Lethal heparin-induced thrombocytopenia after transfemoral aortic valve implantation

SIN FINANCIACIÓN

Comparison of 1-year outcome in patients with severe aorta stenosis treated conservatively or by aortic valve replacement or by percutaneous transcatheter aortic valve implantation (data from a multicenter Spanish registry)

The factors that influence decision making in severe aortic stenosis (AS) are unknown. Our aim was to assess, in patients with severe AS, the determinants of management and prognosis in a multicenter registry that enrolled all consecutive adults with severe AS during a 1-month period. One-year follow-up was obtained in all patients and included vital status and aortic valve intervention (aortic valve replacement [AVR] and transcatheter aortic valve implantation [TAVI]). A total of 726 patients were included, mean age was 77.3 ± 10.6 years, and 377 were women (51.8%). The most common management was conservative therapy in 468 (64.5%) followed by AVR in 199 (27.4%) and TAVI in 59 (8.1%). The strongest association with aortic valve intervention was patient management in a tertiary hospital with cardiac surgery (odds ratio 2.7, 95% confidence interval 1.8 to 4.1, p <0.001). The 2 main reasons to choose conservative management were the absence of significant symptoms (136% to 29.1%) and the presence of co-morbidity (128% to 27.4%). During 1-year follow-up, 132 patients died (18.2%). The main causes of death were heart failure (60% to 45.5%) and noncardiac diseases (46% to 34.9%). One-year survival for patients treated conservatively, with TAVI, and with AVR was 76.3%, 94.9%, and 92.5%, respectively, p <0.001. One-year survival of patients treated conservatively in the absence of significant symptoms was 97.1%. In conclusion, most patients with severe AS are treated conservatively. The outcome in asymptomatic patients managed conservatively was acceptable. Management in tertiary hospitals is associated with valve intervention. One-year survival was similar with both interventional strategies.

Incidence and clinical impact of infective endocarditis after transcatheter aortic valve implantation

The aim of this study is to describe the characteristics of infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). This study was performed using the GAMES database, a national prospective registry of consecutive patients with IE in 26 Spanish hospitals. Of the 739 cases of IE diagnosed during the study, 1.3% were post-TAVI IE, and these 10 cases, contributed by five centres, represented 1.1% of the 952 TAVIs performed. Mean age was 80 years. All valves were implanted transfemorally. IE appeared a median of 139 days after implantation. The mean age-adjusted Charlson comorbidity index was 5.45. Chronic kidney disease was frequent (five patients), as were atrial fibrillation (five patients), chronic obstructive pulmonary disease (four patients), and ischaemic heart disease (four patients). Six patients presented aortic valve involvement, and four only mitral valve involvement; the latter group had a higher percentage of prosthetic mitral valves (0% vs. 50%). Vegetations were found in seven cases, and four presented embolism. One patient underwent surgery. Five patients died during follow-up: two of these patients died during the admission in which the valve was implanted. Conclusions: IE is a rare but severe complication after TAVI which affects about 1% of patients and entails a relatively high mortality rate. IE occurred during the first year in nine of the 10 patients.

Les consultants face aux défis d’implantation de la Réforme du Secteur de la Sécurité (RSS)

Travail dirigé présenté à la Faculté des études supérieures et postdoctorales en vue de l’obtention du grade de Maître ès sciences (M. SC.) en Criminologie, option Sécurité Intérieure

Implantation d’une innovation au sein d’une région rurale éloignée au Québec : le rôle d’infirmière praticienne spécialisée en soins de première ligne- une étude de cas multiples

