Differences across health care systems in outcome and cost-utility of surgical and conservative treatment of chronic low back pain: a study protocol

BACKGROUND: There is little evidence on differences across health care systems in choice and outcome of the treatment of chronic low back pain (CLBP) with spinal surgery and conservative treatment as the main options. At least six randomised controlled trials comparing these two options have been performed; they show conflicting results without clear-cut evidence for superior effectiveness of any of the evaluated interventions and could not address whether treatment effect varied across patient subgroups. Cost-utility analyses display inconsistent results when comparing surgical and conservative treatment of CLBP. Due to its higher feasibility, we chose to conduct a prospective observational cohort study. METHODS: This study aims to examine if1. Differences across health care systems result in different treatment outcomes of surgical and conservative treatment of CLBP2. Patient characteristics (work-related, psychological factors, etc.) and co-interventions (physiotherapy, cognitive behavioural therapy, return-to-work programs, etc.) modify the outcome of treatment for CLBP3. Cost-utility in terms of quality-adjusted life years differs between surgical and conservative treatment of CLBP.This study will recruit 1000 patients from orthopaedic spine units, rehabilitation centres, and pain clinics in Switzerland and New Zealand. Effectiveness will be measured by the Oswestry Disability Index (ODI) at baseline and after six months. The change in ODI will be the primary endpoint of this study.Multiple linear regression models will be used, with the change in ODI from baseline to six months as the dependent variable and the type of health care system, type of treatment, patient characteristics, and co-interventions as independent variables. Interactions will be incorporated between type of treatment and different co-interventions and patient characteristics. Cost-utility will be measured with an index based on EQol-5D in combination with cost data. CONCLUSION: This study will provide evidence if differences across health care systems in the outcome of treatment of CLBP exist. It will classify patients with CLBP into different clinical subgroups and help to identify specific target groups who might benefit from specific surgical or conservative interventions. Furthermore, cost-utility differences will be identified for different groups of patients with CLBP. Main results of this study should be replicated in future studies on CLBP.

C1 esterase inhibitor reduces lower extremity ischemia/reperfusion injury and associated lung damage

BACKGROUND Ischemia/reperfusion injury of lower extremities and associated lung damage may result from thrombotic occlusion, embolism, trauma, or surgical intervention with prolonged ischemia and subsequent restoration of blood flow. This clinical entity is characterized by high morbidity and mortality. Deprivation of blood supply leads to molecular and structural changes in the affected tissue. Upon reperfusion inflammatory cascades are activated causing tissue injury. We therefore tested preoperative treatment for prevention of reperfusion injury by using C1 esterase inhibitor (C1 INH). METHODS AND FINDINGS Wistar rats systemically pretreated with C1 INH (n = 6), APT070 (a membrane-targeted myristoylated peptidyl construct derived from human complement receptor 1, n = 4), vehicle (n = 7), or NaCl (n = 8) were subjected to 3h hind limb ischemia and 24h reperfusion. The femoral artery was clamped and a tourniquet placed under maintenance of a venous return. C1 INH treated rats showed significantly less edema in muscle (P<0.001) and lung and improved muscle viability (P<0.001) compared to controls and APT070. C1 INH prevented up-regulation of bradykinin receptor b1 (P<0.05) and VE-cadherin (P<0.01), reduced apoptosis (P<0.001) and fibrin deposition (P<0.01) and decreased plasma levels of pro-inflammatory cytokines, whereas deposition of complement components was not significantly reduced in the reperfused muscle. CONCLUSIONS C1 INH reduced edema formation locally in reperfused muscle as well as in lung, and improved muscle viability. C1 INH did not primarily act via inhibition of the complement system, but via the kinin and coagulation cascade. APT070 did not show beneficial effects in this model, despite potent inhibition of complement activation. Taken together, C1 INH might be a promising therapy to reduce peripheral ischemia/reperfusion injury and distant lung damage in complex and prolonged surgical interventions requiring tourniquet application.

Classification of support staff in a consortium medical library: a case study.

