Physiological cross sectional area (PCSA) is used to compare force-producing capabilities of skeletal muscles. PCSA has been defined as the summation of the cross sectional area of the fiber bundles composing the muscle. As PCSA cannot be measured directly from a specimen, a formula requiring averaged muscle architectural parameters has traditionally been used. The purpose of this study was to develop a finite element method (FEM) to calculate PCSA of extensor carpi radialis longus (ECRL) and brevis (ECRB) directly from digitized fiber bundle data obtained throughout the volume of the muscle and to compare the PCSAs calculated using the FEM and formula methods. Differences were found between the FEM and formula method for both muscles. The FEM provides an approach that takes into account architectural variances while minimizing the need for averaged architectural parameters.

Physiological cross sectional area (PCSA) is used to compare force-producing capabilities of skeletal muscles. PCSA has been defined as the summation of the cross sectional area of the fiber bundles composing the muscle. As PCSA cannot be measured directly from a specimen, a formula requiring averaged muscle architectural parameters has traditionally been used. The purpose of this study was to develop a finite element method (FEM) to calculate PCSA of extensor carpi radialis longus (ECRL) and brevis (ECRB) directly from digitized fiber bundle data obtained throughout the volume of the muscle and to compare the PCSAs calculated using the FEM and formula methods. Differences were found between the FEM and formula method for both muscles. The FEM provides an approach that takes into account architectural variances while minimizing the need for averaged architectural parameters.

Carbon nanotubes (CNT) and graphene have been one of the noticeable research areas in science and technology. In recent years, the assembly of these carbon nanostructures is one of the most interesting topic to the scientific world due to its variety of applications from nano to macroscale. These bulk nanostructures to be applicable in shock absorbers, batteries, sensors, photodetectors, actuators, solar cells, fuel cells etc. The present work is motivated to study the detailed compressive behavior of three dimensional cellular assemblies of CNT and graphene. The CNT foams are synthesized by chemical vapor deposition method. It is interesting to study the compressive behavior of CNT foam in the presence external magnetic field applied perpendicular to CNT axis. The peak stress and energy absorption capability of CNT foam enhances by four and nearly two times in the presence of magnetic field as compared to the absence of the magnetic field. In the absence of magnetic field the deformation of CNT foam is obtained elastic, plateau and densification regions. Further CNT foam is loaded with iron oxide nanoparticles of diameter is ~ 40nm on the surface and detailed study of the compressive behavior of the foam by varying iron nanoparticles concentration. The peak stress and energy absorption capability of CNT foam initially decreases with increasing the intensity of the magnetic field, further increases the intensity of the magnetic field the maximum stress and energy absorption capability increases which is due to magnetic CNT and particles align in the direction of the magnetic field. CNT surfaces were further modified by fluid of different viscosities. The mechanical behavior of CNT foam filled with fluids of varying viscosities like 100%, 95% and 90% glycerol and silicone oil are 612, 237, 109 and 279 mPa-s respectively. The mechanical behavior of CNT foam depends on both the intensity of magnetic field and fluid viscosity. The non linear relation between peak stress of CNT and magnetic field intensity is σp(B, η) = σ0 ± α(B-B0) where σ0 is the peak stress at B = B0 , η is the fluid viscosity, parameter α depends on properties of the MR fluid and B0 is an optimum magnetic field for which peak stress is maximum or minimum depending on the fluid viscosity. Graphene is assembled into a three dimensional structure called graphene foam. The graphene foam is infiltrated with polymer and study the detailed compressive behavior of graphene foam and graphene foam/PDMS at different strains of 20, 40, 60 and 70%. The maximum stress and energy absorption capability of graphene foam/PDMS is six times higher than the graphene foam. Also the graphene foam/PDMS is highly stable and reversible for 100 cycles at strains of 30 and 50%. The mechanical behavior of CNT, graphene foam, CNT/PDMS and graphene foam/PDMS is compared. Among all the foams, graphene foam/PDMS has shown the highest elastic modulus as compared to other foams. This behavior can be attributed to the wrinkles formation during the growth of graphene and a coupling between PDMS and interfacial interactions of graphene foam. Therefore it suggests potential applications for dampers, cushions and electronic packaging. Furthermore, the interaction between nanoparticles and polymer in a novel architecture composed of PDMS and iron oxide nanoparticles is studied. The load bearing capacity of uniform composites enhanced by addition of nanoparticles, reaching to a maximum to 1.5 times of the PDMS upon addition of 5wt.% of nanoparticles, and then gradually decreased to 1/6th of PDMS upon addition of 20wt.% of nanoparticles. On the other hand, the load bearing capacity of architectured composites at high strains (≥40%) monotonically increased with addition of nanoparticles in the pillars.

