Standardization of a computerized method for calculating autonomic function test responses in healthy subjects and patients with diabetes mellitus

The objectives of the present study were 1) to compare results obtained by the traditional manual method of measuring heart rate (HR) and heart rate response (HRR) to the Valsalva maneuver, standing and deep breathing, with those obtained using a computerized data analysis system attached to a standard electrocardiograph machine; 2) to standardize the responses of healthy subjects to cardiovascular tests, and 3) to evaluate the response to these tests in a group of patients with diabetes mellitus (DM). In all subjects (97 healthy and 143 with DM) we evaluated HRR to deep breathing, HRR to standing, HRR to the Valsalva maneuver, and blood pressure response (BPR) to standing up and to a sustained handgrip. Since there was a strong positive correlation between the results obtained with the computerized method and the traditional method, we conclude that the new method can replace the traditional manual method for evaluating cardiovascular responses with the advantages of speed and objectivity. HRR and BPR of men and women did not differ. A correlation between age and HRR was observed for standing (r = -0.48, P<0.001) and deep breathing (r = -0.41, P<0.002). Abnormal BPR to standing was usually observed only in diabetic patients with definite and severe degrees of autonomic neuropathy.

Reference values for lung function tests: II. Maximal respiratory pressures and voluntary ventilation

The strength of the respiratory muscles can be evaluated from static measurements (maximal inspiratory and expiratory pressures, MIP and MEP) or inferred from dynamic maneuvers (maximal voluntary ventilation, MVV). Although these data could be suitable for a number of clinical and research applications, no previous studies have provided reference values for such tests using a healthy, randomly selected sample of the adult Brazilian population. With this main purpose, we prospectively evaluated 100 non-smoking subjects (50 males and 50 females), 20 to 80 years old, selected from more than 8,000 individuals. Gender-specific linear prediction equations for MIP, MEP and MVV were developed by multiple regression analysis: age and, secondarily, anthropometric measurements explained up to 56% of the variability of the dependent variables. The most cited previous studies using either Caucasian or non-Caucasian samples systematically underestimated the observed values of MIP (P<0.05). Interestingly, the self-reported level of regular physical activity and maximum aerobic power correlates strongly with both respiratory and peripheral muscular strength (knee extensor peak torque) (P<0.01). Our results, therefore, provide a new frame of reference to evaluate the normalcy of some useful indexes of respiratory muscle strength in Brazilian males and females aged 20 to 80.

Clinical trial of gabexate in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis

The objective of the present study was to determine the efficacy of prophylactic administration of gabexate for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, hyperamylasemia and pancreatic pain. Patients scheduled for ERCP were randomized into two groups in a double-blind manner: the patients in the gabexate group were treated with continuous intravenous infusion of 300 mg gabexate dissolved in 500 mL Ringer's solution at 111 mL/h, starting 30 min before the endoscopic maneuvers and continuing up to 4 h after them; placebo group patients were treated only with Ringer's solution also starting 30 min before the endoscopic maneuvers and continuing up to 4 h. Data for 193 patients were analyzed. The incidence of post-ERCP pancreatitis was 3 patients (3.1%) in the gabexate group and 10 (10.5%) in the placebo group (P = 0.040). The incidence of hyperamylasemia was 33 patients (33.7%) in the gabexate group and 42 (43.7%) in the placebo group (P = 0.133). The incidence of pancreatic pain was 15 patients (15.3%) in the gabexate group and 28 (29.5%) in the placebo group (P = 0.018). The results suggest that a 4.5-h infusion of gabexate (for a total of 300 mg) could prevent post-ERCP pancreatitis and pancreatic pain.

