Os estudos clínicos são importantes para a sociedade, contribuem para o avanço da ciência, geram novos conhecimentos, trazem benefícios, melhoria da qualidade de vida e o bem-estar das pessoas. Devem ser realizados de acordo com os princípios éticos e vários agentes devem estar envolvidos: as autoridades regulatórias, o patrocinador, o pesquisador, o participante de pesquisa e o comitê de ética em pesquisa. Os regulamentos e guias internacionais e nacionais relacionados aos estudos clínicos, entre eles a Diretriz de Boas Práticas Clínicas foram implantados principalmente, para proteger e garantir a segurança e integridade dos participantes de pesquisa. No decorrer dos estudos clínicos podem ocorrer eventos adversos, portanto a plena monitorização é fundamental, pois torna o estudo mais seguro para o participante de pesquisa. Este trabalho teve como objetivo elaborar um manual direcionado a pesquisadores visando orientar a notificação de eventos adversos aos órgãos pertinentes. O estudo foi realizado em quatro etapas. Na primeira etapa realizou-se uma revisão da literatura sobre eventos adversos em estudos clínicos. Na segunda etapa, elaborou-se um manual piloto. Na terceira etapa, o material foi qualificado por um Painel de Especialistas formado por cinco pesquisadores do Hospital Universitário Cassiano Antonio Moraes, que analisaram o conteúdo e responderam a um questionário de onze questões. Na quarta etapa, analisou-se as respostas dos questionários e com as sugestões do Painel de Especialistas aprimorou-se o manual e obteve-se a versão denominada Manual de Procedimentos para Notificação de Eventos Adversos em Estudos Clínicos. Após a apreciação final do produto pela banca do mestrado profissional, o manual será disponibilizado em formato eletrônico, para que vários pesquisadores tenham acesso, em especial os pesquisadores que atuam no Hospital Universitário Cassiano Antonio Moraes e nos hospitais vinculados a rede da Empresa Brasileira de Serviços Hospitalares (EBSERH). / Clinical studies are important to society. They contribute to the advance of science, generate new knowledge, bring benefits, improve the quality of life and the well-being of people. They must be carried out in accordance with ethical principles and several agents should be involved: the regulatory authorities, the sponsor, the researcher, the research participant and the research ethics committee. International and national regulations and guidelines related to clinical studies, including the Clinical Good Practice Guideline, were primarily implemented to protect and ensure the safety and integrity of the research participants. Adverse events can occur during clinical studies; it means that, full monitoring is critical in order to lead the study safer for the research participant. The aim of this work is to elaborate a manual directed at researchers to guide them on the notification of adverse events process to the government organizations. The study was divided in four steps. In the first step, a bibliographic review on adverse events in clinical studies was done. In the second step, a pilot manual was developed. In the third step, the analyzed material was qualified by a Panel of Experts composed of five University Hospital Cassiano Antonio Moraes’ researchers who analyzed the content and answered a questionnaire of eleven questions. In the fourth step, the analyzed questionnaire as well as the Panel of Expert’s suggestions were used for improving the manual, reaching the version called the Manual of Procedures for Notification of Adverse Events in Clinical Studies. After the final evaluation of the product by the master's degree examining board, the manual will be available in electronic format, so that several researchers will have access, especially researchers working in University Hospital Cassiano Antonio Moraes and hospitals linked to the network of the Brazilian Hospital Services Company (EBSERH).

