Alcohol Septal Ablation in Obstructive Hypertrophic Cardiomyopathy: Four Years of Experience at a Reference Center

INTRODUCTION: We describe our center's initial experience with alcohol septal ablation (ASA) for the treatment of obstructive hypertrophic cardiomyopathy. The procedure, its indications, results and clinical outcomes will be addressed, as will its current position compared to surgical myectomy. OBJECTIVE: To assess the results of ASA in all patients treated in the first four years of activity at our center. METHODS: We retrospectively studied all consecutive and unselected patients treated by ASA between January 2009 and February 2013. RESULTS: In the first four years of experience 40 patients were treated in our center. In three patients (7.5%) the intervention was repeated. Procedural success was 84%. Minor complications occurred in 7.5%. Two patients received a permanent pacemaker for atrioventricular block (6% of those without previous pacemaker). The major complication rate was 5%. There were no in-hospital deaths; during clinical follow-up (22 ± 14 months) cardiovascular mortality was 2.5% and overall mortality was 5%. DISCUSSION AND CONCLUSION: The results presented reflect the initial experience of our center with ASA. The success rate was high and in line with published results, but with room to improve with better patient selection. ASA was shown to be safe, with a low complication rate and no procedure-related mortality. Our experience confirms ASA as a percutaneous alternative to myectomy for the treatment of symptomatic patients with obstructive hypertrophic cardiomyopathy refractory to medical treatment.

Hypermedia-based Web Services as System Integrators

As we move more closely to the practical concept of the Internet of Things and, our reliance on public and private APIs increases, web services and their related topics have become utterly crucial to the informatics community. However, the question about which style of web services would best solve a particular problem, can raise signi cant and multifarious debates. There can be found two implementation styles that highlight themselves: the RPC-oriented style represented by the SOAP protocol’s implementations and the hypermedia style, which is represented by the REST architectural style’s implementations. As we search examples of already established web services, we can nd a handful of robust and reliable public and private SOAP APIs, nevertheless, it seems that RESTful services are gaining popularity in the enterprise community. For the current generation of developers that work on informatics solutions, REST seems to represent a fundamental and straightforward alternative and even, a more deep-rooted approach than SOAP. But are they comparable? Do both approaches have each speci c best suitable scenarios? Such study is brie y carried out in the present document’s chapters, starting with the respective background study, following an analysis of the hypermedia approach and an instantiation of its architecture, in a particular case study applied in a BPM context.

The use of long acting sulfonamides, alone or with pyrimethamine, in malaria (with special reference to sulformetoxine)

Review of the early literature as well as more recent results show that sulfonamides possess a distinct antimalarial activity. However, when give alone, their action is less marked and slower than that of the antimalarials commonly used in the treatment of the acute attack. Combinations with pyrimethamine provide better results, even in cases of pyrimethamine and chloroquine resistance. This warrants further investigations in an attempt to develop a therapeutic agent suitable for the treatment of such resistant cases. It may also be possible with an appropriate combination of pyrimethamine with a sulfonamide to achieve a satisfactory method for suppressive treatment both in areas with and without pyrimethamine resistance. Three main points must still be carefully studied: 1) the risk of developing malaria resistance against one or both of the components of the combination. 2) The risk of developing bacterial resistance to sulfonamides if these substances are used on a large scale in too low doses. It seems indeed that antimalarial effect with the combination of sufonamides + pyrimethamine can be obtained with doses of sulfonamides which are below those usually employed in bacterial diseases. Since the range of the ratios providing potentiation is rather large, only ratios of the combination sulfonamides: pyrimethamine should be chosen in which an antfbacterial sulfonamidemia is guaranteed. 3) It goes without sayinq that, although both pyrimethamine and modem sulfonamides, when given by themselves, have proved tc possess a large margin of safety, long term administration of their combination should be careful studied from the point of view of possible side effects. Substantial evidence has already been produced to show that the long acting sulfonamide Fanasil (Ro 4-4393) given once or once weekly possesses marked schizonticidal activity against P. falciparum. Although its action is slower than that of 4-aminoquinolines, it may be useful as a second choice drug in semi-immune subjects for the therapy of falciparum malaria. Preliminary results show that, when combined with pyrimethamine, Fanasil is highly effective in suppressing fever and asexual parasitemia due to P. falciparum. Single doses of 1 g Fanasil together with 50 mg pyrimethamine seem to be adequate for the treatment of acute falciparum malaria in semi-immune patients. The onset of action of the combination is much more rapid than that of the single components. Weekly doses of 500 mg Fanasil and 25 mg pyrimeihamine appear to provide satisfactory suppressive effects against P. falciparum at least in East Africa. This combination is active on strains which do not respond satisfactorily to the standard doses of pyrimethamine and/or chloroquine and seems to have a satisfactory sporontocidal effect. Preliminary results indicate that Fanasil alone cannot be recommended for use against the other human malaria parasites. The combination with pyrimethamine appears to be much more effective. East African strains of P. malariae seem to respond better to the combination than do Malayan strains of P. vivax but further trials are required before definite assessment can be made. Fanasil by itself has no gametocytoddal or sporontocidal action but seems to potentiate the effect of pyrimethamine at least on sporogony of P. falciparum.

