Endovascular Treatment for Acute Aortic Syndrome

Background: The term "acute aortic syndrome" (AAS) includes conditions of high mortality, such as ruptured aneurysm, pseudoaneurysm and, aortic dissection. Open surgery for these cases has demonstrated unsatisfactory results, and endovascular treatment has become an excellent alternative. Methods: We performed a retrospective review of patients with AAS who underwent endovascular treatment in our emergency department from July 2009 to February 2011. They represent 64% (16 of 25) of all patients with AAS seen during this period. Results: Sixteen patients underwent endovascular treatment: eight ruptured aneurysms, six aortic dissections, one nonruptured painful aneurysm, and one pseudoaneurysm. No intramural hematoma or penetrating atherosclerotic ulcer was found. The mean age was 64.3 years, and arterial hypertension (100%) and smoking (64.7%) were the major comorbidities. Technical success rate was 93%, and overall 30-day mortality was 6.25%. Conclusion: Endovascular treatment for AAS was feasible. Technical success, 30-day mortality, hospital stay, and procedure time were similar to those of the other series reported in the literature, and the endovascular approach has became the main technique for AAS in our hospital.

Mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke in a Brazilian population

OBJECTIVE: Large vessel occlusion in acute ischemic stroke is associated with low recanalization rates under intravenous thrombolysis. We evaluated the safety and efficacy of the Solitaire AB stent in treating acute ischemic stroke. METHODS: Patients presenting with acute ischemic stroke were prospectively evaluated. The neurological outcomes were assessed using the National Institutes of Health Stroke Scale and the modified Rankin Scale. Time was recorded from the symptom onset to the recanalization and procedure time. Recanalization was assessed using the thrombolysis in cerebral infarction score. RESULTS: Twenty-one patients were evaluated. The mean patient age was 65, and the National Institutes of Health Stroke Scale scores ranged from 7 to 28 (average 17+/-6.36) at presentation. The vessel occlusions occurred in the middle cerebral artery (61.9%), distal internal carotid artery (14.3%), tandem carotid occlusion (14.3%), and basilar artery (9.5%). Primary thrombectomy, rescue treatment and a bridging approach represented 66.6%, 28.6%, and 4.8% of the performed procedures, respectively. The mean time from symptom onset to recanalization was 356.5+/-107.8 minutes (range, 80-586 minutes). The mean procedure time was 60.4+/-58.8 minutes (range, 14-240 minutes). The overall recanalization rate (thrombolysis in cerebral infarction scores of 3 or 2b) was 90.4%, and the symptomatic intracranial hemorrhage rate was 14.2%. The National Institutes of Health Stroke Scale scores at discharge ranged from 0 to 25 (average 6.9+/-7). At three months, 61.9% of the patients had a modified Rankin Scale score of 0 to 2, with an overall mortality rate of 9.5%. CONCLUSIONS: Intra-arterial thrombectomy with the Solitaire AB device appears to be safe and effective. Large randomized trials are necessary to confirm the benefits of this approach in acute ischemic stroke.

Darstellung der Grenze zwischen dem rechten und linken Leberlappen mit 3D-Rekonstruktionen von Spiral-Computertomographien

Zusammenfassung:Hintergrund/Ziel: Die Beschreibung der funktionellen Einteilung der Leber basiert auf dem Schema von Claude de Couinaud. Die Grenze zwischen der rechten und linken Leberhälfte scheint leicht durch die Lage der mittleren Lebervene lokalisierbar. Nach der gängigen Meinung wird diese Grenze nicht durch die Trias aus Pfortader, Arterie und Gallengang überschritten. Es soll untersucht werden, ob die Lage dieser gefäßarmen Zone zwischen den Pfortaderästen benachbarter Segmente von der Lage der Grenzebene durch die mittlere Lebervene abweicht.Methode: Bei 73 Patienten wurden im Rahmen der normalen präoperativen Diagnostik dreiphasige Spiral-CT Untersuchungen durchgeführt. Aus diesen Daten wurden dreidimensionale Rekonstruktionen erzeugt und ausgewertet. Ergebnisse: In der vorliegenden Untersuchung konnte gezeigt werden, dass die mittlere Sektorengrenze unterschiedliche Positionen einnimmt, je nach welchem Gefäßsystem sie bestimmt wird. Die mittlere Sektorengrenze zeigt hierbei einen Unterschied in ihrer Lage von 14,2° im Median. An der ventralen Leberoberfläche liegt die Grenzebene nach der mittleren Lebervene damit rechts lateral der gefäßarmen Zone zwischen den Pfortaderästen.Schlussfolgerung: Der Unterschied der Grenzebenen ist in dreidimensionalen Rekonstruktionen demonstrierbar und findet Anwendung bei der Segmentzuordnung von Läsionen. Diese Rekonstruktionen erleichtern die interdisziplinäre Kommunikation und erlauben eine vereinfachte und möglicherweise präzisere Operationsplanung.