O objetivo deste trabalho foi realizar diagnóstico para solução de problemas de atraso na entrega das atividades e relatórios de pesquisa, bem como de dificuldade de se definir o objetivo e escopo do projeto, encontrados no departamento de estudos pré-clínicos e clínicos de empresa de saúde animal. Isso porque, antes dos novos produtos veterinários entrarem no mercado, estes devem passar por testes que comprovem sua eficácia e segurança, conforme exigido pelo órgão regulatório. Neste contexto, verifica-se a importância da realização de estudos clínicos conforme planejamento e prazos previamente estabelecidos, pois estes impactam diretamente nos resultados e planejamento estratégico da empresa. Para tanto, foi realizado diagnóstico dos atrasos através de avaliação de cronogramas de projetos finalizados. Como proposta de solução foi elaborado um formulário de planejamento de projetos a partir dos conceitos do PMBOK®. Este foi aplicado no início de cada novo projeto e inserido no fluxograma de processos do departamento. Para avaliação dos resultados da inserção deste formulário foram aplicados aos colaboradores do departamento questionários fechados juntamente a cada preenchimento do formulário. Os dados obtidos destes questionários foram avaliados através da análise de componentes principais. Além disso, foi realizada entrevista semiestruturada com os colaboradores para verificar efetivamente a mudança no cenário do departamento pós-formulário, sendo os dados avaliados conforme método de análise de discurso. Como resultados foi verificado que ocorreram atrasos em pelo menos 50% das atividades presentes nos 22 cronogramas de projetos avaliados, isso devido principalmente ao planejamento inadequado, de acordo com os relatos dos colaboradores. Com a aplicação do formulário e análise dos dados dos questionários e das entrevistas foi possível verificar que a utilização do formulário tem grande importância na definição dos objetivos do projeto, definição de escopo, e consequente definição das atividades indicadas para cada estudo, ou seja, auxilia no planejamento do estudo. Além disso, proporciona aos colaboradores a reflexão e visão crítica dos projetos, assim como deixa documentado tudo aquilo que foi pensado evitando retrabalhos posteriores. / The objective of this study was to perform a diagnosis to solve problems of delay in activities and research reports\' delivery, as well as the difficulty to define project\'s objective and scope, found in the pre-clinical and clinical studies department of animal health company. This happens because new veterinary products must undergo tests that prove their efficacy and safety, as required by the regulatory agencies before being marketed. In this context, it is important to carry out clinical studies according to the planning and deadlines previously established, as these have a direct impact on the results and strategic planning of the company. For this purpose, the delays were diagnosed through the evaluation of completed project schedules. As a proposal for solution, a project planning form was developed based on PMBOK® concepts. This was applied at the beginning of each new project and inserted into the department\'s process flowchart. To evaluate insertions\' results of this form a closed questionnaire was applied to employees of the department with each filling out form. The data obtained from these questionnaires were analyzed through principal components analysis. In addition, a semi-structured interview was conducted with the employees to effectively verify the change in the post-form department scenario and the data were evaluated according to the discourse analysis method. As results it was verified that there were delays in at least 50% of the activities present in the 22 schedules of evaluated projects, mainly due to inadequate planning, according to the collaborators reports. With form\'s application and data\'s analysis of questionnaires and interviews it was possible to verify that the use of the form has great importance in the definition of project\'s objectives, definition of scope and consequent activities\' definition indicated for each study. In other words, it assists in the planning of the study. In addition, it provides the employees with the reflection and critical vision of projects, as well as documenting everything that was thought avoiding subsequent rework.

Os estudos clínicos são importantes para a sociedade, contribuem para o avanço da ciência, geram novos conhecimentos, trazem benefícios, melhoria da qualidade de vida e o bem-estar das pessoas. Devem ser realizados de acordo com os princípios éticos e vários agentes devem estar envolvidos: as autoridades regulatórias, o patrocinador, o pesquisador, o participante de pesquisa e o comitê de ética em pesquisa. Os regulamentos e guias internacionais e nacionais relacionados aos estudos clínicos, entre eles a Diretriz de Boas Práticas Clínicas foram implantados principalmente, para proteger e garantir a segurança e integridade dos participantes de pesquisa. No decorrer dos estudos clínicos podem ocorrer eventos adversos, portanto a plena monitorização é fundamental, pois torna o estudo mais seguro para o participante de pesquisa. Este trabalho teve como objetivo elaborar um manual direcionado a pesquisadores visando orientar a notificação de eventos adversos aos órgãos pertinentes. O estudo foi realizado em quatro etapas. Na primeira etapa realizou-se uma revisão da literatura sobre eventos adversos em estudos clínicos. Na segunda etapa, elaborou-se um manual piloto. Na terceira etapa, o material foi qualificado por um Painel de Especialistas formado por cinco pesquisadores do Hospital Universitário Cassiano Antonio Moraes, que analisaram o conteúdo e responderam a um questionário de onze questões. Na quarta etapa, analisou-se as respostas dos questionários e com as sugestões do Painel de Especialistas