Development of Clinical Decision Support Systems based on Mathematical Models of Physiological Systems

In the last years of research, I focused my studies on different physiological problems. Together with my supervisors, I developed/improved different mathematical models in order to create valid tools useful for a better understanding of important clinical issues. The aim of all this work is to develop tools for learning and understanding cardiac and cerebrovascular physiology as well as pathology, generating research questions and developing clinical decision support systems useful for intensive care unit patients. I. ICP-model Designed for Medical Education We developed a comprehensive cerebral blood flow and intracranial pressure model to simulate and study the complex interactions in cerebrovascular dynamics caused by multiple simultaneous alterations, including normal and abnormal functional states of auto-regulation of the brain. Individual published equations (derived from prior animal and human studies) were implemented into a comprehensive simulation program. Included in the normal physiological modelling was: intracranial pressure, cerebral blood flow, blood pressure, and carbon dioxide (CO2) partial pressure. We also added external and pathological perturbations, such as head up position and intracranial haemorrhage. The model performed clinically realistically given inputs of published traumatized patients, and cases encountered by clinicians. The pulsatile nature of the output graphics was easy for clinicians to interpret. The manoeuvres simulated include changes of basic physiological inputs (e.g. blood pressure, central venous pressure, CO2 tension, head up position, and respiratory effects on vascular pressures) as well as pathological inputs (e.g. acute intracranial bleeding, and obstruction of cerebrospinal outflow). Based on the results, we believe the model would be useful to teach complex relationships of brain haemodynamics and study clinical research questions such as the optimal head-up position, the effects of intracranial haemorrhage on cerebral haemodynamics, as well as the best CO2 concentration to reach the optimal compromise between intracranial pressure and perfusion. We believe this model would be useful for both beginners and advanced learners. It could be used by practicing clinicians to model individual patients (entering the effects of needed clinical manipulations, and then running the model to test for optimal combinations of therapeutic manoeuvres). II. A Heterogeneous Cerebrovascular Mathematical Model Cerebrovascular pathologies are extremely complex, due to the multitude of factors acting simultaneously on cerebral haemodynamics. In this work, the mathematical model of cerebral haemodynamics and intracranial pressure dynamics, described in the point I, is extended to account for heterogeneity in cerebral blood flow. The model includes the Circle of Willis, six regional districts independently regulated by autoregulation and CO2 reactivity, distal cortical anastomoses, venous circulation, the cerebrospinal fluid circulation, and the intracranial pressure-volume relationship. Results agree with data in the literature and highlight the existence of a monotonic relationship between transient hyperemic response and the autoregulation gain. During unilateral internal carotid artery stenosis, local blood flow regulation is progressively lost in the ipsilateral territory with the presence of a steal phenomenon, while the anterior communicating artery plays the major role to redistribute the available blood flow. Conversely, distal collateral circulation plays a major role during unilateral occlusion of the middle cerebral artery. In conclusion, the model is able to reproduce several different pathological conditions characterized by heterogeneity in cerebrovascular haemodynamics and can not only explain generalized results in terms of physiological mechanisms involved, but also, by individualizing parameters, may represent a valuable tool to help with difficult clinical decisions. III. Effect of Cushing Response on Systemic Arterial Pressure. During cerebral hypoxic conditions, the sympathetic system causes an increase in arterial pressure (Cushing response), creating a link between the cerebral and the systemic circulation. This work investigates the complex relationships among cerebrovascular dynamics, intracranial pressure, Cushing response, and short-term systemic regulation, during plateau waves, by means of an original mathematical model. The model incorporates the pulsating heart, the pulmonary circulation and the systemic circulation, with an accurate description of the cerebral circulation and the intracranial pressure dynamics (same model as in the first paragraph). Various regulatory mechanisms are included: cerebral autoregulation, local blood flow control by oxygen (O2) and/or CO2 changes, sympathetic and vagal regulation of cardiovascular parameters by several reflex mechanisms (chemoreceptors, lung-stretch receptors, baroreceptors). The Cushing response has been described assuming a dramatic increase in sympathetic activity to vessels during a fall in brain O2 delivery. With this assumption, the model is able to simulate the cardiovascular effects experimentally observed when intracranial pressure is artificially elevated and maintained at constant level (arterial pressure increase and bradicardia). According to the model, these effects arise from the interaction between the Cushing response and the baroreflex response (secondary to arterial pressure increase). Then, patients with severe head injury have been simulated by reducing intracranial compliance and cerebrospinal fluid reabsorption. With these changes, oscillations with plateau waves developed. In these conditions, model results indicate that the Cushing response may have both positive effects, reducing the duration of the plateau phase via an increase in cerebral perfusion pressure, and negative effects, increasing the intracranial pressure plateau level, with a risk of greater compression of the cerebral vessels. This model may be of value to assist clinicians in finding the balance between clinical benefits of the Cushing response and its shortcomings. IV. Comprehensive Cardiopulmonary Simulation Model for the Analysis of Hypercapnic Respiratory Failure We developed a new comprehensive cardiopulmonary model that takes into account the mutual interactions between the cardiovascular and the respiratory systems along with their short-term regulatory mechanisms. The model includes the heart, systemic and pulmonary circulations, lung mechanics, gas exchange and transport equations, and cardio-ventilatory control. Results show good agreement with published patient data in case of normoxic and hyperoxic hypercapnia simulations. In particular, simulations predict a moderate increase in mean systemic arterial pressure and heart rate, with almost no change in cardiac output, paralleled by a relevant increase in minute ventilation, tidal volume and respiratory rate. The model can represent a valid tool for clinical practice and medical research, providing an alternative way to experience-based clinical decisions. In conclusion, models are not only capable of summarizing current knowledge, but also identifying missing knowledge. In the former case they can serve as training aids for teaching the operation of complex systems, especially if the model can be used to demonstrate the outcome of experiments. In the latter case they generate experiments to be performed to gather the missing data.

