Management of diabetes mellitus and associated cardiovascular risk factors in Brazil – the Brazilian study on the practice of diabetes care

Abstract Background The Brazilian Study on the Practice of Diabetes Care main objective was to provide an epidemiological profile of individuals with type 1 and 2 diabetes mellitus (DM) in Brazil, concerning therapy and adherence to international guidelines in the medical practice. Methods This observational, cross-sectional, multicenter study collected and analyzed data from individuals with type 1 and 2 DM attending public or private clinics in Brazil. Each investigator included the first 10 patients with type 2 DM who visited his/her office, and the first 5 patients with type 1 DM. Results A total of 1,358 patients were analyzed; 375 (27.6%) had type 1 and 983 (72.4%) had type 2 DM. Most individuals were women, Caucasian, and private health care users. High prevalence rates of hypertension, dyslipidemia and central obesity were observed, particularly in type 2 DM. Only 7.3% and 5.1% of the individuals with types 1 and 2 DM, respectively, had optimal control of blood pressure, plasma glucose and lipids. The absence of hypertension and female sex were associated with better control of type 1 DM and other cardiovascular risk factors. In type 2 DM, older age was also associated with better control. Conclusions Female sex, older age, and absence of hypertension were associated with better metabolic control. An optimal control of plasma glucose and other cardiovascular risk factors are obtained only in a minority of individuals with diabetes. Local numbers, compared to those from other countries are worse.

Differential forms on Carnot groups

The main goal of this thesis is to understand and link together some of the early works by Michel Rumin and Pierre Julg. The work is centered around the so-called Rumin complex, which is a construction in subRiemannian geometry. A Carnot manifold is a manifold endowed with a horizontal distribution. If further a metric is given, one gets a subRiemannian manifold. Such data arise in different contexts, such as: - formulation of the second principle of thermodynamics; - optimal control; - propagation of singularities for sums of squares of vector fields; - real hypersurfaces in complex manifolds; - ideal boundaries of rank one symmetric spaces; - asymptotic geometry of nilpotent groups; - modelization of human vision. Differential forms on a Carnot manifold have weights, which produces a filtered complex. In view of applications to nilpotent groups, Rumin has defined a substitute for the de Rham complex, adapted to this filtration. The presence of a filtered complex also suggests the use of the formal machinery of spectral sequences in the study of cohomology. The goal was indeed to understand the link between Rumin's operator and the differentials which appear in the various spectral sequences we have worked with: - the weight spectral sequence; - a special spectral sequence introduced by Julg and called by him Forman's spectral sequence; - Forman's spectral sequence (which turns out to be unrelated to the previous one). We will see that in general Rumin's operator depends on choices. However, in some special cases, it does not because it has an alternative interpretation as a differential in a natural spectral sequence. After defining Carnot groups and analysing their main properties, we will introduce the concept of weights of forms which will produce a splitting on the exterior differential operator d. We shall see how the Rumin complex arises from this splitting and proceed to carry out the complete computations in some key examples. From the third chapter onwards we will focus on Julg's paper, describing his new filtration and its relationship with the weight spectral sequence. We will study the connection between the spectral sequences and Rumin's complex in the n-dimensional Heisenberg group and the 7-dimensional quaternionic Heisenberg group and then generalize the result to Carnot groups using the weight filtration. Finally, we shall explain why Julg required the independence of choices in some special Rumin operators, introducing the Szego map and describing its main properties.