Efficacy of the FEV1/FEV6 ratio compared to the FEV1/FVC ratio for the diagnosis of airway obstruction in subjects aged 40 years or over

The present cross-sectional, population-based study was designed to evaluate the performance of the FEV1/FEV6 ratio for the detection of airway-obstructed subjects compared to the FEV1/FVC <0.70 fixed ratio test, as well as the lower limit of normality (LLN) for 1000 subjects ³40 years of age in the metropolitan area of São Paulo, SP, Brazil. After the exclusion of 37 (3.7%) spirometries, a total of 963 pre-bronchodilator (BD) and 918 post-BD curves were constructed. The majority of the post-BD curves (93.1%) were of very good quality and achieved grade A (762 curves) or B (93 curves). The FEV1/FEV6 and FEV1/FVC ratios were highly correlated (r² = 0.92, P < 0.000). Two receiver operator characteristic curves were constructed in order to express the imbalance between the sensitivity and specificity of the FEV1/FEV6 ratio compared to two FEV1/FVC cut-off points for airway obstruction: equal to 70 (area under the curve = 0.98, P < 0.0001) and the LLN (area under the curve = 0.97, P < 0.0001), in the post-BD curves. According to an FEV1/FVC <0.70, the cut-off point for the FEV1/FEV6 ratio with the highest sum for sensitivity and specificity was 0.75. The FEV1/FEV6 ratio can be considered to be a good alternative to the FEV1/FVC ratio for the diagnosis of airway obstruction, both using a fixed cut-off point or below the LLN as reference. The FEV1/FEV6 ratio has the additional advantage of being an easier maneuver for the subjects and for the lung function technicians, providing a higher reproducibility than traditional spirometry maneuvers.

Variable positive end-expiratory pressure can maintain oxygenation in experimental acute respiratory distress syndrome induced by oleic acid in dogs

The use of positive end-expiratory pressure (PEEP) or lung recruitment maneuvers (RM) to improve oxygenation in acute respiratory distress syndrome (ARDS) is used but it may reduce cardiac output (CO). Intermittent PEEP may avoid these complications. Our objective was to determine if variable PEEP compared with constant PEEP is capable of maintaining arterial oxygenation and minimizing hemodynamic alterations with or without RM. Eighteen dogs with ARDS induced by oleic acid were randomized into three equal groups: group 1, low variable PEEP; group 2, high variable PEEP, and group 3, RM + high variable PEEP. All groups were submitted to constant PEEP, followed by variable PEEP (PEEP was increased from 5 to 10 cmH2O in group 1, and from 5 to 18 cmH2O in the other two groups). PaO2 was higher in group 3 (356.2 ± 65.4 mmHg) than in group 1 (92.7 ± 29.7 mmHg) and group 2 (228.5 ± 72.4 mmHg), P < 0.05. PaO2 was maintained during variable PEEP except in group 2 (318.5 ± 82.9 at constant PEEP to 228.5 ± 72.4 at variable PEEP). There was a reduction in CO in group 3 after RM (3.9 ± 1.1 before to 2.7 ± 0.5 L·min-1·(m2)-1 after; P < 0.05), but there was not any difference between constant and variable PEEP periods (2.7 ± 0.5 and 2.4 ± 0.7 L·min-1·(m2)-1; P > 0.05. Variable PEEP is able to maintain PaO2 when performed in combination with RM in dogs with ARDS. After RM, CO was reduced and there was no relevant difference between the variable and constant PEEP periods.

Une sagesse qui ne vient jamais : esthétique, politique et personnalité dans l’œuvre de Guy Debord