Starch distribution in pear tree organs in relation to training systems, rootstocks and fruit quality

Starch is the main form in which plants store carbohydrates reserves, both in terms of amounts and distribution among different plant species. Carbohydrates are direct products of photosynthetic activity, and it is well know that yield efficiency and production are directly correlated to the amount of carbohydrates synthesized and how these are distributed among vegetative and reproductive organs. Nowadays, in pear trees, due to the modernization of orchards, through the introduction of new rootstocks and the development of new training systems, the understanding and the development of new approaches regarding the distribution and storage of carbohydrates, are required. The objective of this research work was to study the behavior of carbohydrate reserves, mainly starch, in different pear tree organs and tissues: i.e., fruits, leaves, woody organs, roots and flower buds, at different physiological stages during the season. Starch in fruit is accumulated at early stages, and reached a maximum concentration during the middle phase of fruit development; after that, its degradation begins with a rise in soluble carbohydrates. Moreover, relationships between fruit starch degradation and different fruit traits, soluble sugars and organic acids were established. In woody organs and roots, an interconversion between starch and soluble carbohydrates was observed during the dormancy period that confirms its main function in supporting the growth and development of new tissues during the following spring. Factors as training systems, rootstocks, types of bearing wood, and their position on the canopy, influenced the concentrations of starch and soluble carbohydrates at different sampling dates. Also, environmental conditions and cultural practices must be considered to better explain these results. Thus, a deeper understanding of the dynamics of carbohydrates reserves within the plant could provide relevant information to improve several management practices to increase crop yield efficiency.

Influence of plant structure, cultural pratices and environmental conditions on the development of the bacterial canker of kiwifruits

Italy has a preeminent rank in kiwifruit industry, being the first exporter and the second largest producer after China. However, in the last years kiwifruit yields and the total cultivated area considerably decreased, due to the pandemic spread of the bacterial canker caused by Pseudomonas syringae pv. actinidiae (Psa). Several climatic conditions and cultural practices affect the development of the bacterial canker. This research work focused on the impact of agricultural practices and microclimate conditions on the incidence and epidemiology of Psa in the orchard. Therefore, the effect of fertilization, irrigation, use of bio-regulators, rootstock, training system and pruning were examined. The effect of different tunnel systems was analyzed as well, to study the plant-pathogen interaction. Considering the importance of insects as vectors in other pathosystems, the role of Metcalfa pruinosa in the spread of the bacterial canker was investigated in controlled conditions. In addition, quality and storage properties of fruits from infected plants were assessed. The study of all these aspects of the agronomic practices is useful to define a strategy to limit the bacterial diffusion in the orchard. Overall, excess nitrogen fertilization, water stress, stagnant water supplies, pruning before summer and the high number of Metcalfa pruinosa increased the Psa incidence. In contrast, tunnel covers may be useful for the control of the disease, with special attention to the kind of material.

Emergency skill training--a randomized controlled study on the effectiveness of the 4-stage approach compared to traditional clinical teaching

The "4-stage approach" has been widely accepted for practical skill training replacing the traditional 2 stages ("see one, do one"). However, the superior effectiveness of the 4-stage approach was never proved.

