Development of Clinical Decision Support Systems based on Mathematical Models of Physiological Systems

In the last years of research, I focused my studies on different physiological problems. Together with my supervisors, I developed/improved different mathematical models in order to create valid tools useful for a better understanding of important clinical issues. The aim of all this work is to develop tools for learning and understanding cardiac and cerebrovascular physiology as well as pathology, generating research questions and developing clinical decision support systems useful for intensive care unit patients. I. ICP-model Designed for Medical Education We developed a comprehensive cerebral blood flow and intracranial pressure model to simulate and study the complex interactions in cerebrovascular dynamics caused by multiple simultaneous alterations, including normal and abnormal functional states of auto-regulation of the brain. Individual published equations (derived from prior animal and human studies) were implemented into a comprehensive simulation program. Included in the normal physiological modelling was: intracranial pressure, cerebral blood flow, blood pressure, and carbon dioxide (CO2) partial pressure. We also added external and pathological perturbations, such as head up position and intracranial haemorrhage. The model performed clinically realistically given inputs of published traumatized patients, and cases encountered by clinicians. The pulsatile nature of the output graphics was easy for clinicians to interpret. The manoeuvres simulated include changes of basic physiological inputs (e.g. blood pressure, central venous pressure, CO2 tension, head up position, and respiratory effects on vascular pressures) as well as pathological inputs (e.g. acute intracranial bleeding, and obstruction of cerebrospinal outflow). Based on the results, we believe the model would be useful to teach complex relationships of brain haemodynamics and study clinical research questions such as the optimal head-up position, the effects of intracranial haemorrhage on cerebral haemodynamics, as well as the best CO2 concentration to reach the optimal compromise between intracranial pressure and perfusion. We believe this model would be useful for both beginners and advanced learners. It could be used by practicing clinicians to model individual patients (entering the effects of needed clinical manipulations, and then running the model to test for optimal combinations of therapeutic manoeuvres). II. A Heterogeneous Cerebrovascular Mathematical Model Cerebrovascular pathologies are extremely complex, due to the multitude of factors acting simultaneously on cerebral haemodynamics. In this work, the mathematical model of cerebral haemodynamics and intracranial pressure dynamics, described in the point I, is extended to account for heterogeneity in cerebral blood flow. The model includes the Circle of Willis, six regional districts independently regulated by autoregulation and CO2 reactivity, distal cortical anastomoses, venous circulation, the cerebrospinal fluid circulation, and the intracranial pressure-volume relationship. Results agree with data in the literature and highlight the existence of a monotonic relationship between transient hyperemic response and the autoregulation gain. During unilateral internal carotid artery stenosis, local blood flow regulation is progressively lost in the ipsilateral territory with the presence of a steal phenomenon, while the anterior communicating artery plays the major role to redistribute the available blood flow. Conversely, distal collateral circulation plays a major role during unilateral occlusion of the middle cerebral artery. In conclusion, the model is able to reproduce several different pathological conditions characterized by heterogeneity in cerebrovascular haemodynamics and can not only explain generalized results in terms of physiological mechanisms involved, but also, by individualizing parameters, may represent a valuable tool to help with difficult clinical decisions. III. Effect of Cushing Response on Systemic Arterial Pressure. During cerebral hypoxic conditions, the sympathetic system causes an increase in arterial pressure (Cushing response), creating a link between the cerebral and the systemic circulation. This work investigates the complex relationships among cerebrovascular dynamics, intracranial pressure, Cushing response, and short-term systemic regulation, during plateau waves, by means of an original mathematical model. The model incorporates the pulsating heart, the pulmonary circulation and the systemic circulation, with an accurate description of the cerebral circulation and the intracranial pressure dynamics (same model as in the first paragraph). Various regulatory mechanisms are included: cerebral autoregulation, local blood flow control by oxygen (O2) and/or CO2 changes, sympathetic and vagal regulation of cardiovascular parameters by several reflex mechanisms (chemoreceptors, lung-stretch receptors, baroreceptors). The Cushing response has been described assuming a dramatic increase in sympathetic activity to vessels during a fall in brain O2 delivery. With this assumption, the model is able to simulate the cardiovascular effects experimentally observed when intracranial pressure is artificially elevated and maintained at constant level (arterial pressure increase and bradicardia). According to the model, these effects arise from the interaction between the Cushing response and the baroreflex response (secondary to arterial pressure increase). Then, patients with severe head injury have been simulated by reducing intracranial compliance and cerebrospinal fluid reabsorption. With these changes, oscillations with plateau waves developed. In these conditions, model results indicate that the Cushing response may have both positive effects, reducing the duration of the plateau phase via an increase in cerebral perfusion pressure, and negative effects, increasing the intracranial pressure plateau level, with a risk of greater compression of the cerebral vessels. This model may be of value to assist clinicians in finding the balance between clinical benefits of the Cushing response and its shortcomings. IV. Comprehensive Cardiopulmonary Simulation Model for the Analysis of Hypercapnic Respiratory Failure We developed a new comprehensive cardiopulmonary model that takes into account the mutual interactions between the cardiovascular and the respiratory systems along with their short-term regulatory mechanisms. The model includes the heart, systemic and pulmonary circulations, lung mechanics, gas exchange and transport equations, and cardio-ventilatory control. Results show good agreement with published patient data in case of normoxic and hyperoxic hypercapnia simulations. In particular, simulations predict a moderate increase in mean systemic arterial pressure and heart rate, with almost no change in cardiac output, paralleled by a relevant increase in minute ventilation, tidal volume and respiratory rate. The model can represent a valid tool for clinical practice and medical research, providing an alternative way to experience-based clinical decisions. In conclusion, models are not only capable of summarizing current knowledge, but also identifying missing knowledge. In the former case they can serve as training aids for teaching the operation of complex systems, especially if the model can be used to demonstrate the outcome of experiments. In the latter case they generate experiments to be performed to gather the missing data.

