eHealth e a ado����o da inova����o em assisted living technologies : o caso das dem��ncias

RESUMO - Assistimos hoje a um contexto marcado (i) pelo progressivo envelhecimento das sociedades ocidentais, (ii) pelo aumento da preval��ncia das doen��as cr��nicas, de que as dem��ncias s��o um exemplo, (iii) pelo significativo aumento dos custos associados a estas patologias, (iv) por or��amentos p��blicos fortemente pressionadas pelo controlo da despesa, (v) por uma vida moderna que dificulta o apoio intergeracional, tornando o suporte proporcionado pelos filhos particularmente dif��cil, (vi) por fortes expectativas relativamente �� presta����o de cuidados de sa��de com qualidade. Teremos assim de ser capazes de conseguir melhorar os servi��os de sa��de, ao mesmo tempo que recorremos a menos recursos financeiros e humanos, pelo que a inova����o parece ser cr��tica para a sustentabilidade do sistema. Contudo a difus��o das Assistive Living Technologies, apesar do seu potencial, tem sido bastante baixa, nomeadamente em Portugal. Porqu��? Hamer, Plochg e Moreira (2012), no editorial do International Journal of Healthcare Management, enquadram a Inova����o como ���podendo ser imprevis��vel e mesmo dolorosa, pelo que talvez possamos n��o ficar surpreendidos se surgirem resist��ncias e que, inova����es bastante necess��rias, capazes de melhorar os indicadores de sa��de, tenham sido de ado����o lenta ou que tenham mesmo sido insustent��veis���. Em Portugal n��o h�� bibliografia que procure caracterizar o modelo de difus��o da inova����o em eHealth ou das tecnologias de viv��ncia assistida. A bibliografia internacional �� igualmente escassa. O presente projeto de investiga����o, de natureza explorat��ria, tem como objetivo principal, identificar barreiras e oportunidades para a implementa����o de tecnologias eHealth, aplicadas ao campo das dem��ncias. Como objetivos secund��rios pretendemse identificar as oportunidades e limita����es em Portugal: mapa de compet��ncias nacionais, e propor medidas que possa acelerar a inova����o em ALT, no contexto nacional. O projeto seguir�� o modelo de um estudo qualitativo. Para o efeito foram conduzidas entrevistas em profundidade junto de experts em ALT, procurando obter a vis��o daqueles que participam do lado da Oferta- a Ind��stria; do lado da Procura- doentes, cuidadores e profissionais de sa��de; bem como dos Reguladores. O instrumento utilizado para a recolha da informa����o pretendida foi o question��rio n��o estruturado. A an��lise e interpreta����o da informa����o recolhida foram feitas atrav��s da t��cnica de An��lise de Conte��do. Os resultados da An��lise de Conte��do efetuada permitiram expressar a dicotomia barreira/oportunidade, nas seguintes categorias aqui descritas como contextos (i) Contexto Tecnol��gico, nas subcategorias de Acesso ��s Infraestruturas; Custo da Tecnologia; Interoperabilidade, (ii) Contexto do Valor Percecionado, nas subcategorias de Utilidade; Efici��ncia; Divulga����o, (iii) Contexto Pol��tico, compreendendo a Lideran��a; Organiza����o; Regula����o; Recursos, (iv) Contexto Sociocultural, incluindo nomeadamente Idade; Literacia; Capacidade Econ��mica, (v) Contexto Individual, incluindo como subcategorias, Capacidade de Adapta����o a Novas tecnologias; Motiva����o; Acesso a equipamentos (vi) Contexto Espec��fico da Doen��a, nomeadamente o Impacto Cognitivo; Tipologia Heterog��nea e a Import��ncia do Cuidador. Foi proposto um modelo explorat��rio, designado de Modelo de Contextos e For��as, que estudos subsequentes poder��o validar. Neste modelo o Contexto Tecnol��gico �� um For��a B��sica ou Fundamental; o Contexto do Valor Percecionado, constitui-se numa For��a Cr��tica para a ado����o de inova����o, que assenta na sua capacidade para oferecer valor aos diversos stakeholders da cadeia de cuidados. Temos tamb��m o Contexto Pol��tico, com capacidade de modelar a ado����o da inova����o e nomeadamente com capacidade para o acelerar, se dele emitir um sinal de urg��ncia para a mudan��a. O Contexto Sociocultural e Individual expressam uma For��a Intr��nseca, dado que elas s��o caracter��sticas internas, pr��prias e imut��veis no curto-prazo, das sociedade e das pessoas. Por fim h�� que considerar o Contexto Espec��fico da Doen��a, nesta caso o das dem��ncias. Das conclus��es do estudo parece evidente que as condi����es tecnol��gicas est��o medianamente satisfeitas em Portugal, com evidentes progressos nos ��ltimos anos (exce����o para a interoperabilidade aonde h�� necessidade de maiores progressos), n��o constituindo portanto barreira �� introdu����o de ALT. Aonde h�� necessidade de investir �� nas ��reas do valor percebido. Da an��lise feita, esta �� uma ��rea que constitui uma barreira �� introdu����o e ado����o das ALT em Portugal. A falta de perce����o do valor que estas tecnologias trazem, por parte dos profissionais de sa��de, doentes, cuidadores e decisores pol��ticos, parece ser o principal entrave �� sua ado����o. S��o recomendadas estrat��gias de modelos colaborativos de Investiga����o e Desenvolvimento e de abordagens de cocria����o com a contribui����o de todos os intervenientes na cadeia de cuidados. H�� tamb��m um papel que cabe ao estado no ��mbito das prioridades e da mobiliza����o de recursos, sendo-lhe requerida a express��o do sentido de urg��ncia para que esta mudan��a aconte��a. Foram tamb��m identificadas oportunidades em diversas ��reas, como na preven����o, no diagn��stico, na compliance medicamentosa, na terap��utica, na monitoriza����o, no apoio �� vida di��ria e na integra����o social. O que �� necess��rio �� que as solu����es encontradas constituam respostas ��quilo que s��o as verdadeiras necessidades dos intervenientes e n��o uma imposi����o tecnol��gica que s�� por si nada resolve. Do estudo resultou tamb��m a perce����o de que h�� que (i) continuar a trabalhar no sentido de aproximar a comunidade cient��fica, da cl��nica e do doente, (ii) fomentar a colabora����o entre centros, com vista �� cria����o de escala a n��vel global. Essa colabora����o j�� parece acontecer a n��vel empresarial, tendo sido identificadas empresas Portuguesas com voca����o global. A qualidade individual das institui����es de ensino, dos centros de investiga����o, das empresas, permite criar as condi����es para que Portugal possa ser pa��s um piloto e um case-study internacional em ALT, desde que para tal pud��ssemos contar com um trabalho colaborativo entre institui����es e com decis��es pol��ticas arrojadas.