Sviluppo di sperimentazioni per la produzione di getti in lega di alluminio a caratteristiche difettologiche e microstrutturali controllate, per la validazione di modelli di previsione delle porosità

Nei processi di progettazione e produzione tramite tecnologie di colata di componenti in alluminio ad elevate prestazioni, risulta fondamentale poter prevedere la presenza e la quantità di difetti correlabili a design non corretti e a determinate condizioni di processo. Fra le difettologie più comuni di un getto in alluminio, le porosità con dimensioni di decine o centinaia di m, note come microporosità, hanno un impatto estremamente negativo sulle caratteristiche meccaniche, sia statiche che a fatica. In questo lavoro, dopo un’adeguata analisi bibliografica, sono state progettate e messe a punto attrezzature e procedure sperimentali che permettessero la produzione di materiale a difettologia e microstruttura differenziata, a partire da condizioni di processo note ed accuratamente misurabili, che riproducessero la variabilità delle stesse nell’ambito della reale produzione di componenti fusi. Tutte le attività di progettazione delle sperimentazioni, sono state coadiuvate dall’ausilio di software di simulazione del processo fusorio che hanno a loro volta beneficiato di tarature e validazioni sperimentali ad hoc. L’apparato sperimentale ha dimostrato la propria efficacia nella produzione di materiale a microstruttura e difettologia differenziata, in maniera robusta e ripetibile. Utilizzando i risultati sperimentali ottenuti, si è svolta la validazione di un modello numerico di previsione delle porosità da ritiro e gas, ritenuto ad oggi allo stato dell’arte e già implementato in alcuni codici commerciali di simulazione del processo fusorio. I risultati numerici e sperimentali, una volta comparati, hanno evidenziato una buona accuratezza del modello numerico nella previsione delle difettologie sia in termini di ordini di grandezza che di gradienti della porosità nei getti realizzati.

Magnetic actuators for nanosatellite attitude control

The research and the activities presented in the following thesis report have been led at the California Polytechnic State University (US) under the supervision of Prof. Jordi Puig Suari. The objective of the research has been the study of magnetic actuators for nanosatellite attitude control, called magnetorquer. Theese actuators are generally divided in three different kinds: air core torquer, embedded coil and torquerod. In a first phase of the activity, each technology has been analyzed, defining advantages and disadvantages, determining manufacturing procedures and creating mathematical model and designing equation. Dimensioning tools have been then implemented in numerical software to create an instrument that permits to determine the optimal configuration for defined requirements and constraints. In a second phase of the activities the models created have been validated exploiting prototypes and proper instruments for measurements. The instruments and the material exploited for experiments and prototyping have been provided by the PolySat and CubeSat laboratories. The results obtained led to the definition of a complete designing tool and procedure for nanosatellite magnetic actuators, introducing a cost analysis for each kind of solution. The models and the tools have been maintained fully parametric in order to offer a universal re-scalable instrument for satellite of different dimension class.

