Neurocritical Patient Characteristics Related to Brain Death.

BACKGROUND: The lack of viable organs for transplantation led to the creation in Argentina of the Glasgow 7 Program based on the detection and follow-up of acute neurologic patients admitted with Glasgow scores ≤7 in selected hospitals. The objective of this study was to determine the likelihood of hospitalized acute neurologic patients progressing to brain death (BD) based on several variables, including age, sex, and admission diagnosis. METHODS: This study was a retrospective cohort analysis of data obtained from the SINTRA (Procurement and Transplantation National Information System) database between 2006 and 2015. Independent variables included the following: age, sex, and diagnosis at admission; ischemic stroke; spontaneous intracerebral hematoma (SIH); subarachnoid hemorrhage (SH); anoxia, meningitis; penetrating head injury (PHI); closed head injury; and tumors. A multivariate analysis was performed adjusting the diagnosis at admission according to age and sex. RESULTS: A total of 31,877 patients were included: 19,308 (61%) patients died and 9736 (30%) evolved to BD. Overall, 36% of women and 28% of men evolved to BD (relative risk, 0.87 [95% confidence interval (CI), 0.86-0.89]; P < .001). In the multivariate analysis adjusted for age and sex, we observed the following: SIH OR, 1.79 (95% CI, 1.69-1.9; P < .001); ischemic stroke OR, 0.82 (95% CI, 0.73-0.92; P < .001); SH OR, 2.33 (95% CI, 2.16-2.52; P < .001); anoxia OR, 0.71 (95% CI, 0.64-0.79; P < .001); closed head injury OR, 0.41 (95% CI, 0.38-0.43; P < .001); PHI OR, 2.64 (95% CI, 2.38-2.94; P < .001); and tumors OR, 1.07 (95% CI, 0.93-1.24; P = .31). CONCLUSIONS: Thirty percent of the patients who entered the Glasgow 7 Program evolved with BD. The characteristics most likely to result in BD were age, female sex, PHI, SH, and SIH.

Automatic Identification of the Repolarization Endpoint by Computing the Dominant T-wave on a Reduced Number of Leads.

Electrocardiographic (ECG) T-wave endpoint (Tend) identification suffers lack of reliability due to the presence of noise and variability among leads. Tend identification can be improved by using global repolarization waveforms obtained by combining several leads. The dominant T-wave (DTW) is a global repolarization waveform that proved to improve Tend identification when computed using the 15 (I to III, aVr, aVl, aVf, V1 to V6, X, Y, Z) leads usually available in clinics, of which only 8 (I, II, V1 to V6) are independent. The aim of the present study was to evaluate if the 8 independent leads are sufficient to obtain a DTW which allows a reliable Tend identification. To this aim Tend measures automatically identified from 15-dependent-lead DTWs of 46 control healthy subjects (CHS) and 103 acute myocardial infarction patients (AMIP) were compared with those obtained from 8-independent-lead DTWs. Results indicate that Tend distributions have not statistically different median values (CHS: 340 ms vs. 340 ms, respectively; AMIP: 325 ms vs. 320 ms, respectively), besides being strongly correlated (CHS: ρ=0.97, AMIP: 0.88; P<10(-27)). Thus, measuring Tend from the 15-dependent-lead DTWs is statistically equivalent to measuring Tend from the 8-independent-lead DTWs. In conclusion, for the clinical purpose of automatic Tend identification from DTW, the 8 independent leads can be used without a statistically significant loss of accuracy but with a significant decrement of computational effort. The lead dependence of 7 out of 15 leads does not introduce a significant bias in the Tend determination from 15 dependent lead DTWs.

A statistical approach to discriminate between non-fallers, rare fallers and frequent fallers in older adults based on posturographic data.

