A problemática do cuidador familiar do portador de acidente vascular cerebral

Objetivou-se identificar a problemática da família de pessoas acometidas de acidente vascular cerebral hospitalizadas e discutir as dificuldades do cuidador familiar para o cuidado no âmbito domiciliar. A amostra constou de 154 famílias de pacientes internados em um hospital da rede pública de saúde, Fortaleza-CE. Conforme os resultados denotam, a maioria dos cuidadores são mulheres, 104 (67,5%); 122 casos (79,2%) apresentam comprometimento familiar e alterações na vida diária em 115 dos acompanhantes (74,7%); 150 (97,4%) não receberam orientações acerca dos cuidados, mas 143 (92,9%) sentem-se seguros para acompanhá-los. O sentimento predominante foi a tristeza, 125 (81,2%), e as dúvidas principais foram: alimentação, 64 (41,6%), administração de medicamentos, 49 (29,9%), e possíveis complicações clínicas após a alta, 49 (29,9%). Estes resultados alertam para o papel do enfermeiro como educador, não somente na prevenção das doenças crônico-degenerativas, mas, também, na orientação aos cuidadores familiares sobre os cuidados dispensados após a alta hospitalar.

Mophological analysis of the human vasculature from medical imaging. Application to cerebral and coranary arteries

In this project, we have investigated new ways of modelling and analysis of human vasculature from Medical images. The research was divided in two main areas: cerebral vasculature analysis and coronary arteries modeling. Regarding cerebral vasculature analysis, we have studed cerebral aneurysms, internal carotid and the Circle of Willis (CoW). Aneurysms are abnormal vessel enlargements that can rupture causing important cerebral damages or death. The understanding of this pathology, together with its virtual treatment, and image diagnosis and prognosis, includes identification and detailed measurement of the aneurysms. In this context, we have proposed two automatic aneurysm isolation method, to separate the abnormal part of the vessel from the healthy part, to homogenize and speed-up the processing pipeline usually employed to study this pathology, [Cardenes2011TMI, arrabide2011MedPhys]. The results obtained from both methods have been also compared and validatied in [Cardenes2012MBEC]. A second important task here the analysis of the internal carotid [Bogunovic2011Media] and the automatic labelling of the CoW, Bogunovic2011MICCAI, Bogunovic2012TMI]. The second area of research covers the study of coronary arteries, specially coronary bifurcations because there is where the formation of atherosclerotic plaque is more common, and where the intervention is more challenging. Therefore, we proposed a novel modelling method from Computed Tomography Angiography (CTA) images, combined with Conventional Coronary Angiography (CCA), to obtain realistic vascular models of coronary bifurcations, presented in [Cardenes2011MICCAI], and fully validated including phantom experiments in [Cardene2013MedPhys]. The realistic models obtained from this method are being used to simulate stenting procedures, and to investigate the hemodynamic variables in coronary bifurcations in the works submitted in [Morlachi2012, Chiastra2012]. Additionally, another preliminary work has been done to reconstruct the coronary tree from rotational angiography, and published in [Cardenes2012ISBI].