Fate map of zebrafish left-right organizer

The organizer is a ciliated signalling transient organ, responsible for the patterning of embryo tissues during embryonic development. In higher vertebrates, such as mouse and chick, this organizer (the node and the Hensen���s node, respectively) performs dorsalventral and anteriorposterior axis definition, as well as left-right patterning of the internal organs. In lower vertebrates, such as frog and zebrafish, there is a separate specialized organ for left-right purposes called the Gastrocoel Roof Plate (GRP) and Kupffer���s Vesicle (KV), respectively. It is known that mouse and chick organizer cells give rise to structures like floor plate, notochord, hypochord and somites. Frog GRP originates all these but floor plate. In zebrafish, at 13-14 somite stage (ss) the KV finished its left-right patterning but what happens to this organizer��� cells is still poorly studied. This research attempts to understand the fate and behaviour of the KV cells. We followed the fate of KV cells by live imaging and by tight time-courses with fixed larvae. We assessed in detail their proliferative and death profile, as well as cilia length progression from 9-10 ss until 29-30 ss. We conclude that the KV cells mostly follow the evolutionarily conserved fates described for other organizers. These cells mainly incorporate the notochord and hypochord; few cells incorporate the floor plate and the somites. As a novelty, it is also hypothesized that the hypural cell fate may be among the KV cell fates.

Design and implementation of an assurance map at Sonae retail business

The present Working Project aims at studying the topic of assurance mapping in a specific organizational context of a Portuguese retail company. For this purpose, an assurance map framework was designed to support the decision making process of stakeholders, through the delivery of comfort concerning risks, operations and control. In the end, the framework was successfully implemented for the process sourcing of goods in two business units of the company. Although, further implementation of the framework proved not to be feasible during the project���s timespan, it is expected to occur in the near future.