Cette thèse développe une méthode de faisceau non convexe pour la minimisation de fonctions localement lipschitziennes lower C1 puis l’applique à des problèmes de synthèse de lois de commande structurées issus de l’industrie aéronautique. Ici loi de commande structurée fait référence à une architecture de contrôle, qui se compose d’éléments comme les PIDs, combinés avec des filtres variés, et comprenant beaucoup moins de paramètres de réglage qu’un contrôleur d’ordre plein. Ce type de problème peut se formuler dans le cadre théorique et général de la programmation non convexe et non lisse. Parmi les techniques numériques efficaces pour résoudre ces problèmes non lisses, nous avons dans ce travail, opté pour les méthodes de faisceau, convenablement étendues au cas non convexe. Celles-ci utilisent un oracle qui, en chaque itéré x, retourne la valeur de la fonction et un sous-gradient de Clarke arbitraire. Afin de générer un pas de descente satisfaisant à partir de l’itéré sérieux courant, ces techniques stockent et accumulent de l’information, dans ce que l’on appelle le faisceau, obtenu à partir d’évaluations successives de l’oracle à chaque pas d’essai insatisfaisant. Dans cette thèse, on propose de construire le faisceau en décalant vers le bas une tangente de l’objectif en un pas d’essai ne constituant pas un pas de descente satisfaisant. Le décalage est indispensable dans le cas non convexe pour préserver la consistance, on dit encore l’exactitude, du modèle vis à vis de l’objectif. L’algorithme développé est validé sur un problème de synthèse conjointe du pilote automatique et de la loi des commandes de vol d’un avion civil en un point de vol donné et sur un problème de synthèse de loi de commande par séquencement de gain pour le contrôle longitudinal dans une enveloppe de vol. / This thesis develops a non convex bundle method for the minimization of lower C1 locally Lipschitz functions which it then applies to the synthesis of structured control laws for problems arising in aerospace control. Here a structured control law refers to a control architecture preferred by practitioners, which consist of elements like PIDs, combined with various filters, featuring significantly less tunable parameters than a full-order controller. This type of problem can be formulated under the theoretical and general framework of non convex and non smooth programming. Among the efficient numerical techniques to solve such non smooth problems, we have in this work opted for bundle methods, suitably extended to address non-convex optimization programs. Bundle methods use oracles which at every iterate x return the function value and one unspecified Clarke subgradient. In order to generate descent steps away from a current serious iterate, these techniques hinge on storing and accumulating information, called the bundle, obtained from successive evaluations of the oracle along the unsuccessful trial steps. In this thesis, we propose to build the bundle by shifting down a tangent of the objective at a trial step which is not a satisfactory descent step. The shift is essential in the non convex case in order to preserve the consistency, named also the exactitude, of the model with regard to the objective. The developed algorithm is validated on a synthesis problem combining the automatic pilot and the flight control law of a civil aircraft at a given flying point ; and a gain scheduled control law synthesis for the longitudinal control in a flight envelope.

