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.

Cache-aware development of high integrity real-time systems

Cost, performance and availability considerations are forcing even the most conservative high-integrity embedded real-time systems industry to migrate from simple hardware processors to ones equipped with caches and other acceleration features. This migration disrupts the practices and solutions that industry had developed and consolidated over the years to perform timing analysis. Industry that are confident with the efficiency/effectiveness of their verification and validation processes for old-generation processors, do not have sufficient insight on the effects of the migration to cache-equipped processors. Caches are perceived as an additional source of complexity, which has potential for shattering the guarantees of cost- and schedule-constrained qualification of their systems. The current industrial approach to timing analysis is ill-equipped to cope with the variability incurred by caches. Conversely, the application of advanced WCET analysis techniques on real-world industrial software, developed without analysability in mind, is hardly feasible. We propose a development approach aimed at minimising the cache jitters, as well as at enabling the application of advanced WCET analysis techniques to industrial systems. Our approach builds on:(i) identification of those software constructs that may impede or complicate timing analysis in industrial-scale systems; (ii) elaboration of practical means, under the model-driven engineering (MDE) paradigm, to enforce the automated generation of software that is analyzable by construction; (iii) implementation of a layout optimisation method to remove cache jitters stemming from the software layout in memory, with the intent of facilitating incremental software development, which is of high strategic interest to industry. The integration of those constituents in a structured approach to timing analysis achieves two interesting properties: the resulting software is analysable from the earliest releases onwards - as opposed to becoming so only when the system is final - and more easily amenable to advanced timing analysis by construction, regardless of the system scale and complexity.

Model reduction of stochastic groundwater flow and transport processes

This work presents a comprehensive methodology for the reduction of analytical or numerical stochastic models characterized by uncertain input parameters or boundary conditions. The technique, based on the Polynomial Chaos Expansion (PCE) theory, represents a versatile solution to solve direct or inverse problems related to propagation of uncertainty. The potentiality of the methodology is assessed investigating different applicative contexts related to groundwater flow and transport scenarios, such as global sensitivity analysis, risk analysis and model calibration. This is achieved by implementing a numerical code, developed in the MATLAB environment, presented here in its main features and tested with literature examples. The procedure has been conceived under flexibility and efficiency criteria in order to ensure its adaptability to different fields of engineering; it has been applied to different case studies related to flow and transport in porous media. Each application is associated with innovative elements such as (i) new analytical formulations describing motion and displacement of non-Newtonian fluids in porous media, (ii) application of global sensitivity analysis to a high-complexity numerical model inspired by a real case of risk of radionuclide migration in the subsurface environment, and (iii) development of a novel sensitivity-based strategy for parameter calibration and experiment design in laboratory scale tracer transport.

Da Laodice I a Laodice III: l'orizzonte politico delle regine seleucidi

Questo studio indaga la tradizione storiografica sulle regine seleucidi di III secolo a.C. - da Laodice I fino all’ascesa al trono di Laodice III - alla luce delle testimonianze documentarie. L’intento è stabilire l’orizzonte politico dell’azione delle regine nel momento meno conosciuto e più buio della storia del regno di Siria. Il III secolo seleucidico è infatti un periodo caratterizzato da incertezza nella ricostruzione evenemenziale e nell’analisi delle dinamiche sociopolitiche, soprattutto a causa dell’interesse relativo e limitato delle fonti storiografiche antiche a noi giunte relativamente alle vicende della monarchia seleucidica precedenti l’avvento di Antioco III il Grande. In questo panorama rappresenta un’eccezione il caso di Laodice I, che è al centro di un rilevante numero di testimonianze. Tenendo conto della differente natura delle fonti e della complessità del contesto evenemenziale, non sempre ricostruibile, è stata studiata la figura di Laodice I nell’intento di comprendere il paradigma di regalità femminile stabilito dalle azioni della regina, e quindi l’influenza di tale paradigma sulla generazione seleucide successiva. La ricerca si articola in tre sezioni, legate agli eventi principali del III secolo seleucide che vedono coinvolta la regina. La prima parte è dedicata all’attività di Laodice I dopo il secondo matrimonio di Antioco II con la tolemaica Berenice. La seconda parte riguarda il ruolo di Laodice nei complessi eventi che seguirono la morte del marito Antioco II nel 246 e nella Terza Guerra Siriaca, che vide la regina a fianco del figlio Seleuco II contrapporsi a Tolemeo III e Berenice Sira. La terza sezione si occupa dell’azione di Laodice I nella Guerra Fraterna al fianco di Antioco Ierace contro Seleuco II e Laodice II. Nella conclusione si riflette sull’influenza delle azioni politiche di Laodice I sulla scelta di Antioco III di sposare la cugina Laodice III, prima principessa del Ponto entrata nella dinastia regnante.