A General Latent Class Model for Performance Evaluation of Diagnostic Tests in the Absence of a Gold Standard: An Application to Chagas Disease

We propose a new general Bayesian latent class model for evaluation of the performance of multiple diagnostic tests in situations in which no gold standard test exists based on a computationally intensive approach. The modeling represents an interesting and suitable alternative to models with complex structures that involve the general case of several conditionally independent diagnostic tests, covariates, and strata with different disease prevalences. The technique of stratifying the population according to different disease prevalence rates does not add further marked complexity to the modeling, but it makes the model more flexible and interpretable. To illustrate the general model proposed, we evaluate the performance of six diagnostic screening tests for Chagas disease considering some epidemiological variables. Serology at the time of donation (negative, positive, inconclusive) was considered as a factor of stratification in the model. The general model with stratification of the population performed better in comparison with its concurrents without stratification. The group formed by the testing laboratory Biomanguinhos FIOCRUZ-kit (c-ELISA and rec-ELISA) is the best option in the confirmation process by presenting false-negative rate of 0.0002% from the serial scheme. We are 100% sure that the donor is healthy when these two tests have negative results and he is chagasic when they have positive results.

Texture analysis of high resolution MRI allows discrimination between febrile and afebrile initial precipitating injury in mesial temporal sclerosis

A computational pipeline combining texture analysis and pattern classification algorithms was developed for investigating associations between high-resolution MRI features and histological data. This methodology was tested in the study of dentate gyrus images of sclerotic hippocampi resected from refractory epilepsy patients. Images were acquired using a simple surface coil in a 3.0T MRI scanner. All specimens were subsequently submitted to histological semiquantitative evaluation. The computational pipeline was applied for classifying pixels according to: a) dentate gyrus histological parameters and b) patients' febrile or afebrile initial precipitating insult history. The pipeline results for febrile and afebrile patients achieved 70% classification accuracy, with 78% sensitivity and 80% specificity [area under the reader observer characteristics (ROC) curve: 0.89]. The analysis of the histological data alone was not sufficient to achieve significant power to separate febrile and afebrile groups. Interesting enough, the results from our approach did not show significant correlation with histological parameters (which per se were not enough to classify patient groups). These results showed the potential of adding computational texture analysis together with classification methods for detecting subtle MRI signal differences, a method sufficient to provide good clinical classification. A wide range of applications of this pipeline can also be used in other areas of medical imaging. Magn Reson Med, 2012. (c) 2012 Wiley Periodicals, Inc.

Femtosecond Laser in Polymeric Materials: Microfabrication of Doped Structures and Micromachining

The use of laser light to modify the material's surface or bulk as well as to induce changes in the volume through a chemical reaction has received great attention in the last few years, due to the possibility of tailoring the material's properties aiming at technological applications. Here, we report on recent progress of microstructuring and microfabrication in polymeric materials by using femtosecond lasers. In the first part, we describe how polymeric materials' micromachining, either on the surface or bulk, can be employed to change their optical and chemical properties promising for fabricating waveguides, resonators, and self-cleaning surfaces. In the second part, we discuss how two-photon absorption polymerization can be used to fabricate active microstructures by doping the basic resin with molecules presenting biological and optical properties of interest. Such microstructures can be used to fabricate devices with applications in optics, such as microLED, waveguides, and also in medicine, such as scaffolds for tissue growth.

E' possibile giustificare moralmente l'obiezione di coscienza in campo medico?