A simple voltage/mass index increases the suspicion of amyloidotic cardiomyopathy: an electrocardiographic and echocardiographic study of 767 patients with increased left ventricular wall thickness due to different causes

Background-Amyloidotic cardiomyopathy (AC) can mimic true left ventricular hypertrophy (LVH), including hypertrophic cardiomyopathy (HCM) and hypertensive heart disease (HHD). We assessed the diagnostic value of combined electrocardiographic/echocardiographic indexes to identify AC among patients with increased echocardiographic LV wall thickness due to either different etiologies of amyloidosis or HCM or HHD. Method-First, we studied 469 consecutive patients: 262 with biopsy/genetically proven AC (with either AL or transthyretin (TTR)-related amyloidosis); 106 with HCM; 101 with HHD. We compared the diagnostic performance of: low QRS voltage, symmetric LVH, low QRS voltage plus interventricular septal thickness >1.98 cm, Sokolow index divided by the cross-sectional area of LV wall, Sokolow index divided by body surface area indexed LV mass (LVMI), Sokolow index divided by LV wall thickness, Sokolow index divided by (LV wall/height^2.7); peripheral QRS score divided by LVMI, Peripheral QRS score divided by LV wall thickness, Peripheral QRS score divided by LV wall thickness indexed to height^2.7, total QRS score divided by LVMI, total QRS score divided by LV wall thickness; total QRS score divided by (LV wall/height^2.7). We tested each criterion, separately in males and females, in the following settings: AC vs. HCM+HHD; AC vs. HCM; AL vs. HCM+HHD; AL vs. HCM; TTR vs. HCM+HHD; TTR vs. HCM. Results-Low QRS voltage showed high specificity but low sensitivity for the identification of AC. All the combined indexes had a higher diagnostic accuracy, being total QRS score divided by LV wall thickness or by LVMI associated with the best performances and the largest areas under the ROC curve. These results were validated in 298 consecutive patients with AC, HCM or HHD. Conclusions-In patients with increased LV wall thickness, a combined ECG/ echocardiogram analysis provides accurate indexes to non-invasively identify AC. Total QRS score divided by LVMI or LV wall thickness offers the best diagnostic performance.

Influenza dell'Omeostasi Idrico-Elettrolitica sul Ciclo Veglia-Sonno

During the wake sleep (W-S) cycle in mammals, the alternation of the different states, wake, NREM sleep (NREMS) and REM sleep (REMS), is associated not only with electroencephalographic or behavioural changes, but also with modifications in the physiological regulations of the organism. The most evident change is the existence of a suspension of the somatic and autonomic thermoregulatory responses during REMS. Since thermoregulation is prevalently controlled by the Preoptic Area-Anterior Hypothalamus (PO-AH), its suspension during REM sleep has been taken as a sign of an impairment of the hypothalamic integrative activity that could explain the modifications in physiological regulation observed in this sleep stage. The recent finding from our laboratory that the secretion of the antidiuretic hormone arginine-vasopressin (AVP) in response to a central osmotic stimulation is quantitatively the same throughout the different stages of the W-S cycle, has shown that hypothalamic osmoregulation is not suspended during REMS. In order to clarify the extent of the hypothalamic involvement in the regulation of the W-S cycle, we have studied the effects of three days of water deprivation and of two days of recovery during which animals were allowed a free access to water, on the architecture of the W-S cycle. The condition of water deprivation represents a severe challenge involving neuroendocrine and autonomic hypothalamic regulations. In contradiction with thermoregulatory studies, in which it has been clearly demonstrated that a thermal challenge selectively reduces REMS occurrence, the results of this study show that REMS occurrence is mildly reduced only in the third day of water deprivation. The most striking effects produced by water deprivation appear to concern NREMS, which shows a selective and significant reduction in its slow EEG activity (delta-power) but not in its duration. The recovery period is mainly characterized by a disruption of the normal circadian rhythm of REMS occurrence and by a rebound of the delta power in NREMS. Thus, an autonomic challenge different from those related to thermoregulation and an endocrine challenge as the continuous secretion of AVP show to exert different effects on the stages of the wake-sleep cycle. Also, this study demonstrates that the impairment of the hypothalamic integrative activity thought to characterize the occurrence of REMS only involves thermoregulatory structures.