A representative committee of Houston Academy of Medicine-Texas Medical Center Library staff and faculty, under the direction of the library administration, successfully redesigned a job classification system for the library's nonprofessional staff. In the new system all nonprofessionals are assigned to one of five grade levels, each with a corresponding salary range. To determine its appropriate grade level each job is analyzed and assigned a numerical value using a point system based on a set of five factors, each of which is assigned a relative number of points. The factors used to measure jobs are: education and experience, complexity of work, administrative accountability, manual skill, and contact with users. Each factor is described according to degrees, so that a job can be given partial credit for a factor. An advisory staff classification committee now participates in the ongoing administration of the classification system.

Chronic spontaneous activity generated in the somata of primary nociceptors is associated with pain-related behavior after spinal cord injury.

Mechanisms underlying chronic pain that develops after spinal cord injury (SCI) are incompletely understood. Most research on SCI pain mechanisms has focused on neuronal alterations within pain pathways at spinal and supraspinal levels associated with inflammation and glial activation. These events might also impact central processes of primary sensory neurons, triggering in nociceptors a hyperexcitable state and spontaneous activity (SA) that drive behavioral hypersensitivity and pain. SCI can sensitize peripheral fibers of nociceptors and promote peripheral SA, but whether these effects are driven by extrinsic alterations in surrounding tissue or are intrinsic to the nociceptor, and whether similar SA occurs in nociceptors in vivo are unknown. We show that small DRG neurons from rats (Rattus norvegicus) receiving thoracic spinal injury 3 d to 8 months earlier and recorded 1 d after dissociation exhibit an elevated incidence of SA coupled with soma hyperexcitability compared with untreated and sham-treated groups. SA incidence was greatest in lumbar DRG neurons (57%) and least in cervical neurons (28%), and failed to decline over 8 months. Many sampled SA neurons were capsaicin sensitive and/or bound the nociceptive marker, isolectin B4. This intrinsic SA state was correlated with increased behavioral responsiveness to mechanical and thermal stimulation of sites below and above the injury level. Recordings from C- and Aδ-fibers revealed SCI-induced SA generated in or near the somata of the neurons in vivo. SCI promotes the entry of primary nociceptors into a chronic hyperexcitable-SA state that may provide a useful therapeutic target in some forms of persistent pain.

Highly efficient ketone body treatment in multiple acyl-CoA dehydrogenase deficiency-related leukodystrophy.

BACKGROUND Multiple acyl-CoA dehydrogenase deficiency- (MADD-), also called glutaric aciduria type 2, associated leukodystrophy may be severe and progressive despite conventional treatment with protein- and fat-restricted diet, carnitine, riboflavin, and coenzyme Q10. Administration of ketone bodies was described as a promising adjunct, but has only been documented once. METHODS We describe a Portuguese boy of consanguineous parents who developed progressive muscle weakness at 2.5 y of age, followed by severe metabolic decompensation with hypoglycaemia and coma triggered by a viral infection. Magnetic resonance (MR) imaging showed diffuse leukodystrophy. MADD was diagnosed by biochemical and molecular analyses. Clinical deterioration continued despite conventional treatment. Enteral sodium D,L-3-hydroxybutyrate (NaHB) was progressively introduced and maintained at 600 mg/kg BW/d (≈3% caloric need). Follow up was 3 y and included regular clinical examinations, biochemical studies, and imaging. RESULTS During follow up, the initial GMFC-MLD (motor function classification system, 0 = normal, 6 = maximum impairment) level of 5-6 gradually improved to 1 after 5 mo. Social functioning and quality of life recovered remarkably. We found considerable improvement of MR imaging and spectroscopy during follow up, with a certain lag behind clinical recovery. There was some persistent residual developmental delay. CONCLUSION NaHB is a highly effective and safe treatment that needs further controlled studies.

European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa

Hidradenitis suppurativa/acne inversa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal and anogenital regions. A mean disease incidence of 6.0 per 100,000 person-years and an average prevalence of 1% has been reported in Europe. HS has the highest impact on patients' quality of life among all assessed dermatological diseases. HS is associated with a variety of concomitant and secondary diseases, such as obesity, metabolic syndrome, inflammatory bowel disease, e.g. Crohn's disease, spondyloarthropathy, follicular occlusion syndrome and other hyperergic diseases. The central pathogenic event in HS is believed to be the occlusion of the upper part of the hair follicle leading to a perifollicular lympho-histiocytic inflammation. A highly significant association between the prevalence of HS and current smoking (Odds ratio 12.55) and overweight (Odds ratio 1.1 for each body mass index unit) has been documented. The European S1 HS guideline suggests that the disease should be treated based on its individual subjective impact and objective severity. Locally recurring lesions can be treated by classical surgery or LASER techniques, whereas medical treatment either as monotherapy or in combination with radical surgery is more appropriate for widely spread lesions. Medical therapy may include antibiotics (clindamycin plus rifampicine, tetracyclines), acitretin and biologics (adalimumab, infliximab). A Hurley severity grade-relevant treatment of HS is recommended by the expert group following a treatment algorithm. Adjuvant measurements, such as pain management, treatment of superinfections, weight loss and tobacco abstinence have to be considered.

