La France se démarque par un ratio de mortalité maternelle par hémorragie du postpartum (HPP) élevé.Les objectifs de cette thèse étaient: 1/comparer les caractéristiques épidémiologiques de l'HPP entre la France et le Canada 2/décrire les pratiques d'anesthésie-réanimation dans l'HPP et évaluer leur adéquation par rapport aux recommandations chez les femmes décédées d'HPP et dans une population de femmes avec HPP.Les sources de données utilisées étaient: La base nationale canadienne de données hospitalières sur les séjours des patients, l'essai Pithagore6 et l'Enquête nationale confidentielle sur les morts maternelles.La comparaison du profil épidémiologique de l'HPP entre la France et le Canada montre que l'HPP n'est pas plus fréquente en France. Le recours plus fréquent à des traitements de seconde ligne suggère une incidence plus élevée de l'HPP sévère en France. Dans les décès maternels par HPP, certaines pratiques d'anesthésie-réanimation apparaissent comme inadéquates: le monitorage clinique et la mise en condition des patientes, la surveillance paraclinique, le protocole d'anesthésie générale et la stratégie transfusionnelle. La description en population des pratiques transfusionnelles dans l'HPP montre un recours insuffisant à la transfusion. Inversement des stratégies transfusionnelles dont l'efficacité n'est pas prouvée sont fréquemment appliquées.Ce travail suggère une sévérité importante de l'HPP en France, pouvant expliquer l'importance de la mortalité par HPP. Certaines pratiques d'anesthésie-réanimation apparaissant comme non-optimales pourraient être impliquées dans cette sévérité. L'association entre pratiques et sévérité de l'HPP reste à être étudiée. / In France, the maternal mortality ratio due to postpartum hemorrhage (PPH) is higher than in other high resources countries. This situation remains partially unexplained. The objectives of this PhD thesis were: 1/ to compare PPH epidemiological characteristics between France and Canada, 2/ to describe anesthesia and intensive care practices in PPH and to compare them with guidelines, first in cases of maternal deaths from PPH and secondly in a large population of women with PPH. The data sources were: the Discharge Abstract Database from the Canadian Institute for Health Information, the Pithagore6 trial and the French Confidential Enquiry into Maternal Deaths. The comparison of PPH epidemiological profiles between France and Canada shows that PPH incidence is not higher in France. Second-line treatments in PPH management are more frequently performed, suggesting a higher incidence of severe PPH in France. Among maternal deaths from PPH, some practices in anesthesia and critical care management appear to be inadequate: clinical monitoring and laboratory assessment, protocol for general anesthesia and transfusion strategy. The description on transfusion practices in a large population of women with PPH shows that the use of blood products is not sufficient. Conversely, transfusion strategies with unproved efficacy are frequently used. These results suggest a higher rate of severe PPH in France, that may result in the higher maternal mortality due to PPH. Inadequate practices in anesthesia and critical care could be involved in this severity. But the association between specific components of anesthesia and critical care management and PPH severity remains to be explored

Thesis (MMED. (Forensic Medicine)) --University of Limpopo, 2019 / Traumatic intracranial haemorrhages are common, carry a high mortality rate and are therefore commonly known in the practice of forensic pathology as unnatural deaths. Studies have demonstrated a significant decrease in mortality rate among patients who received surgical interventions compared to patients who were treated medically. Missed or mis-diagnoses, which may be apparent during an autopsy procedure, present possible missed treatment opportunities. Aim/objective and methods The study investigated the discrepancy rate and discrepancy pattern of diagnosis between antemortem brain computed tomography (CT) scan findings and autopsy findings in deceased patients with traumatic intracranial haemorrhage (TIH). A quantitative retrospective descriptive study was conducted based on bodies presented with TIH at Pietersburg Hospital Forensic Pathology Department. A total of consecutive 85 cases with antemortem CT (ACT) scan findings were compared to autopsy findings using percentage agreement and Cohen’s kappa statistics. Results and conclusion There was a fair overall agreement (k=0.38) with overall discrepancy rate of 24.74%, ranging from 9.41% to 34.12% for individual TIH between ACT scan and autopsy findings. Subarachnoid haemorrhage had the lowest agreement between the ACT scan and autopsy findings for TIH. Patient and doctor factors associated with the discrepancies were assessed. Those associated factors, if addressed, may have a positive impact on patient outcome. As far as the debate on non-invasive autopsy procedure is concerned, as a result of existing discrepancy rate, we conclude that ACT should not be used alone in the determination of cause of death but may be used in conjunction with autopsy findings.