Les travaux réalisés au cours de cette thèse s’inscrivent dans la problématique de localisation en temps réel d’une caméra par vision monoculaire. Dans la littérature, il existe différentes méthodes qui peuvent être classées en trois catégories. La première catégorie de méthodes considère une caméra évoluant dans un environnement complètement inconnu (SLAM). Cette méthode réalise une reconstruction enligne de primitives observées dans des images d’une séquence vidéo et utilise cette reconstruction pour localiser la caméra. Les deux autres permettent une localisation par rapport à un objet 3D de la scène en s’appuyant sur la connaissance, a priori, d’un modèle de cet objet (suivi basé modèle). L’une utilise uniquement l’information du modèle 3D de l’objet pour localiser la caméra, l’autre peut être considérée comme l’intermédiaire entre le SLAM et le suivi basé modèle. Cette dernière méthode consiste à localiser une caméra par rapport à un objet en utilisant, d’une part, le modèle de ce dernier et d’autre part, une reconstruction en ligne des primitives de l’objet d’intérêt. Cette reconstruction peut être assimilée à une mise à jour du modèle initial (suivi basé modèle avec mise à jour). Chacune de ces méthodes possède des avantages et des inconvénients. Dans le cadre de ces travaux de thèse, nous proposons une solution unifiant l’ensemble de ces méthodes de localisation dans un unique cadre désigné sous le terme de SLAM contraint. Cette solution, qui unifie ces différentes méthodes, permet de tirer profit de leurs avantages tout en limitant leurs inconvénients respectifs. En particulier, nous considérons que la caméra évolue dans un environnement partiellement connu, c’est-à-dire pour lequel un modèle (géométrique ou photométrique) 3D d’un objet statique de la scène est disponible. L’objectif est alors d’estimer de manière précise la pose de la caméra par rapport à cet objet 3D. L’information absolue issue du modèle 3D de l’objet d’intérêt est utilisée pour améliorer la localisation de type SLAM en incluant cette information additionnelle directement dans le processus d’ajustement de faisceaux. Afin de pouvoir gérer un large panel d’objets 3D et de scènes, plusieurs types de contraintes sont proposées dans ce mémoire. Ces différentes contraintes sont regroupées en deux approches. La première permet d’unifier les méthodes SLAM et de suivi basé modèle, en contraignant le déplacement de la caméra via la projection de primitives existantes extraites du modèle 3D dans les images. La seconde unifie les méthodes SLAM et de suivi basé modèle avec mise à jour en contraignant les primitives reconstruites par le SLAM à appartenir à la surface du modèle (unification SLAM et mise à jour du modèle). Les avantages de ces différents ajustements de faisceaux contraints, en terme de précision, de stabilité de recalage et de robustesse aux occultations, sont démontrés sur un grand nombre de données de synthèse et de données réelles. Des applications temps réel de réalité augmentée sont également présentées sur différents types d’objets 3D. Ces travaux ont fait l’objet de 4 publications internationales, de 2 publications nationales et d’un dépôt de brevet. / This thesis tackles the problem of real time location of a monocular camera. In the literature, there are different methods which can be classified into three categories. The first category considers a camera moving in a completely unknown environment (SLAM). This method performs an online reconstruction of the observed primitives in the images and uses this reconstruction to estimate the location of the camera. The two other categories of methods estimate the location of the camera with respect to a 3D object in the scene. The estimation is based on an a priori knowledge of a model of the object (Model-based). One of these two methods uses only the information of the 3D model of the object to locate the camera. The other method may be considered as an intermediary between the SLAM and Model-based approaches. It consists in locating the camera with respect to the object of interest by using, on one hand the 3D model of this object, and on the other hand an online reconstruction of the primitives of the latter. This last online reconstruction can be regarded as an update of the initial 3D model (Model-based with update). Each of these methods has advantages and disadvantages. In the context of this thesis, we propose a solution in order to unify all these localization methods in a single framework referred to as the constrained SLAM, by taking parts of their benefits and limiting their disadvantages. We, particularly, consider that the camera moves in a partially known environment, i.e. for which a 3D model (geometric or photometric) of a static object in the scene is available. The objective is then to accurately estimate the pose (position and orientation) of the camera with respect to this object. The absolute information provided by the 3D model of the object is used to improve the localization of the SLAM by directly including this additional information in the bundle adjustment process. In order to manage a wide range of 3D objets and scenes, various types of constraints are proposed in this study and grouped into two approaches. The first one allows to unify the SLAM and Model-based methods by constraining the trajectory of the camera through the projection, in the images, of the 3D primitives extracted from the model. The second one unifies the SLAM and Model-based with update methods, by constraining the reconstructed 3D primitives of the object to belong to the surface of the model (unification SLAM and model update). The benefits of the constrained bundle adjustment framework in terms of accuracy, stability, robustness to occlusions, are demonstrated on synthetic and real data. Real time applications of augmented reality are also presented on different types of 3D objects. This work has been the subject of four international publications, two national publications and one patent.