Introduction : La situation de l’accès, de la continuité et de la coordination des services de santé au Canada et au Québec est des plus préoccupantes. Pour contribuer à résoudre ces problématiques, l’élargissement des champs de pratique professionnels a été proposé. Lorsqu’il est question d’élargir le rôle des infirmières, la pratique infirmière avancée (PIA) est fréquemment abordée. Au Québec, ce n’est qu’en 2006 qu’un rôle associé à la PIA en première ligne a pu officiellement être mis en place, celui d’infirmière praticienne spécialisée en soins de première ligne (IPSPL) (Durand, Allard, & Ménard, 2006). L’implantation du rôle d’IPSPL est récente et peut être conçue comme une innovation. Les difficultés liées à l’implantation des rôles de PIA font l’objet d’un consensus. Pour pallier à ces difficultés, il est proposé d’approfondir la compréhension de la façon dont les rôles de PIA sont implantés, et ce, en considérant les contextes. Encore peu de recherches s’intéressent au processus d’implantation du rôle d’IPSPL au Québec, et aucune n’est centrée sur le contexte rural éloigné. But : Cette recherche vise à comprendre le processus d’implantation du rôle d’IPSPL au sein d’une région rurale éloignée du Québec, à travers l’éclairage d’un cadre de référence intégrant les théories de la diffusion de l’innovation et des transitions. Méthode : Cette étude de trois cas se situe dans un paradigme pragmatique, avec des visées descriptive et explicative. Des stratégies de collecte de données mixtes ont été utilisées auprès de personnes provenant du contexte québécois, de la région ciblée et des cas (IPSP, médecins partenaires, DSI, DSP, gestionnaires, personnes soignées et leur famille). Résultats : L’implantation est un processus multidimensionnel, multifactoriel et évolutif. Le contexte, le déroulement, la compréhension, les acteurs et le temps sont des parties intégrantes de l’implantation et sont étroitement inter-reliés. Le déroulement de l’implantation et des transitions se produit simultanément. Discussion : Cette recherche a permis de mettre en lumière la raison pour laquelle le processus d’implantation du rôle d’IPSPL doit être considéré comme un processus complexe. Cette thèse contribue à éclairer la recherche axée sur l’efficacité en permettant de mieux comprendre les différentes composantes de l’implantation. Mots-clés : implantation, rôle, infirmière praticienne, première ligne, rural, éloigné, innovation, transition.

Gestion de contexte dans un habitat intelligent à base d’ontologie : modélisation, implantation et validation

Le laboratoire DOMUS développe des applications sensibles au contexte dans une perspective d’intelligence ambiante. L’architecture utilisée présentement pour gérer le contexte a atteint ses limites en termes de capacité d’évoluer, d’intégration de nouvelles sources de données et de nouveaux capteurs et actionneurs, de capacité de partage entre les applications et de capacité de raisonnement. Ce projet de recherche a pour objectif de développer un nouveau modèle, un gestionnaire de contexte et de proposer une architecture pour les applications d’assistance installées dans un habitat intelligent. Le modèle doit répondre aux exigences suivantes : commun, abstrait, évolutif, décentralisé, performant et une accessibilité uniforme. Le gestionnaire du contexte doit permettre de gérer les événements et offrir des capacités de raisonnement sur les données et le contexte. La nouvelle architecture doit simplifier le développement d’applications d’assistance et la gestion du contexte. Les applications doivent pouvoir se mettre à jour si le modèle de données évolue dans le temps sans nécessiter de modification dans le code source. Le nouveau modèle de données repose sur une ontologie définie avec le langage OWL 2 DL. L’architecture pour les applications d’assistance utilise le cadre d’applications Apache Jena pour la gestion des requêtes SPARQL et un dépôt RDF pour le stockage des données. Une bibliothèque Java a été développée pour gérer la correspondance entre le modèle de données et le modèle Java. Le serveur d’événements est basé sur le projet OpenIoT et utilise un dépôt RDF. Il fournit une API pour la gestion des capteurs / événements et des actionneurs / actions. Les choix d’implémentation et l’utilisation d’une ontologie comme modèle de données et des technologies du Web sémantique (OWL, SPARQL et dépôt RDF) pour les applications d’assistance dans un habitat intelligent ont été validés par des tests intensifs et l’adaptation d’applications déjà existantes au laboratoire. L’utilisation d’une ontologie a pour avantage une intégration des déductions et du raisonnement directement dans le modèle de données et non au niveau du code des applications.