Parahydrogen induced polarization on a clinical MRI system : polarization transfer of two spin order

Hyperpolarization techniques enhance the nuclear spin polarization and thus allow for new nuclear magnetic resonance applications like in vivo metabolic imaging. One of these techniques is Parahydrogen Induced Polarization (PHIP). It leads to a hyperpolarized 1H spin state which can be transferred to a heteronucleus like 13C by a radiofrequency (RF) pulse sequence. In this work, timing of such a sequence was analyzed and optimized for the molecule hydroxyethyl propionate. The pulse sequence was adapted for the work on a clinical magnetic resonance imaging (MRI) system which is usually equipped only with a single RF transmit channel. Optimal control theory optimizations were performed to achieve an optimized polarization transfer. A drawback of hyperpolarization is its limited lifetime due to relaxation processes. The lifetime can be increased by storing the hyperpolarization in a spin singlet state. The second part of this work therefore addresses the spin singlet state of the Cs-symmetric molecule dimethyl maleate which needs to be converted to the spin triplet state to be detectable. This conversion was realized on a clinical MRI system, both by field cycling and by two RF pulse sequences which were adapted and optimized for this purpose. Using multiple conversions enables the determination of the lifetime of the singlet state as well as the conversion efficiency of the RF pulse sequence. Both, the hyperpolarized 13C spin state and the converted singlet state were utilized for MR imaging. Careful choice of the echo time was shown to be crucial for both molecules.

An Actor-Critic based controller for glucose regulation in type 1 diabetes

A novel adaptive approach for glucose control in individuals with type 1 diabetes under sensor-augmented pump therapy is proposed. The controller, is based on Actor-Critic (AC) learning and is inspired by the principles of reinforcement learning and optimal control theory. The main characteristics of the proposed controller are (i) simultaneous adjustment of both the insulin basal rate and the bolus dose, (ii) initialization based on clinical procedures, and (iii) real-time personalization. The effectiveness of the proposed algorithm in terms of glycemic control has been investigated in silico in adults, adolescents and children under open-loop and closed-loop approaches, using announced meals with uncertainties in the order of ±25% in the estimation of carbohydrates. The results show that glucose regulation is efficient in all three groups of patients, even with uncertainties in the level of carbohydrates in the meal. The percentages in the A+B zones of the Control Variability Grid Analysis (CVGA) were 100% for adults, and 93% for both adolescents and children. The AC based controller seems to be a promising approach for the automatic adjustment of insulin infusion in order to improve glycemic control. After optimization of the algorithm, the controller will be tested in a clinical trial.

Consensus Document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management

Arterio-venous malformations (AVMs) are congenital vascular malformations (CVMs) that result from birth defects involving the vessels of both arterial and venous origins, resulting in direct communications between the different size vessels or a meshwork of primitive reticular networks of dysplastic minute vessels which have failed to mature to become 'capillary' vessels termed "nidus". These lesions are defined by shunting of high velocity, low resistance flow from the arterial vasculature into the venous system in a variety of fistulous conditions. A systematic classification system developed by various groups of experts (Hamburg classification, ISSVA classification, Schobinger classification, angiographic classification of AVMs,) has resulted in a better understanding of the biology and natural history of these lesions and improved management of CVMs and AVMs. The Hamburg classification, based on the embryological differentiation between extratruncular and truncular type of lesions, allows the determination of the potential of progression and recurrence of these lesions. The majority of all AVMs are extra-truncular lesions with persistent proliferative potential, whereas truncular AVM lesions are exceedingly rare. Regardless of the type, AV shunting may ultimately result in significant anatomical, pathophysiological and hemodynamic consequences. Therefore, despite their relative rarity (10-20% of all CVMs), AVMs remain the most challenging and potentially limb or life-threatening form of vascular anomalies. The initial diagnosis and assessment may be facilitated by non- to minimally invasive investigations such as duplex ultrasound, magnetic resonance imaging (MRI), MR angiography (MRA), computerized tomography (CT) and CT angiography (CTA). Arteriography remains the diagnostic gold standard, and is required for planning subsequent treatment. A multidisciplinary team approach should be utilized to integrate surgical and non-surgical interventions for optimum care. Currently available treatments are associated with significant risk of complications and morbidity. However, an early aggressive approach to elimiate the nidus (if present) may be undertaken if the benefits exceed the risks. Trans-arterial coil embolization or ligation of feeding arteries where the nidus is left intact, are incorrect approaches and may result in proliferation of the lesion. Furthermore, such procedures would prevent future endovascular access to the lesions via the arterial route. Surgically inaccessible, infiltrating, extra-truncular AVMs can be treated with endovascular therapy as an independent modality. Among various embolo-sclerotherapy agents, ethanol sclerotherapy produces the best long term outcomes with minimum recurrence. However, this procedure requires extensive training and sufficient experience to minimize complications and associated morbidity. For the surgically accessible lesions, surgical resection may be the treatment of choice with a chance of optimal control. Preoperative sclerotherapy or embolization may supplement the subsequent surgical excision by reducing the morbidity (e.g. operative bleeding) and defining the lesion borders. Such a combined approach may provide an excellent potential for a curative result. Conclusion. AVMs are high flow congenital vascular malformations that may occur in any part of the body. The clinical presentation depends on the extent and size of the lesion and can range from an asymptomatic birthmark to congestive heart failure. Detailed investigations including duplex ultrasound, MRI/MRA and CT/CTA are required to develop an appropriate treatment plan. Appropriate management is best achieved via a multi-disciplinary approach and interventions should be undertaken by appropriately trained physicians.