Introdução: As infecções primárias da corrente sanguínea associadas ao cateter venoso central (IPCS) são um grande problema nas unidades de terapia intensiva (UTI) pediátricas e neonatais em todo o mundo. Evidências sugerem que a prevenção das IPCSs é crucial para o atendimento seguro ao paciente. Uma percentagem significativa (65-70%) das IPCSs são evitáveis utilizando as estratégias baseadas em evidências, incluindo os bundles. Estas medidas têm um papel bem estabelecido em pacientes adultos.O objetivo deste estudo foi avaliar, a partir de uma ampla revisão sistemática da literatura, o benefício da implementação do bundle do cateter central na prevenção das IPCSs em pacientes pediátricos e neonatais internados em UTI. Métodos: Foram pesquisadas as bases de dados Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), além de busca manual e literatura cinzenta entre 1 de janeiro de 2005 até 31 de dezembro de 2015. Não houve restrição dos estudos com relação ao idioma, a data ou status de publicação. Para avaliar o benefício do bundle do cateter central, foram selecionados estudos envolvendo pelo menos dois componentes (higiene de mãos, precauções de barreira máxima, antissepsia da pele, seleção adequada do sítio do cateter, revisão diária da necessidade do cateter) como medida preventiva para pacientes com cateter venoso central (CVC). O desfecho foi o número de IPCSs por 1000 cateteres-dias antes e depois da implementação do bundle. Resultados: Foram identificados inicialmente 6369 estudos, após a exclusão dos títulos duplicados e os inelegíveis, 31 estudos preencheram os critérios de elegibilidade. Os estudos foram heterogêneos tanto na composição do bundle quanto na estratégia de implementação. A mediana da densidade de incidência de IPCS foi de 5.9 por 1000 cateteres-dias (2.6-23.1) nas unidades de terapia intensiva pediátricas (UTIP) e 4.9 por 1000 cateteres-dias (2.0-24.1) nas unidades de terapia intensiva neonatais (UTIN). Após a implementação do bundle do cateter central, a densidade de incidência de IPCS variou de 0 a 14.9 por 1000 cateteres-dias (mediana de 2.1) nas UTIPs e 0.3 a 13.9 (mediana de 2.8) nas UTINs. Conclusões: As IPCSs continuam sendo um problema significativo em unidades de terapia intensiva pediátricas e neonatais, mas a implementação do bundle do cateter central pode reduzir significativamente as taxas dessas infecções. Intervenções assistenciais com as melhores práticas baseadas em evidência permitem uma redução substancial das IPCSs pela promoção de grupos ou bundles de procedimentos e tecnologias, e pela utilização de uma estratégia multimodal para a educação, formação, implementação e divulgação. / Background: Central-line-associated bloodstream infections (CLABSIs) are a major problem in neonatal and pediatric intensive care units (ICUs) worldwide. Evidence suggests that CLABSI prevention is crucial for safe patient care. A significant percentage of CLABSIs (65- 70%) are preventable using evidenced-based guidelines. Strategies to prevent these infections have included a myriad of different preventive maneuvers gathered as “bundles”. These measures have a well established role in the adult ICU setting. We aimed to assess the benefit of the implementation of central-line bundles to prevent CLABSIs in neonatal and pediatric ICU patients, populations where their actual efficacy is yet to be proven. Methods: We searched Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), manual search and gray literature to identify studies reporting the implementation of central-line bundles in pediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 2005, and December 21, 2015, without language restriction. To evaluate the benefit of the central line bundle were selected studies involving at least two components (hand hygiene, maximal barrier precautions, skin antisepsis, optimal catheter site selection and daily review of line necessity) as a preventive measure to patients with central venous catheter (CVC). The outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Results: We initially identified 6369 records, and after excluding duplicates and those ineligible, 