aprimorou-se o manual e obteve-se a versão denominada Manual de Procedimentos para Notificação de Eventos Adversos em Estudos Clínicos. Após a apreciação final do produto pela banca do mestrado profissional, o manual será disponibilizado em formato eletrônico, para que vários pesquisadores tenham acesso, em especial os pesquisadores que atuam no Hospital Universitário Cassiano Antonio Moraes e nos hospitais vinculados a rede da Empresa Brasileira de Serviços Hospitalares (EBSERH). / Clinical studies are important to society. They contribute to the advance of science, generate new knowledge, bring benefits, improve the quality of life and the well-being of people. They must be carried out in accordance with ethical principles and several agents should be involved: the regulatory authorities, the sponsor, the researcher, the research participant and the research ethics committee. International and national regulations and guidelines related to clinical studies, including the Clinical Good Practice Guideline, were primarily implemented to protect and ensure the safety and integrity of the research participants. Adverse events can occur during clinical studies; it means that, full monitoring is critical in order to lead the study safer for the research participant. The aim of this work is to elaborate a manual directed at researchers to guide them on the notification of adverse events process to the government organizations. The study was divided in four steps. In the first step, a bibliographic review on adverse events in clinical studies was done. In the second step, a pilot manual was developed. In the third step, the analyzed material was qualified by a Panel of Experts composed of five University Hospital Cassiano Antonio Moraes’ researchers who analyzed the content and answered a questionnaire of eleven questions. In the fourth step, the analyzed questionnaire as well as the Panel of Expert’s suggestions were used for improving the manual, reaching the version called the Manual of Procedures for Notification of Adverse Events in Clinical Studies. After the final evaluation of the product by the master's degree examining board, the manual will be available in electronic format, so that several researchers will have access, especially researchers working in University Hospital Cassiano Antonio Moraes and hospitals linked to the network of the Brazilian Hospital Services Company (EBSERH).

Empresa que pertenece a la industria Farmacéutica, ubicada dentro de la categoría de Estudios clínicos. Denominada CRO (Clinical Research Organization – Organización de investigación por contrato). El rol que cumple la CRO dentro de la cadena de valor de esta categoría, es realizar los estudios clínicos por encargo de las Empresas Farmacéuticas que realizan desarrollo e investigación de medicamentos. Una vez realizadas las investigaciones pre-clínicas y clínicas por las empresas farmacéuticas, estas contratan a Depósitos para almacenaje de la droga y a las CRO, quienes ejecutarán el proyecto en cada país encargándose de reclutar los grupos de personas en las que se realizarán las pruebas, distribuir las drogas en los grupos seleccionados, para proceder a analizar y entregar los resultados a la empresa farmacéutica. Si los resultados reportados por la CRO son óptimos, la empresa farmacéutica procederá a registrar la patente y a la comercialización de los medicamentos. El éxito de los resultados de los Estudios clínicos depende de 3 factores principales: 1. Un almacenaje correcto de la droga en estudio, bajo condiciones óptimas de conservación. 2. Compromiso de los pacientes participantes, siguiendo estrictamente las indicaciones y las dosis planificadas para cada uno de ellos. 3. Monitoreo y análisis por parte de la CRO Actualmente los servicios que provee BIOCLINICAL RESEARCH a las Industrias Farmacéuticas son: Asesoría en el diseño de protocolos. Reclutamiento de investigadores. Monitoreo de estudios clínicos. Análisis de datos. de Fármaco-Vigilancia. Gerenciamiento de desarrollo del estudio clínico para el cual ha sido contratada la Compañía. Manejo de resultados de Estudios clínicos Considerando el impacto que representa el correcto almacenaje de la droga en análisis, para los resultados obtenidos; BIOCLINICAL RESEARH creará una nueva Unidad de Negocio, referida al almacenaje de los medicamentos para Estudio Clínicos; pretendiendo de esta forma, cerrar el círculo de suministro de la droga en estudio, desde que se importa hasta que se distribuye a los Centros de investigación para uso del paciente. / Tesis

The emerging research issues in evidence-based healthcare decision-making and explosion of comparative effectiveness research (CER) are evident proof of the effort to thoroughly incorporate the rich data currently available within the system. The flexibility of Bayesian data mining techniques lends its strength to handle the challenging issues in the biomedical and health care domains. My research focuses primarily on Bayesian data mining techniques for non-traditional data in this domain, which includes, 1. Missing data: Matched-pair studies with fixed marginal totals with application to meta-analysis of dental sealants effectiveness. 2. Data with unusual distribution: Modeling spatial repeated measures with excess zeros and no covariates to estimate U.S. county level natural fluoride concentration. 3. Highly irregular data: Assess overall image regularity in complex wavelet domain to classify mammography image. The goal of my research is to strengthen the link from data to decisions. By using Bayesian data mining techniques including signal and image processing (wavelet analysis), hierarchical Bayesian modeling, clinical trials meta-analyses and spatial statistics, this thesis resolves challenging issues of how to incorporate data to improve the systems of health care and bio fields and ultimately benefit public health.