La protection des biotopes en droit suisse : étude de droit matériel

Introduction : Confronter les intérêts de la protection de la nature à d'autres, c'est vouloir faire passer les petites fleurs et les grenouilles avant l'Homme. Hérésie ! C'est en effet parfois l'existence même d'un régime légal de protection des biotopes qui fait sourire. L'étudier en profondeur n'en paraît que plus oiseux. Ce problème d'acceptation est sans doute propre au droit de l'environnement de manière générale : l'intérêt public défendu ici n'est pas rattachable directement à l'intérêt du plus grand nombre. On peut parfois même en être très loin. Si, malgré cela, certains domaines du droit de l'environnement sont actuellement très en vogue, la protection de la nature fait partie de ses aspects moins porteurs. Ce type de préoccupations est pour beaucoup futile, voire inutile ou même déplacé. Il apparaît ainsi important de commencer par se demander pourquoi protéger la nature, et que protéger dans cette nature (chapitre 1). Vient ensuite évidemment la question de la portée de la protection. Il convient pour cela tout d'abord de faire le point sur le droit en vigueur (chapitre 2) : l'histoire des règles topiques en matière de protection des biotopes a été particulièrement mouvementée et son analyse apporte un important éclairage à la compréhension des dispositions actuelles ; cette législation est en outre complétée par une multitude de dispositions connexes ou apparentées, de droit interne et de droit international. Ce contexte général posé, la portée de la protection s'examine plus précisément par l'analyse des articles 18 ss LPN (chapitre 3) : les biotopes protégés de manière générale par l'article 18 LPN lui-même - remarquable exemple d'un droit dynamique -, les biotopes inventoriés et la végétation des rives. Il est enfin nécessaire de se pencher sur le « comment protéger» par une étude des instruments de mise en oeuvre (chapitre 4) et des instruments auxiliaires à la protection (chapitre 5). Ce faisant, la pertinence du régime légal de protection des biotopes sera soulignée, tant sur le fond que sur la forme. En l'introduisant aux subtilités de ce régime et de son intégration dans l'ordre juridique en général, nous espérons ainsi faire passer le lecteur au-delà des idées reçues.

Mapeo cerebral en el paciente despierto en las resecciones de tumoraciones cerebrales supratentoriales. Metodología, eficacia y seguridad de la técnica.

Estudio prospectivo sobre la realización de cirugía cerebral con el paciente despierto para la exéresis de lesiones cerebrales que afectan o se encuentran cerca de áreas elocuentes (área motora, sensitiva, del lenguaje y visual). El trabajo se centra en los grados de resección que se consiguen en esta clase de cirugía, metodología a seguir, tolerancia de los pacientes, evolución de la sintomatología tras la cirugía y complicaciones intra y postoperatorios.

Estudio neurofisiológico mediante potenciales evocados auditivos de tronco cerebral y somatosensoriales en pacientes con malformación de Chiari tipo 1.

La malformación de Chiari tipo 1 (MC-1) puede condicionar fenómenos compresivos del tronco del encéfalo, de la médula espinal alta y de los nervios craneales y alterar las exploraciones neurofisiológicas de los potenciales evocados auditivos de tronco cerebral (PEATC) y de los potenciales evocados somatosensoriales (PESS). Este trabajo describe la incidencia y los tipos de hallazgos de los PEATC y PESS en una serie homogénea de 50 pacientes con MC-1 controlados en el Servicio de Neurocirugía del Hospital Universitari Vall d’Hebron y estudia su relación con la sintomatología clínica y la severidad de la malformación.

Synthesis of Best Practice for Increasing Protection and Visibility of Highway Maintenance Vehicles, CTRE Final Report Iowa DOT Project TR-475, August 2002

The purpose of this research project is to study current practices in enhancing visibility and protection of highway maintenance vehicles involved in moving operations such as snow removal and shoulder operations, crack sealing, and pothole patching. The results will enable the maintenance staff to adequately assess the applicability and impact of each strategy to their use and budget. The report’s literature review chapter examines the use of maintenance vehicle warning lights, retroreflective tapes, shadow vehicles and truck-mounted attenuators, and advanced vehicle control systems, as well as other practices to improve visibility for both snowplow operators and vehicles. The chapter concludes that the Manual on Uniform Traffic Control Devices does not specify what color or kind of warning lights to use. Thus, a wide variety of lights are being used on maintenance vehicles. The study of the relevant literatures also suggests that there are no clear guidelines for moving work zones at this time. Two types of surveys were conducted to determine current practices to improve visibility and safety in moving work zones across the country and in the state of Iowa. In the first survey of state departments of transportation, most indicated using amber warning lights on their maintenance vehicles. Almost all the responding states indicated using some form of reflective material on their vehicles to make them more visible. Most participating states indicated that the color of their vehicles is orange. Most states indicated using more warning lights on snow removal vehicles than their other maintenance vehicles. All responding state agencies indicated using shadow vehicles and/or truck-mounted attenuators during their moving operations. In the second survey of Iowa counties, most indicated using very similar traffic control and warning devices during their granular road maintenance and snow removal operations. Mounting warning signs and rotating or strobe lights on the rear of maintenance vehicles is common for Iowa counties. The most common warning devices used during the counties’ snow removal operations are reflective tapes, warning flags, strobe lights, and auxiliary headlamps.