Cervical spinal locking plate in combination with cortical ring allograft for a one level fusion in dogs with cervical spondylotic myelopathy.

OBJECTIVE To evaluate use of a surgical technique commonly used in humans for treatment of cervical spondylotic myelopathy (CSM) in dogs. DESIGN Prospective case series. ANIMALS Dogs with CSM (n=10). METHODS Dogs weighing >30 kg that had CSM at 1 vertebral articulation were eligible for inclusion. Dogs had vertebral column distraction/fusion performed using a cortical ring allograft, cancellous autograft, and a spinal locking plate. Dogs were evaluated temporally by repeat neurological examinations and by client perception of postsurgical outcome, determined by telephone interview. RESULTS Nine dogs survived the immediate postoperative period. Seven of 8 dogs had moderate to complete improvement without recurrence (mean follow-up, 2.48 years). The most common postsurgical complications were screw loosening (n=4) and plate shifting (2), neither of which required surgical revision. One dog had pseudoarthrosis that may have negatively impacted outcome. CONCLUSION Treatment of single level CSM in dogs with ring allograft and a spinal locking plate system may lead to successful outcomes. The major problems encountered with included cost of the implants and adjusting the system designed for humans to fit the vertebral column of a dog. CLINICAL RELEVANCE For dogs with CSM at a single level, the use of a spinal locking plate in combination with a cortical ring allograft can be an effective surgical treatment. Costs of the implants as well as anatomic differences in dogs make this type of surgery less appealing.

Risk factors of pneumonia in traumatic spinal-cord-injured patients

Pneumonia is a well-documented and common respiratory infection in patients with acute traumatic spinal cord injuries, and may recur during the course of acute care. Using data from the North American Clinical Trials Network (NACTN) for Spinal Cord Injury, the incidence, timing, and recurrence of pneumonia were analyzed. The two main objectives were (1) to investigate the time and potential risk factors for the first occurrence of pneumonia using the Cox Proportional Hazards model, and (2) to investigate pneumonia recurrence and its risk factors using a Counting Process model that is a generalization of the Cox Proportional Hazards model. The results from survival analysis suggested that surgery, intubation, American Spinal Injury Association (ASIA) grade, direct admission to a NACTN site and age (older than 65 or not) were significant risks for first event of pneumonia and multiple events of pneumonia. The significance of this research is that it has the potential to identify patients at the time of admission who are at high risk for the incidence and recurrence of pneumonia. Knowledge and the time of occurrence of pneumonias are important factors for the development of prevention strategies and may also provide some insights into the selection of emerging therapies that compromise the immune system. ^

Detección de patrones y anomalías espectrales del terreno mediante espectrometría de imagen de alta resolución : reconocimiento, optimización y evaluación multiescenario

