Academic literature on the topic 'Monitoraggio emodinamico non invasivo'

Questo volume raccoglie i risultati di alcuni degli studi condotti dal nostro gruppo di ricerca in merito ad un'importante patologia che negli ultimi anni ha presentato un aumento in termini di incidenza, prevalenza e mortalità, quale lo scompenso cardiaco. La nostra attività vorrebbe riuscire a definire : 1)nuove modalità diagnostiche semplici nell’ esecuzione e di basso impatto economico che permettano una valutazione rapida ed efficace dello stato emodinamico del paziente 2)nuovi criteri di stratificazione prognostica inquadrare precocemente la possibile evoluzione del paziente 3) nuove strategie terapeutiche sia di tipo farmacologico che non farmacologico

Minimally invasive hemodynamic monitoring in intensive care: methodological approach The aim of the study was to validate the reliability of some new systems of hemodynamic monitoring: the Nexfin system (BMEYE BV, Amsterdam, Netherlands ) totally non-invasive, and the Pressure-Recording Analytical Method (PRAM/MostCare, Vygon, Italy ), minimally invasive and without the need of calibration, either external or internal. MATERIALS AND METHODS NEXFIN. We enrolled 40 patients admitted to two intensive care units at Padua Hospital. For each patient we collected data about systolic blood pressure (SBP) and diastolic blood pressure (DBP) continuously for 30 minutes, both using standard intra-arterial method (IBP) and Nexfin system (“finger cuff” technology). We compared a total of 79263 pairs of blood pressure values. On 9 patients we compared the value of cardiac output (CO) with the value measured by trans-thoracic echocardiography Doppler (TTE ) . PRAM. We connected the PRAM system to a Siemens sc7000 monitor linked to a sophisticated simulator HPS/METI® HPS/METI® which can produce different CO values according to the clinical conditions set. We simulated 6 different clinical scenarios to obtain a total of 168 measurements of CO . In the second step, we tested the system on 38 hemodynamically stable patients by comparing the values of CO with those measured by TTE with Doppler technique. Finally, we compared the CO data on 21 hemodynamically unstable patients, supported by Norepinephrine in continuous infusion, by comparing the CO values with those measured by transpulmonary thermodilution system: PiCCO2 (Pulse Contour Cardiac Output, Pulsion Medical Systems, Munich, Germany ). We compared the data before (T1) and after (T2) the reduction of 0,05 mcg/kg/min of the drug. The results obtained were analyzed according to the Bland and Altman method. We calculated mean differences, limits of agreement and percentual errors. RESULTS NEXFIN. We collected 158525 pressure points, 79263 for each device: for SBP the mean a difference was -4,89 mmHg, limits of agreement were +18,11mmHg/-27,91 mmHg, %error 18%; for DBP the mean difference was +6.07 mmHg, limits of agreement +23,60/-11,45 mmHg, with %error of 26%. For values of CO we calculated a mean difference of -0,5 L/min, with limits of agreement +2.24/-3.38 L/min. PRAM/MostCare. The comparison of 168 values of CO with those set to HPS/METI® showed a mean difference of -0,32 L/min, limits of agreement respectively +0,88 and -1,53 L/min. The %error calculated was 23%; R2 = 78.1%. The comparison of the values of CO with those measured with TTE on 38 stable patients showed a mean difference of -0,03 L/min (SD 0,66) and the limits of agreement respectively between + 1,28 e -1,35 L/min. The comparison of the values of CO with those measured by transpulmonary thermodilution on 21 hemodynamically unstable patients showed a mean difference of 0,13 L/min at T1 and 0,1 L/min at T2, with limits of agreement = -1,41/1,69 L/min at T1 and -1,67/1,87 L/min at T2. The percentage error at T1 was 28,27%, at T2 was 32%. In the subgroup of patients with atrial fibrillation, the mean difference was 0,28 L/min at T1, with the limits of agreement of -0,79 and +1,37 L/min and with a %error of 22%; at T2 the mean difference was 0,55 L/min, the limits of agreement were between -1,82 and 2,93 L/min and the error rate was 49%. CONCLUSIONS About Nexfin we can conclude that the values of SBP, DBP and CO measured by this device can not be considered reliable in critically ill patients; there might be a more appropriate application in the operating room or in medical departiments. The method remains strongly linked to correctly reading the wave form, which appears to be strongly influenced by several pathophysiological and environmental variables . Regarding PRAM, in relation to the CO measurement compared with both the TTE and the method of the transpulmonary thermodilution, its application seems useful in the context of critically ill patients, providing fundamental information about hemodynamic setting to the intensivist without risk. To confirm our results the study needs to be expand to include more hemodynamically unstable patients as well as patients affected by atrial fibrillation. The PRAM system is operator-dependent: it needs to be used by experienced staff, who are able to asses the correct arterial wave form.