Estimating crustal deformation from geodetic data

By the end of the 19th century, geodesy has contributed greatly to the knowledge of regional tectonics and fault movement through its ability to measure, at sub-centimetre precision, the relative positions of points on the Earth’s surface. Nowadays the systematic analysis of geodetic measurements in active deformation regions represents therefore one of the most important tool in the study of crustal deformation over different temporal scales [e.g., Dixon, 1991]. This dissertation focuses on motion that can be observed geodetically with classical terrestrial position measurements, particularly triangulation and leveling observations. The work is divided into two sections: an overview of the principal methods for estimating longterm accumulation of elastic strain from terrestrial observations, and an overview of the principal methods for rigorously inverting surface coseismic deformation fields for source geometry with tests on synthetic deformation data sets and applications in two different tectonically active regions of the Italian peninsula. For the long-term accumulation of elastic strain analysis, triangulation data were available from a geodetic network across the Messina Straits area (southern Italy) for the period 1971 – 2004. From resulting angle changes, the shear strain rates as well as the orientation of the principal axes of the strain rate tensor were estimated. The computed average annual shear strain rates for the time period between 1971 and 2004 are γ˙1 = 113.89 ± 54.96 nanostrain/yr and γ˙2 = -23.38 ± 48.71 nanostrain/yr, with the orientation of the most extensional strain (θ) at N140.80° ± 19.55°E. These results suggests that the first-order strain field of the area is dominated by extension in the direction perpendicular to the trend of the Straits, sustaining the hypothesis that the Messina Straits could represents an area of active concentrated deformation. The orientation of θ agree well with GPS deformation estimates, calculated over shorter time interval, and is consistent with previous preliminary GPS estimates [D’Agostino and Selvaggi, 2004; Serpelloni et al., 2005] and is also similar to the direction of the 1908 (MW 7.1) earthquake slip vector [e.g., Boschi et al., 1989; Valensise and Pantosti, 1992; Pino et al., 2000; Amoruso et al., 2002]. Thus, the measured strain rate can be attributed to an active extension across the Messina Straits, corresponding to a relative extension rate ranges between < 1mm/yr and up to ~ 2 mm/yr, within the portion of the Straits covered by the triangulation network. These results are consistent with the hypothesis that the Messina Straits is an important active geological boundary between the Sicilian and the Calabrian domains and support previous preliminary GPS-based estimates of strain rates across the Straits, which show that the active deformation is distributed along a greater area. Finally, the preliminary dislocation modelling has shown that, although the current geodetic measurements do not resolve the geometry of the dislocation models, they solve well the rate of interseismic strain accumulation across the Messina Straits and give useful information about the locking the depth of the shear zone. Geodetic data, triangulation and leveling measurements of the 1976 Friuli (NE Italy) earthquake, were available for the inversion of coseismic source parameters. From observed angle and elevation changes, the source parameters of the seismic sequence were estimated in a join inversion using an algorithm called “simulated annealing”. The computed optimal uniform–slip elastic dislocation model consists of a 30° north-dipping shallow (depth 1.30 ± 0.75 km) fault plane with azimuth of 273° and accommodating reverse dextral slip of about 1.8 m. The hypocentral location and inferred fault plane of the main event are then consistent with the activation of Periadriatic overthrusts or other related thrust faults as the Gemona- Kobarid thrust. Then, the geodetic data set exclude the source solution of Aoudia et al. [2000], Peruzza et al. [2002] and Poli et al. [2002] that considers the Susans-Tricesimo thrust as the May 6 event. The best-fit source model is then more consistent with the solution of Pondrelli et al. [2001], which proposed the activation of other thrusts located more to the North of the Susans-Tricesimo thrust, probably on Periadriatic related thrust faults. The main characteristics of the leveling and triangulation data are then fit by the optimal single fault model, that is, these results are consistent with a first-order rupture process characterized by a progressive rupture of a single fault system. A single uniform-slip fault model seems to not reproduce some minor complexities of the observations, and some residual signals that are not modelled by the optimal single-fault plane solution, were observed. In fact, the single fault plane model does not reproduce some minor features of the leveling deformation field along the route 36 south of the main uplift peak, that is, a second fault seems to be necessary to reproduce these residual signals. By assuming movements along some mapped thrust located southward of the inferred optimal single-plane solution, the residual signal has been successfully modelled. In summary, the inversion results presented in this Thesis, are consistent with the activation of some Periadriatic related thrust for the main events of the sequence, and with a minor importance of the southward thrust systems of the middle Tagliamento plain.

