Fundação Carlos Chagas Filho de Amparo a Pesquisa do Estado do Rio de Janeiro / Os pacientes agressivos e/ou agitados correspondem a 10% de todas as internações em emergências psiquiátricas. Dependendo do grau de agitação, esses pacientes representam um risco para a integridade física, tanto para os profissionais que ali estão como para si mesmos. Dentre as alternativas para lidar com esses casos está a contenção física. Ainda que amplamente utilizada, seu uso é controverso e proibido em alguns países. No Brasil inexistem protocolos orientando o seu uso. O objetivo deste estudo foi conhecer a freqüência e os fatores associados a esta prática através de uma revisão sistemática e de um estudo em emergências psiquiátricas do município do Rio de Janeiro. A revisão identificou apenas quatro estudos, sendo três nos EUA e um na Índia. A freqüência de contenção em pacientes agitados e/ou agressivos nos serviços de emergência psiquiátrica variou de 14% até 59%. Os desenhos adotados, assim como as análises estatísticas, mostraram fragilidades para a investigação dos fatores explicativos para o uso de contenção física. O estudo nas emergências psiquiátricas do Rio de Janeiro lançou mão de informações sobre o uso de contenção física entre 298 pacientes participantes de um ensaio clínico comparando dois medicamentos para lidar com quadros de agitação psicomotora e comportamento agressivo nesses serviços. As variáveis investigadas foram aquelas coletadas antes da entrada do paciente no ensaio clínico. Portanto, variáveis que antecederam a decisão do médico conter o paciente. A análise dos dados fez uso do método Bayesiano. As prioris dos parâmetros utilizadas no modelo de regressão binária foram obtidas de um outro ensaio clínico, conduzido em uma das três emergências envolvidas no presente estudo. A freqüência no emprego da contenção física foi 24,5%, sem diferença entre os três hospitais. O estudo mostrou ainda que pacientes mais jovens, com quadros mais intensos, com suspeita diagnóstica de entrada de abuso de substâncias e que foram atendidos na parte da manhã apresentaram maior chance de serem fisicamente contidos. O presente trabalho aponta para a necessidade de conduzir estudos especificamente desenhados para avaliar a freqüência e os fatores associados com o uso de contenção física, os quais deverão subsidiar o desenvolvimento de protocolos sobre o uso desta prática em nosso meio. / Agressive and/or agitated patients corresponds to 10% of all patients in psychiatric emergencies. Depending on the severity of the agitation, these patients represent a great risk not only for their physical integrity, but also for professionals. Use of restraints is one among several ways of dealing with these cases. Although it is largely used, its indication is not so clear and some countries not even allow such practice. In Brazil we dont have any protocol for this practice. The objective of this study is to learn about the frequency and the factors associated with this practice by doing a systematic review and a study in some emergency rooms in Rio de Janeiro. The systematic review identified only four studies, three from the United States and one conducted in India. The frequency of restraints in psychiatric emergency rooms went from 14% to 59% for aggressive/agitated patients. The studies considered in our systematic review were not conducted with the same purpose as ours and the statistical analyses were not appropriated for identifying associations. The study in the psychiatric emergencies in Rio de Janeiro showed provided information on the use of physical restraints among 298 participant patients of a randomized clinical trial comparing two different drugs to deal with cases of psicomotor agitation and aggressive behavior in these services. The analyzed variables were those collected before the entrance of the patient in the clinical trial. This was done to guarantee that variables preceded the doctors decision to contain or not the patient. The analysis of the data made use of the Bayesian method. The prioris of the parameters used in the model of binary regression came from a similar study conducted in one of the three involved emergencies of the present study. The frequency in the use of the physical restraints was 24.5%, without difference between the three hospitals. The study also showed that younger patients, with more intense agitation, with suspicious initial diagnosis of abuse of substances and that they had been admitted in the morning presented a greater probability of being physically restrained. The present study points out the necessity to carry out other investigations specifically designed to evaluate the frequency and the factors associated with the use of physical restraint, aiming to subsidize the development of protocols on the use of physical restraints in our services.