Talents in Migration Processes in the Conditions of the Czech Republic of the Nineties

The transformation of the 1990s has had a bearing on the academic and scientific world, as is becoming increasingly obvious with the changing numbers of foreign students wishing to study in the Czech Republic and of Czech students wishing to study abroad, the virtual collapse of doctoral studies, and the rapidly increasing age of Czech academics (placed at 48 by official sources and at rather more by this research). At the same time there is an apparent lack of interest in analysing and understanding these trends, which Mr. Cermak terms an ostrich policy, although his research showed that academics are in fact both aware and concerned about them. The mid-1990s migration of talent to and from R+D in the Czech Republic is also reflected in the number of talented Czech students studying abroad, who represent the largest and most interesting group of actual and potential migrants. Mr. Cermak's study took the form of a Delphi enquiry participated in by 44 specialists, including experts in the problems of higher education and science policy from the Presidium of the Higher Education Council (n = 23), members of the Council's Science and Research Commission (n = 14), former and current managers of higher education authorities (n = 4) and selected participants of the longitudinal talent research (n = 3). Questions considered included the influence of continuing talent migration from domestic R+D on the efficiency of domestic higher education, the diversification of forms of the brain drain and their impact on other processes in society, the possibility of positive influence on the brain drain processes to minimise the risks it presents, and the use of the knowledge obtained about the brain drain. The study revealed a clear drop of interest in brain drain problems in higher education in the mid-1990s, which is probably related to the collapsed of Czech R+D in the field of talent education. The effects on this segment of the labour market appeared earlier, with a major migration wave in 1991-1993 which significantly "cleared" the area of scientific talent. In addition, prospective talents from the ranks of younger students have not been integrated into domestic R+D, leading to the increasing average age of those working in this field. "Talent scouting" tended to be oriented towards much younger individuals, even in some cases towards undergraduate students. The R+D institutions deprived of human resources considered as basic in a functional R+D system have lost much of their dynamism and so no longer attract not only domestic talent but also talent from other regions. As a result the public, including the mass media and political structures, have stopped regarding the support of domestic science as a priority. This is clear both among the young people who are important for the future development of R+D (support for the education of talented children has dropped), from the drop in the prestige of this area as a profession among university students, and from the lack of explicit support for R+D by any of the political parties. On the basis of his findings Mr. Cermak concludes that there is no basis for the belief that the brain drain will represent a positive force in stimulating the development of the open society. Migration data shows that the outflow of talent from the Czech Republic far exceeds the inflow, and that the latter is largely short-term. Not only has the number of returning Czech professors dropped to half of its level at the beginning of the 1990s, but they also tend to take up only short-term contracts and retain their foreign positions. Recruitment of scientific talent from other countries, including the Slovak Republic, is limited. Furthermore internal contacts between those already involved in R+D have been badly hit by economic pressures and institutional co-operation has dropped to a minimum. There have been few moves to counteract this situation, the only notable one being the Program 250, launched in 1996 with government support to try and attract younger (i.e. under 40) talent into R+D. Its resources are however limited and its effects have not so far been evaluated. The deficit of academic and scientific talent in the Czech Republic is increasing and two major directions of academic work are emerging. Classic higher education science based on the teaching process is declining, largely due to economic factors, while there is an increasing emphasis on special; ad hoc projects which cannot be related directly to teaching but are often interesting to specialists outside the Czech Republic. This is shown clearly by the increase in publishing and in participation in domestic and foreign grant projects, which often serve to supplement the otherwise low salaries in the higher education sector. This tend was also accelerated by the collapse of applied R+D in individual sectors of the national economy and by substantial cutbacks in the Czech Academy of Sciences, which formerly fostered such research. Some part of the output of this research can be used in the education system and its financial contribution does significantly affect the stability of the present staff, but Mr. Cermak sees it as generally unfavourable for the development of talent education. In addition, it has led to a certain resignation on the question of integration into international structures, due to the emphasis on short-term targets, commercial advantages and individualism rather than team work. At the same time, he admits that these developments reflect those in other areas of the transformation in the Czech Republic.

"What is the Value of Youth Work?" Symposium Booklet

As a group of experienced and novice youth workers, we believe that youth work is fundamentally about building trust-filled, mutually respectful relationships with young people. We create safe environments for young people to connect with other supportive adults and peers and to avoid violence in their neighborhoods and their homes. We guide those harmed by oppressive community conditions such as racism, sexism, agism, homophobia, and classism through a process of healing. As we get to know more about young people’s interests, we help them develop knowledge and skills in a variety of areas including: academic, athletic, leadership/civic, the arts, health and wellbeing, and career exploration. In short, we create transformative experiences for young people. In spite of the critical roles we play, we have largely been overlooked in youth development research, policy, and as a professional workforce. We face challenges ‘moving up’ in our careers. We get frustrated by how little money we earn. We are discouraged that despite our knowledge and experience we are not invited to the tables where youth funding, programming, and policy decisions are made. It is true—many of us do not have formal training or degrees in youth work—a reality which at times we regret. Yet, as our colleague communicates in the accompanying passage (see below), we resent that formal education is required for us to get ahead, particularly because we question whether we need it to do our jobs more effectively. Through the “What is the Value of Youth Work?” symposium, we hope to address these concerns through a dialogue about youth work with the following objectives: • Increase awareness of the knowledge, skills, contributions, and professionalism of youth workers; • Advance a youth worker professional development model that integrates a dilemma-focused approach with principles of social justice youth development; • Launch an ongoing Worcester area Youth Worker network. This booklet provides a brief overview of the challenges in ‘professionalizing’ youth work and an alternative approach that we are advancing that puts the knowledge and expertise of youth workers at the center of professional development.

