Navigation globale d'un fauteuil roulant motorisé dans de grands espaces intérieurs

Résumé Dans ce mémoire nous présentons un nouveau module de navigation conçu pour un fauteuil roulant motorisé. Ce module a pour objectif de fournir des fonctionnalités essentielles à l'ensemble des personnes à mobilité réduite utilisant ces fauteuils. Différents services ont été prévus lors de la conception de ce module, tels que l'assistance à l'évitement d'obstacle, l'exécution de manœuvres automatiques (mouvements rectilignes, suivi de personnes, traversée de passages étroits et stationnement) et la génération de carte de l'environnement, le tout en respectant les modalités de sécurité et convivialité. De plus, il a été conçu et développé sous une plateforme collaborative de développement se distinguant par sa facilité d'intégration et sa modularité. Même si nous nous limitons sur un fauteuil roulant, ce travail contribue au domaine de la robotique mobile avec l'architecture de contrôle proposée, cette architecture englobant : un superviseur, un mode manuel, un mode semi-manuel et un mode automne. Ainsi, il propose des solutions au problème de navigation globale en fournissant une méthode de construction de carte basée sur différents capteurs, et une méthode de localisation globale permettant de se retrouver sur une carte. Le prototype développé se caractérise par la multitude de capteurs utilisés : télémètre laser, télémètre ultrason et caméra Kinect. Nous allons présenter un travail de synthèse permettant d'identifier parmi ces capteurs, ceux nécessaires pour assurer les performances recherchées dans un tel module de navigation. Enfin, l'ensemble des expérimentations que nous avons effectuées, incluant des cartographies de grands espaces, démontre les performances de notre module de navigation, ainsi que ses limites.---------- Abstract In this thesis we present a new navigation system designed for powered wheelchairs. This system aims at providing essential functionalities to disabled people using wheelchairs. Different services were planned during the design of the navigation module, such as collision avoidance, execution of automatic maneuvers (straight movements, following a person, passing through narrow passage and parking) but also generating maps of the environment. All these actions must comply with the terms of safety and security. In addition, it has been designed and developed in a collaborative operating system characterized by its ease of integration and modularity. Even if we do limit our investigation to motorized wheelchairs, our new control architecture is a contribution to the field of mobile robotics with the proposed control architecture. This architecture includes: a supervisor, a manual mode, a semi-manual mode and an automatic mode. Thus, it offers solutions to the global navigation problem by providing a mapping method based on various sensors, and a global localisation method to localise on a map. The prototype developed is characterized by a multitude of sensors: laser rangefinder, ultrasound rangefinder and Kinect camera. We will perform a synthesis to identify among these sensors, those necessary to ensure the desired performance in such a navigation module. Finally, the set of experiments we carried out, including mapping of large interior spaces, demonstrates the performance of our navigation module and its limits

Using Reinforcement Learning to Simplify Mealtime Insulin Dosing for People with Type 1 Diabetes: In-Silico Experiments

People with type 1 diabetes (T1D) struggle to calculate the optimal insulin dose at mealtime, especially when under multiple daily injections (MDI) therapy. Effectively, they will not always perform rigorous and precise calculations, but occasionally, they might rely on intuition and previous experience. Reinforcement learning (RL) has shown outstanding results in outperforming humans on tasks requiring intuition and learning from experience. In this work, we propose an RL agent that recommends the optimal meal-accompanying insulin dose corresponding to a qualitative meal (QM) strategy that does not require precise carbohydrate counting (CC) (e.g., a usual meal at noon.). The agent is trained using the soft actor-critic approach and comprises long short-term memory (LSTM) neurons. For training, eighty virtual subjects (VS) of the FDA-accepted UVA/Padova T1D adult population were simulated using MDI therapy and QM strategy. For validation, the remaining twenty VS were examined in 26-week scenarios, including intra- and inter-day variabilities in glucose. \textit{In-silico} results showed that the proposed RL approach outperforms a baseline run-to-run approach and can replace the standard CC approach. Specifically, after 26 weeks, the time-in-range ($70-180$mg/dL) and time-in-hypoglycemia ($<70$mg/dL) were $73.1\pm11.6$% and $2.0\pm 1.8$% using the RL-optimized QM strategy compared to $70.6\pm14.8$% and $1.5\pm 1.5$% using CC. Such an approach can simplify diabetes treatment, resulting in improved quality of life and glycemic outcomes.Comment: 6 pages, 4 figures, conferenc

Intermittent Control for Safe Long-Acting Insulin Intensification for Type 2 Diabetes: In-Silico Experiment

