Aplicação do paradigma Lean em processos clínicos do Centro Hospitalar do Alto Ave

Dissertação de mestrado em Engenharia Industrial

Quantificação da massa infartada do ventrículo esquerdo pela ressonância magnética cardíaca: comparação entre a planimetria e o método de escore visual semi-quantitativo

OBJETIVO: Validar um novo método de escore visual semi-quantitativo contra a planimetria digital quantitativa para a determinação da massa infartada do ventrículo esquerdo pela ressonância magnética cardíaca com técnica de realce tardio. MÉTODO: Estudados 77 pacientes com infarto miocárdico prévio em aparelho de ressonância magnética de 1,5T utilizando técnica de realce tardio para avaliação da viabilidade miocárdica e cálculo da massa infartada. Para avaliação da função ventricular esquerda pelo método de Simpson utilizamos técnica de cine-ressonância. O cálculo da massa infartada foi realizado nas imagens de realce tardio de duas formas: planimetria e método de escore. Utilizamos métodos de regressão linear simples, correlação e concordância entre métodos e observadores segundo a análise de Bland-Altman. RESULTADOS: Em todos os 77 pacientes as áreas de infarto foram detectadas pela ressonância magnética cardíaca utilizando a técnica de realce tardio. O tamanho do infarto medido pela planimetria foi semelhante ao obtido pelo método de escore, com a média das diferenças entres as medidas de apenas 1,03% da massa do ventrículo esquerdo. As variabilidades inter (0,41%) e intra-observador (0,34%) evidenciaram excelente reprodutibilidade do método de escore. A massa infartada apresentou boa correlação com a fração de ejeção e volumes distólico e sistólico finais indexados, r=-0,76, r=0,63 e r=0,67, respectivamente. CONCLUSÃO: A avaliação de pacientes com infarto agudo do miocárdio prévio pela ressonância magnética cardíaca, utilizando a técnica de realce tardio, permite a determinação reprodutível do tamanho do infarto, tanto pelo método de planimetria, quanto pelo modelo semi-quantitativo de escore.

Mecanismos de Fotopercepción No-Visual y Control Circadiano en la Retina Interna de Vertebrados en Condiciones Fisiológicas y en un Modelo Animal de Ceguera. Mechanisms of Non-visual Perception and Circadian Control in the Vertebrate Inner Retina under Physiological Conditions and in Animal Model of Blindness.

La retina juega un rol esencial en el funcionamiento del sistema circadiano de los vertebrados al ser la encargada de sensar las condiciones de iluminación ambiental que ajustan el reloj interno con el fotoperíodo exterior a través de un circuito no-visual. Este circuito es independiente de la vía de formación de imágenes e involucra a las células ganglionares retinianas (CGRs) que proyectan a varias estructuras no-visuales del cerebro; esta vía es la encargada de regular el reflejo pupilar, la sincronización de los ritmos diarios de actividad, el sueño y la supresión de melatonina pineal. La retina contiene además un reloj autónomo que genera ritmos diarios autosostenidos en distintas funciones bioquímicas y fisiológicas, que le confiere la capacidad de predecir el tiempo y anticiparse en su fisiología a los cambios lumínicos a lo largo del ciclo día-noche. Este laboratorio ha demostrado por 1ra vez que las CGRs de pollo poseen osciladores endógenos que generan variaciones diarias en la biosíntesis de fosfolípidos (Guido et al, J Neurochem. 2001; Garbarino et al., J Neurosci Res. 2004a) y de la hormona melatonina con niveles máximos durante el día (Garbarino et al., J Biol Chem 2004b). Aún más, cultivos primarios de CGRs responden a la luz a través de una cascada bioquímica de fototransducción similar a la de invertebrados y que involucra la activación de la enzima fosfolipasa C (PLC) (Contin et al., FASEB J 2006). Estos cultivos fueron obtenidos a estadios embrionarios muy tempranos en dónde solo las CGRs son postmitóticas y mayoritariamente maduras. A estos estadios, los cultivos expresan marcadores de especificación de células ganglionares (pax6, brn3), la proteina Gq y los fotopigmentos melanopsina y criptocromos con gran homología con marcadores descriptos para fotorreceptores rabdoméricos de invertebrados (Contin et al, 2006). Recientemente comenzamos a investigar la percepción de luz en pollos GUCY1*, un modelo de ceguera, en animales que carecen de células fotorreceptoras-conos y bastones-funcionales. Resultados preliminares indicarían que la retina interna, y potencialmente las CGRs de estos animales conservarían la capacidad de responder a la luz regulando el reflejo pupilar y sincronizando los ritmos diarios de alimentación. La convergencia de osciladores y fotopigmentos en la población de CGRs podría contribuir al control temporal de la fisiología del organismo y regulación de funciones no-visuales. Son objetivos de este proyecto: a) Investigar el rol de las CGRs en el sistema circadiano estudiando: i- su habilidad para sintetizar melatonina y, su regulación por luz y dopamina; ii- su capacidad fotorreceptora intrínseca, investigando la presencia de fotopigmentos y componentes de la cascada de fototransducción fundamentalmente la vía de los fosfoinosítidos y la activación de PLC, mediante ensayos moleculares, bioquímicos y farmacológicos; b) Extender estos estudios a cultivos primarios de CGRs inmunopurificadas midiendo la respuesta a la luz sobre la síntesis de melatonina, y los niveles de los mensajeros 2rios Ca2+ y AMP cíclico, la inducción de genes tempranos y la regulación de la actividad NAT, enzima clave en la síntesis de melatonina; y c) Investigar la percepción de luz en pollos GUCY1*(ciegos), sobre distintas funciones no-visuales tales como el reflejo pupilar, la sincronización de los ritmos diarios de alimentación, la síntesis de melatonina y la expresión génica en animales expuestos a estimulación lumínica de distintas intensidades y longitudes de onda. Estos estudios permitirán construir el espectro de acción de la respuesta a la luz en los pollos ciegos a fin de identificar el/los fotopigmentos intervinientes en este fenómeno. Este proyecto profundizará el conocimiento sobre la capacidad fotorreceptora-no visual de la retina interna y particularmente de las CGRs, de la naturaleza de la cascada bioquímica que opera en las mismas y de los mecanismos de regeneración del cromóforo utilizado.