Scopo di questa tesi di dottorato è stabilire se l’obiezione di coscienza in ambito medico sia moralmente giustificabile. Esistono essenzialmente tre tipi di rifiuto motivati dall’obiezione di coscienza (1) rifiuto di informare un paziente relativamente alle opzioni terapeutiche come ad esempio l’uso di un contraccettivo di emergenza o l’interruzione volontaria di gravidanza (2) rifiuto di rinviare un paziente che chiede un particolare intervento (o terapia) presso un collega non obiettore (3) rifiuto di svolgere in prima persona una certa attività richiesta dal paziente Per rispondere a questo interrogativo si è svolta un’analisi filosofico-morale dei principali argomenti utilizzati dalla letteratura su questo tema per giustificare o per negare un diritto morale all’obiezione di coscienza degli operatori sanitari. Il diritto degli operatori sanitari all’integrità morale e a non essere complici di attività ritenute immorali dev’essere infatti confrontato con il diritto dei pazienti ad avere un’assistenza sanitaria efficiente, a poter compiere scelte autonome riguardo alla propria salute e ad essere informati relativamente a tutte le opzioni terapeutiche disponibili. Nel corso dell’intero lavoro è stato dimostrato come suddetti diritti dei pazienti sono facilmente e frequentemente violati a causa dell’incidenza dell’obiezione di coscienza in ambito medico. L’analisi condotta nel corso del lavoro di tesi si concentra fondamentalmente su quattro importanti aspetti del problema quali diritto all’integrità morale dell’ operatore sanitario, obblighi professionali, cooperazione al male e laicità dello stato. Alla fine del lavoro di analisi si è giunti alla conclusione che: le obiezioni di tipo (1) e (2) non sono mai moralmente giustificabili perché comportano sempre una violazione dei diritti fondamentali del paziente. Le obiezioni di coscienza di tipo (3) sono moralmente accettabili solo quando non impongono un peso eccessivo al paziente, vale a dire quando il rinvio presso un collega non obiettore è veloce, sicuro e agevole. Tuttavia le condizioni ideali in cui vengono rispettati i criteri minimi di ammissibilità dell’obiezione di coscienza di tipo (3) non si verificano quasi mai nella realtà dei fatti (per ragioni ampiamente spiegate nel corso del lavoro), per cui tali obiezioni risultano in pratica solo raramente accettabili da un punto d vista morale.

Sensitivity enhancement in NMR by using parahydrogen induced polarization

Enhancing the sensitivity of nuclear magnetic resonance measurements via hyperpolarization techniques like parahydrogen induced polarization (PHIP) is of high interest for spectroscopic investigations. Parahydrogen induced polarization is a chemical method, which makes use of the correlation between nuclear spins in parahydrogen to create hyperpolarized molecules. The key feature of this technique is the pairwise and simultaneous transfer of the two hydrogen atoms of parahydrogen to a double or triple bond resulting in a population of the Zeeman energy levels different from the Boltzmann equation. The obtained hyperpolarization results in antiphase peaks in the NMR spectrum with high intensities. Due to these strong NMR signals, this method finds arnlot of applications in chemistry e.g. the characterization of short-lived reaction intermediates. Also in medicine it opens up the possibility to boost the sensitivity of medical diagnostics via magnetic labeling of active contrast agents. Thus, further examination and optimization of the PHIP technique is of significant importance in order to achieve the highest possible sensitivity gain.rnrnIn this work, different aspects concerning PHIP were studied with respect to its chemical and spectroscopic background. The first part of this work mainly focused on optimizing the PHIP technique by investigating different catalyst systems and developing new setups for the parahydrogenation. Further examinations facilitated the transfer of the generated polarization from the protons to heteronuclei like 13C. The second part of this thesis examined the possibility to transfer these results to different biologically active compounds to enable their later application in medical diagnostics. Onerngroup of interesting substances is represented by metabolites or neurotransmitters in mammalian cells. Other interesting substances are clinically relevant drugs like a barbituric acid derivative or antidepressant drugs like citalopram which were investigated with regard to their applicability for the PHIP technique and the possibility to achievernpolarization transfer to 13C nuclei. The last investigated substrate is a polymerizable monomer whose polymer was used as a blood plasma expander for trauma victims after the first half of the 20th century. In this case, the utility of the monomer for the PHIP technique as a basis for later investigations of a polymerization reaction using hyperpolarized monomers was examined.rnrnHence, this thesis covers the optimization of the PHIP technology, hereby combining different fields of research like chemical and spectroscopical aspects, and transfers the results to applications of real biologally acitve compounds.