Serum anticholinergic activity and postoperative cognitive dysfunction in elderly patients

Background: Cerebral cholinergic transmission plays a key role in cognitive function and anticholinergic drugs are associated with impaired cognitive functions [1]. In the perioperative phase many substances with anticholinergic effects are administered and disturbed cholinergic transmission is a hypothetical cause of postoperative cognitive dysfunction (POCD). Serum anticholinergic activity (SAA; pmol/ml) may be measured as a summary marker of anticholinergic activity in an individual patient's blood. We hypothesised that an increase in SAA from preoperatively to one week postoperatively is associated with POCD in elderly patients. Methods: Thirty-two patients aged >65 yrs undergoing elective major surgery under standardized general anaesthesia (thiopental, sevoflurane, fentanyl) were investigated. Cognitive functions were measured preoperatively and 7 days postoperatively using the extended version of the Consortium to Establish a Registry for Alzheimer's Disease - Neuropsychological Assessment Battery. POCD was defined as a postoperative decline >1 z-score in at least 2 cognitive domains. SAA was measured preoperatively and 7 days postoperatively at the time of cognitive testing. Results: 50% of the investigated patients developed POCD. There were no statistically significant differences between patients with and without POCD regarding age, education, baseline cognitive function, duration of anaesthesia, SAA preoperatively (median (range) 1.0 (0.3 to 5.0) vs 1.5 (0.4 to 5.0), SAA 7 days postoperatively (median (range) 1.3 (0.1 to 7.0) vs 1.4 (0.6 to 5.5) or changes in SAA (median (range) 0.1 (-1.6 to 2.2) vs 0.2 (-1.4 to 2.8). The variability of SAA in individual patients was considerable and marked changes in SAA between the two examinations were observed in some patients. However, there was no significant relationship between changes in SAA and changes in cognitive function. Conclusion: In this preliminary analysis of a small group of patients, changes in SAA in the perioperative phase were highly variable. SAA was not associated with POCD suggesting that POCD is not simply caused by anticholinergic medications administered in the perioperative phase. A further analysis of a larger group of patients is in progress.

Long-term outcome after cognitive and behavioral regression in nonlesional epilepsy with continuous spike-waves during slow-wave sleep.

PURPOSE: To present the long-term follow-up of 10 adolescents and young adults with documented cognitive and behavioral regression as children due to nonlesional focal, mainly frontal, epilepsy with continuous spike-waves during slow wave sleep (CSWS). METHODS: Past medical and electroencephalography (EEG) data were reviewed and neuropsychological tests exploring main cognitive functions were administered. KEY FINDINGS: After a mean duration of follow-up of 15.6 years (range, 8-23 years), none of the 10 patients had recovered fully, but four regained borderline to normal intelligence and were almost independent. Patients with prolonged global intellectual regression had the worst outcome, whereas those with more specific and short-lived deficits recovered best. The marked behavioral disorders resolved in all but one patient. Executive functions were neither severely nor homogenously affected. Three patients with a frontal syndrome during the active phase (AP) disclosed only mild residual executive and social cognition deficits. The main cognitive gains occurred shortly after the AP, but qualitative improvements continued to occur. Long-term outcome correlated best with duration of CSWS. SIGNIFICANCE: Our findings emphasize that cognitive recovery after cessation of CSWS depends on the severity and duration of the initial regression. None of our patients had major executive and social cognition deficits with preserved intelligence, as reported in adults with early destructive lesions of the frontal lobes. Early recognition of epilepsy with CSWS and rapid introduction of effective therapy are crucial for a best possible outcome.