Evaluating the relationship between moisture induced expansion and horizontal stress orientation in samples from the nonesuch formation

High horizontal stresses can cause numerous ground control problems in mines and other underground structures ultimately impacting worker safety, productivity and the economics of an underground operation. Mine layout and design can be optimized when the presence and orientation of these stresses are recognized and their impact minimized. A simple technique for correlating the principal horizontal stress direction in a sedimentary rock mass with the preferential orientation of moisture induced expansion in a sample of the same rock was introduced in the 1970s and has since gone un-reported and unused. This procedure was reexamined at a locality near the original test site at White Pine, Michigan in order to validate the original research and to consider its usefulness in mining and civil engineering applications in high horizontal stress conditions. This procedure may also be useful as an economical means for characterizing regional stress fields.

RAPID SPACE TRAJECTORY GENERATION USING A FOURIER SERIES SHAPE-BASED APPROACH

With the insatiable curiosity of human beings to explore the universe and our solar system, it is essential to benefit from larger propulsion capabilities to execute efficient transfers and carry more scientific equipment. In the field of space trajectory optimization the fundamental advances in using low-thrust propulsion and exploiting the multi-body dynamics has played pivotal role in designing efficient space mission trajectories. The former provides larger cumulative momentum change in comparison with the conventional chemical propulsion whereas the latter results in almost ballistic trajectories with negligible amount of propellant. However, the problem of space trajectory design translates into an optimal control problem which is, in general, time-consuming and very difficult to solve. Therefore, the goal of the thesis is to address the above problem by developing a methodology to simplify and facilitate the process of finding initial low-thrust trajectories in both two-body and multi-body environments. This initial solution will not only provide mission designers with a better understanding of the problem and solution but also serves as a good initial guess for high-fidelity optimal control solvers and increases their convergence rate. Almost all of the high-fidelity solvers enjoy the existence of an initial guess that already satisfies the equations of motion and some of the most important constraints. Despite the nonlinear nature of the problem, it is sought to find a robust technique for a wide range of typical low-thrust transfers with reduced computational intensity. Another important aspect of our developed methodology is the representation of low-thrust trajectories by Fourier series with which the number of design variables reduces significantly. Emphasis is given on simplifying the equations of motion to the possible extent and avoid approximating the controls. These facts contribute to speeding up the solution finding procedure. Several example applications of two and three-dimensional two-body low-thrust transfers are considered. In addition, in the multi-body dynamic, and in particular the restricted-three-body dynamic, several Earth-to-Moon low-thrust transfers are investigated.