El objeto de esta Tesis doctoral es el desarrollo de una metodologia para la deteccion automatica de anomalias a partir de datos hiperespectrales o espectrometria de imagen, y su cartografiado bajo diferentes condiciones tipologicas de superficie y terreno. La tecnologia hiperespectral o espectrometria de imagen ofrece la posibilidad potencial de caracterizar con precision el estado de los materiales que conforman las diversas superficies en base a su respuesta espectral. Este estado suele ser variable, mientras que las observaciones se producen en un numero limitado y para determinadas condiciones de iluminacion. Al aumentar el numero de bandas espectrales aumenta tambien el numero de muestras necesarias para definir espectralmente las clases en lo que se conoce como Maldicion de la Dimensionalidad o Efecto Hughes (Bellman, 1957), muestras habitualmente no disponibles y costosas de obtener, no hay mas que pensar en lo que ello implica en la Exploracion Planetaria. Bajo la definicion de anomalia en su sentido espectral como la respuesta significativamente diferente de un pixel de imagen respecto de su entorno, el objeto central abordado en la Tesis estriba primero en como reducir la dimensionalidad de la informacion en los datos hiperespectrales, discriminando la mas significativa para la deteccion de respuestas anomalas, y segundo, en establecer la relacion entre anomalias espectrales detectadas y lo que hemos denominado anomalias informacionales, es decir, anomalias que aportan algun tipo de informacion real de las superficies o materiales que las producen. En la deteccion de respuestas anomalas se asume un no conocimiento previo de los objetivos, de tal manera que los pixeles se separan automaticamente en funcion de su informacion espectral significativamente diferenciada respecto de un fondo que se estima, bien de manera global para toda la escena, bien localmente por segmentacion de la imagen. La metodologia desarrollada se ha centrado en la implicacion de la definicion estadistica del fondo espectral, proponiendo un nuevo enfoque que permite discriminar anomalias respecto fondos segmentados en diferentes grupos de longitudes de onda del espectro, explotando la potencialidad de separacion entre el espectro electromagnetico reflectivo y emisivo. Se ha estudiado la eficiencia de los principales algoritmos de deteccion de anomalias, contrastando los resultados del algoritmo RX (Reed and Xiaoli, 1990) adoptado como estandar por la comunidad cientifica, con el metodo UTD (Uniform Targets Detector), su variante RXD-UTD, metodos basados en subespacios SSRX (Subspace RX) y metodo basados en proyecciones de subespacios de imagen, como OSPRX (Orthogonal Subspace Projection RX) y PP (Projection Pursuit). Se ha desarrollado un nuevo metodo, evaluado y contrastado por los anteriores, que supone una variacion de PP y describe el fondo espectral mediante el analisis discriminante de bandas del espectro electromagnetico, separando las anomalias con el algortimo denominado Detector de Anomalias de Fondo Termico o DAFT aplicable a sensores que registran datos en el espectro emisivo. Se han evaluado los diferentes metodos de deteccion de anomalias en rangos del espectro electromagnetico del visible e infrarrojo cercano (Visible and Near Infrared-VNIR), infrarrojo de onda corta (Short Wavelenght Infrared-SWIR), infrarrojo medio (Meadle Infrared-MIR) e infrarrojo termico (Thermal Infrared-TIR). La respuesta de las superficies en las distintas longitudes de onda del espectro electromagnetico junto con su entorno, influyen en el tipo y frecuencia de las anomalias espectrales que puedan provocar. Es por ello que se han utilizado en la investigacion cubos de datos hiperepectrales procedentes de los sensores aeroportados cuya estrategia y diseno en la construccion espectrometrica de la imagen difiere. Se han evaluado conjuntos de datos de test de los sensores AHS (Airborne Hyperspectral System), HyMAP Imaging Spectrometer, CASI (Compact Airborne Spectrographic Imager), AVIRIS (Airborne Visible Infrared Imaging Spectrometer), HYDICE (Hyperspectral Digital Imagery Collection Experiment) y MASTER (MODIS/ASTER Simulator). Se han disenado experimentos sobre ambitos naturales, urbanos y semiurbanos de diferente complejidad. Se ha evaluado el comportamiento de los diferentes detectores de anomalias a traves de 23 tests correspondientes a 15 areas de estudio agrupados en 6 espacios o escenarios: Urbano - E1, Semiurbano/Industrial/Periferia Urbana - E2, Forestal - E3, Agricola - E4, Geologico/Volcanico - E5 y Otros Espacios Agua, Nubes y Sombras - E6. El tipo de sensores evaluados se caracteriza por registrar imagenes en un amplio rango de bandas, estrechas y contiguas, del espectro electromagnetico. La Tesis se ha centrado en el desarrollo de tecnicas que permiten separar y extraer automaticamente pixeles o grupos de pixeles cuya firma espectral difiere de manera discriminante de las que tiene alrededor, adoptando para ello como espacio muestral parte o el conjunto de las bandas espectrales en las que ha registrado radiancia el sensor hiperespectral. Un factor a tener en cuenta en la investigacion ha sido el propio instrumento de medida, es decir, la caracterizacion de los distintos subsistemas, sensores imagen y auxiliares, que intervienen