Social Work Education and Training in Europe and the Bologna Process

A short review of the last three decades shows that social work programmes have developed similarly in (almost) all European countries, both in terms of structural and content-related characteristics. Here I would like to focus on the following aspects: Increased academic focus of training, Generalist programme, International/European orientation. Increased academic focus means that social work programmes have been established at uni-versities or comparable higher education institutions, such as universities of applied sciences. The only exception is France where the approximately 150, generally fairly small colleges and the 14 larger instituts regionaux have a hybrid position between vocational colleges and universities and are roughly comparable to academies.

Why Freeter and NEET are Misunderstood: Recognizing the New Precarious Conditions of Japanese Youth

In developed countries, the transition from school to work has radically changed over the past two decades. It has become prolonged, complicated and individualized (Bynner et al., 1997; Walther et al., 2004). Young people used to transition directly from school to stable employment, or with a very short unemployed period. In many European countries, this situation has been changing since the eighties: overall youth unemployment has increased, and many young people experience long periods of unemployment, government training schemes and part-time or temporary jobs. In Japan, this change has taken a decade later to appear, becoming prevalent by the late nineties (Inui, 2003). The transiting process has become not only precarious for young people, but also difficult for society to precisely understand the risks and problems. Traditionally, we have been able to recognize young people's situation by a simple category: in education, employed, in training or unemployed. However, these categories no longer accurately represent young people's state. In Japan, most young people used to move from school directly to full-time employment through the new graduate recruitment system (Inui, 1993). Therefore, in official statistics such as the School Basic Survey, 'employed' includes only those who are in regular employment, while those who are in part-time or temporary work are covered by the categories 'jobless' and 'others'. However, with the increase in non-full-time jobs in the nineties, these categories have become less useful for describing the actual employment conditions of young people. Indeed, this is why, in the late of nineties, the Japanese Ministry of Education changed the category name from 'jobless' to 'others'.

Work Experiences and Well-Being in the First Years of Professional Work in Switzerland: A Ten-Year Follow-Up Study

The ÆQUAS (a German acronym for “Work Experiences and Quality of Life in Switzerland”) study followed young workers in five occupations over their first ten years in the labor market. Participants of the study reported on working conditions and well-being at five occasions. Overall, resources at work as well as well-being, health and personal resources remained stable or increased. Concurrently, task-related stressors increased as well. This result may reflect career progress (e.g., gaining more responsibilities may be accompanied by increasing time pressure) but development in task-related stressors as well as resources may also be related to specific occupations. Several trajectories had their turning point after the first or second year of being in the labor market, which may reflect a successful professional socialization. Even though a substantial number of participants did change their occupation over these ten years (with benefits for their well-being), development over the first ten years after vocational training implies a successful transition into labor market.

Learning processes in student teaching: Analyses from a study using learning diaries

The present study seeks to obtain deeper insight into the learning processes in practical training in primary teacher education in Upper Austria. Based on the offer-and-use model of instruction, 230 diary entries of 46 student teachers (28 students in their third semester, 18 students in their fifth semester) were analysed with legard to the learning topics, learning sourcesJ and Ìealning processes involved in practical training. The results show a variety of learning forms, ranging from the unreflective imitation of school mentors' practices to active knowledge construction. In addition, they illustrate that the available learning offers were suboptimally utilized by stuclent teachers who failed to work systernatically and continuously on their professional development.

Interprofessional Education in Anatomy: Learning Together in Medical and Nursing Training

Teamwork and the interprofessional collaboration of all health professions are a guarantee of patient safety and highly qualified treatment in patient care. In the daily clinical routine, physicians and nurses must work together, but the education of the different health professions occurs separately in various places, mostly without interrelated contact. Such training abets mutual misunderstanding and cements professional protectionism, which is why interprofessional education can play an important role in dismantling such barriers to future cooperation. In this article, a pilot project in interprofessional education involving both medical and nursing students is presented, and the concept and the course of training are described in detail. The report illustrates how nursing topics and anatomy lectures can be combined for interprofessional learning in an early phase of training. Evaluation of the course showed that the students were highly satisfied with the collaborative training and believed interprofessional education (IPE) to be an important experience for their future profession and understanding of other health professionals. The results show that the IPE teaching concept, which combines anatomy and nursing topics, provides an optimal setting for learning together and helps nurses and doctors in training to gain knowledge about other health professionals’ roles, thus evolving mutual understanding.