<p>Cilj doktorske disertacije je pobolj&scaron;anje hidrodinamičkih i<br />masenoprenosnih karakteristika airlift reaktora sa<br />spolja&scaron;njom recirkulacijom umetanjem samo-rotirajućih<br />impelera u uzlaznu cev. Uticaj ugradnje samo-rotirajućih<br />impelera na osnovne hidrodinamičke i masenoprenosne<br />osobine ispitivan je pri radu sa različitim tečnostima i<br />distributorima gasa. Rezultati su tumačeni poređenjem<br />vrednosti za sadržaj gasa u uzlaznoj cevi, za brzinu<br />tečnosti u silaznoj cevi, i za zapreminski koeficijent<br />prenosa mase, dobijenih za dve konfiguracije reaktora (sa<br />i bez impelera).<br />Rezultati disertacije ukazuju da ugradnja samo-rotirajućih<br />impelera dovodi do znatnog razbijanja mehurova i<br />smanjenja srednjeg prečnika mehurova gasa, naročito u<br />viskoznim rastvorima karboksimetilceluloze. Prividna<br />brzina gasa, vrsta tečne faze i tip distributora gasa u<br />velikoj meri utiču na efikasnost samo-rotirajućih impelera.<br />Dobijene vrednosti sadržaja gasa u uzlaznoj cevi su do<br />47% veće u konfiguraciji sa impelerima u odnosu na<br />konfiguraciju bez impelera. Iako samo-rotirajući impeleri<br />predstavljaju dodatni otpor proticanju tečnosti, njihovom<br />ugradnjom je u svim ispitivanim sistemima postignuto<br />relativno malo smanjenje brzine tečnosti (oko 10%).<br />Zahvaljujući impelerima, zapreminski koeficijent prenosa<br />mase uvećan je do 82% pri manjim protocima gasa. Pri<br />većim protocima, koji odgovaraju uslovima rada koji se<br />sreću u većini fermentacionih procesa, postignute su oko<br />20-30% veće vrednosti zapreminskog koeficijenta prenosa<br />mase.<br />Pored empirijskih modela, u ovom radu uspe&scaron;no su<br />razvijeni i modeli ve&scaron;tačkih neuronskih mreža kojim se<br />predviđaju sadržaj gasa u uzlaznoj cevi, brzina tečnosti i<br />zapreminski koeficijent prenosa mase za obe konfiguracije<br />airlift reaktora sa spolja&scaron;njom recirkulacijom.</p> / <p>The aim of this study was intensification of<br />hydrodynamic and mass transfer properties of<br />external-loop airlift reactor by means of self-agitated<br />impellers mounted in the riser section. The influence<br />of impellers&rsquo; insertion on the main hydrodynamic<br />and mass transfer characteristics was investigated for<br />various liquid phases and sparger types. The values<br />of riser gas holdup, downcomer liquid velocity and<br />volumetric mass transfer coefficient obtained in<br />configurations with and without impellers were<br />compared.<br />Results showed that the installment of self-agitated<br />impellers led to a significant bubble breakage and<br />decrease of bubble size, especially in viscous<br />carboxymethylcellulose solutions. The efficiency of<br />self-agitated impellers was immensely influenced by<br />superficial gas velocity, liquid phase, and distributor<br />type. Obtained riser gas holdup values were up to<br />47% higher in the configuration with impellers, in<br />comparison to the configuration wthout impellers.<br />Despite the fact that self-agitated impellers<br />represented an obstacle to liquid flow, relatively low<br />reduction of downcomer liquid velocity was attained<br />(about 10%). Furthermore, the insertion of impellers<br />induced up to 82% higher values of volumetric mass<br />transfer coefficient at lower superficial gas velocities.<br />At higher superficial gas velocities, i.e. conditions<br />mainly operated in various fermentation processes,<br />about 20-30% higher values of volumetric mass<br />transfer coefficient were achieved with impellers.<br />In addition to empirical correlations, artificial neural<br />network models were sucessfully developed to<br />predict riser gas holdup, downcomer liquid velocity<br />and volumetric mass transfer coefficient in both<br />external-loop airlift configurations.</p>

To quench a thermal runaway reaction in a chemical rector, an efficient approach is the introduction of a small quantity of a liquid inhibiting agent, named a “killer”, into the mixing vessel. In this thesis, an experimental approach has been coupled tightly with numerical modelling using Computational Fluid Dynamics (CFD). The first part of this thesis is devoted to a study of the hydrodynamics of partially-baffled mixing vessels, including the free-surface deformation caused by the central vortex. The use of an inhomogeneous, multiphase approach allowed simulation of the free-surface deformation. The capability of this novel method was demonstrated by very good agreement between the numerical predictions and experimental data. In the second part, liquid jet injection at the free-surface was coupled with the vessel hydrodynamics. Numerical results, obtained using an Eulerian-Lagrangian approach, have again shown good agreement with experimental data. These results allowed the jet trajectory to be modelled and its penetration into the agitated vessel was quantified. New mixing criteria were introduced that are specific to this application. Finally, the numerical methods validated at the pilot scale were applied at the industrial scale and allowed the proposal of practical improvements to the safety of the synthesis reactors studied