Il est avéré que les signaux de pléthysmographie par inductance comportent des composantes cardiaques et respiratoires pouvant présenter un intérêt pour un suivi physiologique. Cette technique est largement utilisée chez l’homme et chez les mammifères de taille moyenne, mais n’a jamais été mise en œuvre chez les petits rongeurs de laboratoire comme le rat. Cette thèse vise à apporter la preuve analytique et expérimentale (TRL3) d’une application cardiaque de la pléthysmographie cardiorespiratoire par inductance (PCRI) fondée sur le concept amont de « bague aortique virtuelle » (BAOV). La BAOV permet de mettre en œuvre une mesure externe des débits aortiques « instantanés » à l’aide de la PCRI en lieu et place d’un instrument positionné autour du vaisseau lui-même.La thèse a débuté par une phase de spécification et de conception guidée par l’interdépendance entre la physiologie et les contraintes instrumentales. Les performances métrologiques à atteindre sont dictées par un saut d’échelle entre l’homme et le rat. Le développement d’une chaine de mesure optimisée a permis de repousser les limites des systèmes existants en rendant possible la mesure de variations de volumes de quelques microlitres. En parallèle, l’identification de critères de validation, de méthodes de référence et la mise au point de protocoles expérimentaux ont conduit à la définition d’une stratégie de validation de l’instrument de mesure développé et du concept de BAOV.À l’issue de ces trois années, un système de PCRI à ultra-haute résolution a été mis au point. Après calibration, l’exactitude sur les mesures de variations de section est de 5 % sur un banc de test micrométrique. L’interchangeabilité de la mesure des variations de volume du thorax sur la gamme physiologique a été évaluée par rapport à une mesure pneumotachographique sur 9 animaux anesthésiés. Les limites d’agrément obtenues sont inférieures à 20 %. L’induction d’un challenge hémodynamique sur 11 animaux anesthésiés dont le débit aortique est mesuré en parallèle avec la PCRI et une bague de débit ultrasonique placée au niveau sous-diaphragmatique démontre l’équivalence entre les deux systèmes. Par ailleurs, la grande similitude entre les signaux de débits des deux méthodes valide le concept de bague aortique virtuelle proposé / It is recognized that inductive plethysmographic signals contain cardiac and respiratory components, which can be of interest for physiological monitoring. This technology is widely used in humans and medium mammals, but it has never been implemented in small laboratory rodents. This PhD aims to provide the analytic and experimental proof (TRL3) of a cardiac application of the cardio-respiratory inductive plethysmography (CRIP), based on the upstream concept of an “virtual aortic probe” (VAP). The VAP allows to realize an extern measure of “instantaneous” aortic flows thanks to CRIP instead of an instrument located directly around the vessel.The PhD starts with a phase of specification and conception driven by the interdependency between physiology and instrumental constraints. The expected metrological performances are established by a scale jumping between man and rat. The development of an optimized acquisition line has enabled to stretch the limits of existing systems; it allows to measure volume variations of a few microliters. At the same time, validation criteria and reference methods have been identified and experimental protocols have been specified in order to define the validation strategy of the developed instrument and VAP concept.At the end of these 3 years, an ultra-high resolution CRIP system has been developed. After calibration, the accuracy on the section variation measurements is 5% on a micrometric test-bench. The interchangeability of the thorax volume variation measure on a physiological range has been evaluated by comparison with a pneumotachographic measure on 9 anesthetized animals and the limits of agreement are lower than 20%. A hemodynamic challenge has been induced on 11 anesthetized animals, and the aortic flow has been simultaneously measured by CRIP and with an ultrasonic flow probe at under diaphragm level. This demonstrates the equivalence between both systems. And the high similarity between flow signals from both methods validates the proposed concept of virtual aortic probe

