Diagnostic value of the tilt-table test for the assessment of syncope in children and adolescents

OBJECTIVE - To assess the diagnostic value, the characteristics, and feasibility of tilt-table testing in children and adolescents. METHODS - From August 1991 to June 1997, we retrospectively assessed 94 patients under the age of 18 years who had a history of recurring syncope and presyncope of unknown origin and who were referred for tilt-table testing. These patients were divided into 2 groups: group I (children) - 36 patients with ages ranging from 3 to 12 (mean of 9.19±2.31) years; group II (adolescents) - 58 patients with ages ranging from 13 to 18 (mean of 16.05±1.40) years. We compared the positivity rate, the type of hemodynamic response, and the time period required for the test to become positive in the 2 groups. RESULTS - The positivity rates were 41.6 % and 50% for groups I and II, respectively. The pattern of positive hemodynamic response that predominated in both groups was the mixed response. The mean time period required for the test to become positive was shorter in group I (11.0±7.23 min) than in group II (18.44±7.83 min). No patient experienced technical difficulty or complications. CONCLUSION - No difference was observed in regard to feasibility, positivity rate, and pattern of positive response for the tilt-table test in children and adolescents. Pediatric patients had earlier positive responses.

Optimization techniques to detect early ventilation extubation in intensive care units

The decision support models in intensive care units are developed to support medical staff in their decision making process. However, the optimization of these models is particularly difficult to apply due to dynamic, complex and multidisciplinary nature. Thus, there is a constant research and development of new algorithms capable of extracting knowledge from large volumes of data, in order to obtain better predictive results than the current algorithms. To test the optimization techniques a case study with real data provided by INTCare project was explored. This data is concerning to extubation cases. In this dataset, several models like Evolutionary Fuzzy Rule Learning, Lazy Learning, Decision Trees and many others were analysed in order to detect early extubation. The hydrids Decision Trees Genetic Algorithm, Supervised Classifier System and KNNAdaptive obtained the most accurate rate 93.2%, 93.1%, 92.97% respectively, thus showing their feasibility to work in a real environment.

Projeto para a aquisição de um equipamento PET-CT: análise da viabilidade financeira

Projeto de mestrado em Gestão de Unidades de Saúde

Assessment of the techniques of blood pressure measurement by health professionals

OBJECTIVE: To assess blood pressure measurement by health professionals of a public hospital in São Paulo State. METHODS: Semi-structured interviews and direct observation were performed with a verification list according to the criteria reported by Perloff et al. One hundred and five health professionals took part in the study. After measuring blood pressure, the level of concordance between the way the procedure was performed and the recommended one was assessed. RESULTS: Nurses and nurse's aides abided by 40% of the recommended procedures for adequate blood pressure measurement. The other categories of health professionals (nursing and medicine teachers, physicians, residents, and nursing students) abided by approximately 70%. CONCLUSION: Permanent educational activities aiming at standardizing blood pressure measurement should be implemented among the different categories of health professionals.

Initial diagnostic errors in children suspected of having heart disease: prevalence and long-term consequences

OBJECTIVE: To access the incidence of diagnostic errors in the initial evaluation of children with cardiac murmurs. METHODS: We evaluated our 7-years of experience in a public pediatric cardiology outpatient clinic. Of 3692 patients who were sent to the hospital, 2603 presented with a heart murmur and were investigated. Patients for whom a disagreement existed between the initial and final diagnoses were divided into the following 2 groups: G1 (n=17) with an initial diagnosis of an innocent murmur and a final diagnosis of cardiopathy, and G2 (n=161) with an initial diagnosis of cardiopathy and a final diagnosis of a normal heart. RESULTS: In G1, the great majority of patients had cardiac defects with mild hemodynamic repercussions, such as small ventricular septal defect and mild pulmonary stenosis. In G2, the great majority of structural defects were interventricular communication, atrial septal defect and pulmonary valve stenosis. CONCLUSION: A global analysis demonstrated that diagnostic error in the initial evaluation of children with cardiac murmurs is real, reaching approximately 6% of cases. The majority of these misdiagnoses were in patients with an initial diagnosis of cardiopathy, which was not confirmed through later complementary examinations. Clinical cardiovascular examination is an excellent resource in the evaluation of children suspected of having cardiopathy. Immediate outpatient discharge of children with an initial diagnosis of an innocent heart murmur seems to be a suitable approach.

Abordagem e maneio médico-cirúrgico de feridas abertas em cães e gatos : caracterização etiológica e estudo de padrões traumáticos

Dissertação de Mestrado Integrado em Medicina Veterinária

Técnicas Experimentales para Caracterizar Flujos Complejos. Experimental techniques for complex flows characterization.