Changes in tumor stiffness for early prediction of tumor response to sorafenib: a proof-of-concept study with elastosonography in an animal model of Hepatocellular Carcinoma (HCC)

Background and aims: Sorafenib is the reference therapy for advanced Hepatocellular Carcinoma (HCC). No method exists to predict in the very early period subsequent individual response. Starting from the clinical experience in humans that subcutaneous metastases may rapidly change consistency under sorafenib and that elastosonography a new ultrasound based technique allows assessment of tissue stiffness, we investigated the role of elastonography in the very early prediction of tumor response to sorafenib in a HCC animal model. Methods: HCC (Huh7 cells) subcutaneous xenografting in mice was utilized. Mice were randomized to vehicle or treatment with sorafenib when tumor size was 5-10 mm. Elastosonography (Mylab 70XVG, Esaote, Genova, Italy) of the whole tumor mass on a sagittal plane with a 10 MHz linear transducer was performed at different time points from treatment start (day 0, +2, +4, +7 and +14) until mice were sacrified (day +14), with the operator blind to treatment. In order to overcome variability in absolute elasticity measurement when assessing changes over time, values were expressed in arbitrary units as relative stiffness of the tumor tissue in comparison to the stiffness of a standard reference stand-off pad lying on the skin over the tumor. Results: Sor-treated mice showed a smaller tumor size increase at day +14 in comparison to vehicle-treated (tumor volume increase +192.76% vs +747.56%, p=0.06). Among Sor-treated tumors, 6 mice showed a better response to treatment than the other 4 (increase in volume +177% vs +553%, p=0.011). At day +2, median tumor elasticity increased in Sor-treated group (+6.69%, range –30.17-+58.51%), while decreased in the vehicle group (-3.19%, range –53.32-+37.94%) leading to a significant difference in absolute values (p=0.034). From this time point onward, elasticity decreased in both groups, with similar speed over time, not being statistically different anymore. In Sor-treated mice all 6 best responders at day 14 showed an increase in elasticity at day +2 (ranging from +3.30% to +58.51%) in comparison to baseline, whereas 3 of the 4 poorer responders showed a decrease. Interestingly, these 3 tumours showed elasticity values higher than responder tumours at day 0. Conclusions: Elastosonography appears a promising non-invasive new technique for the early prediction of HCC tumor response to sorafenib. Indeed, we proved that responder tumours are characterized by an early increase in elasticity. The possibility to distinguish a priori between responders and non responders based on the higher elasticity of the latter needs to be validated in ad-hoc experiments as well as a confirmation of our results in humans is warranted.

Geomorphological and statistical analysis on Ravenna dune fields changes, based on Terrestrial Laser Technology

Coastal sand dunes represent a richness first of all in terms of defense from the sea storms waves and the saltwater ingression; moreover these morphological elements constitute an unique ecosystem of transition between the sea and the land environment. The research about dune system is a strong part of the coastal sciences, since the last century. Nowadays this branch have assumed even more importance for two reasons: on one side the born of brand new technologies, especially related to the Remote Sensing, have increased the researcher possibilities; on the other side the intense urbanization of these days have strongly limited the dune possibilities of development and fragmented what was remaining from the last century. This is particularly true in the Ravenna area, where the industrialization united to the touristic economy and an intense subsidence, have left only few dune ridges residual still active. In this work three different foredune ridges, along the Ravenna coast, have been studied with Laser Scanner technology. This research didn’t limit to analyze volume or spatial difference, but try also to find new ways and new features to monitor this environment. Moreover the author planned a series of test to validate data from Terrestrial Laser Scanner (TLS), with the additional aim of finalize a methodology to test 3D survey accuracy. Data acquired by TLS were then applied on one hand to test some brand new applications, such as Digital Shore Line Analysis System (DSAS) and Computational Fluid Dynamics (CFD), to prove their efficacy in this field; on the other hand the author used TLS data to find any correlation with meteorological indexes (Forcing Factors), linked to sea and wind (Fryberger's method) applying statistical tools, such as the Principal Component Analysis (PCA).