Differentiation and extracellular matrix interactions of chondrocytes in response to signaling molecules and biomaterials for cartilage repair = Differenzierung und Interaktionen von Chondrozyten mit der extrazellulären Matrix als Reaktion auf Signalmoleküle und Biomaterialien für die Wiederinstandsetzung von Knorpel

Chondrocytes live isolated in the voluminous extracellular matrix of cartilage, which they secrete and is neither vascularized nor innervated. Nutrient and waste exchanges occur through diffusion leading to low oxygen tension around the cells. Consequently even normal cartilage under normal physiological conditions suffers from a poor reparative potential that predisposes to degenerative conditions, such as osteoarthritis of the joints, with significant clinical effects.rnOne of the key challenges in medicine is the structural and functional replacement of lost or damaged tissues. Current therapeutical approaches are to transplant cells, implant bioartificial tissues, and chemically induce regeneration at the site of the injury. None of them reproduces well the biological and biomechanical properties of hyaline cartilage.rnThis thesis investigates the re-differentiation of chondrocytes and the repair of cartilage mediated by signaling molecules, biomaterials, and factors provided in mixed cellular cultures (co-culture systems). As signaling molecules we have applied prostaglandin E2 (PGE2) and bone morphogenetic protein 1 (BMP-1) and we have transfected chondrocytes with BMP-1 expressing vectors. Our biomaterials have been hydrogels of type-I collagen and gelatin-based scaffolds designed to mimic the architecture and biochemistry of native cartilage and provide a suitable three-dimensional environment for the cells. We have brought chondrocytes to interact with osteosarcoma Cal 72 cells or with murine preosteoblastic KS483 cells, either in a cell-to-cell or in a paracrine manner.rnExogenous stimulation with PGE2 or BMP-1 did not improve the differentiation or the proliferation of human articular chondrocytes. BMP-1 induced chondrocytic de-differentiation in a dose-dependent manner. Prostaglandin stimulation from gelatin-based scaffolds (three-dimensional culture) showed a certain degree of chondrocyte re-differentiaton. Murine preosteoblastic KS483 cells had no beneficial effect on human articular chondrocytes jointly cultivated with them in hydrogels of type I collagen. Although the hydrogels provided the chondrocytes with a proper matrix in which the cells adopted their native morphology; additionally, the expression of chondrocytic proteoglycan increased in the co-cultures after two weeks. The co-culture of chondrocytes with osteoblast-like cells (in transwell systems) resulted in suppression of the regular de-differentiation program that passaged chondrocytes undergo when cultured in monolayers. Under these conditions, the extracellular matrix of the chondrocytes, rich in type-II collagen and aggrecan, was not transformed into the extracellular matrix characteristic of de-differentiated human articular chondrocytes, which is rich in type-I collagen and versican.rnThis thesis suggests novel strategies of tissue engineering for clinical attempts to improve cartilage repair. Since implants are prepared in vitro (ex-vivo) by expanding human articular chondrocytes (autologous or allogeneic), we conclude that it will be convenient to provide a proper three-dimensional support to the chondrocytes in culture, to supplement the culture medium with PGE2, and to stimulate chondrocytes with osteoblastic factors by cultivating them with osteoblasts.rn

The role of indigenous people in national development processes: Participation and marginalisation of indigenous Bedouin in South Sinai tourism development