Un nouveau système d’aération de surface pour le traitement des eaux usées a été étudié. Sa spécificité réside dans sa capacité à fonctionner selon deux modes : aération ou simple brassage, en modifiant uniquement le sens de rotation du système. Un pilote a permis de cibler le travail sur l’étude expérimentale du transfert de matière et de l’hydrodynamique. Les champs d'écoulement et les mesures de vitesse à l'intérieur de la cuve agitée ont été réalisés par vélocimétrie laser à effet Doppler (LDV) et par vélocimétrie par images des particules (PIV) pour le mode monophasique (brassage) et pour le mode diphasique (aération). Le transfert d'oxygène se produit à la fois dans la cuve et dans le spray au-dessus de la surface de l'eau. Il a été étudié dans les deux zones. Différentes configurations et conditions opératoires ont été testées afin de comprendre les phénomènes d’interaction : tube de guidage, hélice complémentaire RTP, vitesse de rotation, niveau de submersion des pales de la turbine. La partie expérimentale sur l’hydrodynamique et les champs d'écoulement montre que le mode de fonctionnement en pompage vers le bas (brassage) avec tube de guidage procure les meilleurs résultats en termes de mélange si on se réfère aux champs d'écoulement et à la mesure du temps de mélange. Pour le mode de fonctionnement en pompage vers le haut (aération), les résultats expérimentaux montrent que la configuration du système complet est la plus efficace si on considère le transfert d’oxygène, les vitesses moyennes, l'intensité de l'écoulement turbulent et le temps de mélange. Il est constaté que la meilleure efficacité d'aération standard est atteinte (SAEb = 2.65 kgO2kw-1h-1) lorsque le système complet est utilisé. L'efficacité d'aération standard à 20°C la plus élevée au niveau du spray d'eau est obtenue ((ESP)20 = 51,3%) avec la configuration du système complet. Plusieurs modèles sont proposés pour calculer le transfert d'oxygène dans la cuve et dans le spray, la consommation énergique et le temps de mélange. Ces relations permettent d’évaluer l’influence des différents paramètres géométriques et de fonctionnement dans des systèmes similaires à une échelle industrielle. / A new surface aeration system for water and wastewater treatment has been studied. Its uniqueness lies in its ability to operate in two modes: aeration or simply blending (mixing) by just reversing the direction of rotation. An experimental plant has enabled to focus on mass transfer performance and hydrodynamics. The flow pattern and the velocity field measurements inside the agitated tank were performed by both the Laser Doppler Velocimetry (LDV) and the Particle Image Velocimetry (PIV) techniques for the single phase (Mixing) mode and for the two phases (Aeration) mode. The oxygen mass transfer occurs both in the water bulk and in the spray above water surface and has been independently investigated. Different configurations and operational conditions were tested during the experimental part in order to interpret phenomenon effect of the draft tube and RTP propeller, rotational speed, turbine blades submergence and else on the flow field and the oxygen mass transfer in the agitated system that produced mainly by a cone shape turbine. The experimental part dealing with hydrodynamics and flow field shows that the down-pumping operation mode with the draft tube has the most convenient results in the mixing mode with respect to turbulent flow field and mixing time. Whilst for the up-pumping aeration mode the hydrodynamics experimental results show the whole system configuration is the most convenient with regarded to mean velocities, turbulent flow intensity and mixing time. For the oxygen mass transfer experimental part, it is found that the highest standard liquid bulk aeration efficiency is achieved (SAEb = 2.65 kgO2 kw-1h-1) when the whole system configuration is used. The highest standard aeration efficiency at 20°C for the water spray zone is accomplished ((Esp)20 = 51.3 %) with the whole system configuration. Several correlations models have been derived for the oxygen mass transfer in water bulk and spray zones, power consumption and mixing time, on the basis of experimental results. They can be used as tools to estimate these parameters for geometrical and dynamical similar systems at industrial scales.

