Inspiratory Muscle Training Reduces Sympathetic Nervous Activity and Improves Inspiratory Muscle Weakness and Quality of Life in Patients With Chronic Heart Failure A CLINICAL TRIAL

PURPOSE: To evaluate the effect of inspiratory muscle training (IMT) on cardiac autonomic modulation and on peripheral nerve sympathetic activity in patients with chronic heart failure (CHF). METHODS: Functional capacity, low-frequency (LF) and high-frequency (HF) components of heart rate variability, muscle sympathetic nerve activity inferred by microneurography, and quality of life were determined in 27 patients with CHF who had been sequentially allocated to 1 of 2 groups: (1) control group (with no intervention) and (2) IMT group. Inspiratory muscle training consisted of respiratory exercises, with inspiratory threshold loading of seven 30-minute sessions per week for a period of 12 weeks, with a monthly increase of 30% in maximal inspiratory pressure (PImax) at rest. Multivariate analysis was applied to detect differences between baseline and followup period. RESULTS: Inspiratory muscle training significantly increased PImax (59.2 +/- 4.9 vs 87.5 +/- 6.5 cmH(2)O, P = .001) and peak oxygen uptake (14.4 +/- 0.7 vs 18.9 +/- 0.8 mL.kg(-1).min(-1), P = .002); decreased the peak ventilation (V. E) +/- carbon dioxide production (V-CO2) ratio (35.8 +/- 0.8 vs 32.5 +/- 0.4, P = .001) and the (V) over dotE +/-(V) over dotCO(2) slope (37.3 +/- 1.1 vs 31.3 +/- 1.1, P = .004); increased the HF component (49.3 +/- 4.1 vs 58.4 +/- 4.2 normalized units, P = .004) and decreased the LF component (50.7 +/- 4.1 vs 41.6 +/- 4.2 normalized units, P = .001) of heart rate variability; decreased muscle sympathetic nerve activity (37.1 +/- 3 vs 29.5 +/- 2.3 bursts per minute, P = .001); and improved quality of life. No significant changes were observed in the control group. CONCLUSION: Home-based IMT represents an important strategy to improve cardiac and peripheral autonomic controls, functional capacity, and quality of life in patients with CHF.

Basketball from perspective of nonlinear complex systems

Doctoral program: Motor praxiology, physical education and sport training

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.

The Role of Anharmonicity in Hydrogen-Bonded Systems: The Case of Water Clusters

The nature of vibrational anharmonicity has been examined for the case of small water clusters using second-order vibrational perturbation theory (VPT2) applied on second-order Møller–Plesset perturbation theory (MP2) potential energy surfaces. Using a training set of 16 water clusters (H2O)n=2–6,8,9 with a total of 723 vibrational modes, we determined scaling factors that map the harmonic frequencies onto anharmonic ones. The intermolecular modes were found to be substantially more anharmonic than intramolecular bending and stretching modes. Due to the varying levels of anharmonicity of the intermolecular and intramolecular modes, different frequency scaling factors for each region were necessary to achieve the highest accuracy. Furthermore, new scaling factors for zero-point vibrational energies (ZPVE) and vibrational corrections to the enthalpy (ΔHvib) and the entropy (Svib) have been determined. All the scaling factors reported in this study are different from previous works in that they are intended for hydrogen-bonded systems, while others were built using experimental frequencies of covalently bonded systems. An application of our scaling factors to the vibrational frequencies of water dimer and thermodynamic functions of 11 larger water clusters highlights the importance of anharmonic effects in hydrogen-bonded systems.

The Role of Anharmonicity in Hydrogen-Bonded Systems: The Case of Water Clusters

The nature of vibrational anharmonicity has been examined for the case of small water clusters using second-order vibrational perturbation theory (VPT2) applied on second-order Møller–Plesset perturbation theory (MP2) potential energy surfaces. Using a training set of 16 water clusters (H2O)n=2–6,8,9 with a total of 723 vibrational modes, we determined scaling factors that map the harmonic frequencies onto anharmonic ones. The intermolecular modes were found to be substantially more anharmonic than intramolecular bending and stretching modes. Due to the varying levels of anharmonicity of the intermolecular and intramolecular modes, different frequency scaling factors for each region were necessary to achieve the highest accuracy. Furthermore, new scaling factors for zero-point vibrational energies (ZPVE) and vibrational corrections to the enthalpy (ΔHvib) and the entropy (Svib) have been determined. All the scaling factors reported in this study are different from previous works in that they are intended for hydrogen-bonded systems, while others were built using experimental frequencies of covalently bonded systems. An application of our scaling factors to the vibrational frequencies of water dimer and thermodynamic functions of 11 larger water clusters highlights the importance of anharmonic effects in hydrogen-bonded systems.