1. Clinical studies. Clinical diagnosis of dementia has been made largely on the basis of clinical findings supported by appropriate radiological and laboratory investigations. A minority of patients have treatable or reversible underlying causes for their dementing syndrome. It is important to distinguish between the two main forms of dementia Alzheimer's disease, senile dementia of Alzheimer type (AD/SDAT) and MID so that advantage can be taken of any future progress in treatments. In the clinical study significant differences between several diagnostic procedures were found between patients with AD/SDAT and MID. Blood pressure was significantly lower in the AD/SDAT group and focal neurological signs were seen in 70% of the MID patients but only in 6% of patients with AD/SDAT. Electrocardiogram was normal in all patients with AD/SDAT but pathological in 75% of the MID patients. Electroencephalogram showed generalized slow frequencies in 79% of the AD/SDAT patients and localized changes in 65% of the MID patients. Computerized tomography showed a significantly greater dilation of the ventricular system in MID patients compared to AD/SDAT patients and controls. Monoamine metabolites in the cerebrospinal fluid were lower in AD/SDAT patients and normal in MID patients. Psychopathological signs were found to be more variable and more pronounced in the AD/SDAT group compared with MID patients. 2. Etiological studies. Immunoglobulin and albumin were found changed in serum and CSF of both AD/SDAT and MID, indicating a more active immune response in MID and a less dense cerebrospinal fluid barrier in both MID and AD/SDAT. There appears to be a consumption of IgG in the central nervous system in patients with AD/SDAT. Abnormal chromosomes appearing as acentric fragments, i.e. without visible centromeres, were found in 90% of patients with AD/SDAT, 30% of patients with MID, and not at all in the control group. Increased aneuploidy was also seen both in patients with MID and AD/SDAT. Diabetes mellitus in old age and AD/SDAT do not seem to coexist. Furthermore, patients with AD/SDAT have changed carbohydrate metabolism with decreased fasting blood sugar concentrations, increased glucose tolerance and higher concentration of insulin during an oral glucose tolerance test. / <p>S. 1-47: sammanfattning, s. 49-144: 5 uppsatser</p> / digitalisering@umu.se

Les avancées technologiques endovasculaires des dernières décennies ont été nombreuses ; la diversion de flux en fait partie. Lorsqu’une nouvelle approche permet de traiter de façon efficace et sûre un certain nombre de patients présentant des défis jusque-là difficiles à surmonter, son adoption en pratique clinique peut-être précoce, voire prématurée. Nous avons dans un premier travail réalisé une revue systématique sur les stents dits «Flow Diverters» (FD) et les modèles animaux. Puis nous avons mené quatre expérimentations animales évaluant l’efficacité des FDs dans différents modèles d’anévrismes canins adaptés à l’hypothèse de travail par l’application d’une méthodologie rigoureuse. Nous avons été en mesure de montrer que la technique de diversion de flux est plus à même d’occlure les anévrismes avec de petits collets, des anévrismes dont la branche couverte par le FD est occluse, ou encore quand la porosité du FD en regard de l’anévrisme est diminuée par l’opérateur. Dans le sixième travail, nous avons expérimenté les résultats de la mise en place d’un clip chirurgical sur ces FDs avant d’en déconseiller la pratique. Puis nous avons étudié la variabilité dans la décision des opérateurs d’implanter un FD pour le traitement d’un anévrisme à l’aide d’un questionnaire et ainsi montré l’importante variabilité présente. Enfin nous rapportons le design de l’étude randomisée, pragmatique, multicentrique FIAT (Flow diversion In Aneurysm Treatment) ainsi que ces résultats. / Flow Diversion is one of the relevant technical improvements of the past decade in the endovascular treatment of cerebral aneurysms. When the efficacy and safety of a new tool allow treating challenging aneurysms, this adoption in daily practice can be fast even if the benefit of use is not clearly, scientifically show. We performed a systematic review of studies of these stents called “Flow Diverters” (FD) in animal models. Then we performed 4 animal studies in models we create in order to isolate the propriety of the FD we wanted to study. By using this methodology, we have been able to show that Flow Diversion is more likely to occlude small neck aneurysms, aneurysms in which the jailed branch has been occluded, or when the operator compact the FD in order to decrease the porosity of the device. In a 6th study, we test the result of the use of a clip to occlude a FD. Regarding the results of the test, we recommand to avoid clipping FDs.Then by using a questionaire; we showed the poor agreement of using FD in daily practice by using clinical vignettes. Then we presented the design and the result of the first randomized clinical study on flow diverters FIAT (Flow diversion In Aneurysm Treatment).