Hyperaldosteronism in pregnancy

Aldosterone is a key regulator of electrolyte and water homeostasis and plays a central role in blood pressure regulation. Hormonal changes during pregnancy, among them increased progesterone and aldosterone production, lead to the required plasma volume expansion of the maternal body as an accommodation mechanism for fetus growth. This review discusses the regulation of aldosterone production by aldosterone synthase (CYP11B2); the impact on aldosterone secretion due to the presence of a chimeric gene originating from a crossover between CYP11B1 and CYP11B2 in glucocorticoid remediable aldosteronism (GRA) - the inherited form of hypertension; enhanced aldosterone production in aldosterone-producing adenoma (APA); and idiopathic hyperaldosteronism (IHA). Features of hyperaldosteronism are also found in patients with apparent mineralocorticoid excess (AME), in which glucocorticoids exacerbate activation of the mineralocorticoid receptor (MR) because of a defect in the 11beta-hydroxysteroid dehydrogenase type 2 enzyme. Regulation of aldosterone production and tissue-specific activation of the mineralocorticoid receptor are prerequisites for optimal control of body fluids and blood pressure during pregnancy and contribute largely to the wellbeing of the mother-to-be.

Adaptive Algorithms for Personalized Diabetes Treatment

Dynamic systems, especially in real-life applications, are often determined by inter-/intra-variability, uncertainties and time-varying components. Physiological systems are probably the most representative example in which population variability, vital signal measurement noise and uncertain dynamics render their explicit representation and optimization a rather difficult task. Systems characterized by such challenges often require the use of adaptive algorithmic solutions able to perform an iterative structural and/or parametrical update process towards optimized behavior. Adaptive optimization presents the advantages of (i) individualization through learning of basic system characteristics, (ii) ability to follow time-varying dynamics and (iii) low computational cost. In this chapter, the use of online adaptive algorithms is investigated in two basic research areas related to diabetes management: (i) real-time glucose regulation and (ii) real-time prediction of hypo-/hyperglycemia. The applicability of these methods is illustrated through the design and development of an adaptive glucose control algorithm based on reinforcement learning and optimal control and an adaptive, personalized early-warning system for the recognition and alarm generation against hypo- and hyperglycemic events.

Optimization of Schwinger pair production in colliding laser pulses

Recent studies of Schwinger pair production have demonstrated that the asymptotic particle spectrum is extremely sensitive to the applied field profile. We extend the idea of the dynamically assisted Schwinger effect from single pulse profiles to more realistic field configurations to be generated in an all-optical experiment searching for pair creation. We use the quantum kinetic approach to study the particle production and employ a multi-start method, combined with optimal control theory, to determine a set of parameters for which the particle yield in the forward direction in momentum space is maximized. We argue that this strategy can be used to enhance the signal of pair production on a given detector in an experimental setup.

The inverse problem for Schwinger pair production

The production of electron–positron pairs in time-dependent electric fields (Schwinger mechanism) depends non-linearly on the applied field profile. Accordingly, the resulting momentum spectrum is extremely sensitive to small variations of the field parameters. Owing to this non-linear dependence it is so far unpredictable how to choose a field configuration such that a predetermined momentum distribution is generated. We show that quantum kinetic theory along with optimal control theory can be used to approximately solve this inverse problem for Schwinger pair production. We exemplify this by studying the superposition of a small number of harmonic components resulting in predetermined signatures in the asymptotic momentum spectrum. In the long run, our results could facilitate the observation of this yet unobserved pair production mechanism in quantum electrodynamics by providing suggestions for tailored field configurations.

The use of arc-erosion as a patterning technique for transparent conductive materials

Within the framework of cost-effective patterning processes a novel technique that saves photolithographic processing steps, easily scalable to wide area production, is proposed. It consists of a tip-probe, which is biased with respect to a conductive substrate and slides on it, keeping contact with the material. The sliding tip leaves an insulating path (which currently is as narrow as 30 μm) across the material, which enables the drawing of tracks and pads electrically insulated from the surroundings. This ablation method, called arc-erosion, requires an experimental set up that had to be customized for this purpose and is described. Upon instrumental monitoring, a brief proposal of the physics below this process is also presented. As a result an optimal control of the patterning process has been acquired. The system has been used on different substrates, including indium tin oxide either on glass or on polyethylene terephtalate, as well as alloys like Au/Cr, and Al. The influence of conditions such as tip speed and applied voltage is discussed

Some applications of distributed signal processing

In this work we review some earlier distributed algorithms developed by the authors and collaborators, which are based on two different approaches, namely, distributed moment estimation and distributed stochastic approximations. We show applications of these algorithms on image compression, linear classification and stochastic optimal control. In all cases, the benefit of cooperation is clear: even when the nodes have access to small portions of the data, by exchanging their estimates, they achieve the same performance as that of a centralized architecture, which would gather all the data from all the nodes.

