconsistencies between clinician-assessed and patient self-reported levels of functioning could be related to psychopathology among patients admitted for evaluation of gastrointestinal motility.

Promoting self-regulated learning in technology enhanced learning environments : keeping a digital track of the learning process

Tese de doutoramento (co-tutela), Psicologia (Psicologia da Educação), Faculdade de Psicologia da Universidade de Lisboa, Faculdade de Psicologia e de Ciências da Educação da Universidade de Coimbra, Technial University of Darmstadt, 2014

The effect of smoking nicotine tobacco versus smoking deprivation on motion sickness

BACKGROUND: The experienced smoker maintains adequate nicotine levels by 'puff-by-puff self-control' which also avoids symptomatic nauseating effects of nicotine overdose. It is postulated that there is a varying 'dynamic threshold for nausea' into which motion sickness susceptibility provides an objective toxin-free probe. Hypotheses were that: (i) nicotine promotes motion sickness whereas deprivation protects; and (ii) pleasurable effects of nicotine protect against motion sickness whereas adverse effects of withdrawal have the opposite effect. METHODS: Twenty-six healthy habitual cigarette smokers (mean±SD) 15.3±7.6cigs/day, were exposed to a provocative cross-coupled (coriolis) motion on a turntable, with sequences of 8 head movements every 30s. This continued to the point of moderate nausea. Subjects were tested after either ad-lib normal smoking (SMOKE) or after overnight deprivation (DEPRIV), according to a repeated measures design counter-balanced for order with 1-week interval between tests. RESULTS: Deprivation from recent smoking was confirmed by objective measures: exhaled carbon monoxide CO was lower (P<0.001) for DEPRIV (8.5±5.6ppm) versus SMOKE (16.0±6.3ppm); resting heart rate was lower (P<0.001) for DEPRIV (67.9±8.4bpm) versus SMOKE (74.3±9.5bpm). Mean±SD sequences of head movements tolerated to achieve moderate nausea were more (P=0.014) for DEPRIV (21.3±9.9) versus SMOKE (18.3±8.5). DISCUSSION: Tolerance to motion sickness was aided by short-term smoking deprivation, supporting Hypothesis (i) but not Hypothesis (ii). The effect was was approximately equivalent to half of the effect of an anti-motion sickness drug. Temporary nicotine withdrawal peri-operatively may explain why smokers have reduced risk for postoperative nausea and vomiting (PONV).

Screening primary-care patients forgoing health care for economic reasons.

BACKGROUND: Growing social inequities have made it important for general practitioners to verify if patients can afford treatment and procedures. Incorporating social conditions into clinical decision-making allows general practitioners to address mismatches between patients' health-care needs and financial resources. OBJECTIVES: Identify a screening question to, indirectly, rule out patients' social risk of forgoing health care for economic reasons, and estimate prevalence of forgoing health care and the influence of physicians' attitudes toward deprivation. DESIGN: Multicenter cross-sectional survey. PARTICIPANTS: Forty-seven general practitioners working in the French-speaking part of Switzerland enrolled a random sample of patients attending their private practices. MAIN MEASURES: Patients who had forgone health care were defined as those reporting a household member (including themselves) having forgone treatment for economic reasons during the previous 12 months, through a self-administered questionnaire. Patients were also asked about education and income levels, self-perceived social position, and deprivation levels. KEY RESULTS: Overall, 2,026 patients were included in the analysis; 10.7% (CI95% 9.4-12.1) reported a member of their household to have forgone health care during the 12 previous months. The question "Did you have difficulties paying your household bills during the last 12 months" performed better in identifying patients at risk of forgoing health care than a combination of four objective measures of socio-economic status (gender, age, education level, and income) (R(2) = 0.184 vs. 0.083). This question effectively ruled out that patients had forgone health care, with a negative predictive value of 96%. Furthermore, for physicians who felt powerless in the face of deprivation, we observed an increase in the odds of patients forgoing health care of 1.5 times. CONCLUSION: General practitioners should systematically evaluate the socio-economic status of their patients. Asking patients whether they experience any difficulties in paying their bills is an effective means of identifying patients who might forgo health care.