Das Biobankgeheimnis : Schutz der Persönlichkeitsrechte in der biomedizinischen Forschung

Biobanken sind Sammlungen von Körpersubstanzen, die mit umfangreichen gesundheits- und lebensstilbezogenen sowie geneologischen Daten ihrer Spender verknüpft sind. Sie dienen der Erforschung weit verbreiteter Krankheiten. Diese sog. Volkskrankheiten sind multifaktoriell bedingte Krankheiten. Dies bedeutet, dass diese Krankheiten das Ergebnis eines komplizierten Zusammenspiels von umwelt- und verhaltensrelevanten Faktoren mit individuellen genetischen Prädispositionen sind. Forschungen im Bereich von Pharmakogenomik und Pharmakogenetik untersuchen den Einfluss von Genen und Genexpressionen auf die individuelle Wirksamkeit von Medikamenten sowie auf die Entstehung ungewollter Nebenwirkungen und könnten so den Weg zu einer individualisierten Medizin ebnen. Menschliches Material ist ein wichtiger Bestandteil dieser Forschungen und die Nachfrage nach Sammlungen, die Proben mit Daten verknüpfen, steigt. Einerseits sehen Mediziner in Biobanken eine Chance für die Weiterentwicklung der medizinischen Forschung und des Gesundheitswesens. Andererseits lösen Biobanken auch Ängste und Misstrauen aus. Insbesondere wird befürchtet, dass Proben und Daten unkontrolliert verwendet werden und sensible Bereiche des Persönlichkeitsrechts und der persönlichen Identität betroffen sind. Diese Gefahren und Befürchtungen sind nicht neu, sondern bestanden schon in der Vergangenheit bei jeglicher Form der Spende von Körpersubstanzen. Neu ist aber der Umfang an Informationen, der durch die Genanalyse entsteht und den Spender in ganz besonderer Weise betreffen kann. Bei der Speicherung und Nutzung der medizinischen und genetischen Daten ergibt sich somit ein Spannungsfeld insbesondere zwischen dem Recht der betroffenen Datenspender auf informationelle Selbstbestimmung und den Forschungsinteressen der Datennutzer. Im Kern dreht sich die ethisch-rechtliche Bewertung der Biobanken um die Frage, ob diese Forschung zusätzliche Regeln braucht, und falls ja, wie umfassend diese sein müssten. Im Zentrum dieser Diskussion stehen dabei v.a. ethische Fragen im Zusammenhang mit der informierten Einwilligung, dem Datenschutz, der Wiederverwendung von Proben und Daten, der Information der Spender über Forschungsergebnisse und der Nutzungsrechte an den Daten. Ziel dieser Arbeit ist es, vor dem Hintergrund des Verfassungsrechts, insbesondere dem Recht auf informationelle Selbstbestimmung, das Datenschutzrecht im Hinblick auf die Risiken zu untersuchen, die sich aus der Speicherung, Verarbeitung und Kommunikation von persönlichen genetischen Informationen beim Aufbau von Biobanken ergeben. Daraus ergibt sich die weitere Untersuchung, ob und unter welchen Voraussetzungen die sich entgegenstehenden Interessen und Rechte aus verfassungsrechtlichem Blickwinkel in Einklang zu bringen sind. Eine wesentliche Frage lautet, ob die bisherigen rechtlichen Rahmenbedingungen ausreichen, um den Schutz der gespeicherten höchstpersönlichen Daten und zugleich ihre angemessene Nutzung zu gewährleisten. Das Thema ist interdisziplinär im Schnittfeld von Datenschutz, Verfassungsrecht sowie Rechts- und Medizinethik angelegt. Aus dem Inhalt: Naturwissenschaftliche und empirische Grundlagen von Biobanken – Überblick über Biobankprojekte in Europa und im außereuropäischen Ausland – Rechtsgrundlagen für Biobanken - Recht auf informationelle Selbstbestimmung - Recht auf Nichtwissen - Forschungsfreiheit - Qualitätssicherung und Verfahren – informierte Einwilligung – globale Einwilligung - Datenschutzkonzepte - Forschungsgeheimnis –– Biobankgeheimnis - Biobankgesetz

Automated end-to-side anastomosis to the middle cerebral artery: a feasibility study

The treatment of complex cerebrovascular or skull base pathological conditions necessitates a microsurgical blood flow preservation or augmentative revascularization procedure as either an adjunctive safety measure or a definitive treatment. The brain is susceptible to ischemia, and procedure-related risks can be minimized by the reduction of occlusion time or the use of a nonocclusive technique. The authors therefore analyzed the feasibility of an automatic device (C-Port xA, Cardica) designed for constructing an end-to-side anastomosis with or without flow interruption for a middle cerebral artery (MCA) bypass in a human cadaveric model and in an in vivo craniotomy simulation model.