en el proceso. Para poder emplear cuantitativamente los datos medidos ha sido necesario definir las relaciones espaciales y espectrales del sensor con la superficie observada y las potenciales anomalias y patrones objetivos de deteccion. Se ha analizado la repercusion que en la deteccion de anomalias tiene el tipo de sensor, tanto en su configuracion espectral como en las estrategias de diseno a la hora de registrar la radiacion prodecente de las superficies, siendo los dos tipos principales de sensores estudiados los barredores o escaneres de espejo giratorio (whiskbroom) y los barredores o escaneres de empuje (pushbroom). Se han definido distintos escenarios en la investigacion, lo que ha permitido abarcar una amplia variabilidad de entornos geomorfologicos y de tipos de coberturas, en ambientes mediterraneos, de latitudes medias y tropicales. En resumen, esta Tesis presenta una tecnica de deteccion de anomalias para datos hiperespectrales denominada DAFT en su variante de PP, basada en una reduccion de la dimensionalidad proyectando el fondo en un rango de longitudes de onda del espectro termico distinto de la proyeccion de las anomalias u objetivos sin firma espectral conocida. La metodologia propuesta ha sido probada con imagenes hiperespectrales reales de diferentes sensores y en diferentes escenarios o espacios, por lo tanto de diferente fondo espectral tambien, donde los resultados muestran los beneficios de la aproximacion en la deteccion de una gran variedad de objetos cuyas firmas espectrales tienen suficiente desviacion respecto del fondo. La tecnica resulta ser automatica en el sentido de que no hay necesidad de ajuste de parametros, dando resultados significativos en todos los casos. Incluso los objetos de tamano subpixel, que no pueden distinguirse a simple vista por el ojo humano en la imagen original, pueden ser detectados como anomalias. Ademas, se realiza una comparacion entre el enfoque propuesto, la popular tecnica RX y otros detectores tanto en su modalidad global como local. El metodo propuesto supera a los demas en determinados escenarios, demostrando su capacidad para reducir la proporcion de falsas alarmas. Los resultados del algoritmo automatico DAFT desarrollado, han demostrado la mejora en la definicion cualitativa de las anomalias espectrales que identifican a entidades diferentes en o bajo superficie, reemplazando para ello el modelo clasico de distribucion normal con un metodo robusto que contempla distintas alternativas desde el momento mismo de la adquisicion del dato hiperespectral. Para su consecucion ha sido necesario analizar la relacion entre parametros biofisicos, como la reflectancia y la emisividad de los materiales, y la distribucion espacial de entidades detectadas respecto de su entorno. Por ultimo, el algoritmo DAFT ha sido elegido como el mas adecuado para sensores que adquieren datos en el TIR, ya que presenta el mejor acuerdo con los datos de referencia, demostrando una gran eficacia computacional que facilita su implementacion en un sistema de cartografia que proyecte de forma automatica en un marco geografico de referencia las anomalias detectadas, lo que confirma un significativo avance hacia un sistema en lo que se denomina cartografia en tiempo real. The aim of this Thesis is to develop a specific methodology in order to be applied in automatic detection anomalies processes using hyperspectral data also called hyperspectral scenes, and to improve the classification processes. Several scenarios, areas and their relationship with surfaces and objects have been tested. The spectral characteristics of reflectance parameter and emissivity in the pattern recognition of urban materials in several hyperspectral scenes have also been tested. Spectral ranges of the visible-near infrared (VNIR), shortwave infrared (SWIR) and thermal infrared (TIR) from hyperspectral data cubes of AHS (Airborne Hyperspectral System), HyMAP Imaging Spectrometer, CASI (Compact Airborne Spectrographic Imager), AVIRIS (Airborne Visible Infrared Imaging Spectrometer), HYDICE (Hyperspectral Digital Imagery Collection Experiment) and MASTER (MODIS/ASTER Simulator) have been used in this research. It is assumed that there is not prior knowledge of the targets in anomaly detection. Thus, the pixels are automatically separated according to their spectral information, significantly differentiated with respect to a background, either globally for the full scene, or locally by the image segmentation. Several experiments on different scenarios have been designed, analyzing the behavior of the standard RX anomaly detector and different methods based on subspace, image projection and segmentation-based anomaly detection methods. Results and their consequences in unsupervised classification processes are discussed. Detection of spectral anomalies aims at extracting automatically pixels that show significant responses in relation of their surroundings. This Thesis deals with the unsupervised technique of target detection, also called anomaly detection. Since this technique assumes no prior knowledge about the target or the statistical characteristics of the data, the only available option is to look for objects that are differentiated from the background. Several methods have been developed in