Quantifying consistency of Event Related Potentials across subjects based on single-trial topographic analysis

Introduction: Non-invasive brain imaging techniques often contrast experimental conditions across a cohort of participants, obfuscating distinctions in individual performance and brain mechanisms that are better characterised by the inter-trial variability. To overcome such limitations, we developed topographic analysis methods for single-trial EEG data [1]. So far this was typically based on time-frequency analysis of single-electrode data or single independent components. The method's efficacy is demonstrated for event-related responses to environmental sounds, hitherto studied at an average event-related potential (ERP) level. Methods: Nine healthy subjects participated to the experiment. Auditory meaningful sounds of common objects were used for a target detection task [2]. On each block, subjects were asked to discriminate target sounds, which were living or man-made auditory objects. Continuous 64-channel EEG was acquired during the task. Two datasets were considered for each subject including single-trial of the two conditions, living and man-made. The analysis comprised two steps. In the first part, a mixture of Gaussians analysis [3] provided representative topographies for each subject. In the second step, conditional probabilities for each Gaussian provided statistical inference on the structure of these topographies across trials, time, and experimental conditions. Similar analysis was conducted at group-level. Results: Results show that the occurrence of each map is structured in time and consistent across trials both at the single-subject and at group level. Conducting separate analyses of ERPs at single-subject and group levels, we could quantify the consistency of identified topographies and their time course of activation within and across participants as well as experimental conditions. A general agreement was found with previous analysis at average ERP level. Conclusions: This novel approach to single-trial analysis promises to have impact on several domains. In clinical research, it gives the possibility to statistically evaluate single-subject data, an essential tool for analysing patients with specific deficits and impairments and their deviation from normative standards. In cognitive neuroscience, it provides a novel tool for understanding behaviour and brain activity interdependencies at both single-subject and at group levels. In basic neurophysiology, it provides a new representation of ERPs and promises to cast light on the mechanisms of its generation and inter-individual variability.

Alcohol and relatively pure cannabis use, but not schizotypy, are associated with cognitive attenuations

Elevated schizotypy relates to similar cognitive attenuations as seen in psychosis and cannabis/polydrug use. Also, in schizotypal populations cannabis and polydrug (including licit drug) use are enhanced.These cognitive attenuations may therefore either be a behavioral marker of psychotic (-like) symptoms or the consequence of enhanced drug use in schizotypal populations.To elucidate this, we investigated the link between cognitive attenuation and cannabis use in largely pure cannabis users (35) and non-using controls (48), accounting for the potential additional influence of both schizotypy and licit drug use (alcohol, nicotine). Cognitive attenuations commonly seen in psychosis were associated with cannabis and alcohol use, but not schizotypy. Future studies should therefore consider (i) non-excessive licit substance use (e.g., alcohol) in studies investigating the effect of cannabis use on cognition and (ii) both enhanced illicit and licit substance use in studies investigating cognition in schizotypal populations.

Performances et d��faillances du sujet c��r��bral : regard anthropologique sur la plasticit�� c��r��brale, les neurosciences et la clinique de la d��g��n��rescence cognitive