A psychoeducational intervention reduces the need for anesthesia during radiotherapy for young childhood cancer patients

BACKGROUND: Radiotherapy (RT) has become an important treatment modality in pediatric oncology, but its delivery to young children with cancer is challenging and general anesthesia is often needed. METHODS: To evaluate whether a psychoeducational intervention might reduce the need for anesthesia, 223 consecutive pediatric cancer patients receiving 4141 RT fractions during 244 RT courses between February 1989 and January 2006 were studied. Whereas in 154 RT courses corresponding with 2580 RT fractions patients received no psychoeducational intervention (group A), 90 RT courses respectively 1561 RT fractions were accomplished by using psychoeducational intervention (group B). This tailored psychoeducational intervention in group B included a play program and interactive support by a trained nurse according to age to get familiar with staff, equipment and procedure of radiotherapy. RESULTS: Group A did not differ significantly from group B in age at RT, gender, diagnosis, localization of RT and positioning during RT. Whereas 33 (21.4%) patients in group A got anesthesia, only 8 (8.9%) patients in group B needed anesthesia. The median age of cooperating patients without anesthesia decreased from 3.2 to 2.7 years. In both uni- and multivariate analyses the psychoeducational intervention significantly and independently reduced the need for anesthesia. CONCLUSION: We conclude that a specifically tailored psychoeducational intervention is able to reduce the need for anesthesia in children undergoing RT for cancer. This results in lower costs and increased cooperation during RT.

Computerized provider order entry adoption: implications for clinical workflow.

OBJECTIVE: To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems. METHODS: We analyzed qualitative data from field observations and formal interviews gathered over a three-year period at five hospitals in three organizations. Five multidisciplinary researchers worked together to identify themes related to the impacts of CPOE systems on clinical workflow. RESULTS: CPOE systems can affect clinical work by 1) introducing or exposing human/computer interaction problems, 2) altering the pace, sequencing, and dynamics of clinical activities, 3) providing only partial support for the work activities of all types of clinical personnel, 4) reducing clinical situation awareness, and 5) poorly reflecting organizational policy and procedure. CONCLUSIONS: As CPOE systems evolve, those involved must take care to mitigate the many unintended adverse effects these systems have on clinical workflow. Workflow issues resulting from CPOE can be mitigated by iteratively altering both clinical workflow and the CPOE system until a satisfactory fit is achieved.

Prospective, multicenter, single-arm study of mechanical thrombectomy using Solitaire Flow Restoration in acute ischemic stroke

BACKGROUND AND PURPOSE Mechanical thrombectomy using stent retriever devices have been advocated to increase revascularization in intracranial vessel occlusion. We present the results of a large prospective study on the use of the Solitaire Flow Restoration in patients with acute ischemic stroke. METHODS Solitaire Flow Restoration Thrombectomy for Acute Revascularization was an international, multicenter, prospective, single-arm study of Solitaire Flow Restoration thrombectomy in patients with large vessel anterior circulation strokes treated within 8 hours of symptom onset. Strict criteria for site selection were applied. The primary end point was the revascularization rate (thrombolysis in cerebral infarction ≥2b) of the occluded vessel as determined by an independent core laboratory. The secondary end point was the rate of good functional outcome (defined as 90-day modified Rankin scale, 0-2). RESULTS A total of 202 patients were enrolled across 14 comprehensive stroke centers in Europe, Canada, and Australia. The median age was 72 years, 60% were female patients. The median National Institute of Health Stroke Scale was 17. Most proximal intracranial occlusion was the internal carotid artery in 18%, and the middle cerebral artery in 82%. Successful revascularization was achieved in 79.2% of patients. Device and procedure-related severe adverse events were found in 7.4%. Favorable neurological outcome was found in 57.9%. The mortality rate was 6.9%. Any intracranial hemorrhagic transformation was found in 18.8% of patients, 1.5% were symptomatic. CONCLUSIONS In this single-arm study, treatment with the Solitaire Flow Restoration device in intracranial anterior circulation occlusions results in high rates of revascularization, low risk of clinically relevant procedural complications, and good clinical outcomes in combination with low mortality at 90 days. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01327989.

