Design and experimental assessment of a novel damper with high endurance to seismic loads

The study presents the design and the experimental characterization of a new energy dissipation device aimed at providing improved resistance to repeated seismic loads. Differently from conventional steel hysteretic dampers, which dissipate energy by yielding of a mild steel core and are noted to suffer low-cycle fatigue, the new damper provides energy dissipation by the friction that is activated between a moving shaft and a lead core prestressed within a tube. The prestress level is controlled during the assembling process, allowing to adjust the axial strength of the damper. Thanks to the ability of lead to restore its properties by static recrystallization taking place immediately after deformation, repeated cycles of loading do not produce damages that may accrue and eventually lead to failure of the device. Moreover, prestressing of the lead core allows to achieve high specific strength (i.e., high force to volume ratio), thereby providing low dimensions which help to reduce the architectural invasiveness. Prototypes of the damper were subjected to the test procedure established in the European standard EN 15129 for Displacement Dependent Devices, fulfilling the relevant requirements. The damper provides a robust and stable response over repeated cycles, characterized by essentially rectangular hysteresis loops with an equivalent viscous damping ratio ξeff of about 55%. Moreover, it shows low sensitivity of mechanical properties on the loading rate and the ability to withstand multiple cycles of motion at the design earthquake displacement without deterioration of performance, demonstrating maintenance-free operation in presence of repeated ground shakes. Its ability to survive several strong motions without being damaged, and its high damping capability coupled to a compact design and low manufacturing cost, are the distinctive features that make it suitable for social housing

Evidence-based careflow management systems: the case of post-stroke rehabilitation

AbstractThe activities of a care providers’ team need to be coordinated within a process properly designed on the basis of available best practice medical knowledge. It requires a rethinking of the management of care processes within health care organizations. The current workflow technology seems to offer the most convenient solution to build such cooperative systems. However, some of its present weaknesses still require an intense research effort to find solutions allowing its exploitation in real medical practice. This paper presents an approach to design and build evidence-based careflow management systems, which can be viewed as components of a knowledge management infrastructure each health care organization should be provided with to increase its performance in delivering high quality care by efficiently exploiting the available knowledge resources. The post-stroke rehabilitation process has been taken as a challenging care problem to assess our methodology for designing and developing careflow management systems. Then a system was co-developed with a team of rehabilitation professionals who will be committed to use it in their daily work. The system’s main goal is to deliver a full array of rehabilitation services provided by an interdisciplinary team. They are related to identify which patients are most likely to benefit from rehabilitation, manage a rehabilitation treatment plan, and monitor progress both during rehabilitation and after return to a community residence. A model of the rehabilitation process was derived from an international guideline and adapted to the local organization of work. It involves different organizational units, such as wards, rehabilitation units, clinical laboratories, and imaging services. Several organizational agents work within them and play one or more roles. Each role is defined by the goals’ set that she/he must fulfill. Special effort has been given to the design and development of a knowledge-based system for managing exceptions, which may occur in daily medical work as any deviation from the normal flow of activities. It allows either avoiding or recovering automatically from expected exceptions. When they are not expected, organizational agents, with enough power to do that, are allowed to modify the scheduled flow of activities for an individual patient under the only constraint of justifying their decision. After an intensive testing in a research laboratory, the system is now in the process of being transferred in a real working setting with the full support of its future users

NIGER-DELTA: ENVIRONMENT, OGONI CRISIS AND THE STATE

Among the well agreed-on benefits of a guideline computerisation, with respect to the traditional text format, there are the disambiguation, the possibility of looking at the guideline at different levels of detail and the possibility of generating patient-tailored suggestions. Nevertheless, the connection of guidelines with patient records is still a challenging problem, as well as their effective integration into the clinical workflow. In this paper, we describe the evolution of our environment for representing and running guidelines. The main new features concern the choice of a commercial product as the middle layer with the electronic patient record, the consequent possibility of gathering information from different legacy systems, and the extension of this "virtual medical record" to the storage of process data. This last feature allows managing exceptions, i.e. decisions that do not comply with guidelines

Parental evaluation of a telemonitoring service for children with Type 1 Diabetes

Introduction In the past years, we developed a telemonitoring service for young patients affected by Type 1 Diabetes. That service provides data to the clinical staff and offers an important tool to the parents, that are able to oversee in real time their children. The aim of this work was to analyze the parents' perceived usefulness of the service. Methods The service was tested by the parents of 31 children enrolled in a seven-day clinical trial during a summer camp. To study the parents' perception we proposed and analyzed two questionnaires. A baseline questionnaire focused on the daily management and implications of their children's diabetes, while a post-study one measured the perceived benefits of telemonitoring. Questionnaires also included free text comment spaces. Results Analysis of the baseline questionnaires underlined the parents' suffering and fatigue: 51% of total responses showed a negative tendency and the mean value of the perceived quality of life was 64.13 in a 0-100 scale. In the post-study questionnaires about half of the parents believed in a possible improvement adopting telemonitoring. Moreover, the foreseen improvement in quality of life was significant, increasing from 64.13 to 78.39 ( p-value\u2009=\u20090.0001). The analysis of free text comments highlighted an improvement in mood, and parents' commitment was also proved by their willingness to pay for the service (median\u2009=\u2009200\u2009euro/year). Discussion A high number of parents appreciated the telemonitoring service and were confident that it could improve communication with physicians as well as the family's own peace of mind

Implementation of a distributed guideline-based decision support model within a patient-guidance framework