Cette thèse se propose de réévaluer l’œuvre de Guy Debord en privilégiant la lecture de ses autoportraits littéraires et cinématographiques. Cette recherche favorise une réception de Debord mettant en lumière l’importance de l’écriture de soi dans l’ensemble de sa production. L’inscription de soi, chez Debord, passe en effet par la création d’une légende. L’introduction démontre comment la trajectoire singulière de Debord témoigne d’un brouillage entre les frontières traditionnelles séparant l’esthétique et le politique. Elle explore les moyens pris par Debord afin de redéfinir le statut de l’artiste et la fonction de l’écriture dans le cadre d’une transformation d’une vie quotidienne. Dans ce cadre, la production artistique se subordonne entièrement au caractère de Debord, une personnalité qui se manifeste d’abord à travers la création d’un Grand style qui lui est propre. En célébrant le primat du vécu sur l’œuvre, la manœuvre de Debord s’inscrit dans la tradition moderniste de l’art. Le chapitre II montre comment Debord souhaita participer à l’entreprise de politisation de l’esthétique qui définit l’action des avant-gardes historiques. On y explique notamment comment l’œuvre de Debord s’est construite à partir des ruines du surréalisme. Pour se distinguer de ses ancêtres, le mouvement situationniste rejeta cependant l’esthétique surréaliste du rêve au profit d’une nouvelle poétique de l’ivresse se basant sur la dérive et sur l’intensification du moi. La dernière section de ce chapitre se consacre à la question de la création d’un mythe moderne, volonté partagée par les deux groupes. La troisième partie de cette thèse traite spécifiquement de la construction mythologique de Debord. Ce chapitre situe le projet mémorialiste de Debord dans la tradition littéraire française de l’écriture du moi. Il explore ensuite l’économie des sources classiques de Debord, en soulignant l’importance chez lui d’une éthique aristocratique issue du Grand siècle, éthique qui met de l’avant la distinction individuelle. Enfin, l’importance de la mentalité baroque est abordée conjointement à la question primordiale de la stratégie et de la manipulation. Le quatrième chapitre aborde la question de l’identification. Quand Debord décide de parler de sa vie, il le fait toujours en employant des éléments qui lui sont extérieurs : des « détournements ». Son « mode d’emploi » des détournements est défini dans la perspective d’un dévoilement de soi. On explore par la suite la question de l’imaginaire politique de Debord, imaginaire qui convoque sans cesse des représentations issues du XIXe siècle (classes dangereuses, conspirateur, bohème). Ce dernier chapitre se termine sur un essai d’interprétation approfondissant l’utilisation répétée de certaines figures criminelles, notamment Lacenaire. On mettra de l’avant la fonction centrale qu’occupent le crime et la transgression dans la sensibilité de Debord.

The career of the missed encounter in classic american literature

Cette dissertation explore la carrière de la rencontre manquée Lacanienne dans la littérature canonique américaine du dix-neuvième siècle à travers le prisme de la psychanalyse, la déconstruction, le postmodernisme et le postcolonialisme. Je me concentre particulièrement sur La Lettre Écarlate de Hawthorne et Moby-Dick de Melville, en montrant comment ils sont investis dans l'économie narrative de la rencontre manquée, l'économie de ce qui est au-delà de la symbolisation et l'assimilation. L’introduction examine les contours et les détours historiques, philosophiques et théoriques du concept de la rencontre manquée. Cette dissertation a donc deux objectifs: d'une part, elle tente d'examiner le statut et la fonction de la rencontre manquée dans la littérature américaine du dix-neuvième siècle, et d’autre part, elle explore comment la théorisation de la rencontre manquée pourrait nous aider à aller au-delà de la théorisation binaire qui caractérise les scènes géopolitiques actuelles. Mon premier chapitre sur La Lettre Écarlate de Hawthorne, tente de tracer la carrière du signifiant comme une navette entre l'archive et l'avenir, entre le sujet et l'objet, entre le signifiant et le signifié. Le but de ce chapitre est de rendre compte de la temporalité du signifiant et la temporalité de la subjectivité et d’expliquer comment ils répondent à la temporalité du tuché. En explorant la dimension crypto-temporelle de la rencontre manquée, ce chapitre étudie l'excès de cryptes par la poétique (principalement prosopopée, anasémie, et les tropes d'exhumation). Le deuxième chapitre élabore sur les contours de la rencontre manquée. En adoptant des approches psychanalytiques et déconstructives, ce chapitre négocie la temporalité de la rencontre manquée (la temporalité de l'automaton et de la répétition). En explorant la temporalité narrative (prolepse et analepse) conjointement à la psycho-poétique du double, ce chapitre essaie de dévoiler les vicissitudes de la mélancolie et la “dépression narcissique” dans Moby-Dick (en particulier la répétition d'Achab lors de sa rencontre originelle dénarrée ou jamais racontée avec le cachalot blanc et sa position mélancolique par rapport à l'objet qu'il a perdu). En exposant la nature du trauma comme une rencontre manquée, dont les résidus se manifestent symptomatiquement par la répétition (et le doublement), ce chapitre explique le glissement de la lettre (par l'entremise du supplément et de la différance). Le troisième chapitre élargit la portée de la rencontre manquée pour inclure les Autres de l'Amérique. Le but principal de ce chapitre est d'évaluer les investitures politiques, culturelles, imaginaires et libidinales de la rencontre manquée dans le Réel, le Symbolique nationale des États-Unis et la réalité géopolitique actuelle. Il traite également de la relation ambiguë entre la jouissance et le Symbolique: la manière dont la jouissance anime et régit le Symbolique tout en confondant la distinction entre le Réel et la réalité et en protégeant ses manœuvres excessives.