BACKGROUND: Identification of future non-fallers, infrequent and frequent fallers among older people would permit focusing the delivery of prevention programs on selected individuals. Posturographic parameters have been proven to differentiate between non-fallers and frequent fallers, but not between the first group and infrequent fallers. METHODS: In this study, postural stability with eyes open and closed on both a firm and a compliant surface and while performing a cognitive task was assessed in a consecutive sample of 130 cognitively able elderly, mean age 77(7)years, categorized as non-fallers (N=67), infrequent fallers (one/two falls, N=45) and frequent fallers (more than two falls, N=18) according to their last year fall history. Principal Component Analysis was used to select the most significant features from a set of 17posturographic parameters. Next, variables derived from principal component analysis were used to test, in each task, group differences between the three groups. FINDINGS: One parameter based on a combination of a set of Centre of Pressure anterior-posterior variables obtained from the eyes-open on a compliant surface task was statistically different among all groups, thus distinguishing infrequent fallers from both non-fallers (P<0.05) and frequent fallers (P<0.05). INTERPRETATION: For the first time, a method based on posturographic data to retrospectively discriminate infrequent fallers was obtained. The joint use of both the eyes-open on a compliant surface condition and this new parameter could be used, in a future study, to improve the performance of protocols and to verify the ability of this method to identify new-fallers in elderly without cognitive impairment.

A markerless system based on smartphones and webcam for the measure of step length, width and duration on treadmill.

BACKGROUND AND OBJECTIVE: A markerless low cost prototype has been developed for the determination of some spatio-temporal parameters of human gait: step-length, step-width and cadence have been considered. Only a smartphone and a high-definition webcam have been used. METHODS: The signals obtained by the accelerometer embedded in the smartphone are used to recognize the heel strike events, while the feet positions are calculated through image processing of the webcam stream. Step length and width are computed during gait trials on a treadmill at various speeds (3, 4 and 5 km/h). RESULTS: Six subjects have been tested for a total of 504 steps. Results were compared with those obtained by a stereo-photogrammetric system (Elite, BTS Engineering). The maximum average errors were 3.7 cm (5.36%) for the right step length and 1.63 cm (15.16%) for the right step width at 5 km/h. The maximum average error for step duration was 0.02 s (1.69%) at 5 km/h for the right steps. CONCLUSION: The system is characterized by a very high level of automation that allows its use by non-expert users in non-structured environments. A low cost system able to automatically provide a reliable and repeatable evaluation of some gait events and parameters during treadmill walking, is relevant also from a clinical point of view because it allows the analysis of hundreds of steps and consequently an analysis of their variability.

The surface electromyographic evaluation of the Functional Reach in elderly subjects.

This study proposes a comprehensive assessment of myoelectric activity of the main muscles involved in the Functional Reach (FR) test, in 24 elderly subjects. A specific protocol for the surface electromyography (sEMG) signal acquisition during FR-test was developed. Results show that anterior muscles activate following a caudo-cranial order. Tibialis Anterior (TA) is the first to be activated (-18.0±16.3% of the FR-period), together with Rectus Femoris (-10.4±17.9%). Then, Rectus Abdominis (19.7±24.7%) and Sternocleidomastoideus (19.9±15.6%) activate after the FR-start. Hamstrings, Soleus, and L4-level Erectores Spinae (posterior muscles) activate after the FR-start in this order (11.4±16.8%, 17.7±16.6%, and 35.2±29.0%, respectively) and remain active until the movement end. The analysis of the kinematic strategies adopted by subjects revealed an association between TA-activation patterns and two kinematic strategies (hip/mixed strategy), quantified by an increase (p<0.05) of TA-activity duration in subjects adopting the hip strategy (89.9±34.5) vs. subjects adopting the mixed strategy (27.0±16.8). This suggests that TA sEMG activity could be able to discriminate among kinematic strategies, providing different information on balance control. Thus, the present analysis represents the first attempt to quantify the sEMG activity during FR-test in elderly subjects, providing an early contribution in building a reference frame for balance assessment in clinical context.

Muscle activation patterns related to diabetic neuropathy in elderly subjects: A Functional Reach Test study.