<p>The present thesis proposes new methods for obtaining objective and accurate diagnoses in modern healthcare. Non-invasive techniques have been used to examine or diagnose three different medical conditions, namely neuropathy among diabetics, radiotherapy induced erythema (skin redness) among breast cancer patients and diagnoses of cutaneous malignant melanoma. The techniques used were Near-InfraRed spectroscopy (NIR), Multi Frequency Bio Impedance Analysis of whole body (MFBIA-body), Laser Doppler Imaging (LDI) and Digital Colour Photography (DCP).</p><p>The neuropathy for diabetics was studied in papers I and II. The first study was performed on diabetics and control subjects of both genders. A separation was seen between males and females and therefore the data had to be divided in order to obtain good models. NIR spectroscopy was shown to be a viable technique for measuring neuropathy once the division according to gender was made. The second study on diabetics, where MFBIA-body was added to the analysis, was performed on males exclusively. Principal component analysis showed that healthy reference subjects tend to separate from diabetics. Also, diabetics with severe neuropathy separate from persons less affected.</p><p>The preliminary study presented in paper III was performed on breast cancer patients in order to investigate if NIR, LDI and DCP were able to detect radiotherapy induced erythema. The promising results in the preliminary study motivated a new and larger study. This study, presented in papers IV and V, intended to investigate the measurement techniques further but also to examine the effect that two different skin lotions, Essex and Aloe vera have on the development of erythema. The Wilcoxon signed rank sum test showed that DCP and NIR could detect erythema, which is developed during one week of radiation treatment. LDI was able to detect erythema developed during two weeks of treatment. None of the techniques could detect any differences between the two lotions regarding the development of erythema.</p><p>The use of NIR to diagnose cutaneous malignant melanoma is presented as unpublished results in this thesis. This study gave promising but inconclusive results. NIR could be of interest for future development of instrumentation for diagnosis of skin cancer.</p>

The present thesis proposes new methods for obtaining objective and accurate diagnoses in modern healthcare. Non-invasive techniques have been used to examine or diagnose three different medical conditions, namely neuropathy among diabetics, radiotherapy induced erythema (skin redness) among breast cancer patients and diagnoses of cutaneous malignant melanoma. The techniques used were Near-InfraRed spectroscopy (NIR), Multi Frequency Bio Impedance Analysis of whole body (MFBIA-body), Laser Doppler Imaging (LDI) and Digital Colour Photography (DCP). The neuropathy for diabetics was studied in papers I and II. The first study was performed on diabetics and control subjects of both genders. A separation was seen between males and females and therefore the data had to be divided in order to obtain good models. NIR spectroscopy was shown to be a viable technique for measuring neuropathy once the division according to gender was made. The second study on diabetics, where MFBIA-body was added to the analysis, was performed on males exclusively. Principal component analysis showed that healthy reference subjects tend to separate from diabetics. Also, diabetics with severe neuropathy separate from persons less affected. The preliminary study presented in paper III was performed on breast cancer patients in order to investigate if NIR, LDI and DCP were able to detect radiotherapy induced erythema. The promising results in the preliminary study motivated a new and larger study. This study, presented in papers IV and V, intended to investigate the measurement techniques further but also to examine the effect that two different skin lotions, Essex and Aloe vera have on the development of erythema. The Wilcoxon signed rank sum test showed that DCP and NIR could detect erythema, which is developed during one week of radiation treatment. LDI was able to detect erythema developed during two weeks of treatment. None of the techniques could detect any differences between the two lotions regarding the development of erythema. The use of NIR to diagnose cutaneous malignant melanoma is presented as unpublished results in this thesis. This study gave promising but inconclusive results. NIR could be of interest for future development of instrumentation for diagnosis of skin cancer.