Post-project assessment and follow-up support for community managed rural water systems in Panama

The Environmental Health (EH) program of Peace Corps (PC) Panama and a non-governmental organization (NGO) Waterlines have been assisting rural communities in Panama gain access to improved water sources through the practice of community management (CM) model and participatory development. Unfortunately, there is little information available on how a water system is functioning once the construction is complete and the volunteer leaves the community. This is a concern when the recent literature suggests that most communities are not able to indefinitely maintain a rural water system (RWS) without some form of external assistance (Sara and Katz, 1997; Newman et al, 2002; Lockwood, 2002, 2003, 2004; IRC, 2003; Schweitzer, 2009). Recognizing this concern, the EH program director encouraged the author to complete a postproject assessment of the past EH water projects. In order to carry out the investigation, an easy to use monitoring and evaluation tool was developed based on literature review and the author’s three years of field experience in rural Panama. The study methodology consists of benchmark scoring systems to rate the following ten indicators: watershed, source capture, transmission line, storage tank, distribution system, system reliability, willingness to pay, accounting/transparency, maintenance, and active water committee members. The assessment of 28 communities across the country revealed that the current state of physical infrastructure, as well as the financial, managerial and technical capabilities of water committees varied significantly depending on the community. While some communities are enjoying continued service and their water committee completing all of its responsibilities, others have seen their water systems fall apart and be abandoned. Overall, the higher score were more prevalent for all ten indicators. However, even the communities with the highest scores requested some form of additional assistance. The conclusion from the assessment suggests that the EH program should incorporate an institutional support mechanism (ISM) to its sector policy in order to systematically provide follow-up support to rural communities in Panama. A full-time circuit rider with flexible funding would be able to provide additional technical support, training and encouragement to those communities in need.

Community managed rural water supply systems in the Dominican Republic : assessment of sustainability of systems built by the National Institute of Potable Water and Peace Corps, Dominican Republic

In the Dominican Republic economic growth in the past twenty years has not yielded sufficient improvement in access to drinking water services, especially in rural areas where 1.5 million people do not have access to an improved water source (WHO, 2006). Worldwide, strategic development planning in the rural water sector has focused on participatory processes and the use of demand filters to ensure that service levels match community commitment to post-project operation and maintenance. However studies have concluded that an alarmingly high percentage of drinking water systems (20-50%) do not provide service at the design levels and/or fail altogether (up to 90%): BNWP (2009), Annis (2006), and Reents (2003). World Bank, USAID, NGOs, and private consultants have invested significant resources in an effort to determine what components make up an “enabling environment” for sustainable community management of rural water systems (RWS). Research has identified an array of critical factors, internal and external to the community, which affect long term sustainability of water services. Different frameworks have been proposed in order to better understand the linkages between individual factors and sustainability of service. This research proposes a Sustainability Analysis Tool to evaluate the sustainability of RWS, adapted from previous relevant work in the field to reflect the realities in the Dominican Republic. It can be used as a diagnostic tool for government entities and development organizations to characterize the needs of specific communities and identify weaknesses in existing training regimes or support mechanisms. The framework utilizes eight indicators in three categories (Organization/Management, Financial Administration, and Technical Service). Nineteen independent variables are measured resulting in a score of sustainability likely (SL), possible (SP), or unlikely (SU) for each of the eight indicators. Thresholds are based upon benchmarks from the DR and around the world, primary data collected during the research, and the author’s 32 months of field experience. A final sustainability score is calculated using weighting factors for each indicator, derived from Lockwood (2003). The framework was tested using a statistically representative geographically stratified random sample of 61 water systems built in the DR by initiatives of the National Institute of Potable Water (INAPA) and Peace Corps. The results concluded that 23% of sample systems are likely to be sustainable in the long term, 59% are possibly sustainable, and for 18% it is unlikely that the community will be able to overcome any significant challenge. Communities that were scored as unlikely sustainable perform poorly in participation, financial durability, and governance while the highest scores were for system function and repair service. The Sustainability Analysis Tool results are verified by INAPA and PC reports, evaluations, and database information, as well as, field observations and primary data collected during the surveys. Future research will analyze the nature and magnitude of relationships between key factors and the sustainability score defined by the tool. Factors include: gender participation, legal status of water committees, plumber/operator remuneration, demand responsiveness, post construction support methodologies, and project design criteria.