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13259号 / 論医博第2177号 / 新制||医||1037(附属図書館) / (主査)教授 横出 正之, 教授 富樫 かおり, 教授 湊谷 謙司 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

This thesis deals with the detection of intracranial haemorrhages and their type classification in head CT images. The method of haemorrhages detection is based on a series of classifiers of the presence and type of haemorrhages in 2D CT slices in axial, sagittal and coronal plane, that may localise the bleedings and determine their types. The classifiers are based on the convolutional neural network architecture Inception-ResNet-v2. The head CT dataset CQ500 which is made available for public access, is used for the experiments. The thesis describes an additional manual annotation of the data, as the available annotations are insufficient for the purposes of the experiments. This thesis includes a theoretical basis of the essential medical knowledge, machine learning based classification and detection methods, and the detection algorithm proposal, realisation and testing. The algorithm performance is evaluated and discussed together with the potential implementation of the algorithm in computer-aided diagnosis systems.

L'anevrysme intracrânien (AIC) est une anomalie morphologique spécifique des artères cérébrales exposant au risque, particulièrement grave, de saignement intracrânien. Malgré les progrès établis dans le traitement curatif , aucun traitement préventif de la formation des AIC n’a été prouvé chez l’Homme. L’absence de traitement non invasif et l’absence de consensus sur le traitement des AIC non rompus sont le corolaire direct d’un manque de connaissance des mécanismes physiopathologiques de la maladie anévrysmale.L’ensemble du travail exposé ici a eu pour but de mieux comprendre les mécanismes de la pathologie anévrysmale intracrânienne pouvant être la base de nouvelles stratégies préventive améliorant le traitement des AIC.Nous avons tout d'abord étudié l'influence des anomalies du tissus de soutien des artères cervicales sur la formation des AIC. Au cours de cette étude, nous avons réalisé une étude cas-témoins dont l’objectif principal était d’étudier l’association entre les anomalies morphologiques des artères cervicales et la présence d’un AIC. Les objectifs secondaires étaient premièrement d’examiner si cette association variait selon le caractère rompu ou non de l’anévrisme et deuxièmement d’examiner si la sévérité des anomalies artérielles cervicales était liée à la sévérité de la pathologie anévrismale. Nous rapportons que la prévalence des anomalies angiographiques chez les patients porteurs d’AIC est élevée. De plus l’incidence d’une pathologie rare, la dysplasie fibro-musculaire est très élevée chez les patients porteurs d’AIC comparativement à la population générale. La présence des anomalies angiographiques n’a aucun impact sur l’évolution naturelle des AIC vers la rupture, ni sur d’autres aspect comme leur taille, leurs nombres ou leur forme. Dans le cadre de notre étude, nous pensons que l’association entre les anomalies angiographiques et les AIC semble être expliquée par l’hypothèse d'une vulnérabilité du tissu de soutien pariétal (condition pathologique particulière de la paroi artérielle à l’origine de la formation des AIC). Cette condition pathologique, affecterait de manière diffuse la vascularisation cérébrale et les artères cervicales. Les AIC seraient ainsi des manifestations cliniquement « bruyantes » de pathologies vasculaires plus silencieuses affectant la paroi de l’ensemble des vaisseaux. Les anomalies morphologiques des artères cervicales témoignent de façon sensible mais très peu spécifique de l’association des pathologies du tissu de soutien avec la présence d’AIC.Dans une deuxième partie nous essayons de décrire et de caractériser une voie inédite de la formation et de la croissance des AIC, la voie de la fibrinolyse via l'activateur de plasminogène de type tissulaire (tPA). Nos données suggèrent que le tPA présent dans la circulation sanguine est suffisant pour favoriser la formation et la rupture des anévrismes. Nous avons donc proposé que le tPA vasculaire était un des responsables de la formation des AIC. Nous avons également constaté une certaine continuité dans le temps de l'influence du tPA sur le remodelage matriciel. Nous avons donc proposé le tPA vasculaire comme une nouvelle cible possible pour prévenir la progression et la rupture des AIC. Différentes expériences ont été entreprise pour inhiber sélectivement le tPA et les résultats préliminaires sont encourageants et ouvrent la voie à une stratégie thérapeutique non invasive inédite. On peut aussi imaginer que ces différentes approches puissent être combinées entre elles et avec des agents matriciels ciblant directement l’activité du tPA dans la paroi des AIC. L’amélioration des stratégies thérapeutiques dans la pathologie anévrysmale intracrânienne est définitivement un axe de recherche dont les possibilités sont immenses et les résultats nécessaires et attendus. / Intracranial aneurysm (IA) is a specific morphological abnormality of the cerebral arteries that exposes to devastating intracranial bleeding. Despite the progress made in the curative treatment, no preventive treatment of IA formation has been proven in humans. The lack of non-invasive treatment and consensus on the treatment of unruptured IA are the consequences of the lack of knowledge of the physiopathological mechanisms of aneurysmal disease. All of the work presented here aims to better understand the mechanisms of intracranial aneurysmal pathology, which may be the basis of new preventive strategies improving the treatment of IA.We first studied the influence of cervical artery abnormalities on IA formation. In this study, we performed a case-control study whose main objective was to study the association between morphologic abnormalities of cervical arteries and the presence of IA. The secondary objectives were first to examine whether this association varied according to whether or not the aneurysm was broken, and secondly to examine whether the severity of the cervical arterial abnormalities was related to the severity of the aneurysmal pathology. We report that the prevalence of angiographic abnormalities in patients harboring IA is high. In addition, the incidence of a rare pathology, fibro-muscular dysplasia is very high in patients with IA compared to the general population. The presence of angiographic abnormalities has no impact on the rupture of the IA, nor on other aspects such as their size, numbers or shape. In our study, we believe that the association between angiographic abnormalities and IA seems to be explained by the hypothesis of a vulnerability of the arterial wall (a particular pathological condition of the arterial wall at the origin of IA formation). This pathological condition would affect the whole cerebral vasculature and cervical arteries. IA would thus be the clinical manifestations of more silent vascular pathologies affecting the wall of all vessels. The morphological abnormalities of the cervical arteries testify sensitively but not very specifically of the association of the arterial wall diseases with the presence of IA.In a second study, we try to describe and characterize an unprecedented pathway of formation and growth of IA : the pathway of fibrinolysis via tissue-type plasminogen activator (tPA). Our data suggest that tPA present in the bloodstream is sufficient to promote formation and rupture of aneurysms. We therefore proposed that vascular tPA was one of those responsible for training IA. We also noted a certain continuity in the time of the influence of the tPA on the matrix remodeling. We therefore proposed vascular tPA as a possible new target to prevent progression and rupture of IA. Various experiments have been undertaken to selectively inhibit tPA and the preliminary results are encouraging and open the way to an unprecedented non-invasive therapeutic strategy. It is also conceivable that these different approaches could be combined with each other and with matrix agents directly targeting tPA activity in the AIC wall. The improvement of therapeutic strategies in intracranial aneurysmal pathology is definitely an topic of ​​research whose possibilities are huge and the results necessary and expected.