Atenuação de vibrações em pás de helicópteros utilizando circuito piezelétrico semi-passivo

O uso de materiais inteligentes em problemas de controle de vibração tem sido investigado em diversas pesquisas ao longo dos últimos anos. Apesar de que diferentes materiais inteligentes estão disponíveis, o piezelétrico tem recebido grande atenção devido à facilidade de uso como sensores, atuadores, ou ambos simultaneamente. As principais técnicas de controle usando materiais piezoelétricos são os ativos e passivos. Circuitos piezelétricos passivos são ajustados para uma frequência específica e, portanto, a largura de banda efetiva é pequena. Embora os sistemas ativos possam apresentar um bom desempenho no controle de vibração, a quantidade de energia externa e hardware adicionado são questões importantes. As técnicas SSD (Synchronized Switch Damping) foram desenvolvidas como uma alternativa aos controladores passivos e controladores ativos de vibração. Elas podem ser técnicas semi-ativas ou semi-passivas que introduzem um tratamento não linear na tensão elétrica proveniente do material piezelétrico e induz um aumento na conversão de energia mecânica para energia elétrica e, consequentemente, um aumento no efeito de amortecimento. Neste trabalho, o controle piezoelétrico semi-passivo de uma pá piezelétrica engastada é apresentado e comparado com outros controladores. O modelo não linear electromecânico de uma pá com piezocerâmicas incorporados é determinado com base no método variacional-assintótico (VAM). O sistema rotativo acoplado não linear é resolvido no domínio do tempo, utilizando um método de integração alfa-generalizado afim de garantir a estabilidade numérica. As simulações são realizadas para uma vasta gama de velocidades de rotação. Em primeiro lugar, um conjunto de resistências (variando desde a condição de curto-circuito para a condição de circuito aberto) é considerada. O efeito da resistência ótima (que resulta em máximo amortecimento) sobre o comportamento do sistema é investigado para o aumento da velocidade de rotação. Mais tarde, a técnica SSDS é utilizada para amortecer as oscilações da pá com o aumento da velocidade de rotação. Os resultados mostram que a técnica SSDS pode ser um método útil para o controle de vibrações de vigas rotativas não lineares, tais como pás de helicóptero.

Controle subótimo de manipuladores subatuados via redundância de atuação

Este trabalho apresenta uma metodologia de controle de posição das juntas passivas de um manipulador subatuado de uma maneira subótima. O termo subatuado se refere ao fato de que nem todas as juntas ou graus de liberdade do sistema serem equipados com atuadores, o que ocorre na prática devido a falhas ou como resultado de projeto. As juntas passivas de manipuladores desse tipo são indiretamente controladas pelo movimento das juntas ativas usando as características de acoplamento da dinâmica de manipuladores. A utilização de redundância de atuação das juntas ativas permite a minimização de alguns critérios, como consumo de energia, por exemplo. Apesar da estrutura cinemática de manipuladores subatuados ser idêntica a do totalmente atuado, em geral suas características dinâmicas diferem devido a presença de juntas passivas. Assim, apresentamos a modelagem dinâmica de um manipulador subatuado e o conceito de índice de acoplamento. Este índice é utilizado na seqüência de controle ótimo do manipulador. A hipótese de que o número de juntas ativas seja maior que o número de passivas permite o controle ótimo das juntas passivas, uma vez que na etapa de controle destas há mais entradas (torques nos atuadores das juntas ativas), que elementos a controlar (posição das juntas passivas). Neste ponto reside a contribuição desta tese ao estado da arte, uma vez que não há até o momento publicação que proponha o controle ótimo das juntas passivas neste caso.