Reference-free high-speed cmos pipeline analog-to-digital converters

Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Electrical and Computer Engineering of the Faculdade de Ciências e Tecnologia of Universidade Nova de Lisboa

NEGOSEIO: framework for the sustainability of model-oriented enterprise interoperability

Dissertation to obtain the degree of Doctor of Philosophy in Electrical and Computer Engineering(Industrial Information Systems)

A multiagent based shop floor transportation system simulator

Dissertação para obtenção do Grau de Mestre em Engenharia Electrotécnica e de Computadores

An agent based architecture for material handling systems

Dissertação para obtenção do Grau de Mestre em Engenharia Electrotécnica e de Computadores

TSKY: a dependable middleware solution for data privacy using public storage clouds

Dissertação para obtenção do Grau de Mestre em Engenharia Informática

Project of a bandgap voltage reference and a temperature sensor for "energy harvest" systems

Dissertação para obtenção do Grau de Mestre em Engenharia Electrotécnica e Computadores

The stone and the cross. Indo-Portuguese Jesuit Architecture in Ethiopia. 1603-33

A fundação de uma missão jesuita no Norte da Etiópia em 1603, na província do Tigré, pelo enérgico Pe. Pero Pais, S. J. teólogo, construtor e historiador vindo de Goa, tomou um forte impulso com a aliança pretendida com os Portugueses pelo imperador Susénios (1619-20) para o apoio militar contra os muçulmanos; e, sobretudo, após a sua conversão oficial à Igreja Católica Romana, em 1626. Uma dúzia de inovadores edifícios foram então construídos pelos Jesuítas na região paradisíaca em torno do Lago Tana: basílicas, igrejas, palácios e jardins, complexos palatinos e eclesiásticos, colégios, etc. A tipologia em cruz latina e ornatos incisos é deliberadamente diferente das igrejas ortodoxas etíopes, circulares e em madeira. A técnica de construção em pedra e cal, ignorada na Etiópia, significou uma revolução. No presente texto procura-se determinar a quem deve ser atribuído este inédito surto construtivo, deixando de lado as teorias tradicionais de pedreiros vindos de Portugal ou de construtores locais. Com base na evidência estilística e em referências de textos da época, atribui-se a inovação a padres e “irmãos” jesuitas com experiência de arquitectos na Índia portuguesa e a construtores de Goa e de Diu, definindo a arte portuguesa na Etiópia como uma província da arquitectura indo-portuguesa na Índia, prosseguida após a expulsão dos Jesuítas (1633) com os “castelos portugueses”, ou paços acastelados da nova capital, Gondar.

Report of a traineeship : audit of antidepressant prescribing in Primary and Mental Care: how to address appropriateness and keep a curb on costs. A tool suitable for all contexts?