Stroke is amongst the leading causes of death and disability worldwide. Today diagnosis of Stroke is restricted to fixed imaging facilities which do not provide a rapid diagnostic. A portable device which could provide a non invasive assessment of stroke would therefore decrease the time of diagnosis and increase the chance of survival. Recent studies have confirmed that Implementing Electrical Bioimpedance in a portable device could provide a reliable means for Stroke diagnostic. However in order to be able to use the brain impedance as an indicator of Stroke, the invariance of brain impedance with time in healthy individuals should be studied first. Experimental Bioimpedance Spectroscopy (BIS) measurements from a healthy control group of 10 subjects have been used in this study to inspect the variation of brain impedance in the span of two weeks. The results of this study suggest that the cap which was used for brain impedance measurements together with  the available device have not been an optimal way of measuring the brain impedance and therefore have affected the data by causing artifacts for the results. With the artifacts available in the data acquired in this study it is not possible to make any statements about the variation of brain impedance and therefore a deeper analysis of collected data using descriptive analysis is required in order to be able to judge on the significance of the obtained errors. In the future a larger study group should be considered in order to increase the predictive power of the observations. / Stroke är bland de ledande orsakerna till död och funktionshinder i  hela världen.I dagsläget är diagnos av stroke begränsad till fasta bildenheter som inte möjliggör en snabb diagnos. En bärbar enhet som möjliggör en icke invasiv bedömning av sjukdomen skulle minska diagnos tiden och följaktligen öka chansen att överleva sjukdomen. Genomförda studier i ämnet har bekräftat att implementering av  Electrical Bioimpedance i en bärbar enhet kan räknas som ett effektivt sätt för Stroke diagnostik. För att kunna använda hjärnans impedans för Stroke diagnostik, bör först en studie av hjärnans impedans på friska individer utföras för att kunna visa att impedansen är oförändrad med tiden. Experimentell Bioimpedans Spektroskopi (BIS) mätningar från en frisk kontrollgrupp av 10 försökspersoner har utförts i denna studie för att inspektera variationen av hjärnans impedans under två veckor. Resultaten från denna studie tyder på att sättet av impedans mätningen i dagsläget är inte optimalt. Artefakter presenterad i resultatet gör det omöjligt för att kunna komma till ett beslut om hjärnans impedans variation . För fortsätta studier bör man överväga en större kontrollgrupp och även en analysering av data med hjälp av t-statistik som var inte inom ramen av denna studie.