Introduction 1.1 Le sujet c��r��bral, rencontre entre le biologique et le social L'objectif de ce travail est d'��clairer une des voies par lesquelles le ph��nom��ne anthropologique de l'individualit�� prend corps au sein de l'environnement contemporain. L'individualisme est compris comme les divers processus par lesquels la d��termination du sujet tend �� s'autonomiser des appartenances pr��constitu��es. Il est la forme sociologique qui gouverne la fa��on contemporaine de faire soci��t�� depuis l'av��nement de la ��modernit�� ��. Le choix de l'angle de la c��r��bralit�� pour aborder la question de recherche repose sur le postulat qu'une des particularit��s culturelles de la figure du sujet individuel contemporain est la tendance �� attribuer aux m��canismes c��r��braux le r��le d��terminant dans la constitution de la subjectivit�� du sujet. D��s lors, si aujourd'hui, penser le cerveau c'est penser l'humain, il s'agit d'un ph��nom��ne anthropologique qui demande �� ��tre explicit��. Il m'appartient de d��montrer que le champ des neurosciences se profile comme r��v��lateur privil��gi�� pour observer comment penser l'individualit�� concorde avec l'��tablissement de v��rit��s relatives au c��r��bral' . Faire l'anthropologie du proche et de l'actuel a ses int��r��ts mais comporte aussi des risques. La perte de ce qui faisait le moteur de la recherche anthropologique -l'alt��rit�� donn��e des sujets de son observation - a ��t�� compens��e par l'��mergence de nouveaux objets de travail et par des reconfigurations des rapports que l'anthropologue entretient avec son terrain. Le renouvellement du cadre de r��flexion op��r�� par l'anthropologie au cours du si��cle ��coul�� suit les transformations des pratiques sociales, culturelles et ��conomiques qui s'op��rent au niveau mondial. L'��chelle d��sormais plan��taire de la circulation des acteurs sociaux et des objets de savoir a forc�� la discipline �� revoir la grille de lecture qui a longtemps oppos�� soci��t��s traditionnelles �� soci��t��s modernes. La prise de conscience de la caducit�� du grand partage a engag�� les anthropologues �� s'int��resser �� des ph��nom��nes en rapport avec des probl��mes rencontr��s au sein de leur propre collectif et, dans le m��me mouvement, les a amen��e �� repenser les articulations entre le global et le local, le particulier et l'universel. Le bouleversement heuristique g��n��r�� par ce repositionnement n'est toutefois pas exempt de nouvelles difficult��s pour la recherche ethnographique. En se posant le d��fi d'��tudier des traits culturels propres �� sa soci��t�� d'appartenance, l'anthropologie s'ouvre �� des terrains enqu��te sur la fa��on dont, dans le monde occidental, le constat toujours plus pesant de la discordance entre les ph��nom��nes de vieillissement cognitif et l'allongement de l'esp��rance de vie est trait��. Dans une d��marche ethnographique, il s'agit de voir quelles sont les logiques d'action et les pratiques sociales d��velopp��es en r��ponse �� ces inad��quations. La th��matique impose une navigation entre des domaines th��oriques sp��cialis��s et des champs d'activit��s poss��dant chacun leurs cadres de r��f��rence. Une telle entreprise suppose une multiplication des syst��mes de r��f��rence devant ��tre pris en compte. Toutes les disciplines approch��es au cours de ce travail abondent en m��taphores utiles �� la mise en ordre de leur pens��e et �� la description de leurs objets de travail. Toutefois, faire r��sonner entre elles les diff��rentes ��cultures ��pist��miques �� (Knorr-Cetina, 1999) pour mieux faire appara��tre la trame sociale qui constitue leur arri��re-fond ��quivaut souvent �� forcer le trait. Le sens des mots varie selon leurs champs d'application et l'exercice de la mise en r��sonance peut s'av��rer p��rilleux. Je me suis efforc��e tout au long de ces pages de pr��ciser de quel point de vue les ��nonc��s consid��r��s sont formul��s. L'analyse anthropologique ��tant guid��e par la recherche des points de liaison entre les diff��rents registres, la d��marche est forc��ment limit��e dans le niveau d'approfondissement auquel elle peut tendre. Elle risque de d��cevoir les lecteurs experts dans les domaines soumis �� la grille de lecture de cette discipline, non familiers avec les concepts anthropologiques. Il est probable qu'un certain flou subsiste dans la fa��on dont ces ��nonc��s sont d��cris par rapport au traitement dont ils sont l'objet dans leurs disciplines respectives. Si on perd de vue la pr��occupation centrale de l'anthropologie, consistant �� ��clairer le syst��me de valeurs commun sous-tendant les pratiques sociales observ��es, la lecture d'un tel travail risque effectivement de rater son but. En revanche, en acceptant d'embl��e de se pr��ter �� un d��centrement par rapport �� son mod��le disciplinaire, le lecteur doit pouvoir appr��hender des aspects int��ressant ses propres pratiques. S'int��resser �� ce qui relie les savoirs et les pratiques au sein d'un monde commun, voil�� un programme heuristique qui va �� l'encontre de la logique de sp��cialisation.

Treatment motivation in adolescents with psychosis or at high risk: Determinants and impact on improvements in symptoms and cognitive functioning, preliminary results.

Abstract Low motivation is frequent in chronic disorders such as psychosis and may limit treatment efficacy. Although some evidence supports this view in adults, few studies so far have focused on adolescents. We assessed the impact of baseline symptoms, cognitive deficits and cognitive treatment characteristics on treatment motivation (TM), and examined whether TM affected treatment outcome. Twenty-eight adolescents with psychotic disorders participated in 16 sessions of computerized cognitive remediation or games. TM was assessed for each session. Lower TM was predicted by more severe symptoms at baseline, and was associated with smaller improvements in symptoms and both cognitive and psychosocial functioning at the end of the intervention. Experiencing success in the treatment exercises enhanced TM in all patients.