En ambientes fluviales, la interacción del flujo con la geometría del cauce y con los sedimentos del lecho define una dinámica turbulenta compleja en permanente evolución. El nivel de complejidad del flujo aumenta ante la presencia de estructuras hidráulicas (pilas de puentes, protecciones contra erosión, etc.). La mayoría de los ríos, o canales naturales, presentan confluencias y bifurcaciones, en donde se genera una convergencia (o divergencia) del flujo con el resultado de un ambiente hidrodinámico complejo en la cercanía de las uniones (Kenworthy y Rhoads 1995). Bajo estas condiciones no es posible extrapolar las soluciones tradicionales básicas de las ecuaciones de gobierno desarrolladas para canales rectos y uniformes. Algunas investigaciones experimentales realizadas en estos sistemas son las de Best (1988), Rhoads y Sukhodolov (2001), Richardson et al. (1996); Richardson y Thorne (1998, 2001); Parsons et al. (2004); Szupiany et al. (2005).Por otro lado, la zona costera en ambientes marítimos se caracteriza por la existencia de diversos procesos dinámicos, entre los que se destacan la acción de olas, corrientes, interacción olas-corrientes, transporte de sedimentos y cambios batimétricos. Estos se manifiestan en una alteración morfodinámica de la playa generando superficies potenciales de erosión. Así, el diseño de las protecciones costeras (ya sean continuas, como escolleras o muros verticales; o discontinuas como espigones o diques externos) sometidas al clima marítimo bajo distintas condiciones de olas y mareas, alteran los patrones de circulación y de transporte afectando la morfodinámica en su zona de influencia y plantean, por ejemplo, la necesidad de ajustes de los coeficientes de estabilidad y pesos de los bloques de roca de las escolleras. Los problemas generados, son especialmente complejos ya que deben considerarse para su estudio, los niveles de turbulencia, la transmisión del oleaje sobre o a través de la estructura, difracción alrededor de la misma, refracción y shoaling sobre un fondo dinámico, reflexión en la estructura, etc. (Alsina et al., 2007) Revisiones bibliográficas previas muestran que, en ambos ambientes (fluvial y marítimo), es necesario optimizar las técnicas experimentales existentes para que ellas permitan caracterizar con precisión los flujos turbulentos complejos presentes. El objetivo general propuesto en esta investigación es contribuir a mejorar el conocimiento de los procesos hidrodinámicos de flujos turbulentos naturales con y sin la presencia de estructuras hidráulicas que den lugar a formaciones complejas (3D). Para alcanzar este objetivo se propone realizar una recopilación de antecedentes y un análisis crítico detallado de los equipos de ultima generación para mediciones de flujo con alta frecuencia y resolución disponibles en el Laboratorio de Hidráulica (LH) de la Universidad Nacional de Córdoba (UNC): ADV 3D (Acoustic Doppler Velocimeter de Sontek) y laser PIV 2D (Particle Image Velocimeter de Dantec). A estos equipamientos se le agrega un moderno equipo de generación bidimensional de oleaje con absorción dinámica (adquiridos a HR Ltd. en 2007 por el CAI 085 del FONTAR). Finalmente se prevé utilizar este equipamiento durante el desarrollo de experimentos y mediciones los cuales se realizarán sobre modelos físicos fluviales y costeros diseñados y construidos con y sin estructuras que interactúen con flujo turbulentos complejos. Los resultados obtenidos en este proyecto permitirá alcanzar una mejor comprensión de los procesos hidrodinámicos de los flujos turbulentos complejos, lo cual es necesario y de gran utilidad para realizar un manejo apropiado de los ambientes fluviales y marítimos, teniendo como campo directo de aplicación el correcto diseño de estructuras hidráulicas, asistiendo a la toma de medidas correctivas en sistemas naturales sometidos a procesos erosivos o de sedimentación, y contribuyendo de esta forma al manejo ambientalmente sustentable de los recursos.

Motivating techniques within Irish and American manufacturing and service companies in the Northwest of Ireland

In today’s world, many companies are concentrating on both their technology and human resources to provide them with their competitive advantage. Hence, understanding what motivates people is particularly important for managers in order to develop and sustain a competitive edge. As a result, numerous theories have been advanced to help our understanding of the subject matter and from these theories many motivational methods have evolved to enhance motivation within the workplace. In addition, research has been conducted on the various types of motivational techniques utilised by companies within Ireland. However, very little research has been completed within specific geographical regions in Ireland concerning the types of motivational techniques implemented at different job levels and their impact on employees work performance. Thus the objective of this research was to identify the motivational techniques utilised at different job levels within large manufacturing and service companies in the Northwest of Ireland and examine how these techniques influence the performance levels of employees. Furthermore, the study examined if these companies have changed from traditional ways of motivating employees to newer techniques. The research methodologies used to undertake the research included interviews with the HR managers and questionnaires completed by different employees at various job levels within the participating companies. Overall the conclusions were varied. Many different types of motivation techniques were found within the study’s participating companies. Irish companies are improving their motivational techniques, however most of these techniques are only used within higher job levels. In contrast to their American counterparts, a variety of motivational techniques are utilised and implemented at all job levels. On a more positive note, the majority of these motivational techniques do increase performance levels at all job levels. From the extensive primary and secondary research conducted, the thesis concludes by offering a number of recommendations to assist companies in further development of their motivational techniques for all job levels. These recommendations hope to augment the success of companies through an enhanced motivated workforce.