What value can be attached to a concept of mystery and has it a place in contemporary Western culture?

The idea for this thesis arose from a chain of reactions first set in motion by a particular experience. In keeping with the contemporary need to deconstruct every phenomenon it seemed important to analyse this experience in the hope of a satisfactory explanation. The experience referred to is the aesthetic experience provoked by works of art. The plan for the thesis involved trying to establish whether the aesthetic experience is unique and individual, or whether it is one that is experienced universally. Each question that arises in the course of this exploration promotes a dialectical reaction. I rely on the history of aesthetics as a philosophical discipline to supply the answers. This study concentrates on the efforts by philosophers and critical theorists to understand the tensions between the empirical and the emotional, the individual and the universal responses to the sociological, political and material conditions that prevail and are expressed through the medium of art. What I found is that the history of aesthetics is full of contradictory evidence and cannot provide a dogmatic solution to the questions posed. In fact what is indicated is that the mystery that attaches to the aesthetic experience is one that can also apply to the spiritual or transcendent experience. The aim of this thesis is to support the contribution of visual art in the spiritual well being of human development and supports the uniqueness of the evaluation and aesthetic judgement by the individual of a work of art. I suggest that mystery will continue to be of value in the holistic development of human beings and this mystery can be expressed through visual art. Furthermore, this thesis might suggest that what could be looked at is whether a work of art may be redemptive in its affect and offset the current decline in affective religious practice.

Development of a data acquisition system to characterise sustainable energy technologies and to support Web-Based learning (DAQ-WBL)

Driven by concerns about rising energy costs, security of supply and climate change a new wave of Sustainable Energy Technologies (SET’s) have been embraced by the Irish consumer. Such systems as solar collectors, heat pumps and biomass boilers have become common due to government backed financial incentives and revisions of the building regulations. However, there is a deficit of knowledge and understanding of how these technologies operate and perform under Ireland’s maritime climate. This AQ-WBL project was designed to address both these needs by developing a Data Acquisition (DAQ) system to monitor the performance of such technologies and a web-based learning environment to disseminate performance characteristics and supplementary information about these systems. A DAQ system consisting of 108 sensors was developed as part of Galway-Mayo Institute of Technology’s (GMIT’s) Centre for the Integration of Sustainable EnergyTechnologies (CiSET) in an effort to benchmark the performance of solar thermal collectors and Ground Source Heat Pumps (GSHP’s) under Irish maritime climate, research new methods of integrating these systems within the built environment and raise awareness of SET’s. It has operated reliably for over 2 years and has acquired over 25 million data points. Raising awareness of these SET’s is carried out through the dissemination of the performance data through an online learning environment. A learning environment was created to provide different user groups with a basic understanding of a SET’s with the support of performance data, through a novel 5 step learning process and two examples were developed for the solar thermal collectors and the weather station which can be viewed at http://www.kdp 1 .aquaculture.ie/index.aspx. This online learning environment has been demonstrated to and well received by different groups of GMIT’s undergraduate students and plans have been made to develop it further to support education, awareness, research and regional development.