31 studies met the eligibility criteria. The studies reviewed were quite heterogeneous both in bundle composition and implementation strategy. Median CLABSIs incidence were 5.9 per 1000 catheter-days (range 2.6–23.1) on PICUs and 4.9 per 1000 catheter-days (range 2.0–24.1) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 14.9 per 1000 catheter-days (median 2.1) on PICUs and 0.3 to 14.9 (median 2.8) on NICUs. Conclusions: CLABSIs remain a significant problem in neonatal and pediatric critical care units, but implementation of catheter care bundles can significantly reduce rates of these infections. Best practice interventions allow substantial CLABSI reduction by promotion of groups or bundles of procedures and technology, and by use of a multimodal strategy for education, training, implementation, and dissemination.

In this Ph.D. thesis I am dealing with the effect of dynamic irradiance on (i) photosynthesis, growth and bundle sheath leakiness (for CO2) of C4 plants and (ii) bryophyte photosynthesis. Part of this thesis is literature review on broader aspects of the dynamic light effects on photosynthetic and growth processes in plants.

Les méthodes de décomposition sont une application du concept de diviser pour régner en optimisation. L'idée est de décomposer un problème d'optimisation donné en une séquence de sous-problèmes plus faciles à résoudre. Bien que ces méthodes soient les meilleures pour un grand nombre de problèmes de recherche opérationnelle, leur application à des problèmes réels de grande taille présente encore de nombreux défis. Cette thèse propose des améliorations méthodologiques et algorithmiques de méthodes de décomposition. Notre approche est basée sur l'analyse convexe et l'optimisation non-différentiable. Dans la décomposition par les contraintes (ou relaxation lagrangienne) du problème de planification de production électrique, même les sous-problèmes sont trop difficiles pour être résolus exactement. Mais des solutions approchées résultent en des prix instables et chahutés. Nous présentons un moyen simple d'améliorer la structure des prix en pénalisant leurs oscillations, en utilisant en particulier une régularisation par variation totale. La consistance de notre approche est illustrée sur des problèmes d'EDF. Nous considérons ensuite la décomposition par les variables (ou de Benders) qui peut avoir une convergence excessivement lente. Avec un point de vue d'optimisation non-différentiable, nous nous concentrons sur l'instabilité de l'algorithme de plans sécants sous-jacent à la méthode. Nous proposons une stabilisation quadratique de l'algorithme de Benders, inspirée par les méthodes de faisceaux en optimisation convexe. L'accélération résultant de cette stabilisation est illustrée sur des problèmes de conception de réseau et de localisation de plates-formes de correspondance (hubs). Nous nous intéressons aussi plus généralement aux problèmes d'optimisation convexe non-différentiable dont l'objectif est coûteux à évaluer. C'est en particulier une situation courante dans les procédures de décomposition. Nous montrons qu'il existe souvent des informations supplémentaires sur le problème, faciles à obtenir mais avec une précision inconnue, qui ne sont pas utilisées dans les algorithmes. Nous proposons un moyen d'incorporer ces informations incontrôlées dans des méthodes classiques d'optimisation convexe non-différentiable. Cette approche est appliquée avec succès à desproblèmes d'optimisation stochastique. Finalement, nous introduisons une stratégie de décomposition pour un problème de réaffectation de machines. Cette décomposition mène à une nouvelle variante de problèmes de conditionnement vectoriel (vectorbin packing) où les boîtes sont de taille variable. Nous proposons des heuristiques efficaces pour ce problème, qui améliorent les résultats de l'état de l'art du conditionnement vectoriel. Une adaptation de ces heuristiques permet de construire des solutions réalisables au problème de réaffectation de machines de Google. / Decomposition methods are an application of the divide and conquer principle to large-scale optimization. Their idea is to decompose