Secondary victimization of crime victims by criminal proceedings

It is conceivable that criminal proceedings cause psychological harm to the crime victims involved, that is, cause secondary victimization. To investigate this hypothesis, negative and positive effects of criminal proceedings were investigated, as perceived by 137 victims of violent crimes who were involved in trials several years previously. Trial outcome and procedure variables were measured as potential causes of secondary victimization. Results show a high proportion of victims reporting overall negative effects. Powerful predictors were outcome satisfaction and procedural justice, but not subjective punishment severity, interactional justice, and psychological stress by criminal proceedings. The practical implications of the results pertain to whether victims should be advised to report the crime to the police or not, and to appropriate prevention and intervention measures of secondary victimization by criminal proceedings.

Neuartiger knochenverankerter Hämodialysezugang

Für Patienten an der Hämodialyse ist nach Versagen der klassischen arterio-venösen Fisteln oder Shunts ein direkter Gefässzugang mittels Katheter lebensnotwendig. Permanente zentralvenöse Katheter penetrieren die Hals- und Thoraxweichteile und die Haut ohne rigide Befestigung. Die Infektionsrate ist hoch und führt oft zur Explantation. Knochenverankerte Hörgeräte sind zur Behandlung bei Schalleitungsschwerhörigkeit etabliert. Das Implantat sitzt fest im Felsenbein und der Aufsatz penetriert die Haut. Schwere Infektionen, die eine Explantation nötig machen, sind sehr selten. Wir nehmen an, dass einer der Hauptgründe für die tiefe Komplikationsrate die starke Befestigung des Implantats am Knochen ist, wodurch die Hautbewegungen relativ zum Knochen minimiert werden. Basierend auf den Erfahrungen mit implantierten Hörsystemen haben wir einen perkutanen knochenverankerten Hämodialysezugang im Bereich des Felsenbeins als vorteilhafte Alternative zum herkömmlichen zentralvenösen Katheterzugang entwickelt. Dabei wurde die Felsenbeinanatomie und Knochendicke zur Lokalisierung des idealen Implantationsortes untersucht; die Schraubenstabilität im Knochen getestet; ein Titanimplantat inklusive Ventile und Katheter, sowie chirurgische Instrumente zur sicheren Implantation entwickelt. Der knochenverankerte Hämodialysezugang wurde auf Flussrate, Dichtigkeit und Reinigung getestet; die Platzierung des Katheters mittels Seldingertechnik in die V. jugularis interna über eine Halsinzision festgelegt. Die Resultate unserer Arbeit zeigen die technische Machbarkeit eines im Felsenbein verankerten neuartigen Hämodialysezuganges und bilden die Grundlage einer inzwischen bewilligten klinischen Pilotstudie.

Employment outcomes in liver transplant recipients: A policy analysis

Liver transplantation is a widely accepted treatment for end stage liver disease. Research has shown that people with end-stage liver disease experience improved survival and health-related quality of life after transplantation. However, the unemployment rate among liver transplant recipients remains high. The reasons for this were the subject of a study that was used as the primary dataset for this policy analysis. According to the primary data and background supporting data, many transplant recipients remain unemployed for fear of losing needed healthcare and disability benefits. When employment is considered as a health outcome, it is important in an era of evidence based medicine to ensure that healthcare interventions such as liver transplantation produce improved health outcomes. Therefore, the high unemployment rate among liver transplant recipients is a poor health outcome that should be addressed. In this policy analysis, it is proposed that policy might affect this outcome. The problem of unemployment after liver transplantation is structured and policies affecting the problem are evaluated according to the validated criteria - Effectiveness, Equity, Efficiency, and Feasibility. A policy solution is proposed, evaluated, and ultimately recommended to effectively address the problem, to make healthcare coverage more equitable for liver transplant recipients, and to provide a more cost-effective healthcare coverage model during this time of healthcare crisis.^

El cambio de paradigma de las Políticas de Protección Social en Chile durante los gobiernos de la Concertación (1990-2010)

El presente artículo aborda la política de protección social en Chile como una política pública, inaugurada por los gobiernos posrégimen militar, que busca cambiar el paradigma, desde la tradicional visión asistencialista coyuntural por parte del Estado, a una perspectiva que persigue reducir las vulnerabilidades de manera sustentable y con una fuerte participación social en la elaboración de las políticas basado en tres pilares: equidad, integración y cohesión social.