Thèse de doctorat présenté en vue de l'obtention du doctorat en psychologie - recherche intervention, option neuropsychologie clinique (Ph.D) / Les traumatismes craniocérébraux (TCC) peuvent entraîner de lourdes conséquences physiques, cognitives, émotionnelles et comportementales. Parmi celles-ci, l’agitation est très fréquente et se caractérise par une hyperactivité motrice, une désorientation, des problèmes d'attention, une labilité émotionnelle, une désinhibition et de l’agressivité. Elle interfère avec le rétablissement et les processus de réadaptation, mais il n'existe pas à ce jour de consensus sur son traitement, outre la contention physique ou la prise de médicaments, qui peuvent respectivement causer des blessures ou entraver la récupération. De récentes données suggèrent que les interventions musicales peuvent réduire l’agitation chez les patients TCC mais la capacité des patients TCC à percevoir et traiter la musique pendant la phase aiguë post-blessure n'a pas été établie. Le premier article de cette thèse visait à évaluer la perception musicale chez les patients TCC hospitalisés en phase aiguë. Dans la présente étude, 42 patients ayant subi un TCC ont été comparés à un groupe témoin. Tous les participants ont complété les tests de Scale et Rhythm de la Montreal Battery of Evaluation of Amusia pour mesurer la perception musicale, et le test d’empan numérique pour mesurer la mémoire verbale à court terme. Comparativement au groupe témoin, les patients TCC ont obtenu des performances significativement inférieures; 43% d'entre eux présentaient des déficits de traitement de la hauteur et 40% des déficits de traitement du rythme. Les patients présentant des lésions à l'hémisphère droit ont obtenu des résultats plus faibles que ceux présentant des lésions à l'hémisphère gauche. Les déficits de traitement de la hauteur et du rythme coexistaient dans 31% des cas, ce qui suggère l'existence de réseaux neuronaux partiellement dissociables. Le deuxième article est une revue non systématique dont l’objectif était de caractériser l'agitation et son traitement. Plusieurs types d’interventions comportementales, dont les interventions musicales, ont été explorées dans cette revue. Les limites méthodologiques ont été discutées et des recommandations ont été faites pour une approche plus systématique de la recherche utilisant des études de cas et de séries de cas chez les patients agités. Le troisième article est une étude pilote de phase II dans laquelle sont inclus des patients ayant subi un TCC modéré à sévère (n = 3) ou un accident vasculaire cérébral de l'artère cérébrale moyenne (n = 1). Ils ont été exposés à leurs musiques préférées, de la musique classique relaxante et un extrait sonore non musical (cascade) pendant la phase aiguë de récupération. Les comportements d’agitation ont été évalués à l'aide de l'Échelle d’Agitation (Agitated Behaviour Scale), de mesures actigraphiques et d’une observation qualitative. Les résultats indiquent que l’agitation a diminué lors de l’écoute de la musique classique relaxante et la cascade. L’agitation est restée stable lors de la musique préférée, mais certains patients ont exprimé des émotions positives ou présenté un comportement plus organisé, comme taper du pied ou chanter. Compte tenu des importantes limites méthodologiques dans ce champ d’études, la présente étude a permis d’explorer la faisabilité et l’effet d’une intervention musicale, ce qui permettra de guider les études futures. / Traumatic brain injury (TBI) has serious physical, cognitive, emotional, and behavioural consequences. Agitation is highly prevalent among patients with TBI, and is characterized by motor hyperactivity, disorientation, attention problems, emotional lability, disinhibition, and aggression. It often results in decreased engagement in rehabilitative treatment, and poorer functional outcomes. There is no consensus on the treatment for agitation. Most often, it is managed with medication and physical restraints, which may cause injury or impede cognitive recovery. Few studies examine novel non-pharmacological interventions for agitation in TBI patients. However, recent evidence suggests that music interventions may decrease agitated behavior in TBI patients. The ability of TBI patients to perceive and process music during the acute phase has not been established, though it may influence the efficacy of preferred music interventions. The first article of this thesis evaluated music perception in acutely hospitalized TBI patients. Music perception deficits have been identified in populations with acquired brain injury due to epilepsy, stroke, and after aneurysmal clipping. However, few studies have evaluated deficits following TBI, resulting in an underdiagnosis in this population. Forty-two patients completed the Scale and Rhythm tests of the Montreal Battery for the Evaluation of Amusia to measure music perception, and Digit Span Forward to measure verbal short-term memory. TBI patients were more often impaired than controls, with 43% demonstrating pitch processing deficits, and 40% demonstrating rhythm processing deficits. Patients with right hemisphere damage performed more poorly than those with left hemisphere damage. Pitch and rhythm deficits co-occurred 31% of the time, suggesting partly dissociable neural networks. Results are discussed in the context of current research and clinical implications. The second article was a non-systematic review in which we characterized agitation and its treatment. We explored behavioural interventions, including music interventions, occupational therapy, the Intervention Contingencies Awareness Relationship behavioural model, operant contingency management, and general therapeutic activities. The methodological limitations were discussed and recommendations made for a more systematic approach to research using case and case series studies in agitated patients. The third article was a phase-II development-of-concept pilot study in which four patients with moderate to severe TBI (n = 3), and middle cerebral artery stroke: (n = 1) were exposed to preferred music, relaxing classical music, and a nonmusical control (waterfall) during the acute phase of recovery. Agitated behaviours were assessed using the Agitated Behavior Scale, actigraphy, and qualitative observation. Agitated behaviour decreased during relaxing classical music, and waterfall. It remained stable in the preferred music condition. However, certain patients expressed positive emotions and organized behaviour such as tapping or singing along. Given important methodological limitations in current studies, a phase-II study allowed for the evaluation of outcomes and the practicality of delivering music listening interventions, which may guide future studies.