BACKGROUND: This study was designed to assess, in healthy elderly, non-neuropathic and neuropathic diabetic subjects, the activation patterns of the main muscles involved in the Functional Reach Test, a well-recognized method to identify elderly subjects at risk of balance impairments. METHODS: Surface electromyographic analysis of Sternocleidomastoideus, Rectus Abdominis, Erectores Spinae at L4 level, Rectus Femoris, Hamstrings, Tibialis Anterior and Soleus was performed in 10 healthy, 10 diabetic non-neuropathic and 10 diabetic neuropathic subjects. FINDINGS: Results showed that in every group the first motor is Tibialis Anterior, that is recruited before the start of the test. An earlier activation of Tibialis Anterior (P<0.05) was detected in diabetic neuropathic (ON at -24% of the test period), compared with healthy (-11%) and diabetic non-neuropathic (-13%) groups. A significant earlier activation of Sternocleidomastoideus and Rectus Abdominis was found in diabetic neuropathic group, only with respect to healthy subjects. No significant difference was found in Rectus Femoris, Soleus, Hamstrings an Erectores Spinae onset among the three groups. INTERPRETATION: Results suggest a trend of diabetic neuropathic patients in earlier anticipation of the activation of the anterior body-muscles. In particular, the earlier onset of Tibialis Anterior is likely to be performed to adjust the movement timing and to compensate for the delay in the recruitment of the motor units. This anticipation might be involved in the altered postural control with increased balance impairment detected in diabetic neuropathic patients, and thereby it might also be proposed as an index of neuropathy, evidenced in a simple and non-invasive manner.

A stereophotogrammetric-based method to assess spatio-temporal gait parameters on healthy and Parkinsonian subjects.

Generally, the study of gait requires the detection of successive heel contacts and toe-off instants. Traditional gait analysis methods obtain these gait events using dynamometric platforms together with stereophotogrammetric data. Usually, are kept valid only those walking trials where the subjects step on each platform by only one foot. For subjects suffering from walking impairments it is very difficult or sometimes impossible to walk naturally and step properly on the dynamometric platforms. The aim of the present study is to propose a new method to identify, in an automatic manner, the initial contact (IC) and the toe-off (TO) time instants using only stereophotogrammetric data and a classic gait analysis protocol. The assessment of spatio-temporal gait variables during natural walking is also performed. The study consisted in analyzing healthy and Parkinsonian elderly subjects. The reliability of the proposed stereophotogrammetric-based method was tested by direct comparison with the IC and TO instants determined by the dynamometric platform data. The absence of any statistically significant differences between the values estimated by the two different modalities, highlights the reliability of the proposed method in the assessment of these two gait events. Results underline, as expected, the reduction of walking velocity in pathological patients during free ambulation. The present study proposes this method as a valid alternative to the traditional technique that use dynamometric platforms to identify main gait events, for subjects unable to walk naturally and to step properly on the platforms.

Assessment of the activation patterns of the muscles involved in the FR test in diabetic neuropathic patients.

This study was designed to assess, in elderly neuropathic diabetic (DN) patients, the activation patterns of the main muscles involved in the Functional Reach (FR) Test, a well-recognized method to identify elderly subjects at risk of recurrent falls. Surface electromyographic (sEMG) analysis of Sternocleidomastoideus (Scm), Rectus Abdominis (RAbd), Erectores Spinae at L4 level (L4), Rectus Femoris (RF), Hamstrings (Ham), Tibialis Anterior (TA) and Soleus (Sol) was performed to this aim. Results in DN patients are compared with a control group (CH) of healthy age-matched subjects. In DN patients, TA is identified as the first muscle to be recruited (ON at -34% of the FR-period) before the movement start, in order to initiate the body forward displacement. RF is the first muscle to be recruited after TA and, togheter with RAbd, showed a progressive earlier onset from CH group. Sol and Ham (ON after the FR-start), followed by L4, act mainly as tonic muscles, opposing the movement and preventing falls. Compared to the CH group, the DN subjects show an anticipatory recruitment (-34%±6%) of TA, showing a statistically significant difference (p<;0.05) in comparison to CH group, together with the Scm activation. Results suggest a trend of DN patients in anticipating the activation of the anterior muscles of the body. This is likely due to an attempt to compensate the neuropathy-related proprioception dysfunction and to adjust the movement timing. In conclusion, the present study shows that sEMG is a suitable tool to deepen the interpretation of the FR-test execution and proposes the earlier start of TA as a possible element to identify the presence of neuropathy in diabetic subjects.