Electronic medical record systems, data quality and loss to follow-up: survey of antiretroviral therapy programmes in resource-limited settings

OBJECTIVE: To describe the electronic medical databases used in antiretroviral therapy (ART) programmes in lower-income countries and assess the measures such programmes employ to maintain and improve data quality and reduce the loss of patients to follow-up. METHODS: In 15 countries of Africa, South America and Asia, a survey was conducted from December 2006 to February 2007 on the use of electronic medical record systems in ART programmes. Patients enrolled in the sites at the time of the survey but not seen during the previous 12 months were considered lost to follow-up. The quality of the data was assessed by computing the percentage of missing key variables (age, sex, clinical stage of HIV infection, CD4+ lymphocyte count and year of ART initiation). Associations between site characteristics (such as number of staff members dedicated to data management), measures to reduce loss to follow-up (such as the presence of staff dedicated to tracing patients) and data quality and loss to follow-up were analysed using multivariate logit models. FINDINGS: Twenty-one sites that together provided ART to 50 060 patients were included (median number of patients per site: 1000; interquartile range, IQR: 72-19 320). Eighteen sites (86%) used an electronic database for medical record-keeping; 15 (83%) such sites relied on software intended for personal or small business use. The median percentage of missing data for key variables per site was 10.9% (IQR: 2.0-18.9%) and declined with training in data management (odds ratio, OR: 0.58; 95% confidence interval, CI: 0.37-0.90) and weekly hours spent by a clerk on the database per 100 patients on ART (OR: 0.95; 95% CI: 0.90-0.99). About 10 weekly hours per 100 patients on ART were required to reduce missing data for key variables to below 10%. The median percentage of patients lost to follow-up 1 year after starting ART was 8.5% (IQR: 4.2-19.7%). Strategies to reduce loss to follow-up included outreach teams, community-based organizations and checking death registry data. Implementation of all three strategies substantially reduced losses to follow-up (OR: 0.17; 95% CI: 0.15-0.20). CONCLUSION: The quality of the data collected and the retention of patients in ART treatment programmes are unsatisfactory for many sites involved in the scale-up of ART in resource-limited settings, mainly because of insufficient staff trained to manage data and trace patients lost to follow-up.

Youth Work and Schools in ‘Full-day’ education systems: International Comparison of Links between Formal and Non-formal Education

In this article I will outline the methodological approach of a non-empirical comparative research project which I began in 2003. The project is situated in the context of the research training group “Youth Welfare in Transition” at the universities of Bielefeld and Dortmund, funded by the German Research Council (Deutsche Forschungsgemeinschaft). In that context I have organised an international conference about the modes of cooperation between school and youth work agencies with colleagues from Canada, France, Finland, Italy, Japan, the Netherlands, Russia, Switzerland, the United Kingdom, the United States, Israel, and Germany. Meeting in Bielefeld from the 9th to the 11th of October 2003, we compared the respective national arrangements of formal and non-formal education (www.uni-bielefeld.de/paedagogik/agn/ag8/Ganztagsbildung.html). This note is based on the scheme of comparison which was given to the contributors in order to help them preparing their presentations. At the moment the scheme is nearing completed with significant data prepared by the contributors/authors (see Otto/Coelen 2004), supplemented with data from research works published in German and English. The next step will be to set up an empirical project about the relationships between schools and youth work agencies in three European countries (probably France, Finland and the Netherlands).

The use of learning management systems: A Longitudinal Case Study

In this article the use of Learning Management Systems (LMS) at the School of Engineering, University of Borås, in the year 2004 and the academic year 2009-2010 is investigated. The tools in the LMS were classified into four groups (tools for distribution, tools for communication, tools for interaction and tools for course administration) and the pattern of use was analyzed. The preliminary interpretation of the results was discussed with a group of teachers from the School of Engineering with long experience of using LMS. High expectations about LMS as a tool to facilitate flexible education, student centered methods and the creation of an effective learning environment is abundant in the literature. This study, however, shows that in most of the surveyed courses the available LMS is predominantly used to distribute documents to students. The authors argue that a more elaborate use of LMS and a transformation of pedagogical practices towards social constructivist, learner centered procedures should be treated as an integrated process of professional development.

The Position of xMOOCs in Educational Systems

The idea of xMOOCs initially aimed at fundamentally changing the US tertiary education system by providing open mass education. This attempt failed for a number of reasons. They include: the ignorance of the importance and benefits of face-to-face instruction, the high workload imposed on students by xMOOCs, the consequences of current xMOOC didactics, the financing of the high costs, and the difficulties of integration into the teaching organization. As a consequence, xMOOCs are turning into methods for professional continuing education including a business model that covers the institution’s cost.