Around a third of type 2 diabetes patients (T2D) are escalated to basal insulin injections. Basal insulin dose is titrated to achieve a tight glycemic target without undue hypoglycemic risk. In the standard of care (SoC), titration is based on intermittent fasting blood glucose (FBG) measurements. Lack of adherence and the day-to-day variabilities in FBG measurements are limiting factors to the existing insulin titration procedure. We propose an adaptive receding horizon control strategy where a glucose-insulin fasting model is identified and used to predict the optimal basal insulin dose. This algorithm is evaluated in \textit{in-silico} experiments using the new UVA virtual lab (UVlab) and a set of T2D avatars matched to clinical data (NCT01336023). Compared to SoC, we show that this control strategy can achieve the same glucose targets faster (as soon as week 8) and safer (increased hypoglycemia protection and robustness to missing FBG measurements). Specifically, when insulin is titrated daily, a time-in-range (TIR, 70--180 mg/dL) of 71.4$\pm$20.0\% can be achieved at week eight and maintained at week 52 (72.6$\pm$19.6%) without an increased hypoglycemia risk as measured by time under 70 mg/dL (TBR, week 8: 1.3$\pm$1.9% and week 52: 1.2$\pm$1.9%), when compared to the SoC (TIR at week 8: 59.3$\pm$28.0% and week:52 72.1$\pm$22.3%, TBR at week 8: 0.5$\pm$1.3% and week 52: 2.8$\pm$3.4%). Such an approach can potentially reduce treatment inertia and prescription complexity, resulting in improved glycemic outcomes for T2D using basal insulin injections.Comment: 6 pages, 2 figures, conferenc

In-Silico Evaluation of Glucose Regulation Using Policy Gradient Reinforcement Learning for Patients with Type 1 Diabetes Mellitus

In this paper, we test and evaluate policy gradient reinforcement learning for automated blood glucose control in patients with Type 1 Diabetes Mellitus. Recent research has shown that reinforcement learning is a promising approach to accommodate the need for individualized blood glucose level control algorithms. The motivation for using policy gradient algorithms comes from the fact that adaptively administering insulin is an inherently continuous task. Policy gradient algorithms are known to be superior in continuous high-dimensional control tasks. Previously, most of the approaches for automated blood glucose control using reinforcement learning has used a finite set of actions. We use the Trust-Region Policy Optimization algorithm in this work. It represents the state of the art for deep policy gradient algorithms. The experiments are carried out in-silico using the Hovorka model, and stochastic behavior is modeled through simulated carbohydrate counting errors to illustrate the full potential of the framework. Furthermore, we use a model-free approach where no prior information about the patient is given to the algorithm. Our experiments show that the reinforcement learning agent is able to compete with and sometimes outperform state-of-the-art model predictive control in blood glucose regulation

Exploring Powered Wheelchair Users and Their Caregivers’ Perspectives on Potential Intelligent Power Wheelchair Use: A Qualitative Study

Power wheelchairs (PWCs) can have a positive impact on user well-being, self-esteem, pain, activity and participation. Newly developed intelligent power wheelchairs (IPWs), allowing autonomous or collaboratively-controlled navigation, could enhance mobility of individuals not able to use, or having difficulty using, standard PWCs. The objective of this study was to explore the perspectives of PWC users (PWUs) and their caregivers regarding if and how IPWs could impact on current challenges faced by PWUs, as well as inform current development of IPWs. A qualitative exploratory study using individual interviews was conducted with PWUs (n = 12) and caregivers (n = 4). A semi-structured interview guide and video were used to facilitate informed discussion regarding IPWs. Thematic analysis revealed three main themes: (1) "challenging situations that may be overcome by an IPW" described how the IPW features of obstacle avoidance, path following, and target following could alleviate PWUs' identified mobility difficulties; (2) "cautious optimism concerning IPW use revealed participants" addresses concerns regarding using an IPW as well as technological suggestions; (3) "defining the potential IPW user" revealed characteristics of PWUs that would benefit from IPW use. Findings indicate how IPW use may help overcome PWC difficulties and confirm the importance of user input in the ongoing development of IPWs

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BackgroundDisorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.MethodsWe estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.FindingsGlobally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378–521), affecting 3·40 billion (3·20–3·62) individuals (43·1%, 40·5–45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7–26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6–38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5–32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7–2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.InterpretationAs the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed

Modelling glucose dynamics during moderate exercise in individuals with type 1 diabetes.

The artificial pancreas is a closed-loop insulin delivery system that automatically regulates glucose levels in individuals with type 1 diabetes. In-silico testing using simulation environments accelerates the development of better artificial pancreas systems. Simulation environments need an accurate model that captures glucose dynamics during exercise to simulate real-life scenarios. We proposed six variations of the Bergman Minimal Model to capture the physiological effects of moderate exercise on glucose dynamics in individuals with type 1 diabetes. We estimated the parameters of each model with clinical data using a Bayesian approach and Markov chain Monte Carlo methods. The data consisted of measurements of plasma glucose, plasma insulin, and oxygen consumption collected from a study of 17 adults with type 1 diabetes undergoing aerobic exercise sessions. We compared the models based on the physiological plausibility of their parameters estimates and the deviance information criterion. The best model features (i) an increase in glucose effectiveness proportional to exercise intensity, and (ii) an increase in insulin action proportional to exercise intensity and duration. We validated the selected model by reproducing results from two previous clinical studies. The selected model accurately simulates the physiological effects of moderate exercise on glucose dynamics in individuals with type 1 diabetes. This work offers an important tool to develop strategies for exercise management with the artificial pancreas