a given optimization problem into a sequence of easier subproblems. Although successful for many applications, these methods still present challenges. In this thesis, we propose methodological and algorithmic improvements of decomposition methods and illustrate them on several operations research problems. Our approach heavily relies on convex analysis and nonsmooth optimization. In constraint decomposition (or Lagrangian relaxation) applied to short-term electricity generation management, even the subproblems are too difficult to solve exactly. When solved approximately though, the obtained prices show an unstable noisy behaviour. We present a simple way to improve the structure of the prices by penalizing their noisy behaviour, in particular using a total variation regularization. We illustrate the consistency of our regularization on real-life problems from EDF. We then consider variable decomposition (or Benders decomposition), that can have a very slow convergence. With a nonsmooth optimization point of view on this method, we address the instability of Benders cutting-planes algorithm. We present an algorithmic stabilization inspired by bundle methods for convex optimization. The acceleration provided by this stabilization is illustrated on network design andhub location problems. We also study more general convex nonsmooth problems whose objective function is expensive to evaluate. This situation typically arises in decomposition methods. We show that it often exists extra information about the problem, cheap but with unknown accuracy, that is not used by the algorithms. We propose a way to incorporate this coarseinformation into classical nonsmooth optimization algorithms and apply it successfully to two-stage stochastic problems.Finally, we introduce a decomposition strategy for the machine reassignment problem. This decomposition leads to a new variant of vector bin packing problems, where the bins have variable sizes. We propose fast and efficient heuristics for this problem that improve on state of the art results of vector bin packing problems. An adaptation of these heuristics is also able to generate feasible solutions for Google instances of the machine reassignment problem.

Introdução: A perfusão miocárdica de estresse pela tomografia (PMT) é um método emergente e não-invasivo para detecção de isquemia miocárdica. O objetivo deste estudo foi avaliar a acurácia diagnóstica da PMT em pacientes com bloqueio de ramo esquerdo (BRE) que estavam em pesquisa diagnóstica de doença arterial coronariana (DAC) e o valor adicional da PMT sobre a tomografia computadorizada com múltiplos detectores (ATC) usando tomógrafo com 320 detectores, e compará-los com a cintilografia de perfusão miocárdica (SPECT) para detecção de isquemia miocárdica com estenose coronariana significativa (estenose >- 70%), utilizando a angiografia coronariana quantitativa (QCA) e a angiografia coronariana pela tomografia computadorizada com múltiplos detectores como referências. Material e Métodos: Quarenta e dois pacientes com BRE e SPECT ( < 2 meses) em avaliação diagnóstica de DAC foram encaminhados para realizar o protocolo de tomografia que incluiu o escore de cálcio, PMT, ATC e realce tardio do miocárdio. Trinta pacientes foram encaminhados para angiografia coronária invasiva. As imagens foram interpretadas por observadores independentes e alheios aos resultados dos exames e aos dados clínicos. Foram realizadas análises por paciente e por território. O estudo obteve a aprovação da comissão de ética e todos os pacientes assinaram consentimento informado. Resultados: A idade média dos pacientes foi 63 +- 10 anos e, destes, 67% mulheres (28 pacientes). A dose média de radiação total foi de 9,3 +- 4,6 mSv. Na análise por paciente, sensibilidade, especificidade, valores preditivos positivo e negativo foram de 86%, 89%, 80 e 93% para a PMT (p=0,001) (kappa 0,74) e 63%, 91%, 65% e 90% (p < 0,001) na análise por território (kappa 0,55), respectivamente. Em ambas as análises, o ATC mostrou excelente precisão, com área sob a curva ROC=0,9. Considerável concordância foi demonstrada entre SPECT e o QCA (kappa 