RESUMO: Este é o relatório de um estágio realizado na Autoridade de Saúde Local de Bolonha com o objectivo de desenvolver capacidades e competências na área de projectos orientados para a avaliação com base epidemiológica. As prescrições de anti-depressivos aumentaram consideravelmente em todo o mundo durante as últimas décadas. O uso cada vez maior dos agentes mais dispendiosos desempenha um papel na subida do custo dos tratamentos. A Autoridade de Saúde Local de Bolonha implementou um processo de auditoria com o objectivo de melhorar a adequação das prescrições de pacientes externos, centrando-se em dois anti-depressivos de marca ainda protegidos por patente, Escitalopram e Duloxetine. Os Departamentos de Cuidados de Saúde Primários e de Cuidados de Saúde Mental, assim como o Departamento Farmacêutico e a Unidade de Gestão Clínica, estiveram envolvidos na fase de planeamento da auditoria. O grupo da auditoria, maioritariamente composto por médicos de clínica geral e psiquiatras, reuniu e analisou provas da eficácia e segurança dos anti-depressivos. Os dados sobre as prescrições das Unidades de Cuidados de Saúde Primários e dos Centros de Saúde Mental Comunitários da Autoridade de Saúde Local (866.294 habitantes) foram comparados, em particular as taxas de consumo de Escitalopram e Duloxetine. O grupo da auditoria definiu os standards a serem abordados, os indicadores a serem avaliados e as medidas a empreender para atingir os objectivos definidos. As directrizes do NICE sobre a depressão foram escolhidas como referência. O objectivo da auditoria foi definido como evitar o Escitalopram e Duloxetine como medicamentos de primeira escolha num tratamento anti-depressivo. De modo a verificar a eficácia das medidas empreendidas foi seleccionado um indicador, consistindo numa redução de 25% das prescrições de ambos os anti-depressivos na prática clínica de pacientes externos e numa redução de 20% da variabilidade nas Unidades de Cuidados de Saúde Primários. O relatório retrospectivo pré-auditoria (Janeiro a Abril de 2012) revelou que os tratamentos com anti-depressivos para pacientes externos eram prescritos pelos médicos de clínica geral em mais de90% dos casos. As medidas da auditoria foram implementadas entre Novembro de 2012 e Maio de 2013. Algumas medidas relevantes foram integradas com a revisão da auditoria, tais como reuniões educacionais de pequena escala com os médicos de clínica geral e psiquiatras, visitas de apoio do assessor de prescrições da Autoridade de Saúde Local aos médicos de clínica geral e Centros de Saúde Mental Comunitários, panfletos para profissionais com informação retirada das directrizes clínicas do NICE, implementação de um serviço de consulta na Web para médicos de clínica geral sobre provas relativas a anti-depressivos. O relatório de feedback é aguardado em Novembro de 2013 depois de se verificar nos standards atingidos a eficácia das medidas implementadas. Foi realizada uma análise SWOT para comprovar as forças e fraquezas, as oportunidades e ameaças do processo. Como identificação de fraquezas poderá ser útil identificar estratégias relevantes para melhoria interna, para que o conhecimento das ameaças possa amortizar factores que possam ter impactos adversos que fujam ao controlo do Departamento de Saúde Mental. Uma melhor compreensão das forças e das oportunidades facilita a consecução dos objectivos estabelecidos no projecto. O primeiro, mas não o último, resultado deste processo consistiu numa maior integração entre os Cuidados de Saúde Primários e de Saúde Mental, permitindo assim que a Autoridade de Saúde Local coloque as alterações em prática.------------ABSTRACT: This is the report of a traineeship held in the Local Health Authority of Bologna with the aim to develop skills and competencies in the field of epidemiogically based evaluation oriented projects. Antidepressants prescriptions have considerably increased all over the world in the last decades. The increasing use of the most expensive agents plays a part in the rising cost of treatments. The Local Health Authority of Bologna has implemented an audit process aimed at improving the appropriateness of outpatient prescriptions focusing on the two branded antidepressants still protected by patent, Escitalopram and Duloxetine. The Primary Care and the Mental Health Care Departments, as well as the Pharmaceutical Department and the Clinical Governance Unit, were involved in the planning phase of the audit. The audit group, mainly composed of general practitioners and psychiatrists, collected and analyzed scientific evidence on effectiveness and safety of antidepressants. Data on prescriptions of Primary Care Units and Community Mental Health Centers of the Local Health Authority (866.294 inhabitants) were compared, in particular consumption rates of Escitalopram and Duloxetine. The audit group defined the standards to be addressed, the indicators to be evaluated and the actions aimed at reaching the defined goals. NICE guidelines on depression were chosen as reference. The aim of the audit was settled as avoiding Escitalopram and Duloxetine as first choice drugs starting an AD treatment. In order to check the efficacy of the actions undertaken an indicator was selected, consisting in a reduction of 25% of prescriptions of both ADs in outpatient practice and in a 20% reduction of To develop skills and competencies across Primary Care Units. The pre-audit retrospective report (January-April 2012) showed that outpatient antidepressant treatments were prescribed by GPs in over 90% of cases. Audit actions were implemented between November 2012 and May 2013. Some relevant actions have been integrated with the audit review, such as small-scale educational meetings with GPs and psychiatrists, outreach visits of the LHA prescribing adviser to GPs and CMHCs,leaflets for professionals with information extracted from NICE clinical guidelines, implementation of a web consultation service for GPs about evidence on antidepressants. The feedback report is expected in November 2013 after checking through the standards attained the effectiveness of actions implemented. A SWOT Analysis was carried out to evidence the strengths and weaknesses, opportunities and threats of the process. As identification of weaknesses may be useful to identify relevant strategies for internal improvement, so the knowledge of threats can amortize factors that may have adverse impacts beyond the control of the Mental Health Department. Better understanding of the strengths and the opportunities facilitates the achievement of the goals set in the project. The first and not least upshot of this process has consisted in further integration between Primary and Mental Health Care, thus enabling the LHA to put the change into practice.