Evaluation of gender-related differences in co-contraction activity of shank muscles during gait.

This study aims to investigate the possible differences between genders in co-contractions of tibialis anterior (TA) and gastrocnemius lateralis (GL), during walking at self-selected speed. To this purpose, the statistical gait analysis (SGA) was performed on seven female (F-group) and seven male (M-group) adults. SGA is a recently developed methodology for the characterization of gait, by averaging spatiotemporal and electromyographic parameters over hundreds of strides per subject. Co-contractions were assessed as the overlapping periods between TA and GL activity. Results showed that four co-contraction intervals are present during gait cycle in both groups. No relevant differences between genders were detected in onset-offset time instants of co-activations or in their temporal length. On the contrary, significant differences were observed in the number of strides where each co-contraction happens (i.e. the occurrence frequency). All the four co-contraction intervals result significantly (p<;0.05) more recurrent in females compared to males. This outcome suggests a larger presence of co-contraction activity in females walking, related to a female tendency for a more complex muscular strategy during gait. These findings could be useful to better understand gender differences in walking mechanisms and to develop separated normal walking reference frames for males and females.

The segmented-beat modulation method for ECG estimation.

Electrocardiographic (ECG) tracings corrupted by noise with frequency components in the ECG frequency band, may result useless unless appropriately processed. The estimation of the clean ECG from such recordings, however, is quite challenging; being linear filtering inappropriate. In the common situations in which the R peaks are detectable, template-based techniques have been proposed to estimate the ECG by a template-beat concatenation. However, such techniques have the major limit of not being able to reproduce physiological heart-rate and morphological variability. Thus, the aim of the present study was to propose the segmented-beat modulation method (SBMM) as the technique that overcomes such limit. The SBMM is an improved template-based technique that provides good-quality estimations of ECG tracings characterized by some heart-rate and morphological variability. It segments the template ECG beat into QRS and TUP segments and then, before concatenation, it applies a modulation/demodulation process to the TUP-segment so that the estimated-beat duration and morphology adjust to those of the corresponding original-beat. To test its performance, the SBMM was applied to 19 ECG tracings from normal subjects. There were no errors in estimating the R peak location, and the errors in the QRS and TUP segments were low (≤65 µV and ≤30 µV, respectively), with the former ones being significantly higher than the latter ones. Eventually, TUP errors tended to increase with increasing heart-rate variability (correlation coefficient: 0.59, P<;10(-2)). In conclusion, the new SBMM proved to be a useful tool for providing good-quality ECG estimations of tracings characterized by heart-rate and morphological variability.

Analytical and multibody modeling for the power analysis of standing jumps.

Two methods for the power analysis of standing jumps are proposed and compared in this article. The first method is based on a simple analytical formulation which requires as input the coordinates of the center of gravity in three specified instants of the jump. The second method is based on a multibody model that simulates the jumps processing the data obtained by a three-dimensional (3D) motion capture system and the dynamometric measurements obtained by the force platforms. The multibody model is developed with OpenSim, an open-source software which provides tools for the kinematic and dynamic analyses of 3D human body models. The study is focused on two of the typical tests used to evaluate the muscular activity of lower limbs, which are the counter movement jump and the standing long jump. The comparison between the results obtained by the two methods confirms that the proposed analytical formulation is correct and represents a simple tool suitable for a preliminary analysis of total mechanical work and the mean power exerted in standing jumps.

Assessment of walking speed by a goniometer-based method.

A quantitative gait analysis is essential to evaluate the kinematic, kinetic and electromyographic gait patterns. These patterns are strongly related to the individual spatio-temporal parameters that characterize each subject. In particular, gait speed is one of the most important spatio-temporal gait parameters: it influences kinematic, kinetic parameters, and muscle activity too. The aim of the present study is to propose a new method to assess stride speed using only 1-degree-of-freedom electrogoniometers positioned on hip and knee joints. The model validation is performed comparing the model results with those automatically obtained from another gait analysis system: GAITRite. The results underline the model reliability. These results show that essential spatio-temporal gait parameters, and in particular the speed of each stride, can be determined during normal walking using only two 1-dof electrogoniometers. The method is easy-to-use and does not interfere with regular walking patterns.