Optimización del peaje en autopistas interurbanas que compiten con carreteras convencionales libres de pago : una perspectiva de eficiencia y equidad

En algunos países, como por ejemplo España, es común que entre un origen y un destino existan dos carreteras paralelas en las que existen ciertas diferencias. La más importante es que una de las vías es una autopista que ofrece a los usuarios una mayor comodidad y un menor tiempo de viaje a cambio del pago de un peaje, el cual no es necesario abonar en la carretera convencional paralela. Así, el problema de la tarificación vial ha sido estudiado en diversas ocasiones. Existe un amplio consenso en que para lograr el máximo bienestar social, los usuarios deben internalizar las externalidades que producen y no perciben a través de un peaje. Sin embargo, dicho peaje puede perjudicar a los usuarios con bajos ingresos. Dependiendo del objetivo (por ejemplo, maximizar el bienestar, maximizar la equidad social, la amortización de la construcción de la carretera, etc) el peaje óptimo podría variar sustancialmente. La literatura académica acerca de los peajes, la eficiencia y la equidad es vasta y diversa. Sin embargo, hemos encontrado una deficiencia en dicha literatura sobre el peaje óptimo, en corredores donde una carretera y una autopista con diferentes características de calidad compiten para capturar el tráfico. Particularmente no se ha encontrado ninguna investigación acerca del establecimiento del peaje que maximice el bienestar social o la equidad para distintas distribuciones del valor del tiempo de viaje (VTT), caracterizadas por su media y varianza. Por ello, el principal objetivo de la investigación es estimar la influencia que tiene la distribución de la renta de una sociedad sobre el peaje óptimo. La presente tesis doctoral trata de obtener, por medio de una metodología robusta, las diferentes políticas de peajes que los planificadores de transporte deberían llevar a cabo según la riqueza y cohesión social de los potenciales usuarios del corredor, la demanda y el objetivo que se busque con dicha tarificación, esto es, maximizar el bienestar social o la equidad. Adicionalmente también se obtienen los peajes óptimos dependiendo de si el corredor se encuentra totalmente tarificado o únicamente se debe pagar un peaje por circular en la autopista. In some countries, such as Spain, it is very common that in the same corridor there are two roads with the same origin and destination but with some differences. The most important contrast is that one is a toll highway which offers a better quality than the parallel road in exchange of a price. The users decide if the price of the toll worth to pay for the advantages offered. The problem of road pricing has been largely studied. It is well acknowledged that in order to achieve the maximum social welfare, users must internalize the externalities they produce and do not perceive through a toll. However, that toll can harm users with low income. Depending on the objective (e.g. maximize welfare, maximize social equity, amortize the construction of the road, etc) the optimal toll might vary substantially. The academic literature about pricing, efficiency and equity is vast and diverse. However, as far as we have found, there is a gap in the literature regarding the optimal price where a road and a highway with different quality characteristics compete for capturing the traffic in a corridor. Particularly we did not find any research estimating the optimal welfare price or the optimal equity price for different Value of Travel Time (VTT) distributions characterized by different VTT average and variance. The objective of the research is to fill this gap. In this research a theoretical model in order to obtain the optimal price in a toll highway that competes for capturing the traffic with a conventional road is developed. This model is done from the welfare and equity perspective and for non‐usual users who decide over the expectation of free flow conditions. The model is finally applied to the variables we want to focus on: average value of travel time (VTT) which is strongly related with income, dispersion of this VTT, different kind of distributions of VTT and traffic levels, from free flow to congestion. Furthermore, we also obtain the optimal tolls with the corridor completely charged or with untolled alternative.