Heritages, Identities, and Policy in the Metropolitan Area of Lisbon

In a world that has moved away from narratives based on the idea of progress, the past has established itself as a place of reference: confirming to ourselves that what we were is indispensible for sustaining what we think we are. The recovery of the past is thus one of the most common symbolic instruments used in negotiating identities. The cultural practices that have recourse to representation mechanisms that call on the past in order to consider the present always end up translating themselves, insofar as they fragment, reorganize and interpret it in their transformation, or, to use a formula that has become unavoidable, in their “invention”. Patrimonialization is one such practice. It associates the notion of heritage – which is not a given fact, but rather a socially constructed classification, and therefore one that is constantly being negotiated – with specific objects that come to serve as cultural representations of the groups who consider themselves to be their rightful owners. In the Lisbon Metropolitan Area, as in other ethnographic contexts, patrimonialization encompasses things as diverse as landscapes, monuments, popular architecture, handicrafts, local feast days/processions/pilgrimages and people; all things that can, once transformed into material representations of the past, serve as arguments for the identity fictions of the people who inhabit them.

Enterprise reference lexicon building from business models

Nowadays, a significant increase on the demand for interoperable systems for exchanging data in business collaborative environments has been noticed. Consequently, cooperation agreements between each of the involved enterprises have been brought to light. However, due to the fact that even in a same community or domain, there is a big variety of knowledge representation not semantically coincident, which embodies the existence of interoperability problems in the enterprises information systems that need to be addressed. Moreover, in relation to this, most organizations face other problems about their information systems, as: 1) domain knowledge not being easily accessible by all the stakeholders (even intra-enterprise); 2) domain knowledge not being represented in a standard format; 3) and even if it is available in a standard format, it is not supported by semantic annotations or described using a common and understandable lexicon. This dissertation proposes an approach for the establishment of an enterprise reference lexicon from business models. It addresses the automation in the information models mapping for the reference lexicon construction. It aggregates a formal and conceptual representation of the business domain, with a clear definition of the used lexicon to facilitate an overall understanding by all the involved stakeholders, including non-IT personnel.

A new MDA-SOA based framework for intercloud interoperability

Cloud computing has been one of the most important topics in Information Technology which aims to assure scalable and reliable on-demand services over the Internet. The expansion of the application scope of cloud services would require cooperation between clouds from different providers that have heterogeneous functionalities. This collaboration between different cloud vendors can provide better Quality of Services (QoS) at the lower price. However, current cloud systems have been developed without concerns of seamless cloud interconnection, and actually they do not support intercloud interoperability to enable collaboration between cloud service providers. Hence, the PhD work is motivated to address interoperability issue between cloud providers as a challenging research objective. This thesis proposes a new framework which supports inter-cloud interoperability in a heterogeneous computing resource cloud environment with the goal of dispatching the workload to the most effective clouds available at runtime. Analysing different methodologies that have been applied to resolve various problem scenarios related to interoperability lead us to exploit Model Driven Architecture (MDA) and Service Oriented Architecture (SOA) methods as appropriate approaches for our inter-cloud framework. Moreover, since distributing the operations in a cloud-based environment is a nondeterministic polynomial time (NP-complete) problem, a Genetic Algorithm (GA) based job scheduler proposed as a part of interoperability framework, offering workload migration with the best performance at the least cost. A new Agent Based Simulation (ABS) approach is proposed to model the inter-cloud environment with three types of agents: Cloud Subscriber agent, Cloud Provider agent, and Job agent. The ABS model is proposed to evaluate the proposed framework.

Lessons from the epidemiological surveillance program, during the influenza A (H1N1) virus epidemic, in a reference university hospital of Southeastern Brazil

INTRODUCTION: The case definition of influenza-like illness (ILI) is a powerful epidemiological tool during influenza epidemics. METHODS: A prospective cohort study was conducted to evaluate the impact of two definitions used as epidemiological tools, in adults and children, during the influenza A H1N1 epidemic. Patients were included if they had upper respiratory samples tested for influenza by real-time reverse transcriptase polymerase chain reaction during two periods, using the ILI definition (coughing + temperature > 38ºC) in period 1, and the definition of severe acute respiratory infection (ARS) (coughing + temperature > 38ºC and dyspnoea) in period 2. RESULTS: The study included 366 adults and 147 children, covering 243 cases of ILI and 270 cases of ARS. Laboratory confirmed cases of influenza were higher in adults (50%) than in children (21.6%) ( p < 0.0001) and influenza infection was more prevalent in the ILI definition (53%) than ARS (24.4%) (p < 0.0001). Adults reported more chills and myalgia than children (p = 0.0001). Oseltamivir was administered in 58% and 46% of adults and children with influenza A H1N1, respectively. The influenza A H1N1 case fatality rate was 7% in adults and 8.3% in children. The mean time from onset of illness until antiviral administration was 4 days. CONCLUSIONS: The modification of ILI to ARS definition resulted in less accuracy in influenza diagnosis and did not improve the appropriate time and use of antiviral medication.