Oxygenation-sensitive cardiovascular magnetic resonance imaging (OS-CMR) : potential confounding factors in use of OS-CMR

La résonance magnétique cardiovasculaire sensible à l'oxygénation (OS-CMR) est devenue une modalité d'imagerie diagnostique pour la surveillance de changements dans l'oxygénation du myocarde. Cette technique offre un grand potentiel en tant qu'outil diagnostic primaire pour les maladies cardiovasculaires, en particulier la détection non-invasive d'ischémie. Par contre, il existe plusieurs facteurs potentiellement confondants de cette technique, quelques-uns d'ordre méthodologique comme les paramètres de séquençage et d'autres de nature physiologiques qui sont peut compris. En raison des effets causés par le contenu tissulaire d'eau, l'état d'hydratation peut avoir un impact sur l'intensité du signal. Ceci est un des aspects physiologiques en particulier dont nous voulions quantifier l'effet confondant par la manipulation de l'état d'hydratation chez des humains et l'observation des changements de l'intensité du signal dans des images OS-CMR. Méthodes: In vitro: Du sang artériel et veineux de huit porcs a été utilisé pour évaluer la dilution en série du sang et son effet correspondant sur l'intensité du signal de la séquence OS. In vivo: Vingt-deux volontaires en santé ont subi OS-CMR. Les concentrations d'hémoglobine (Hb) ont été mesurées au niveau de base et immédiatement après une l'infusion cristalloïde rapide de 1000 mL de solution Lactate Ringer's (LRS). Les images OS-CMR ont été prises dans une vue mid-ventriculaire court axe. L'intensité du signal myocardique a été mesurée durant une rétention respiratoire volontaire maximale, suite à une période d'hyperventilation de 60 secondes. Les changements dans l'intensité du signal entre le début et la fin de la rétention de la respiration ont été exprimés relativement au niveau de base (% de changement). Résultats: L'infusion a résulté en une diminution significative de l'Hb mesurée (142.5±3.3 vs. 128.8±3.3 g/L; p<0.001), alors que l'IS a augmenté de 3.2±1.2% entre les images du niveau de base en normo- et hypervolémie (p<0.05). L'IS d'hyperventilation ainsi que les changements d'IS induits par l'apnée ont été attenués après hémodilution (p<0.05). L'évaluation quantitative T2* a démontré une corrélation négative entre le temps de T2* et la concentration d'hémoglobine (r=-0.46, p<0.005). Conclusions: Il existe plusieurs éléments confondants de la technique OS-CMR qui requièrent de l'attention et de l'optimisation pour une future implémentation clinique à grande échelle. Le statut d'hydratation en particulier pourrait être un élément confondant dans l'imagerie OS-CMR. L'hypervolémie mène à une augmentation en IS au niveau de base et atténue la réponse IS durant des manoeuvres de respiration vasoactives. Cette atténuation de l'intensité du signal devrait être tenue en compte et corrigée dans l'évaluation clinique d'images OS-CMR.