Stroke

Stroke is a preventable and treatable disease. It can present with the sudden onset of any neurological disturbance, including limb weakness or numbness, speech disturbance, visual loss or disturbance of balance. Over the last two decades, a growing body of evidence has overturned the traditional perception that stroke is simply a consequence of aging which inevitably results in death or severe disability. Evidence is accumulating for more effective primary and secondary prevention strategies, better recognition of people at highest risk and thus most in need of active intervention, interventions that are effective so on after the onset of symptoms, and an understanding of the processes of care that contribute to a better outcome. In addition, there is now good evidence to support interventions and care processes in stroke rehabilitation. In the UK, the National Sentinel Stroke Audits 2,3 have documented changes in secondary care provision over the last 10 years, with increasing numbers of patients being treated in stroke units, more evidence-based practice, and reductions in mortality and length of stay. In order for evidence from research studies to improve outcomes for patients, it needs to be put into practice. National guidelines provide clinicians, managers and service users with summaries of evidence and recommendations for clinical practice. Implementation of guidelines in practice, supported by regular audit, improves the processes of care and clinical outcome. This guideline covers interventions in the acute stage of a stroke (‘acute stroke’) or transient ischaemic attack (TIA). Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms, although some interventions of up to 2 weeks are covered as well. This guideline is a stand-alone document, but is designed to be read alongside the Intercollegiate Stroke Working Party guideline ‘National clinical guideline for stroke’* which considers evidence for interventions from the acute stage into rehabilitation and life after stroke. The Intercollegiate Stroke Working Party guideline is an update of the 2004 2nd edition and includes all the recommendations contained within this guideline. This acute stroke and TIA guideline is also designed to be read alongside the Department of Health’s (DH) ‘National stroke strategy’ (NSS). Where there are differences between the recommendations made within this acute stroke and TIA guideline and the NSS, the Guideline Development Group (GDG) members feel that their recommendations are derived from systematic methodology to identify all of the relevant literature.

Governmental start-up support in the light of allocative market failure : justification, analysis, and design

Magdeburg, Univ., Fak. für Wirtschaftswiss., Diss., 2011

Teaching Basic Life Support to Students of Public and Private High Schools

Background:Despite being recommended as a compulsory part of the school curriculum, the teaching of basic life support (BLS) has yet to be implemented in high schools in most countries.Objectives:To compare prior knowledge and degree of immediate and delayed learning between students of one public and one private high school after these students received BLS training.Methods:Thirty students from each school initially answered a questionnaire on cardiopulmonary resuscitation (CPR) and use of the automated external defibrillator (AED). They then received theoretical-practical BLS training, after which they were given two theory assessments: one immediately after the course and the other six months later.Results:The overall success rates in the prior, immediate, and delayed assessments were significantly different between groups, with better performance shown overall by private school students than by public school students: 42% ± 14% vs. 30.2% ± 12.2%, p = 0.001; 86% ± 7.8% vs. 62.4% ± 19.6%, p < 0.001; and 65% ± 12.4% vs. 45.6% ± 16%, p < 0.001, respectively. The total odds ratio of the questions showed that the private school students performed the best on all three assessments, respectively: 1.66 (CI95% 1.26-2.18), p < 0.001; 3.56 (CI95% 2.57-4.93), p < 0.001; and 2.21 (CI95% 1.69-2.89), p < 0.001.Conclusions:Before training, most students had insufficient knowledge about CPR and AED; after BLS training a significant immediate and delayed improvement in learning was observed in students, especially in private school students.

Use of Short-term Circulatory Support as a Bridge in Pediatric Heart Transplantation

Background:Heart transplantation is considered the gold standard therapy for the advanced heart failure, but donor shortage, especially in pediatric patients, is the main limitation for this procedure, so most sick patients die while waiting for the procedure.Objective:To evaluate the use of short-term circulatory support as a bridge to transplantation in end-stage cardiomyopathy.Methods:Retrospective clinical study. Between January 2011 and December 2013, 40 patients with cardiomyopathy were admitted in our Pediatric Intensive Care Unit, with a mean age of 4.5 years. Twenty patients evolved during hospitalization with clinical deterioration and were classified as Intermacs 1 and 2. One patient died within 24 hours and 19 could be stabilized and were listed. They were divided into 2 groups: A, clinical support alone and B, implantation of short-term circulatory support as bridge to transplantation additionally to clinical therapy.Results:We used short-term mechanical circulatory support as a bridge to transplantation in 9. In group A (n=10), eight died waiting and 2 patients (20%) were transplanted, but none was discharged. In group B (n=9), 6 patients (66.7%) were transplanted and three were discharged.The mean support time was 21,8 days (6 to 984h). The mean transplant waiting list time was 33,8 days. Renal failure and sepsis were the main complication and causeof death in group A while neurologic complications were more prevalent en group B.Conclusion:Mechanical circulatory support increases survival on the pediatric heart transplantation waiting list in patients classified as Intermacs 1 and 2.

Visual data analysis in air traffic management

Visual data mining, multi-dimensional scaling, POLARMAP, Sammon's mapping, clustering, outlier detection

spatiotemporal profile of visual attention

Visual attention, focus of attention, mexican hat profile, surround inhibition

Chromatic responses in human visual cortex : effects of color, velocity and contrast

fMRI, color, colour, velocity, speed, contrast, cone contrast, V1, V4, hV4, MT, MT+, V3A, BOLD, Retinotopic Mapping, Contrast Response Function

Speed in early visual processing

Vision, Speed, Electroencephalogram, Gamma Band Activity

Basic components of cortical processing are shared in visual and auditory modality

Magdeburg, Univ., Fak. für Naturwiss., Diss., 2009