0,32 e 0,26) nas análises por paciente e por território, respectivamente. A avaliação combinada da ATC com a PMT permitiu melhorar a acurácia diagnóstica para detecção de estenose coronariana com redução luminal hemodinamicamente significativa ( >= 70%) comparando-se com a ATC, PMT ou SPECT isolados, demonstrado por valores de sensibilidade, especificidade, e valores preditivos positivos e negativos de 93%, 87%, 87%, 93% (p < 0,0001) na avaliação combinada por paciente, e 85%, 90%, 79%, 93% (p < 0,0001) na avaliação combinada por território. Conclusão: O uso do protocolo tomográfico de estresse é viável e possui boa acurácia para diagnóstico de DAC em pacientes com BRE com resultados superiores ao SPECT. A combinação da PMT e ATC permitiu melhorar a acurácia diagnóstica da avaliação de obstrução coronariana significativa em pacientes com BRE / Introduction: Stress computed tomography myocardial perfusion (CTP) is an emerging and non-invasive method to detect myocardial ischemia. The objective of this study was to evaluate diagnostic accuracy of CTP in patients with left bundle branch block (LBBB) who were being evaluated for coronary artery disease (CAD) and the additional value of CTP on computed tomography angiography (CTA) using 320-row detector CT scanner and compare them with single-photon emission computed tomography (SPECT) for detection of myocardial ischemia with significant coronary stenosis >= 70% using quantitative invasive coronary angiography (QCA) and coronary CT angiography as references. Material and Methods: Forty two LBBB patients with SPECT ( < 2 months) in diagnostic evaluation for CAD were referred to stress CT protocol which included calcium score, CTP, CTA and myocardial delayed enhancement. Thirty patients were referred to invasive coronary angiography. Independent blinded observers performed analyses of the images. Per-patient and perterritory analyses were conducted. Ethical committee aproval was obtained and all patients gave informed consent. Results: The mean age was 63 +- 10 years. 67% were women (28 patients). The total mean radiation dose was 9,3 +- 4,6 mSv. In per-patient sensitivity, specificity, positive and negative values were 86%, 89%, 80 and 93%, for CTP (p=0,001) (kappa 0.74) and 63%, 91% 65% and 90% (p < 0,001) in per-territory analysis (kappa 0.55), respectively. In both analyses, CTA showed excellent accuracy with area under receiver operating curve (AUC) = 0.9. Fair agreement was demonstrated between SPECT and QCA (kappa 0,32 e 0,26) in per-patient and per-territory analyses, respectively. The combined analysis of CTA with CTP, improved diagnostic accuracy for detection of coronary stenosis with hemodynamically significant luminal reduction ( >= 70%) compared with CTA, CTP or SPECT alone, demonstrated by sensitivity, specificity, and positive and negative predictive values of 93%, 87%, 87%, 93% (p < 0,0001) in the combined evaluation by patient and 85%, 90%, 79%, 93% (p < 0,0001) in the combined evaluation by territory. Conclusion: The use of customized stress CT protocol is feasible and has good accuracy for the diagnosis of CAD in patients with LBBB with results better than SPECT. The combination of PMT and ATC has improved the diagnostic accuracy of the assessment of significant coronary obstruction in patients with LBBB

Introdução: As infecções primárias da corrente sanguínea associadas ao cateter venoso central (IPCS) são um grande problema nas unidades de terapia intensiva (UTI) pediátricas e neonatais em todo o mundo. Evidências sugerem que a prevenção das IPCSs é crucial para o atendimento seguro ao paciente. Uma percentagem significativa (65-70%) das IPCSs são evitáveis utilizando as estratégias baseadas em evidências, incluindo os bundles. Estas medidas têm um papel bem estabelecido em pacientes adultos.O objetivo deste estudo foi avaliar, a partir de uma ampla revisão sistemática da literatura, o benefício da implementação do bundle do cateter central na prevenção das IPCSs em pacientes pediátricos e neonatais internados em UTI. Métodos: Foram pesquisadas as bases de dados Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), além