the last decades, allowing a better understanding of the relationships between the image dimensionality and the optimization of search procedures as well as the subpixel differentiation of the spectral mixture and its implications in anomalous responses. In other sense, image spectrometry has proven to be efficient in the characterization of materials, based on statistical methods using a specific reflection and absorption bands. Spectral configurations in the VNIR, SWIR and TIR have been successfully used for mapping materials in different urban scenarios. There has been an increasing interest in the use of high resolution data (both spatial and spectral) to detect small objects and to discriminate surfaces in areas with urban complexity. This has come to be known as target detection which can be either supervised or unsupervised. In supervised target detection, algorithms lean on prior knowledge, such as the spectral signature. The detection process for matching signatures is not straightforward due to the complications of converting data airborne sensor with material spectra in the ground. This could be further complicated by the large number of possible objects of interest, as well as uncertainty as to the reflectance or emissivity of these objects and surfaces. An important objective in this research is to establish relationships that allow linking spectral anomalies with what can be called informational anomalies and, therefore, identify information related to anomalous responses in some places rather than simply spotting differences from the background. The development in recent years of new hyperspectral sensors and techniques, widen the possibilities for applications in remote sensing of the Earth. Remote sensing systems measure and record electromagnetic disturbances that the surveyed objects induce in their surroundings, by means of different sensors mounted on airborne or space platforms. Map updating is important for management and decisions making people, because of the fast changes that usually happen in natural, urban and semi urban areas. It is necessary to optimize the methodology for obtaining the best from remote sensing techniques from hyperspectral data. The first problem with hyperspectral data is to reduce the dimensionality, keeping the maximum amount of information. Hyperspectral sensors augment considerably the amount of information, this allows us to obtain a better precision on the separation of material but at the same time it is necessary to calculate a bigger number of parameters, and the precision lowers with the increase in the number of bands. This is known as the Hughes effects (Bellman, 1957) . Hyperspectral imagery allows us to discriminate between a huge number of different materials however some land and urban covers are made up with similar material and respond similarly which produces confusion in the classification. The training and the algorithm used for mapping are also important for the final result and some properties of thermal spectrum for detecting land cover will be studied. In summary, this Thesis presents a new technique for anomaly detection in hyperspectral data called DAFT, as a PP's variant, based on dimensionality reduction by projecting anomalies or targets with unknown spectral signature to the background, in a range thermal spectrum wavelengths. The proposed methodology has been tested with hyperspectral images from different imaging spectrometers corresponding to several places or scenarios, therefore with different spectral background. The results show the benefits of the approach to the detection of a variety of targets whose spectral signatures have sufficient deviation in relation to the background. DAFT is an automated technique in the sense that there is not necessary to adjust parameters, providing significant results in all cases. Subpixel anomalies which cannot be distinguished by the human eye, on the original image, however can be detected as outliers due to the projection of the VNIR end members with a very strong thermal contrast. Furthermore, a comparison between the proposed approach and the well-known RX detector is performed at both modes, global and local. The proposed method outperforms the existents in particular scenarios, demonstrating its performance to reduce the probability of false alarms. The results of the automatic algorithm DAFT have demonstrated improvement in the qualitative definition of the spectral anomalies by replacing the classical model by the normal distribution with a robust method. For their achievement has been necessary to analyze the relationship between biophysical parameters such as reflectance and emissivity, and the spatial distribution of detected entities with respect to their environment, as for example some buried or semi-buried materials, or building covers of asbestos, cellular polycarbonate-PVC or metal composites. Finally, the DAFT method has been chosen as the most suitable for anomaly detection using imaging spectrometers that acquire them in the thermal infrared spectrum, since it presents the best results in comparison with the reference data, demonstrating great computational efficiency that facilitates its implementation in a mapping system towards, what is called, Real-Time Mapping.