Application of multivariate statistical process control to fuel cell manufacturing

Univariate statistical control charts, such as the Shewhart chart, do not satisfy the requirements for process monitoring on a high volume automated fuel cell manufacturing line. This is because of the number of variables that require monitoring. The risk of elevated false alarms, due to the nature of the process being high volume, can present problems if univariate methods are used. Multivariate statistical methods are discussed as an alternative for process monitoring and control. The research presented is conducted on a manufacturing line which evaluates the performance of a fuel cell. It has three stages of production assembly that contribute to the final end product performance. The product performance is assessed by power and energy measurements, taken at various time points throughout the discharge testing of the fuel cell. The literature review performed on these multivariate techniques are evaluated using individual and batch observations. Modern techniques using multivariate control charts on Hotellings T2 are compared to other multivariate methods, such as Principal Components Analysis (PCA). The latter, PCA, was identified as the most suitable method. Control charts such as, scores, T2 and DModX charts, are constructed from the PCA model. Diagnostic procedures, using Contribution plots, for out of control points that are detected using these control charts, are also discussed. These plots enable the investigator to perform root cause analysis. Multivariate batch techniques are compared to individual observations typically seen on continuous processes. Recommendations, for the introduction of multivariate techniques that would be appropriate for most high volume processes, are also covered.

Investigation Route of the Coronary Patient in the Public Health System in Curitiba, São Paulo and in Incor - IMPACT Study

Background: The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization. Objective: To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP. Methods: Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies. Results: There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure. Conclusion: Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS.

Multimodality Imaging of Heart Valve Disease

Unidentified heart valve disease is associated with a significant morbidity and mortality. It has therefore become important to accurately identify, assess and monitor patients with this condition in order that appropriate and timely intervention can occur. Although echocardiography has emerged as the predominant imaging modality for this purpose, recent advances in cardiac magnetic resonance and cardiac computed tomography indicate that they may have an important contribution to make. The current review describes the assessment of regurgitant and stenotic heart valves by multimodality imaging (echocardiography, cardiac computed tomography and cardiac magnetic resonance) and discusses their relative strengths and weaknesses.

Electrophysiological Studies and Radiofrequency Ablations in Children and Adolescents with Arrhythmia

Background:Radiofrequency ablation is the standard non-pharmacological treatment for arrhythmias in pediatric patients. However, arrhythmias and their associated causes have particular features in this population.Objective:To analyze the epidemiological characteristics and findings of electrophysiological diagnostic studies and radiofrequency ablations in pediatric patients referred to the Electrophysiology Unit at Instituto de Cardiologia do Rio Grande do Sul, in order to characterize the particularities of this population.Methods:Cross-sectional study with 330 electrophysiological procedures performed in patients aged less than 20 years between June 1997 and August 2013.Results:In total, 330 procedures (9.6% of the overall procedures) were performed in patients aged less than 20 years (14.33 ± 3.25 years, age range 3 months to 19 years), 201 of which were males (60.9%). A total of 108 (32.7%) electrophysiological diagnostic studies were performed and of these, 48.1% showed abnormal findings. Overall, 219 radiofrequency ablations were performed (66.3%) with a success rate of 84.8%. The presence of an accessory pathway was the most prevalent finding, occurring in 158 cases (72.1%), followed by atrioventricular nodal reentrant tachycardia (16.8%), typical atrial flutter (3.1%) and extrasystoles originating from the right ventricular outflow tract (2.7%). Three patients developed complications during ablation (1.4%). Among congenital heart diseases, which occurred in 51 (15.4%) patients, atrial sept defect was the most frequent (27.4%), followed by ventricular sept defect (25.4%) and Ebstein's anomaly (17.6%).Conclusion:Electrophysiological study and radiofrequency ablation are effective tools for diagnosis and treatment of arrhythmias in the pediatric population.

Enhancing the performance of spread spectrum techniques in different applications

Spread spectrum, Automotive Radar, Indoor Positioning Systems, Ultrasonic and Microwave Imaging, super resolution technique and wavelet transform