A Fast Platform for Interactive E-Learning Systems

Modern e-learning systems represent a special type of web information systems. By definition, information systems are special computerized systems used to perform data operations by multiple users simultaneously. Each active user consumes an amount of hardware resources. A shortage of hardware resources can be caused by growing number of simultaneous users. Such situation can result in overall malfunctioning or slowed-down system. In order to avoid this problem, the underlying hardware system gets usually continuously upgraded. These upgrades, typically accompanied with various software updates, usually result in a temporarily increased amount of available resources. This work deals with the problem in a different way by proposing an implementation of a web e-learning system with a modified software architecture reducing resource usage of the server part to the bare minimum. In order to implement a full-scale e-learning system that could be used as a substitute to a conventional web e-learning system, a Rich Internet Application framework was used as basis. The technology allowed implementation of advanced interactivity features and provided an easy transfer of a substantial part of the application logic from server to clients. In combination with a special server application, the server part of the new system is able to run with a reasonable performance on a hardware with very limited computing resources.

Digital Systems for Open Access to Formal and Informal Learning

Today, Digital Systems and Services for Technology Supported Learning and Education are recognized as the key drivers to transform the way that individuals, groups and organizations “learn” and the way to “assess learning” in 21st Century. These transformations influence: Objectives - moving from acquiring new “knowledge” to developing new and relevant “competences”; Methods – moving from “classroom” based teaching to “context-aware” personalized learning; and Assessment – moving from “life-long” degrees and certifications to “on-demand” and “in-context” accreditation of qualifications. Within this context, promoting Open Access to Formal and Informal Learning, is currently a key issue in the public discourse and the global dialogue on Education, including Massive Open Online Courses (MOOCs) and Flipped School Classrooms. This volume on Digital Systems for Open Access to Formal and Informal Learning contributes to the international dialogue between researchers, technologists, practitioners and policy makers in Technology Supported Education and Learning. It addresses emerging issues related with both theory and practice, as well as, methods and technologies that can support Open Access to Formal and Informal Learning. In the twenty chapters contributed by international experts who are actively shaping the future of Educational Technology around the world, topics such as: - The evolution of University Open Courses in Transforming Learning - Supporting Open Access to Teaching and Learning of People with Disabilities - Assessing Student Learning in Online Courses - Digital Game-based Learning for School Education - Open Access to Virtual and Remote Labs for STEM Education - Teachers’ and Schools’ ICT Competence Profiling - Web-Based Education and Innovative Leadership in a K-12 International School Setting are presented. An in-depth blueprint of the promise, potential, and imminent future of the field, Digital Systems for Open Access to Formal and Informal Learning is necessary reading for researchers and practitioners, as well as, undergraduate and postgraduate students, in educational technology.

New Trends in Networking, Computing, E-learning, Systems Sciences, and Engineering

This book provides the latest in a series of books growing out of the International Joint Conferences on Computer, Information and Systems Sciences and Engineering. It includes chapters in the most advanced areas of Computing, Informatics, Systems Sciences and Engineering. It has accessible to a wide range of readership, including professors, researchers, practitioners and students. This book includes a set of rigorously reviewed world-class manuscripts addressing and detailing state-of-the-art research projects in the areas of Computer Science, Informatics, and Systems Sciences, and Engineering. It includes selected papers form the conference proceedings of the Ninth International Joint Conferences on Computer, Information, and Systems Sciences, and Engineering (CISSE 2013). Coverage includes topics in: Industrial Electronics, Technology & Automation, Telecommunications and Networking, Systems, Computing Sciences and Software Engineering, Engineering Education, Instructional Technology, Assessment, and E-learning.

E-Learning Systems, Environments and Approaches

The volume consists of twenty-five chapters selected from among peer-reviewed papers presented at the CELDA (Cognition and Exploratory Learning in the Digital Age) 2013 Conference held in Fort Worth, Texas, USA, in October 2013 and also from world class scholars in e-learning systems, environments and approaches. The following sub-topics are included: Exploratory Learning Technologies (Part I), e-Learning social web design (Part II), Learner communities through e-Learning implementations (Part III), Collaborative and student-centered e-Learning design (Part IV). E-Learning has been, since its initial stages, a synonym for flexibility. While this dynamic nature has mainly been associated with time and space it is safe to argue that currently it embraces other aspects such as the learners’ profile, the scope of subjects that can be taught electronically and the technology it employs. New technologies also widen the range of activities and skills developed in e-Learning. Electronic learning environments have evolved past the exclusive delivery of knowledge. Technology has endowed e-Learning with the possibility of remotely fomenting problem solving skills, critical thinking and team work, by investing in information exchange, collaboration, personalisation and community building.