The Bedouin of South Sinai have been significantly affected by the politics of external powers for a long time. However, never had the interest of external powers in Sinai been so strong as since the Israeli-Egyptian wars in the second half of the 20th century when Bedouin interests started to collide with Egypt’s plans for a development of luxury tourism in South Sinai. rnrnThe tourism boom that has started in the 1980s has brought economic and infrastructure development to the Bedouin and tourism has become the most important source of income for the Bedouin. However, while the absolute increase of tourists to Sinai has trickled down to the Bedouin to some extent, the participation of Bedouin in the overall tourism development is under-proportionate. Moreover, the Bedouin have become increasingly dependent on monetary income and consequently from tourism as the only significant source of income while at the same time they have lost much of their land as well as their self-determination.rnrnIn this context, the Bedouin livelihoods have become very vulnerable due to repeated depressions in the tourism industry as well as marginalization. Major marginalization processes the Bedouin are facing are the loss of land, barriers to market entry, especially increasingly strict rules and regulations in the tourism industry, as well as discrimination by the authorities. Social differentiation and Bedouin preferences are identified as further factors in Bedouin marginalization.rnrnThe strategies Bedouin have developed in response to all these problems are coping strategies, which try to deal with the present problem at the individual level. Basically no strategies have been developed at the collective level that would aim to actively shape the Bedouin’s present and future. Collective action has been hampered by a variety of factors, such as the speed of the developments, the distribution of power or the decay of tribal structures.rnWhile some Bedouin might be able to continue their tourism activities, a large number of informal jobs will not be feasible anymore. The majority of the previously mostly self-employed Bedouin will probably be forced to work as day-laborers who will have lost much of their pride, dignity, sovereignty and freedom. Moreover, with a return to subsistence being impossible for the majority of the Bedouin, it is likely that an increasing number of marginalized Bedouin will turn to illegal income generating activities such as smuggling or drug cultivation. This in turn will lead to further repression and discrimination and could escalate in a serious violent conflict between the Bedouin and the government.rnrnDevelopment plans and projects should address the general lack of civil rights, local participation and protection of minorities in Egypt and promote Bedouin community development and the consideration of Bedouin interests in tourism development.rnrnWether the political upheavals and the resignation of president Mubarak at the beginning of 2011 will have a positive effect on the situation of the Bedouin remains to be seen.rn

Women in surgery: a survey in Switzerland

An increasing proportion of women work in medicine; however, only few choose surgical specialties. The objective of this study was to analyze the current situation of female surgeons and surgical residents in Switzerland concerning their personal and professional fulfillment. Of 318 female surgeons and surgical residents included in our study, 189 (59.4%) returned the anonymous questionnaire. Mentor-mentee relationships were mentioned by 110 (58.2%) of the 189 respondents. On the basis of a 7-point Likert scale, these women responded that they were moderately satisfied with their professional (mean score [SD], 2.7 [1.3]) and personal (mean score [SD], 3.0 [1.7]) lives. Of the 189 respondents, 113 (59.8%) mentioned that they felt underappreciated. The most important ways suggested for increasing the attractiveness of a surgical career for women were a reduction in workload (49 respondents [25.9%]), more flexible working hours (38 respondents [20.1%]), and better structured residency programs (23 respondents [12.2%]).

VMC++ validation for photon beams in the energy range of 20-1000 keV

In high energy teletherapy, VMC++ is known to be a very accurate and efficient Monte Carlo (MC) code. In principle, the MC method is also a powerful dose calculation tool in other areas in radiation oncology, e.g., brachytherapy or orthovoltage radiotherapy. However, VMC++ is not validated for the low-energy range of such applications. This work aims in the validation of the VMC++ MC code for photon beams in the energy range between 20 and 1000 keV.

Comparison of monte carlo collimator transport methods for photon treatment planning in radiotherapy

The aim of this work was a Monte Carlo (MC) based investigation of the impact of different radiation transport methods in collimators of a linear accelerator on photon beam characteristics, dose distributions, and efficiency. Thereby it is investigated if it is possible to use different simplifications in the radiation transport for some clinical situations in order to save calculation time.

Magnetization exchange with water and T(1) relaxation of the downfield resonances in human brain spectra at 3.0 T

The use of water suppression for in vivo proton MR spectroscopy diminishes the signal intensities from resonances that undergo magnetization exchange with water, particularly those downfield of water. To investigate these exchangeable resonances, an inversion transfer experiment was performed using the metabolite cycling technique for non-water-suppressed MR spectroscopy from a large brain voxel in 11 healthy volunteers at 3.0 T. The exchange rates of the most prominent peaks downfield of water were found to range from 0.5 to 8.9 s(-1), while the T(1) relaxation times in absence of exchange were found to range from 175 to 525 ms. These findings may help toward the assignments of the downfield resonances and a better understanding of the sources of contrast in chemical exchange saturation transfer imaging.