Theses ( MPH.) -- University of Limpopo, 2021 / Background: Maternal mortality is a significant public health problem worldwide, and is a vital indicator of the functioning of a health system. The South African maternal mortality ratio is higher than other countries with same economic growth, despite people having free access to maternal health. How to develop relevant policies and programmes to reduce maternal mortality factors contributing to maternal mortality was investigated. Aims of the Study: To investigate the factors contributing to maternal mortality in public health institutions in the Sekhukhune District, Limpopo Province, South Africa. Methods: A quantitative, retrospective study was undertaken where 138 medical records of maternal mortality cases reported between 2013 to 2017 were reviewed. A simple random sampling method was used to select files that met the selection criteria from seven hospitals in the Sekhukhune District, Information was collected on maternal demographics and health service-related characteristics, including age, marital status, parity, antenatal care utilisation of services and delivery type. Inferential data were analysed using the student t-test and SPSS version 25. Results: The mean age of the women involved in this study was 30 years, with a standard deviation of 5.7. All the women who participated in the study were black African. The majority of maternal mortality occurred in hospital. The women in the majority of maternal mortality cases were unemployed, at 93.5%, while most of the maternal mortality cases involved single women (71%).The women involved in these maternal mortality cases booked their ANC care and the major health provider was a professional nurse (58.0%), while 57.2% of the participants attended their ANC at primary healthcare facilities. Most of the maternal deaths occurred after delivery (58.7%) and, in most deliveries, the Partogram was not used (66%). HIV testing occurred in 99% of the maternal mortality cases. The causes of maternal mortality were both direct (71.0%) and indirect (23.9%) causes. The leading cause of maternal mortality was direct haemorrhage (33%), followed by eclampsia (27%) and infection (16%). The leading indirect cause was respiratory causes (22%) and retro viral disease (RVD) (9%). The personal factor that contributed most to maternal mortality was delay in seeking help (62%). v Conclusion and Recommendations: The personal factor, delay in seeking medical help by the women, contributed to maternal mortality and it was further concluded that the majority of maternal mortality cases did not occur as a result of any complications in ANC and delivery. It is recommended that the training of healthcare providers in the utilisation of the Partogram be implemented to improve skills in the management of haemorrhage and eclampsia. Furthermore, the management of complications needs to be strengthened through a multi-sectorial approach. / SAMRC

This paper examines the concept of safety as it encompasses the personal and technological spheres as imagined by a group of active duty service members, veterans, a police officer, and civilians, as well as the agency exercised by those with military or police backgrounds when it comes to safety technology. A group of seventeen individuals took part in a battlefield simulation to test a wearable junctional tourniquet created by ARMR Systems, LLC, an innovative advancement in tourniquet technology. After the simulation, participants were interviewed, surveyed, and took part in a focus group to determine not only product suitability but also to explore the underlying reasons for their recommendations for product changes. Results showed that those with military or police background performed safety rituals prior to duty and exercised agency in the desire to obtain the best possible personal safety devices and technology to be used for themselves and their comrade-in-arms. All participants expressed concerns for their safety in regards to technology in general, specifically, the hacking and use of personal data and what is perceived as lack of governmental oversight. Almost all of the changes to improve product safety, comfort, and utility were adapted. The topics discovered during the course of this research proves a need for safety product testing from an applied anthropological perspective.

No description available.

Purpose: This study sought to determine the previously undescribed cytologic and metabolic alterations that accompany endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC). Methods: Cerebrospinal fluid (CSF) samples were collected from infant patients with hydrocephalus at the time of index ETV/CPC and again at each reintervention for persistent hydrocephalus. Basic CSF parameters, including glucose, protein, and cell counts, were documented. A multivariable regression model, incorporating known predictors of ETV/CPC outcome, was constructed for each parameter to inform time-dependent normative values. Results: A total of 187 infants were treated via ETV/CPC for hydrocephalus; initial laboratory values were available for 164 patients. Etiology of hydrocephalus included myelomeningocele (53, 32%), intraventricular hemorrhage of prematurity (43, 26%), aqueductal stenosis (24, 15%), and others (44, 27%). CSF parameters did not differ significantly with age or etiology. Glucose levels initially drop below population average (36 to 32 mg/dL) post-operatively before slowly rising to normal levels (42 mg/dL) by 3 months. Dramatically elevated protein levels post-ETV/CPC (baseline of 59 mg/dL up to roughly 200 mg/dL at 1 month) also normalized over 3 months. No significant changes were appreciated in WBC. RBC counts were very elevated following ETV/CPC and quickly declined over the subsequent month. Conclusion: CSF glucose and protein deviate significantly from normal ranges following ETV/CPC before normalizing over 3 months. High RBC values immediately post-ETV/CPC decline rapidly. Age at time of procedure and etiology have little influence on common clinical CSF laboratory parameters. Of note, the retrospective study design necessitates ETV/CPC failure, which could introduce bias in the results.