Sleep deprivation effects on circadian clock gene expression in the cerebral cortex parallel electroencephalographic differences among mouse strains.

Sleep deprivation (SD) results in increased electroencephalographic (EEG) delta power during subsequent non-rapid eye movement sleep (NREMS) and is associated with changes in the expression of circadian clock-related genes in the cerebral cortex. The increase of NREMS delta power as a function of previous wake duration varies among inbred mouse strains. We sought to determine whether SD-dependent changes in circadian clock gene expression parallel this strain difference described previously at the EEG level. The effects of enforced wakefulness of incremental durations of up to 6 h on the expression of circadian clock genes (bmal1, clock, cry1, cry2, csnk1epsilon, npas2, per1, and per2) were assessed in AKR/J, C57BL/6J, and DBA/2J mice, three strains that exhibit distinct EEG responses to SD. Cortical expression of clock genes subsequent to SD was proportional to the increase in delta power that occurs in inbred strains: the strain that exhibits the most robust EEG response to SD (AKR/J) exhibited dramatic increases in expression of bmal1, clock, cry2, csnkIepsilon, and npas2, whereas the strain with the least robust response to SD (DBA/2) exhibited either no change or a decrease in expression of these genes and cry1. The effect of SD on circadian clock gene expression was maintained in mice in which both of the cryptochrome genes were genetically inactivated. cry1 and cry2 appear to be redundant in sleep regulation as elimination of either of these genes did not result in a significant deficit in sleep homeostasis. These data demonstrate transcriptional regulatory correlates to previously described strain differences at the EEG level and raise the possibility that genetic differences underlying circadian clock gene expression may drive the EEG differences among these strains.

Toward integrated management of cerebral aneurysms

In the last few years, some of the visionary concepts behind the virtual physiological human began to be demonstrated on various clinical domains, showing great promise for improving healthcare management. In the current work, we provide an overview of image- and biomechanics-based techniques that, when put together, provide a patient-specific pipeline for the management of intracranial aneurysms. The derivation and subsequent integration of morphological, morphodynamic, haemodynamic and structural analyses allow us to extract patient-specific models and information from which diagnostic and prognostic descriptors can be obtained. Linking such new indices with relevant clinical events should bring new insights into the processes behind aneurysm genesis, growth and rupture. The development of techniques for modelling endovascular devices such as stents and coils allows the evaluation of alternative treatment scenarios before the intervention takes place and could also contribute to the understanding and improved design of more effective devices. A key element to facilitate the clinical take-up of all these developments is their comprehensive validation. Although a number of previously published results have shown the accuracy and robustness of individual components, further efforts should be directed to demonstrate the diagnostic and prognostic efficacy of these advanced tools through large-scale clinical trials.

Automated Segmentation of Cerebral Vasculature with Aneurysms in 3DRA and TOF-MRA using Geodesic Active Regions: an Evaluation Study