Le Japon en mal de reconnaissance internationale. Victoires militaires et paix ratées, 1895-1923

À la fin du 19e siècle, le Japon inaugure une politique expansionniste qu’il mène avec succès contre la Chine, puis la Russie et enfin l’Allemagne. De 1895 à 1923, les forces armées japonaises cumulent les victoires militaires impressionnantes et indéniables. Contre toute attente, cependant, Tokyo peine à convertir ces triomphes en un capital politique qui lui assurerait le statut de puissance tant convoité et une paix durable, proche de l’hégémonie régionale. Pour expliquer cet échec politique, il n’est pas à regarder vers la mise en œuvre de guerres de revanche menées par les vaincus. Ce sont plutôt étonnamment des puissances étrangères au conflit qui viennent brimer les aspirations stratégiques du Japon. Parce qu’ils sont inquiets des impacts de la montée en puissance du Japon, des pays neutres comme des nations alliées à Tokyo font obstacles à la pleine exploitation des victoires. Mêlant menaces militaires et manœuvres diplomatiques, certains pays européens et les États-Unis réussissent à contrer les ambitions impériales japonaises, à refuser l’obtention du statut de puissance et à contester la reconnaissance de l’égalité raciale. Par le biais d’une analyse du premier impérialisme japonais, notre étude veut démontrer que l’intervention d’une tierce partie, non impliquée dans la guerre, peut obliger le vainqueur à reconsidérer comment il compte profiter de ses tributs de guerre. Pour qu’un traité de paix soit durable, celui-ci ne peut prendre naissance sans égard du contexte général, sans égard des intérêts des principaux acteurs internationaux de l’époque.

Explorando modelos in vivo para caracterizar a microcirculação periférica : um estudo piloto

Nos últimos anos, a circulação cutânea surgiu como uma janela interessante para analisar a função microcirculatória e os mecanismos de disfunção. Tecnologias não-invasivas, incluindo a Fluxometria por Laser Doppler (FLD), gasimetria transcutânea e a Perda Transepidérmica de Água (PTEA), ajudaram a considerar a circulação cutânea como um modelo de translação útil na doença vascular. Neste estudo procurou-se avaliar o perfil de resposta de um grupo de indivíduos jovens saudáveis ​​(n = 8), de ambos os sexos (24,5 ± 0,8 anos de idade) a três manobras de condicionamento da perfusão no membro inferior - A: elevação da perna enquanto sentado, B: elevação da perna enquanto em decúbito dorsal; C: oclusão supra-sistólica com um torniquete. As técnicas de medição incluiram FLD, pressões parciais transcutâneas (tc) pO2 e pCO2 por gasimetria e PTEA por evaporimetria. Foram aplicados testes de estatística descritiva e não paramétrica, sendo adotado um nível de confiança de 95%. As tcpO2 e tcpCO2 alteraram-se significativamente durante as manobras. Foi registado um perfil de evolução recíproca para FLD e PTEA em A e C, o que pode sugerir que, sob as condições experimentais as condições de perfusão local podem influenciar a função epidérmica "barreira". Os modelos propostos parecem ser adequados para caracterizar a microcirculação periférica in vivo, o que justifica estudos de desenvolvimento posteriores.

Planning autonomous vehicles in the absence of speed lanes using an elastic strip

Planning of autonomous vehicles in the absence of speed lanes is a less-researched problem. However, it is an important step toward extending the possibility of autonomous vehicles to countries where speed lanes are not followed. The advantages of having nonlane-oriented traffic include larger traffic bandwidth and more overtaking, which are features that are highlighted when vehicles vary in terms of speed and size. In the most general case, the road would be filled with a complex grid of static obstacles and vehicles of varying speeds. The optimal travel plan consists of a set of maneuvers that enables a vehicle to avoid obstacles and to overtake vehicles in an optimal manner and, in turn, enable other vehicles to overtake. The desired characteristics of this planning scenario include near completeness and near optimality in real time with an unstructured environment, with vehicles essentially displaying a high degree of cooperation and enabling every possible(safe) overtaking procedure to be completed as soon as possible. Challenges addressed in this paper include a (fast) method for initial path generation using an elastic strip, (re-)defining the notion of completeness specific to the problem, and inducing the notion of cooperation in the elastic strip. Using this approach, vehicular behaviors of overtaking, cooperation, vehicle following,obstacle avoidance, etc., are demonstrated.