<br>Monitoraggio emodinamico mini-invasivo in terapia intensiva: approccio metodologico Negli ultimi anni sono stati proposti diversi sistemi di monitoraggio emodinamico che promettono una buona affidabilità a fronte di una minima invasività. Scopo dello studio è stato quello di validarne alcuni, in particolare il sistema Nexfin (BMEYE BV, Amsterdam, Paesi Bassi) nuovo e totalmente non invasivo, e il Pressure-Recording Analytical Method (PRAM/Mostcare, Vygon, Italia), mini-invasivo e che non necessita di calibrazione né esterna, né interna. MATERIALI E METODI Abbiamo studiato i due sistemi testandoli su pazienti ricoverati in due terapie intensive polivalenti dell’Azienda Ospedaliera di Padova. Per il sistema Nexfin abbiamo arruolato 40 pazienti, per ognuno abbiamo rilevato per 30 minuti in continuo la pressione arteriosa sistolica (SBP) e diastolica (DBP), sia con il metodo standard della cannulazione intra-arteriosa (IBP) che con il sistema Nexfin (tecnologia finger cuff) e abbiamo confrontato un totale 79263 coppie di valori pressori. Su 9 pazienti abbiamo confrontato anche il valore di cardiac output (CO) con quello misurato mediante ecografia transtoracica con tecnica Doppler (TTE). Per quanto riguarda il sistema PRAM lo abbiamo collegato mediante cavo ad un monitor Siemens sc7000 connesso ad un sofisticatissimo simulatore HPS/METI®, in grado di riprodurre valori di CO diversi in base alle condizioni cliniche impostate. Abbiamo simulato 6 scenari clinici differenti per ottenere un totale di 168 misurazioni di CO che abbiamo confrontato con quelli noti risultanti dalle impostazioni del simulatore. Successivamente abbiamo testato il sistema su 38 pazienti emodinamicamente stabili confrontando i valori di CO con quelli misurati mediante TTE con tecnica Doppler. Infine abbiamo confrontato i dati di CO su 21 pazienti emodinamicamente instabili e sostenuti da Noradrenalina in infusione continua, confrontando i valori di CO con quelli misurati tramite termodiluizione transpolmonare con sistema PiCCO2 (Pulse Contour Cardiac Output, Pulsion Medical System, Munich, Germany). Abbiamo confrontato i dati prima (T1) e dopo (T2) la riduzione di 0,05 mcg/Kg/min del farmaco. I risultati ottenuti sono stati analizzati statisticamente secondo il metodo di Bland e Altman; sono state calcolate le differenze medie, i livelli di concordanza e le percentuali d’errore. RISULTATI NEXFIN. Su un totale 158525 punti pressione, 79263 per dispositivo, abbiamo ottenuto per la SBP una mean difference di -4,89 mmHg, dei limits of agreement di +18,11mmHg e -27,91 mmHg ed un errore percentuale del 18% e per la DBP una mean difference di +6,07 mmHg, dei limits of agreement di +23,60 mmHg e -11,45 mmHg, con una percentuale d’errore del 26%. Per i valori di CO abbiamo calcolato una mean difference -0,5 L/min, con dei limits of agreement rispettivamente di +2,24 e -3,38 L/min. PRAM/Mostcare. Il confronto di 168 valori di CO con quelli impostati su HPS/METI® ha mostrato una mean difference di -0,32 L/min e dei limits of agreement rispettivamente di +0,88 e -1,53 L/min. L’errore percentuale calcolato era del 23%. con un R2 = 78,1%. Il confronto dei valori di CO con quelli misurati con TTE su 38 pazienti stabili ha mostrato una mean difference di -0,03 L/min (SD 0,66) e dei limits of agreement rispettivamente compresi tra + 1,28 e -1,35 L/min. Il confronto dei valori di CO con quelli misurati con termodiluizione transpolmonare su 21 pazienti emodinamicamente instabili ha evidenziato una mean diffenrence di 0,13 L/min al T1 e di 0,1 L/min al T2, con dei limits of agreement rispettivamente compresi tra -1,41 e 1,69 L/min e tra -1,67 e 1,87 L/min. L’errore percentuale al T1 è risultato essere pari al 28,27%, al T2 era pari al 32%. Nel sottogruppo di pazienti affetti da fibrillazione atriale la mean difference era di 0,28 L/min a T1, con dei limits of agreement di -0,79 e +1,37 L/min e con un errore percentuale del 22%; al T2 la mean difference era di 0,55 L/min, i limits of agreement erano compresi tra -1.82 e 2,93 L/min e la percentuale d’errore era del 49%. CONCLUSIONI Per quanto riguarda il sistema Nexfin possiamo concludere che i valori di SBP, DBP e CO misurati da questo device completamente non invasivo non possono essere considerati affidabili nei pazienti critici; la tecnologia finger-cuff può trovare probabilmente una più appropriata applicazione in sala operatoria o in ambito più prettamente medico. La metodica rimane fortemente vincolata da una corretta lettura del dato pressorio che ci è parso fortemente suscettibile a una serie di variabili fisiopatologiche e ambientali. Per quanto riguarda il sistema PRAM, in relazione alla misura del CO confrontata sia con la TTE che con il metodo della termodiluizione transpolmonare, la sua applicazione ci sembra possa trovare spazio nel paziente critico, fornendo all’intensivista informazioni fondamentali sull’assetto emodinamico senza rischi aggiunti. Resta la necessità di ampliare le popolazioni di studio relative ai pazienti emodinamicamente più instabili e a quelli affetti da fibrillazione atriale per poter confermare i nostri risultati. Il sistema PRAM è operatore-dipendente: richiede di essere utilizzato da personale esperto, in grado di valutare la corretta lettura dell’onda di pressione.