We report on new projection engine which was developed in order to implement a distributed guideline-based decision support system (DSS) within the European project MobiGuide.In this model, small portions of the guideline knowledge are projected, i.e. 'downloaded', from a central DSS server to a local DSS in the patient's mobile device, which then applies that knowledge using the mobile device’s local resources. Furthermore, the projection engine generates guideline projections which are adapted to the patient’s previously defined preferences and, implicitly, to the patient’s current context, which is embodied in the projected knowledge. We evaluated this distributed guideline application model for two complex guidelines: one for Gestational Diabetes Mellitus, and one for Atrial Fibrillation. We found that the initial specification of what we refer to as the customized guideline should be in the terms of the distributed DSS, i.e., include two levels: one for the central DSS, and one for the local DSS. In addition, we found significant differences between the customized, distributed versions of the two guidelines, indicating further research directions and possibly additional ways to analyze and characterize guidelines

A Scalable Architecture for Incremental Specification and Maintenance of Procedural and Declarative Clinical Decision-Support Knowledge

Clinical guidelines have been shown to improve the quality of medical care and to reduce its costs. However, most guidelines exist in a free-text representation and, without automation, are not sufficiently accessible to clinicians at the point of care. A prerequisite for automated guideline application is a machine-comprehensible representation of the guidelines. In this study, we designed and implemented a scalable architecture to support medical experts and knowledge engineers in specifying and maintaining the procedural and declarative aspects of clinical guideline knowledge, resulting in a machine comprehensible representation. The new framework significantly extends our previous work on the Digital electronic Guidelines Library (DeGeL) The current study designed and implemented a graphical framework for specification of declarative and procedural clinical knowledge, Gesher. We performed three different experiments to evaluate the functionality and usability of the major aspects of the new framework: Specification of procedural clinical knowledge, specification of declarative clinical knowledge, and exploration of a given clinical guideline. The subjects included clinicians and knowledge engineers (overall, 27 participants). The evaluations indicated high levels of completeness and correctness of the guideline specification process by both the clinicians and the knowledge engineers, although the best results, in the case of declarative-knowledge specification, were achieved by teams including a clinician and a knowledge engineer. The usability scores were high as well, although the clinicians’ assessment was significantly lower than the assessment of the knowledge engineers

Clinical pregenetic screening for stroke monogenic diseases: Results from lombardia GENS registry

BACKGROUND AND PURPOSE: Lombardia GENS is a multicentre prospective study aimed at diagnosing 5 single-gene disorders associated with stroke (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, Fabry disease, MELAS [mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes], hereditary cerebral amyloid angiopathy, and Marfan syndrome) by applying diagnostic algorithms specific for each clinically suspected disease METHODS: We enrolled a consecutive series of patients with ischemic or hemorrhagic stroke or transient ischemic attack admitted in stroke units in the Lombardia region participating in the project. Patients were defined as probable when presenting with stroke or transient ischemic attack of unknown etiopathogenic causes, or in the presence of <3 conventional vascular risk factors or young age at onset, or positive familial history or of specific clinical features. Patients fulfilling diagnostic algorithms specific for each monogenic disease (suspected) were referred for genetic analysis. RESULTS: In 209 patients (57.4\ub114.7 years), the application of the disease-specific algorithm identified 227 patients with possible monogenic disease. Genetic testing identified pathogenic mutations in 7% of these cases. Familial history of stroke was the only significant specific feature that distinguished mutated patients from nonmutated ones. The presence of cerebrovascular risk factors did not exclude a genetic disease. CONCLUSIONS: In patients prescreened using a clinical algorithm for monogenic disorders, we identified monogenic causes of events in 7% of patients in comparison to the 1% to 5% prevalence reported in previous series

A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes

Background. To perform a systematic review about the effect of using clinical pathways on length of stay (LOS), hospital costs and patient outcomes. To provide a framework for local healthcare organisations considering the effectiveness of clinical pathways as a patient management strategy. Methods. As participants, we considered hospitalized children and adults of every age and indication whose treatment involved the management strategy "clinical pathways". We include only randomised controlled trials (RCT) and controlled clinical trials (CCT), not restricted by language or country of publication. Single measures of continuous and dichotomous study outcomes were extracted from each study. Separate analyses were done in order to compare effects of clinical pathways on length of stay (LOS), hospital costs and patient outcomes. A random effects meta-analysis was performed with untransformed and log transformed outcomes. Results. In total 17 trials met inclusion criteria, representing 4,070 patients. The quality of the included studies was moderate and studies reporting economic data can be described by a very limited scope of evaluation. In general, the majority of studies reporting economic data (LOS and hospital costs) showed a positive impact. Out of 16 reporting effects on LOS, 12 found significant shortening. Furthermore, in a subgroup-analysis, clinical pathways for invasive procedures showed a stronger LOS reduction (weighted mean difference (WMD) -2.5 days versus -0.8 days)). There was no evidence of differences in readmission to hospitals or in-hospital complications. The overall Odds Ratio (OR) for re-admission was 1.1 (95% CI: 0.57 to 2.08) and for in-hospital complications, the overall OR was 0.7 (95% CI: 0.49 to 1.0). Six studies examined costs, and four showed significantly lower costs for the pathway group. However, heterogeneity between studies reporting on LOS and cost effects was substantial. Conclusion. As a result of the relatively small number of studies meeting inclusion criteria, this evidence base is not conclusive enough to provide a replicable framework for all pathway strategies. Considering the clinical areas for implementation, clinical pathways seem to be effective especially for invasive care. When implementing clinical pathways, the decision makers need to consider the benefits and costs under different circumstances (e.g. market forces)