Integration of smartphones and webcam for the measure of spatio-temporal gait parameters.

A very low cost prototype has been made for the spatial and temporal analysis of human movement using an integrated system of last generation smartphones and a highdefinition webcam, controlled by a laptop. The system can be used to analyze mainly planar motions in non-structured environments. In this paper, the accelerometer signal as captured by the 3D sensor embedded in one smartphone, and the position of colored markers derived by the webcam frames, are used for the computation of spatial-temporal parameters of gait. Accuracy of results is compared with that obtainable by a gold-standard instrumentation. The system is characterized by a very low cost and by a very high level of automation. It has been thought to be used by non-expert users in ambulatory settings.

Grand rounds to provide feedback on procurement activities.

INTRODUCTION: The Argentine Society of Transplants has set in motion an activity called Grand Rounds to Provide Feedback on Procurement Activities with the purpose of informing, training, and creating awareness by providing information about the evolution of transplanted patients. OBJECTIVE: To measure, describe and analyze the impact that the transplant results presented at the rounds had on participants. RESULTS: One hundred and fifty-eight surveys were conducted. The respondents' average age was 40.06 years (95% confidence interval [CI 95%] 38.39-41.73) including 52.08% women (CI 95%: 43.92%-60.24%); 77.14% physicians (CI 95%: 84.09%-70.18%); 7.85% nurses (CI 95%: 3.4%-12.31%;) and 4.28% surgical nurses and other professional (CI 95%: 0.93%-7.64). When asked how comforted they felt when they learnt about a transplantation, the score prior to the round was 4 (CI 95%: 3.79-4.20) and after it, 4.8 (CI 95%: 4.69-4.90; P < .05). When asked about the transparency of the donation process, the average score before the round was 4.16 (CI 95%: 3.96-4.36) and after it, 4.76 (CI 95%: 4.67-4.86; P < .05). When asked how proactive they considered themselves before, before the average score was 3.54 (CI 95% 3.30-3.78) and post-round, 4.53 (CI 95%: 4.38-4.67; P < .05). When asked if they thought that this activity might be useful for them to manage future donors, 97.41% (CI 95%: 89%-96.98%) of respondents answered affirmatively. The answers to the question whether they thought this activity might increase donation were affirmative in 92.99% of cases; "Don't know", 6.36%; and negative in less than 1%. When consulted about their feelings, the preferred one was "happiness" for 46.82% of respondents; followed by "satisfaction" for 29.36% and "emotion" for 23.80%. The analysis of the open-ended questions revealed that the rounds were perceived as closure of the procurement-transplantation process. CONCLUSIONS: This widely accepted tool was viewed as a vehicle to interconnect links in the work process from organ procurement to transplantation.

Identification of peripheral neuropathy in type-2 diabetic subjects by static posturography and linear discriminant analysis.

BACKGROUND: An early diagnosis of peripheral neuropathy in diabetic patients is useful in order to slow down the progress of this complication. Nerve conduction tests are the gold standard for this diagnosis but they are challenging for the patients. This study examines whether it is possible to assess the presence of diabetic neuropathy at an early stage by static posturography tests. METHODS: Static posturography tests were performed on 37 type-2 diabetic subjects (25 neuropathic patients and 12 non-neuropathic control subjects). Each subject was tested twice under two visual conditions: open and closed eyes. Both "global" (classic) and "structural" (model-based) posturographic parameters (PP) were derived from centre-of-pressure trajectories. A total of 65 PP were computed but only five were selected, normalized and fed to a linear classifier based on linear discriminant analysis. RESULTS: This method correctly classified 86.5% of the patients. Five subjects were misclassified and only 2 false negatives out of 25 neuropathic subjects were erroneously diagnosed as control subjects. CONCLUSIONS: This paper shows that "global" and "structural" parameters derived by static posturography tests, and classic linear statistical approaches, can be used for the diagnosis of neuropathy provided PP are properly chosen and normalized.

An estimation of joint kinematics for a standing reach task using ground reaction data.