Using rapid prototyping molds to create patient specific polymethylmethacrylate implants in cranioplasty

Cranioplasty is a commonly performed procedure. Outcomes can be improved by the use of patient specific implants, however, high costs limit their accessibility. This paper presents a low cost alternative technique to create patient specific polymethylmethacrylate (PMMA) implants using rapid prototyped mold template. We used available patient's CT-scans, one dataset without craniotomy and one with craniotomy, for computer-assisted design of a 3D mold template, which itself can be brought into the operating room and be used for fast and easy building of a PMMA implant. We applied our solution to three patients with positive outcomes and no complications.

A sequential Cox approach for estimating the causal effect of treatment in the presence of time-dependent confounding applied to data from the Swiss HIV Cohort Study

When estimating the effect of treatment on HIV using data from observational studies, standard methods may produce biased estimates due to the presence of time-dependent confounders. Such confounding can be present when a covariate, affected by past exposure, is both a predictor of the future exposure and the outcome. One example is the CD4 cell count, being a marker for disease progression for HIV patients, but also a marker for treatment initiation and influenced by treatment. Fitting a marginal structural model (MSM) using inverse probability weights is one way to give appropriate adjustment for this type of confounding. In this paper we study a simple and intuitive approach to estimate similar treatment effects, using observational data to mimic several randomized controlled trials. Each 'trial' is constructed based on individuals starting treatment in a certain time interval. An overall effect estimate for all such trials is found using composite likelihood inference. The method offers an alternative to the use of inverse probability of treatment weights, which is unstable in certain situations. The estimated parameter is not identical to the one of an MSM, it is conditioned on covariate values at the start of each mimicked trial. This allows the study of questions that are not that easily addressed fitting an MSM. The analysis can be performed as a stratified weighted Cox analysis on the joint data set of all the constructed trials, where each trial is one stratum. The model is applied to data from the Swiss HIV cohort study.

E-Health towards ecumenical framework for personalized medicine via Decision Support System

The purpose of the present manuscript is to present the advances performed in medicine using a Personalized Decision Support System (PDSS). The models used in Decision Support Systems (DSS) are examined in combination with Genome Information and Biomarkers to produce personalized result for each individual. The concept of personalize medicine is described in depth and application of PDSS for Cardiovascular Diseases (CVD) and Type-1 Diabetes Mellitus (T1DM) are analyzed. Parameters extracted from genes, biomarkers, nutrition habits, lifestyle and biological measurements feed DSSs, incorporating Artificial Intelligence Modules (AIM), to provide personalized advice, medication and treatment.

Last stop expulsion - The minority question and forced migration in East-Central Europe: 1918-49

This article deals with the European minorities in the period between the two world wars and with their final expulsion from nation-states at the end of World War II. First, the tensions which arose between the organised minorities and the successor states of the Habsburg Monarchy are accounted for primarily by the argument that the various minorities located within the successor states had already undergone a comprehensive processes of nationalisation within the Habsburg Empire. Therefore they were able to resist assimilation by the political elites of the new titular nations (Czechs, Poles, Rumanians, Serbs). A second topic is that of the use made of the minorities issue by Adolf Hitler to help achieve his expansionist aims. The minorities issue was central to the international destabilisation of interwar Europe. Finally, the mass expulsion of minorities (above all, Germans) after the end of the war is explained by strategic considerations on the part of the Allied powers as well as involving the nation-state regimes. It is argued, against a commonly held view, that German atrocities during the period of occupation had little to do with the decision to expel most ethnic Germans from their territories of settlement in Poland, Czechoslovakia and Yugoslavia. The article shows that it is necessary to treat national minorities in the first half of the twentieth century as a single phenomenon which shares similar features across the various nation-states of East-Central Europe.