Ultrassonografia vascular comparada à intravascular no diagnóstico das obstruções venosas ilíacas em portadores de insuficiência venosa crônica

Introdução: O tratamento da Insuficiência Venosa Crônica (IVC) é baseado na correção dos refluxos e obstruções ao fluxo sanguíneo venoso. A detecção, a gravidade e o tratamento dessas obstruções venosas, responsáveis pelos sinais e sintomas da IVC, têm sido recentemente estudados e melhor compreendidos. Estes estudos não definem qual o grau de obstrução significativa nem os critérios ultrassonográficos para sua detecção. O objetivo deste estudo foi determinar critérios ultrassonográficos para o diagnóstico das obstruções venosas ilíacas, avaliando a concordância deste método com o ultrassom intravascular (UI) em pacientes portadores de IVC avançada. Métodos: Foram avaliados 15 pacientes (30 membros; 49,4 ± 10,7 anos; 1 homem) com IVC inicial (Classificação Clínica-Etiológica-Anatômica-Physiopatológica - CEAP C1-2) no grupo I (GI) e 51 pacientes (102 membros; 50,53 ± 14,5 anos; 6 homens) com IVC avançada (CEAP C3-6) no grupo II (GII) pareados por sexo, idade e etnia. Todos pacientes foram submetidos à entrevista clínica e à ultrassonografia vascular com Doppler (UV-D), sendo obtidas as medidas de fasicidade de fluxo, os índices de fluxo e velocidades venosas femorais, e as relações de velocidade e de diâmetro da obstrução ilíaca. Foi analisado o escore de refluxo multisegmentar. Os indivíduos do GI foram avaliados por 3 examinadores independentes. Os pacientes do GII foram submetidos ao UI, sendo obtidos a área dos segmentos venosos comprometidos e comparados com os resultados obtidos pelo UV-D, agrupados em 3 categorias: obstruções < 50%; obstruções entre 50-79% e obstruções >= 80%. Resultados: A classe de severidade clinica CEAP predominante no GI foi C1 em 24/30 (80%) membros, e C3 em 54/102 (52,9%) membros no GII. O refluxo foi severo (escore de refluxo multisegmentar >= 3) em 3/30 (10%) membros no grupo I, e em 45/102 (44,1%) membros no grupo II (p<0,001). Houve uma concordância moderadamente elevada entre o UV-D e o UI, quando agrupadas em 3 categorias (K=0,598; p<0,001), e uma concordância elevada quando agrupadas em 2 categorias (obstruções <50% e >= 50%) (K= 0,784; p<0,001). Os melhores pontos de corte e sua correlação com o UI foram: índice de velocidade (0,9; r=-0,634; p<0,001); índice de fluxo (0,7; r=-0,623; p<0,001); relação de obstrução (0,5; r=0,750; p<0,001); relação de velocidade (2,5; r= 0,790; p<0,001); A ausência de fasicidade de fluxo esteve presente em 88,2% dos pacientes com obstrução >=80% ao UV-D. Foi construído um algoritmo ultrassonográfico vascular, utilizando as medidas e os pontos de corte descritos obtendo-se uma acurácia de 79,6% para 3 categorias (K=0,655; p<0,001) e de 86,7% para 2 categorias (k=0,730; p<0,001). Conclusões: O UV-D apresentou uma concordância elevada com o UI na detecção de obstruções >= 50%. A relação de velocidade na obstrução >= 2,5 é o melhor critério para detecção de obstruções venosas significativas em veias ilíacas.