The objective of this work was to derive a procedure able to estimate joint kinematics, relative to a simple, yet functionally relevant, motor task, starting from ground reaction data. The minimum number of input data has been used: force platform data, few and simple measurements relative to the subject, and protocol-specific parameters. Standing reach (SR) is the motor task analysed. The biomechanical model is a two degrees-of-freedom inverted pendulum moving on the vertical sagittal plane. Joint kinematics has been estimated solving the related direct dynamic problem stated in function of ground reaction data. The original nonlinear differential equation system of the model showed a high sensitivity to errors affecting initial conditions and experimental input data. Consequently, an approximate solution has been looked for in order to reduce the coupling between the model differential equations. This was possible taking into account the peculiar characteristics of the motor task. An optimization procedure has been deemed necessary in order to minimize the effects of the assumed approximation. The method has been tested both with simulated and with experimental data. In this latter case the validation of the angular kinematics estimated by the proposed method has been performed by means of data obtained by a stereophotogrammetric system. Results show a satisfactory behaviour of the whole optimization procedure. Very good results have been obtained in the case of slow reaching tasks.

Analysis and reliability of posturographic parameters in Parkinson patients at an early stage.

Aim of this work was to evaluate Parkinsonian (PARK) patients at their initial stage of the disease by static posturography in order to study: the stability of posture system; the role of visual input; the influence of an acute administration of levodopa. This would allow the creation of a database that can be useful to follow the progression of the disease. Attention was also focused on the assessment of the reliability of quantitative posturographic parameters (PP); a large number of PP that can be derived using classical, structural, and nonlinear approaches have been considered. Particular attention has been given to this latter approach. The class of PD subjects examined in this work resulted to be very different from classical Parkinsonian subjects studied in literature.

Micropropagation of Glandularia perakii Cov. et Schn. (Verbenaceae), a native species with ornamental potential

Glandularia perakii is a perennial species with beautiful violet flowers that grows in the stony soil of Mendocine pedemont. A plentiful and prolonged flowering confers it an important ornamental potential. In this paper, a method of propagation of G. perakii from nodal segments is reported. Proliferating microshoot cultures were obtained by placing nodal segment on Murashige and Skoog medium (MS) supplemented with 20 g.L-1 of sucrose without growth regulators. In this medium multiplication rate after 20 days was 7.9. Rooted plants were acclimatized successfully.

Micropropagation of Glandularia perakii Cov. et Schn. (Verbenaceae), a native species with ornamental potential

Glandularia perakii is a perennial species with beautiful violet flowers that grows in the stony soil of Mendocine pedemont. A plentiful and prolonged flowering confers it an important ornamental potential. In this paper, a method of propagation of G. perakii from nodal segments is reported. Proliferating microshoot cultures were obtained by placing nodal segment on Murashige and Skoog medium (MS) supplemented with 20 g.L-1 of sucrose without growth regulators. In this medium multiplication rate after 20 days was 7.9. Rooted plants were acclimatized successfully. (AU)

Analysis of ground reaction forces by means of wavelet transform.

OBJECTIVE: To identify details of clinical relevance in ground reaction forces by means of wavelet transform. DESIGN: A retrospective analysis of gait tests performed by total knee replacement patients and a control population has been performed. METHODS: The ground reaction forces have been processed by means of wavelet transform. Results of the wavelet analysis are represented, in a time-frequency plane, by tiles. These are coloured in different grey levels associated to the values of a suitable energy function of the expansion coefficients, resulting from the wavelet transform. RESULTS: The high frequency tiles revealed the presence of irregularities with clinical significance in the first part of the stance phase. These transients in ground reaction forces are described in a quantitative manner allowing to monitor their evolution during the patient observation time. The heel strike transient has been identified by the tile representation of the vertical component of ground reaction forces and confirmed by its correlation with corresponding irregularities in the other components. CONCLUSIONS: The tile representation allows to detect and to quantify details not easily perceivable by the examiner through traditional techniques. The wavelet transform seems particularly appealing for clinical applications such as outcome assessment or treatment evaluation and can assist in the definition of normative models of ground reaction forces. The effectiveness of the procedure suggest to try to automate it. RELEVANCE: The tile representation allows to identify and to keep the records of ground reaction forces clinically significant details, such as heel strike transient.