Étude de la sensibilité baroréceptive en sommeil et à l’éveil dans l’insomnie primaire chronique

L’insomnie, une condition fréquemment retrouvée dans la population, se caractérise d’abord par une difficulté à initier ou à maintenir le sommeil et/ou par des éveils précoces le matin ou encore par un sommeil non-réparateur. Lorsqu’elle n’est pas accompagnée par des troubles psychiatriques ou médicaux ou un autre trouble de sommeil et qu’elle perdure plus de 6 mois on parle alors d’insomnie primaire chronique. Selon certains, cette condition serait associée à un état d’hyperéveil caractérisé par une augmentation de l’activité autonome sympathique durant le sommeil et l’éveil. Le baroréflexe est un important mécanisme de contrôle à court terme des fluctuations de la tension artérielle (TA) et de la fréquence cardiaque agissant sur le cœur et les vaisseaux sanguins par l’entremise du système nerveux autonome. On appelle sensibilité baroréceptive (SBR) la capacité du baroréflexe de réagir et de contrôler les fluctuations de TA en modulant le rythme cardiaque. De manière générale, la SBR serait augmentée durant la nuit par rapport à la journée. Aussi, il semblerait que le baroréflexe soit impliqué dans le phénomène de baisse physiologique de la TA pendant la nuit. Or, des données de notre laboratoire ont démontré une augmentation de la TA systolique au cours de la nuit ainsi qu’une atténuation de la baisse nocturne de TA systolique chez des sujets avec insomnie primaire chronique comparé à des témoins bons dormeurs. De plus, il a été démontré que le baroréflexe était altéré de façon précoce dans plusieurs troubles cardiovasculaires et dans l’hypertension artérielle. Or, il semblerait que l’insomnie soit accompagnée d’un risque accru de développement de l’hypertension artérielle. Ces études semblent aller dans le sens d’une altération des mécanismes de régulation de la TA dans l’insomnie. Par ailleurs, une réduction de la SBR serait aussi impliquée dans des états associés à une augmentation de l’activité autonome sympathique. Ainsi, nous nous sommes demandé si le baroréflexe pouvait constituer un des mécanismes de contrôle de la TA qui serait altéré dans l’insomnie et pourrait être impliqué dans l’augmentation de l’activité sympathique qui semble accompagner l’insomnie. Jusqu’à présent, le baroréflexe reste inexploré dans l’insomnie. L’objectif principal de ce mémoire était d’évaluer de façon non-invasive la SBR à l’éveil et en sommeil chez 11 sujets atteints d’insomnie primaire chronique comparé à 11 témoins bons dormeurs. L’évaluation du baroréflexe a été effectuée de façon spontanée par la méthode de l’analyse en séquence et par le calcul du coefficient alpha obtenu par l’analyse spectrale croisée de l’intervalle RR et de la TA systolique. De façon concomitante, les paramètres de la variabilité de l’intervalle RR en sommeil et à l’éveil ont aussi été comparés chez ces mêmes sujets. Aucune différence significative n’a été notée au niveau des index de la SBR entre le groupe d’insomniaques et celui des bons dormeurs, à l’éveil ou en sommeil. Cependant, on observe des valeurs légèrement plus faibles de la SBR chez les insomniaques ayant mal dormi (efficacité de sommeil (ES) < 85%) comparés aux insomniaques ayant bien dormi (ES≥ 85%) à la nuit expérimentale durant l’éveil et en sommeil. Par ailleurs, aucune différence n’a été notée entre le groupe d’insomniaques et celui des bons dormeurs au niveau des paramètres de la variabilité RR considérés (intervalle RR, PNN50, LF et HF en valeurs normalisées). En effet, les insomniaques tout comme les bons dormeurs semblent présenter une variation normale de l’activité autonome en sommeil, telle que représentée par les paramètres de la variabilité RR. Ces résultats préliminaires semblent suggérer que les mécanismes du baroréflexe sont préservés chez les sujets atteints d’insomnie primaire chronique tels que diagnostiqués de manière subjective. Cependant, il est possible qu’une altération des mécanismes du baroréflexe ne se révèle chez les insomniaques que lorsque les critères objectifs d’une mauvaise nuit de sommeil sont présents.