Elevated concentration of TNF-a induces trophoblast differentiation in mouse blastocyst outgrowths

Elevated expression of tumour necrosis factora (TNF-a) is associated with adverse pregnancy outcome. This study has examined the expression of TNF-a and its receptors (TNF-Rs) by mouse blastocysts and blastocyst outgrowths from day 4 to 9.5 of pregnancy and investigated the effects of elevated TNF-a on the inner cell mass (ICM) and trophoblast cells of blastocyst outgrowths. RTPCR demonstrated TNF-a mRNA expression from day 7.5 to 9.5, TNF-R1 from day 6.5 to 9.5 and TNF-R2 from day 5.5 to 7.5 of pregnancy, and in situ hybridisation revealed the trophoblast giant cells (TGCs) of the early placenta as the site of TNF-a expression. Day 4 blastocysts were cultured in a physiologically high concentration of TNF-a (100 ng/ml) for 72 h to the outgrowth stage and then compared to blastocysts cultured in media alone. TNF-a-treated blastocyst outgrowths exhibited a significant reduction in ICM cells (mean € SD 23.90€10.42 vs 9.37€7.45, t-test, P<0.0001) with no significant change in the numbers of trophoblast cells (19.97€8.14 vs 21.73€7.79, t-test, P=0.39). Within the trophoblast cell population, the TNF-a-treated outgrowths exhibited a significant increase in multinucleated cells (14.10€5.53 vs 6.37€5.80, t-test, P<0.0001) and a corresponding significant decrease in mononucleated cells (5.87€3.60 vs 15.37€5.87, t-test, P<0.0001). In summary, this study describes the expression of TNF-a and its receptors during the peri-implantation period in the mouse. It also reports that elevated TNF-a restricts ICM proliferation in the blastocyst and changes the ratio of mononucleated to multinucleated trophoblast cells. These findings suggest a mechanism by which increased

Visitor Relationship Management (VRM) - Repeat Visitation Opportunities for Destination Marketing Organisations

In competitive tourism markets the consumer-traveller is spoilt by choice of available destinations. Successfully differentiating a destination and getting noticed at decision time is arguably the focus of activities by destination marketing organisations (DMOs). In pursuit of differentiation, three emergent themes in the marketing literature during the past decade have been branding, integrated marketing communications (IMC), and customer relationship management (CRM) a fundamental goal of each being stimulating customer loyalty. However there has been little attention given to destination loyalty in the tourism literature. The purpose of this paper is to report an exploratory investigation of visitor relationship management (VRM) by DMOs. Based on interviews with the management of 11 regional tourism organisations (RTO) in Queensland, Australia, the opportunities for, and immediate challenges of, VRM are discussed. While each RTO recognised the potential for VRM, none had yet been able to develop a formal approach to engage in meaningful dialogue with previous visitors from their largest market.

Automated Feedback for 'Fill in the Gap' Programming Exercises

Timely feedback is a vital component in the learning process. It is especially important for beginner students in Information Technology since many have not yet formed an effective internal model of a computer that they can use to construct viable knowledge. Research has shown that learning efficiency is increased if immediate feedback is provided for students. Automatic analysis of student programs has the potential to provide immediate feedback for students and to assist teaching staff in the marking process. This paper describes a “fill in the gap” programming analysis framework which tests students’ solutions and gives feedback on their correctness, detects logic errors and provides hints on how to fix these errors. Currently, the framework is being used with the Environment for Learning to Programming (ELP) system at Queensland University of Technology (QUT); however, the framework can be integrated into any existing online learning environment or programming Integrated Development Environment (IDE)

A model for assessing and correcting construction project health

Abstract Maintaining the health of a construction project can help to achieve the desired outcomes of the project. An analogy is drawn to the medical process of a human health check where it is possible to broadly diagnose health in terms of a number of key areas such as blood pressure or cholesterol level. Similarly it appears possible to diagnose the current health of a construction project in terms of a number of Critical Success Factors (CSFs) and key performance indicators (KPIs). The medical analogy continues into the detailed investigation phase where a number of contributing factors are evaluated to identify possible causes of ill health and through the identification of potential remedies to return the project to the desired level of health. This paper presents the development of a model that diagnoses the immediate health of a construction project, investigates the factors which appear to be causing the ill health and proposes a remedy to return the project to good health. The proposed model uses the well-established continuous improvement management model (Deming, 1986) to adapt the process of human physical health checking to construction project health.