Bio-inspired autonomous visual vertical control of a quadrotor UAV

Near ground maneuvers, such as hover, approach and landing, are key elements of autonomy in unmanned aerial vehicles. Such maneuvers have been tackled conventionally by measuring or estimating the velocity and the height above the ground often using ultrasonic or laser range finders. Near ground maneuvers are naturally mastered by flying birds and insects as objects below may be of interest for food or shelter. These animals perform such maneuvers efficiently using only the available vision and vestibular sensory information. In this paper, the time-to-contact (Tau) theory, which conceptualizes the visual strategy with which many species are believed to approach objects, is presented as a solution for Unmanned Aerial Vehicles (UAV) relative ground distance control. The paper shows how such an approach can be visually guided without knowledge of height and velocity relative to the ground. A control scheme that implements the Tau strategy is developed employing only visual information from a monocular camera and an inertial measurement unit. To achieve reliable visual information at a high rate, a novel filtering system is proposed to complement the control system. The proposed system is implemented on-board an experimental quadrotor UAV and shown not only to successfully land and approach ground, but also to enable the user to choose the dynamic characteristics of the approach. The methods presented in this paper are applicable to both aerial and space autonomous vehicles.

Bioinspired autonomous visual vertical control of a quadrotor unmanned aerial vehicle

Near-ground maneuvers, such as hover, approach, and landing, are key elements of autonomy in unmanned aerial vehicles. Such maneuvers have been tackled conventionally by measuring or estimating the velocity and the height above the ground, often using ultrasonic or laser range finders. Near-ground maneuvers are naturally mastered by flying birds and insects because objects below may be of interest for food or shelter. These animals perform such maneuvers efficiently using only the available vision and vestibular sensory information. In this paper, the time-tocontact (tau) theory, which conceptualizes the visual strategy with which many species are believed to approach objects, is presented as a solution for relative ground distance control for unmanned aerial vehicles. The paper shows how such an approach can be visually guided without knowledge of height and velocity relative to the ground. A control scheme that implements the tau strategy is developed employing only visual information from a monocular camera and an inertial measurement unit. To achieve reliable visual information at a high rate, a novel filtering system is proposed to complement the control system. The proposed system is implemented onboard an experimental quadrotor unmannedaerial vehicle and is shown to not only successfully land and approach ground, but also to enable the user to choose the dynamic characteristics of the approach. The methods presented in this paper are applicable to both aerial and space autonomous vehicles.

End-of-life practices in seven Brazilian pediatric intensive care units

Objective: To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). Design. Cross-sectional multicenter retrospective study based on medical chart review. Setting: Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in Sao Paulo (southeastern region), and three in Salvador (northeastern region). Patients. Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. Interventions: Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (K = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Student`s t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. Measurements and Main Results. Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p =.0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. Conclusions. The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.

As Mudanças Organizacionais e seus Gestores nas Empresas na Era da Informação

In the past, the changes made in organizations were from decisions made by senior administrators and were implemented through authority and power. This sort of change doesn¿t work today because at a time when knowledge is one of the main tools for development, senior administrators need the participation of employees who directly handle strategic information for the company, having the necessary data for the conception, planning and execution of changes. Companies have begun to realize that the use of their own competent staff is the way to implement faster and more efficient strategic maneuvers. Which means, for a successful change, the whole process has to involve their employees. They have to develop efficient methods, such as, techniques for analysis, problem solution, team work, system modeling, change in attitudes and behavior, and management of the organizations culture. These methods define the professional profile of those responsible for the change. Today, each administrator must have the necessary qualifications, knowledge, and competence to identify the need for an organizational change and its introduction. In truth, each administrator is responsible for the structural change in his area and the standardization of his services.