de busca manual e literatura cinzenta entre 1 de janeiro de 2005 até 31 de dezembro de 2015. Não houve restrição dos estudos com relação ao idioma, a data ou status de publicação. Para avaliar o benefício do bundle do cateter central, foram selecionados estudos envolvendo pelo menos dois componentes (higiene de mãos, precauções de barreira máxima, antissepsia da pele, seleção adequada do sítio do cateter, revisão diária da necessidade do cateter) como medida preventiva para pacientes com cateter venoso central (CVC). O desfecho foi o número de IPCSs por 1000 cateteres-dias antes e depois da implementação do bundle. Resultados: Foram identificados inicialmente 6369 estudos, após a exclusão dos títulos duplicados e os inelegíveis, 31 estudos preencheram os critérios de elegibilidade. Os estudos foram heterogêneos tanto na composição do bundle quanto na estratégia de implementação. A mediana da densidade de incidência de IPCS foi de 5.9 por 1000 cateteres-dias (2.6-23.1) nas unidades de terapia intensiva pediátricas (UTIP) e 4.9 por 1000 cateteres-dias (2.0-24.1) nas unidades de terapia intensiva neonatais (UTIN). Após a implementação do bundle do cateter central, a densidade de incidência de IPCS variou de 0 a 14.9 por 1000 cateteres-dias (mediana de 2.1) nas UTIPs e 0.3 a 13.9 (mediana de 2.8) nas UTINs. Conclusões: As IPCSs continuam sendo um problema significativo em unidades de terapia intensiva pediátricas e neonatais, mas a implementação do bundle do cateter central pode reduzir significativamente as taxas dessas infecções. Intervenções assistenciais com as melhores práticas baseadas em evidência permitem uma redução substancial das IPCSs pela promoção de grupos ou bundles de procedimentos e tecnologias, e pela utilização de uma estratégia multimodal para a educação, formação, implementação e divulgação. / Background: Central-line-associated bloodstream infections (CLABSIs) are a major problem in neonatal and pediatric intensive care units (ICUs) worldwide. Evidence suggests that CLABSI prevention is crucial for safe patient care. A significant percentage of CLABSIs (65- 70%) are preventable using evidenced-based guidelines. Strategies to prevent these infections have included a myriad of different preventive maneuvers gathered as “bundles”. These measures have a well established role in the adult ICU setting. We aimed to assess the benefit of the implementation of central-line bundles to prevent CLABSIs in neonatal and pediatric ICU patients, populations where their actual efficacy is yet to be proven. Methods: We searched Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), manual search and gray literature to identify studies reporting the implementation of central-line bundles in pediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 2005, and December 21, 2015, without language restriction. To evaluate the benefit of the central line bundle were selected studies involving at least two components (hand hygiene, maximal barrier precautions, skin antisepsis, optimal catheter site selection and daily review of line necessity) as a preventive measure to patients with central venous catheter (CVC). The outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Results: We initially identified 6369 records, and after excluding duplicates and those ineligible, 31 studies met the eligibility criteria. The studies reviewed were quite heterogeneous both in bundle composition and implementation strategy. Median CLABSIs incidence were 5.9 per 1000 catheter-days (range 2.6–23.1) on PICUs and 4.9 per 1000 catheter-days (range 2.0–24.1) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 14.9 per 1000 catheter-days (median 2.1) on PICUs and 0.3 to 14.9 (median 2.8) on NICUs. Conclusions: CLABSIs remain a significant problem in neonatal and pediatric critical care units, but implementation of catheter care bundles can significantly reduce rates of these infections. Best practice interventions allow substantial CLABSI reduction by promotion of groups or bundles of procedures and technology, and by use of a multimodal strategy for education, training, implementation, and dissemination.