Purpose: To evaluate the suitability of an improved version of an automatic segmentation method based on geodesic active regions (GAR) for segmenting cerebral vasculature with aneurysms from 3D X-ray reconstruc-tion angiography (3DRA) and time of °ight magnetic resonance angiography (TOF-MRA) images available in the clinical routine.Methods: Three aspects of the GAR method have been improved: execution time, robustness to variability in imaging protocols and robustness to variability in image spatial resolutions. The improved GAR was retrospectively evaluated on images from patients containing intracranial aneurysms in the area of the Circle of Willis and imaged with two modalities: 3DRA and TOF-MRA. Images were obtained from two clinical centers, each using di®erent imaging equipment. Evaluation included qualitative and quantitative analyses ofthe segmentation results on 20 images from 10 patients. The gold standard was built from 660 cross-sections (33 per image) of vessels and aneurysms, manually measured by interventional neuroradiologists. GAR has also been compared to an interactive segmentation method: iso-intensity surface extraction (ISE). In addition, since patients had been imaged with the two modalities, we performed an inter-modality agreement analysis with respect to both the manual measurements and each of the two segmentation methods. Results: Both GAR and ISE di®ered from the gold standard within acceptable limits compared to the imaging resolution. GAR (ISE, respectively) had an average accuracy of 0.20 (0.24) mm for 3DRA and 0.27 (0.30) mm for TOF-MRA, and had a repeatability of 0.05 (0.20) mm. Compared to ISE, GAR had a lower qualitative error in the vessel region and a lower quantitative error in the aneurysm region. The repeatabilityof GAR was superior to manual measurements and ISE. The inter-modality agreement was similar between GAR and the manual measurements. Conclusions: The improved GAR method outperformed ISE qualitatively as well as quantitatively and is suitable for segmenting 3DRA and TOF-MRA images from clinical routine.

Deployment of self-expandable stents in aneurysmatic cerebral vessels: comparison of different computational approaches for interventional planning

In the last few years, there has been a growing focus on faster computational methods to support clinicians in planning stenting procedures. This study investigates the possibility of introducing computational approximations in modelling stent deployment in aneurysmatic cerebral vessels to achieve simulations compatible with the constraints of real clinical workflows. The release of a self-expandable stent in a simplified aneurysmatic vessel was modelled in four different initial positions. Six progressively simplified modelling approaches (based on Finite Element method and Fast Virtual Stenting – FVS) have been used. Comparing accuracy of the results, the final configuration of the stent is more affected by neglecting mechanical properties of materials (FVS) than by adopting 1D instead of 3D stent models. Nevertheless, the differencesshowed are acceptable compared to those achieved by considering different stent initial positions. Regarding computationalcosts, simulations involving 1D stent features are the only ones feasible in clinical context.

Morphodynamic analysis of cerebral aneurysm pulsation from time-resolved rotational angiography

This paper presents a technique to estimate and model patient-specific pulsatility of cerebral aneurysms over onecardiac cycle, using 3D rotational X-ray angiography (3DRA) acquisitions. Aneurysm pulsation is modeled as a time varying-spline tensor field representing the deformation applied to a reference volume image, thus producing the instantaneousmorphology at each time point in the cardiac cycle. The estimated deformation is obtained by matching multiple simulated projections of the deforming volume to their corresponding original projections. A weighting scheme is introduced to account for the relevance of each original projection for the selected time point. The wide coverage of the projections, together with the weighting scheme, ensures motion consistency in all directions. The technique has been tested on digital and physical phantoms that are realistic and clinically relevant in terms of geometry, pulsation and imaging conditions. Results from digital phantomexperiments demonstrate that the proposed technique is able to recover subvoxel pulsation with an error lower than 10% of the maximum pulsation in most cases. The experiments with the physical phantom allowed demonstrating the feasibility of pulsation estimation as well as identifying different pulsation regions under clinical conditions.

Parallel Research, Multiple Intellectual Property Right Protection Instruments, and the Correlation among R&D Projects, September 2005

The choice of a research path in attacking scientific and technological problems is a significant component of firms’ R&D strategy. One of the findings of the patent races literature is that, in a competitive market setting, firms’ noncooperative choices of research projects display an excessive degree of correlation, as compared to the socially optimal level. The paper revisits this question in a context in which firms have access to trade secrets, in addition to patents, to assert intellectual property rights (IPR) over their discoveries. We find that the availability of multiple IPR protection instruments can move the paths chosen by firms engaged in an R&D race toward the social optimum.