Il continuo sviluppo di connettività e comunicazione combinato con la ricerca di risparmio, rinnovamento, sicurezza e semplificazione ha reso sempre più semplice ed intuitivo il passaggio ad un edificio intelligente. Ovvero, un ambiente dotato di attrezzature e sistemi tecnologicamente avanzati in grado di svolgere funzioni vincolate, parzialmente o completamente autonome. In questo elaborato si affronta il tema del risparmio energetico, tramite il monitoraggio dei carichi non invasivo, il quale, determina il consumo energetico dei singoli apparecchi che si accendono e si spengono in un carico elettrico, sulla base di un'analisi dettagliata della corrente e della tensione del carico totale, misurati all'interfaccia con la fonte di alimentazione. Tramite uno studio ed una panoramica generale del NILM (“non intrusive load monitoring”) vengono discusse le caratteristiche principali: processi e funzionamento base, applicazioni, classificazione dei carichi e firme caratteristiche, rapportando fra loro i diversi approcci con vantaggi e svantaggi.

L’elaborato espone sei diversi metodi contact-less per la rilevazione della frequenza respiratoria. Sono stati menzionati i vari studi che si sono occupati dell’acquisizione, l’elaborazione ed il confronto dei dati ricavati con quelli ottenuti tramite altre metodiche considerate gold standard. Le tecniche trattano: segnali di pressione quali OscP e KorS, fotocamere ToF, un sistema ibrido che utilizza il segnale PPGI e IRTI, un sensore capacitivo, uno a radiofrequenze ed un radar CW. Il confronto, prendendo in considerazione i segnali rilevati tramite cintura di pressione o polisonnigrafo, ha dimostrato una forte correlazione. Si è osservato che queste tecniche possono essere una valida alternativa con diversi vantaggi: analisi di pazienti dormienti, allettati o con ferite cutanee per cui sarebbe impossibile utilizzare le classiche tecniche esistenti che prevedono cinture o elettrodi a contatto con il corpo.