Injury prevention in Queensland : report to Queensland Injury Prevention Council

Injury is the fourth leading cause of death in Australia. Injury rates in Queensland are amongst the highest in Australia and 21.5% of people surveyed for this research reported that their lifestyle or that of an immediate family member had been permanently affected by injury. Injury results in over 40,000 hospital admissions and 200,000 attendances at hospital Emergency Departments in Queensland each year. Queensland's death rate from injuries is higher than the national average, with consistently higher rates of deaths related to transport injuries. Queensland statistics also show higher than national average rates of injuries due to falls, homicide and accidental drowning. (Pike, Muller, Baade & Ward, 2000) In 2000-01 injuries represented over $4 billion (or 8%) of total health system expenditure, and 185,000 disability-adjusted life years (DALYs), or 7% of the total morbidity burden of disease and injury in Australia in 2003. (Begg, Vos, Barker, Stevenson, Stanley & Lopez, 2007). Injury is one of seven key health areas identified by the Commonwealth, state and territory governments for priority attention as National Health Priority Areas

Leveraging sponsorships on the Internet: Activation, congruence, and articulation

This paper considers how the Internet can be used to leverage commercial sponsorships to enhance audience attitudes toward the sponsor. Definitions are offered that distinguish the terms leverage and activation with respect to sponsorship-linked marketing; leveraging encompasses all marketing communications collateral to the sponsorship investment, whereas activation relates to those communications that encourage interaction with the sponsor. Although activation in many instances may be limited to the immediate event-based audience, leveraging sponsorships via sponsors' Web sites enables activation at the mass-media audience level. Results of a Web site navigation experiment demonstrate that activational sponsor Web sites promote more favorable attitudes than do nonactivational Web sites. It is also shown that sponsorsponsee congruence effects generalize to the online environment, and that the effects of sponsorship articulation on audience attitudes are moderated by the commerciality of the explanation for the sponsor-sponsee relationship. Importantly, the study reveals that attitudinal effects associated with variations in leveraging, congruence, and orientation of articulation may be sustained across time.

Abstracting and correlating heterogeneous events to detect complex scenarios

The research presented in this thesis addresses inherent problems in signaturebased intrusion detection systems (IDSs) operating in heterogeneous environments. The research proposes a solution to address the difficulties associated with multistep attack scenario specification and detection for such environments. The research has focused on two distinct problems: the representation of events derived from heterogeneous sources and multi-step attack specification and detection. The first part of the research investigates the application of an event abstraction model to event logs collected from a heterogeneous environment. The event abstraction model comprises a hierarchy of events derived from different log sources such as system audit data, application logs, captured network traffic, and intrusion detection system alerts. Unlike existing event abstraction models where low-level information may be discarded during the abstraction process, the event abstraction model presented in this work preserves all low-level information as well as providing high-level information in the form of abstract events. The event abstraction model presented in this work was designed independently of any particular IDS and thus may be used by any IDS, intrusion forensic tools, or monitoring tools. The second part of the research investigates the use of unification for multi-step attack scenario specification and detection. Multi-step attack scenarios are hard to specify and detect as they often involve the correlation of events from multiple sources which may be affected by time uncertainty. The unification algorithm provides a simple and straightforward scenario matching mechanism by using variable instantiation where variables represent events as defined in the event abstraction model. The third part of the research looks into the solution to address time uncertainty. Clock synchronisation is crucial for detecting multi-step attack scenarios which involve logs from multiple hosts. Issues involving time uncertainty have been largely neglected by intrusion detection research. The system presented in this research introduces two techniques for addressing time uncertainty issues: clock skew compensation and clock drift modelling using linear regression. An off-line IDS prototype for detecting multi-step attacks has been implemented. The prototype comprises two modules: implementation of the abstract event system architecture (AESA) and of the scenario detection module. The scenario detection module implements our signature language developed based on the Python programming language syntax and the unification-based scenario detection engine. The prototype has been evaluated using a publicly available dataset of real attack traffic and event logs and a synthetic dataset. The distinct features of the public dataset are the fact that it contains multi-step attacks which involve multiple hosts with clock skew and clock drift. These features allow us to demonstrate the application and the advantages of the contributions of this research. All instances of multi-step attacks in the dataset have been correctly identified even though there exists a significant clock skew and drift in the dataset. Future work identified by this research would be to develop a refined unification algorithm suitable for processing streams of events to enable an on-line detection. In terms of time uncertainty, identified future work would be to develop mechanisms which allows automatic clock skew and clock drift identification and correction. The immediate application of the research presented in this thesis is the framework of an off-line IDS which processes events from heterogeneous sources using abstraction and which can detect multi-step attack scenarios which may involve time uncertainty.