Avaliação da capacidade funcional de pacientes vítimas de trauma um ano após alta hospitalar

Objetivos: Avaliar a capacidade funcional de pacientes vítimas de trauma um ano após alta hospitalar e verificar associação da capacidade funcional com fatores relacionados ao trauma e à internação hospitalar. Metodologia: Estudo de coorte prospectivo, com pacientes vítimas de trauma grave (Injury Severity Score - ISS >=16), internados entre Junho e Setembro de 2010 em unidade de terapia intensiva (UTI) cirúrgica especializada em paciente politraumatizado de um hospital público de grande porte na cidade de São Paulo, Brasil. Variáveis de interesse como idade, sexo, escore de Glasgow, Acute Physiology and Chronic Health Disease Classification System II (APACHE II), mecanismos de trauma, número de lesões, região corpórea afetada, número de cirurgias, duração da ventilação mecânica (VM) e tempo de internação hospitalar foram coletadas dos prontuários médicos. A capacidade funcional foi avaliada um ano após alta hospitalar utilizando as escalas Glasgow Outcome Scale (GOS) e Escala de Atividades Instrumentais de Vida Diária de Lawton (AIVDL). Os pacientes também foram questionados se haviam retornado ao trabalho ou estudo. Resultados: O seguimento um ano após trauma foi completo em 49 indivíduos, a maioria composta por jovens (36±11 anos), do sexo masculino (81,6%) e vítimas de acidentes de trânsito (71,5%). Cada indivíduo sofreu aproximadamente 4 lesões corporais, acarretando uma média no ISS de 31 ± 14,4. O traumatismo cranioencefálico foi o tipo de lesão mais comum (65,3%). De acordo com a GOS, a maioria dos pacientes apresentou disfunção moderada (43%) ou disfunção leve ou ausente (37%) um ano após o trauma. A escala AIVDL apresentou pontuação média de 12±4 com aproximadamente 60- 70% dos indivíduos capazes de realizar de forma independente a maioria das atividades avaliadas. Escore de Glasgow, APACHE II, duração da VM e tempo de internação hospitalar foram associadas com a capacidade funcional um ano após lesão. A regressão linear múltipla considerando todas as variáveis significativas revelou associação entre a pontuação da escala AIVDL e o tempo de internação hospitalar. Apenas 32,6% dos indivíduos retornaram ao trabalho ou estudo. Conclusões: A maioria dos pacientes vítimas de trauma grave foi capaz de realizar as atividades avaliadas com independência; apenas um terço deles retornou ao trabalho e/ou estudo um ano após alta hospitalar. O tempo de internação hospitalar foi revelado como preditor significativo para a recuperação da capacidade funcional um ano após lesão grave

Injury scaling research. Final report.

National Highway Traffic Safety Administration, Washington, D.C.

Marine mammal species detection and classification

Thesis (Ph.D.)--University of Washington, 2016-04

Spinal motor neurite outgrowth over glial scar inhibitors is enhanced by coculture with bone marrow stromal cells

Background context Transplantation of bone marrow cells into spinal cord lesions promotes functional recovery in animal models, and recent clinical trials suggest possible recovery also in humans. The mechanisms responsible for these improvements are still unclear. Purpose To characterize spinal cord motor neurite interactions with human bone marrow stromal cells (MSCs) in an in vitro model of spinal cord injury (SCI). Study design/setting Previously, we have reported that human MSCs promote the growth of extending sensory neurites from dorsal root ganglia (DRG), in the presence of some of the molecules present in the glial scar, which are attributed with inhibiting axonal regeneration after SCI. We have adapted and optimized this system replacing the DRG with a spinal cord culture to produce a central nervous system (CNS) model, which is more relevant to the SCI situation. Methods We have developed and characterized a novel spinal cord culture system. Human MSCs were cocultured with spinal motor neurites in substrate choice assays containing glial scar-associated inhibitors of nerve growth. In separate experiments, MSC-conditioned media were analyzed and added to spinal motor neurites in substrate choice assays. Results As has been reported previously with DRG, substrate-bound neurocan and Nogo-A repelled spinal neuronal adhesion and neurite outgrowth, but these inhibitory effects were abrogated in MSC/spinal cord cocultures. However, unlike DRG, spinal neuronal bodies and neurites showed no inhibition to substrates of myelin-associated glycoprotein. In addition, the MSC secretome contained numerous neurotrophic factors that stimulated spinal neurite outgrowth, but these were not sufficient stimuli to promote spinal neurite extension over inhibitory concentrations of neurocan or Nogo-A. Conclusions These findings provide novel insight into how MSC transplantation may promote regeneration and functional recovery in animal models of SCI and in the clinic, especially in the chronic situation in which glial scars (and associated neural inhibitors) are well established. In addition, we have confirmed that this CNS model predominantly comprises motor neurons via immunocytochemical characterization. We hope that this model may be used in future research to test various other potential interventions for spinal injury or disease states. © 2014 Elsevier Inc. All rights reserved.

Weighted ICP Algorithm for Alignment of Stars from Scanned Astronomical Photographic Plates

ACM Computing Classification System (1998): I.2.8, I.2.10, I.5.1, J.2.