Il sonno è una parte della routine quotidiana essenziale per l’essere umano tanto quanto lo sono mangiare e bere. Il sistema nervoso, cardio-circolatorio, respiratorio e immunitario sono estremamente condizionati dal sonno, così come lo sono il nostro umore e il nostro metabolismo. Ulteriori studi hanno dimostrato che una mancanza di sonno, o una bassa qualità di esso, aumentano il rischio di disturbi, quali ipertensione, insufficienze cardiovascolari, diabete, depressione e obesità. Proprio per questi motivi e per queste scoperte è diventata sempre più imperativa la necessità di capire a fondo cosa significhi “qualità del sonno”, cosa si può fare per migliorarla e quali sono quei fattori che possono invece portare ad un suo peggioramento. L’elaborato mira ad analizzare quello che è lo stato dell’arte del monitoraggio del sonno, descrivendo le tecnologie e metodologie che oggi vengono utilizzate per studiare e comprendere al meglio il sonno. Inoltre saranno descritti i principali disturbi del sonno, evidenziando come si diagnosticano e quali sono le terapie ad oggi disponibili. Successivamente si analizzeranno alcuni dei dispositivi più innovativi e promettenti per il monitoraggio del sonno, come ROBIN, un device indossabile in grado di rilevare la frequenza respiratoria tramite la bioimpedenza della gabbia toracica e di diagnosticare apnee notturne.

The advancements in basic sciences and the availability of sophisticated technological aids have led over the last few years to the rise of innovative surgical strategies, the identification of better prognostic/predictive biomolecular factors, and the development of novel drugs all meant to profoundly impact the outcome of neurosurgical patients. This thesis touches upon the window of opportunity to exploit bioengineering techniques in three subspecialties of this vast discipline: neuro-oncology, radiosurgery and neuro-traumatology. After a thorough identification of some unresolved clinical problems and the limits of current management strategies in those areas, some technical solutions are proposed and defined from either experimental hypothesis or clinical research investigations. The neuro-oncology section presents the exciting topic of nanodrugs for adjuvant chemotherapy in high-grade gliomas, the most aggressive primary brain tumours. The use of hyaluronic acid nanoshells is proposed to encapsulate prodrugs and exploit the mechanisms of interaction between glioma cells and hyaluronic acid, a natural component of extracellular matrix. The theoretical advantages of this approach are discussed with details regarding the possible scalability of this technique to increase the efficacy and biodegradability of other molecules suitable as contrast media for neuro-imaging and radiotracers for nuclear medicine investigations. The radiosurgery section in fact continues the previous one, highlighting the rationale for further implementation of radiosurgical protocols thanks to nanoshell-encapsulated radioenhancers and multi-imaging fusion protocols. Experimental data on the optimization of radiosurgical plans for artero-venous malformations close to the motor strip or basal ganglia are presented, demonstrating the dramatic reduction in radiation dose to the pyramidal tract and supporting the anticipated benefits in terms of radioprotection, and avoidance of post-radiosurgical deficits. Finally the neurotrauma section presents the clinical results from a prospective study on an innovative device for non-invasive monitoring of intracranial pressure, a tool that given the high reliability demonstrated in this research might find a role in preclinical or neurointensive care settings and reduce the need for serial neuroimaging in traumatic brain injured patients. The last chapter concludes this thesis duly outlining some forecasts and supporting literature for the widespread application of bioengineering enhanced solutions in neurosurgical theatres, wards or outpatient clinics.