SUCLG2 identified as both a determinator of CSF Aβ1-42 levels and an attenuator of cognitive decline in Alzheimer's disease.

Cerebrospinal fluid amyloid-beta 1-42 (Aβ1-42) and phosphorylated Tau at position 181 (pTau181) are biomarkers of Alzheimer's disease (AD). We performed an analysis and meta-analysis of genome-wide association study data on Aβ1-42 and pTau181 in AD dementia patients followed by independent replication. An association was found between Aβ1-42 level and a single-nucleotide polymorphism in SUCLG2 (rs62256378) (P = 2.5��10(-12)). An interaction between APOE genotype and rs62256378 was detected (P = 9.5 �� 10(-5)), with the strongest effect being observed in APOE-ε4 noncarriers. Clinically, rs62256378 was associated with rate of cognitive decline in AD dementia patients (P = 3.1 �� 10(-3)). Functional microglia experiments showed that SUCLG2 was involved in clearance of Aβ1-42.

Behavioral and psychological symptoms and cognitive decline in patients with amnestic MCI and mild AD: a two-year follow-up study.

BACKGROUND: Mild cognitive impairment (MCI) has been defined as a transitional state between normal aging and dementia. In many cases, MCI represents an early stage of developing cognitive impairment. Patients diagnosed with MCI do not meet the criteria for dementia as their general intellect and everyday activities are preserved, although minor changes in instrumental activities of daily living (ADL) may occur. However, they may exhibit significant behavioral and psychological signs and symptoms (BPS), also frequently observed in patients with Alzheimer's disease (AD). Hence, we wondered to what extent specific BPS are associated with cognitive decline in participants with MCI or AD. METHODS: Our sample consisted of 164 participants, including 46 patients with amnestic (single or multi-domain) MCI and 54 patients with AD, as well as 64 control participants without cognitive disorders. Global cognitive performance, BPS, and ADL were assessed using validated clinical methods at baseline and at two-year follow-up. RESULTS: The BPS variability over the follow-up period was more pronounced in the MCI group than in patients with AD: some BPS improve, others occur newly or worsen, while others still remain unchanged. Moreover, specific changes in BPS were associated with a rapid deterioration of the global cognitive level in MCI patients. In particular, an increase of euphoria, eating disorders, and aberrant motor behavior, as well as worsened sleep quality, predicted a decline in cognitive functioning. CONCLUSIONS: Our findings confirm a higher variability of BPS over time in the MCI group than in AD patients. Moreover, our results provide evidence of associations between specific BPS and cognitive decline in the MCI group that might suggest a risk of conversion of individuals with amnestic MCI to AD.

Cognitive and emotional effects of carotid stenosis.

PRINCIPLES: Patients with carotid artery stenosis (CAS) are at risk of ipsilateral stroke and chronic compromise of cerebral blood flow. It is under debate whether the hypo-perfusion or embolism in CAS is directly related to cognitive impairment. Alternatively, CAS may be a marker for underlying risk factors, which themselves influence cognition. We aimed to determine cognitive performance level and the emotional state of patients with CAS. We hypo-thesised that patients with high grade stenosis, bilateral stenosis, symptomatic patients and/or those with relevant risk factors would suffer impairment of their cognitive performance and emotional state. METHODS: A total of 68 patients with CAS of ���70% were included in a prospective exploratory study design. All patients underwent structured assessment of executive functions, language, verbal and visual memory, motor speed, anxiety and depression. RESULTS: Significantly more patients with CAS showed cognitive impairments (executive functions, word production, verbal and visual memory, motor speed) and anxiety than expected in a normative sample. Bilateral and symptomatic stenosis was associated with slower processing speed. Cognitive performance and anxiety level were not influenced by the side and the degree of stenosis or the presence of collaterals. Factors associated with less co-gnitive impairment included higher education level, female gender, ambidexterity and treated hypercholesterolemia. CONCLUSIONS: Cognitive impairment and increased level of anxiety are frequent in patients with carotid stenosis. The lack of a correlation between cognitive functioning and degree of stenosis or the presence of collaterals, challenges the view that CAS per se leads to cognitive impairment.