During the past decades, the interest of the healthcare community shifted from the simple treatment of the diseases towards the prevention and maintenance of a healthy lifestyle. This approach is associated to a reduced cost for the Health Systems, having to face the constantly increased expenditures due to the reduced mortality for chronical diseases and to the progressive population ageing. Nevertheless, the high costs related to hospitalization of patients for monitoring procedures that could be better performed at home hamper the full implementation of this approach in a traditional way. Information and Communication Technology can provide a solution to implement a care model closer to the patient, crossing the physical boundaries of the hospitals and thus allowing to reach also those patients that, for a geographical or social condition, could not access the health services as other luckier subjects. This is the case of telemonitoring systems, whose aim is that of providing monitoring services for some health-related parameters at a distance, by means of custom-designed electronic devices. In this thesis, the specific issues associated to two telemonitoring applications are presented, along with the proposed solutions and the achieved results. The first telemonitoring application considered is the fetal electrocardiography. Non-invasive fetal electrocardiography is the recording of the fetal heart electrical activity using electrodes placed on the maternal abdomen. It can provide important diagnostic parameters, such as the beat-to-beat heart rate variability, whose recurring analysis would be useful in assessing and monitoring fetal health during pregnancy. Long term electrocardiographic monitoring is sustained by the absence of any collateral effects for both the mother and the fetus. This application has been tackled from several perspectives, mainly acquisition and processing. From the acquisition viewpoint a study on different skin treatments, disposable commercial electrodes and textile electrodes has been performed with the aim of improving the signal acquisition quality, while simplifying the measurement setup. From the processing viewpoint, different algorithms have been developed to allow extracting the fetal ECG heart rate, starting from an on-line ICA algorithm or exploiting a subtractive approach to work on recordings acquired with a reduced number of electrodes. The latter, took part to the international "Physionet/Computing in Cardiology Challenge" in 2013 entering into the top ten best-performing open-source algorithms. The improved version of this algorithm is also presented, which would mark the 5th and 4th position in the final ranking related to the fetal heart rate and fetal RR interval measurements performance, reserved to the open-source challenge entries, taking into account both official and unofficial entrants. The research in this field has been carried out in collaboration with the Pediatric Cardiology Unit of the Hospital G. Brotzu in Cagliari, for the acquisition of non-invasive fetal ECG signals from pregnant voluntary patients. The second telemonitoring application considered is the telerehabilitation of the hand. The execution of rehabilitation exercises has been proven to be effective in recovering hand functionality in a wide variety of invalidating diseases, but the lack of standardization and continuous medical control cause the patients neglecting this therapeutic procedures. Telemonitoring the rehabilitation sessions would allow the physician to closely follow the patients' progresses and compliance to the prescribed adapted exercises. This application leads to the development of a sensorized telerehabilitation system for the execution and objective monitoring of therapeutic exercises at the patients' home and of the telemedicine infrastructure that give the physician the opportunity to monitor patients' progresses through parameters summarizing the patients' performance. The proposed non-CE marked medical device, patent pending, underwent a clinical trial, reviewed and approved by the Italian Public Health Department, involving 20 patients with Rheumatoid Arthritis and 20 with Systemic Sclerosis randomly assigned to the experimental or the control arm, enrolled for 12 weeks in a home rehabilitation program. The trial, carried out with the collaboration of the Rheumatology Department of the Policlinico Universitario of Cagliari, revealed promising results in terms of hand functionality recovering, highlighting greater improvements for the patients enrolled in the experimental arm, that use the proposed telerehabilitation system, with respect to those of the control arm, which perform similar rehabilitation exercises using common objects.

To works of art is often assigned a specific value of cultural and expressive testimony of an artist or, more generally, of a culture. Preserve this value means keeping intact the appearance of the work and its component material in order for the message to reach the public, without alteration. A good knowledge of the materials constituting the work is needed to preserve them appropriately. My research work is focused on the study of modern and contemporary paintings and of materials used, which are not well known compared to traditional materials. The main goal of this work was to investigate some of the most popular art materials to track even the weakest changes, which are index of degradation and occur in the form of chromatic alterations. Image spectroscopy (IS) was the scientific technique on which we focused the attention, since it helps to reveal early alterations using imaging, in a complete non-invasive way. Spectral data in the VIS-NIR range were processed by multivariate statistical analysis. The use of Principal Component Analysis (PCA) on IS spectra was applied to modern painting materials, as Titanium White, Artificial Ultramarine Blue in acrylic and oil binders in a test panel. IS + PCA has proven to be an effective method for the early identification of chromatic alterations, although of faint amounts. Moreover, colorimetric data have provided useful and complementary information, recognizing the alterations trends. Unexpectedly, IS has also demonstrated a discriminant power for some materials. The most striking case was the identification of white Lithopone for an absorption band in the visible range, due to the presence of cobalt as vicariant element of Zinc. The knowledge of changes in the chemical composition of this pigment in a specific time period has allowed the recognition of a fake in contemporary artwork. Other scientific methodologies have been used. X-ray fluorescence was used to collect more detailed information about the materials. This can be the case of examinations on Jean Metzinger’s work, present in the Peggy Guggenheim Collection (Venice). Image diagnostics, as Ultraviolet fluorescence, Wide band infrared reflectography, have proved useful to collect information on the state of conservation of works in non-quantitative way. The common features of such techniques are to be non-invasive, non-destructive, to be used in situ.

Studio sull'applicabilità di tecniche ottiche lineari e nonlineari e metodi fotoacustici innovativi per l'analisi non invasiva (composizionale, strutturale e morfologica) di opere d'arte e per il monitoraggio di operazioni di restauro