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BackgroundThe COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans.MethodsAmerican Association of Endocrine Surgeon members were surveyed for participation. A Research Electronic Data Capture survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. The information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon.ResultsTwelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (interquartile range, 44-66) years. Forty percent (34) of patients had not been seen since their original surgical appointment was delayed; 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs 82.2% of men, χ2= 3.84, P= .05). Median duration of delay was 70 (interquartile range, 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/gastrointestinal neuroendocrine tumors (1.3%). In addition, 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. The duration of delay was not associated with disease progression (P= .96) or a change in operative plan (P= .66).ConclusionAlthough some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicated that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease.

En los últimos años se han generado en diversos escenarios científicos y académicos disputas frente a la posibilidad o alternativa de realizar investigación en Ciencias Sociales a través de la modalidad multimétodo. Por tal razón, el presente artículo tiene como finalidad analizar las posturas de diversos autores en torno a la modalidad del multimétodo como integración metodológica en la investigación. La revisión documental procura brindar algunas luces en cuanto al esclarecimiento de su significancia, implicancia, conveniencia en la práctica investigativa, cuyo análisis de contenido permite un acercamiento al tema. Además, precisa las estrategias de integración metodológica propuesto por Morgan (1997), y Bericat (1998). Se concluye que la implementación de la modalidad multimétodo debe corresponder de manera armónica a la situación en estudio y, por ende, la articulación coherente en el marco metodológico a través de que aporta cada enfoque.

RESUMEN: Ante la escasez de análisis sobre la responsabilidad pública, algunos han creído que el Estado es responsable por el hecho de sus cocontratantes, sin distinción, incluidos sus concesionarios. Una revisión de la jurisprudencia permite apreciar que la categoría “contraparte contractual” de la administración está lejos de ser uniforme. El estudio sugiere que, al contrario, pueden vislumbrarse al menos cuatro regímenes distintos de responsabilidad.

Knowing the areas of service, actions, and parameters that can influence patient perception about a service provided can help hospital executives and healthcare workers to devise improvement plans, leading to higher patient satisfaction.To identify inpatient satisfaction determinants, assess their relationships with hospital variables, and improve patient satisfaction through interventions.We studied the inpatient population of an eight-hospital tertiary medical center in 2015. The satisfaction determinants were based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey answers and included clinical and organizational variables.Interventions began at the end of 2016 included bedside care coordination rounds (BCCR), medications best practices alert (BPA), connect transitions post-discharge calls (CONNECT Transitions) and a framework for provider-patient interactions called AIDET (Acknowledge, Introduce, Duration, Explain, and Thank). Substantial impact upon patient satisfaction was observed after the introduction of these interventions.Three groups were identified: 1. high satisfaction, which correlated with race, surgery, and cancer care; 2. low satisfaction, correlated with elderly, emergency room, intensive care unit, chronic obstructive pulmonary disease, and vascular diseases; and 3. neutral, correlated with hospital-acquired complications, several diagnostic procedures, and medical care delay. Significant improvements in the 3 groups were achieved with interventions that optimize care provider interactions with patients and their families.Based on the HCAHPS-based analysis, we implemented new measures and programs for addressing coordination of care, improving patient safety, reducing the length of stay, and ultimately improving patient satisfaction.

On March 11, 2020, the Director-General of the World Health Organization (WHO) declared the disease caused by SARS-CoV-2 (COVID-19) as a pandemic. The spread and evolution of the pandemic is overwhelming the healthcare systems of dozens of countries and has led to a myriad of opinion papers, contingency plans, case series and emerging trials. Covering all this literature is complex. Briefly and synthetically, in line with the previous recommendations of the Working Groups, the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC) has prepared this series of basic recommendations for patient care in the context of the pandemic.

Annually, companies invest vast amounts of resources into research and development (R&D) in order to remain competitive in today's markets. This investment intensive effort needs to be carefully managed and monitored in order to make the most of these investments. Making informed decisions regarding resource allocation is vital for maximizing return on investment (ROI). One important way to achieve this is use of a valuation model that is capable of estimating the potential return of R&D investment by assessing among other parameters, the level of uncertainty and risk associated with this kind of project. This paper presents a valuation decision model that has been applied to the renewable and environmental sector. Here we present a flexible, user-friendly and understandable model that reflects the intrinsic risks associated with R&D projects. The model can be customized for use across a variety of capital intensive and medium-long term R&D projects in the private and public realms. A real-life case study is used to illustrate the utility of the model within the biofuel sector; specifically, for a project focused on the production of biofuel from municipal solid waste. Use of valuation models, such as the one described here, when used from the very initial phases of the project till project completion can serve a vital role in R&D management—one that enables decision-makers to define realistic and productive targets throughout the full R&D project period., Work in Granada was supported by a grant ( RTI2018-094370-B-I00 ) from the Agencia Estatal de Investigación del Ministerio de Ciencia y Universidades de España.

Purpose Only 34% of breast cancer survivors engage in the recommended level of physical activity because of a lack of accountability and motivation. Methodist Hospital Cancer Health Application (MOCHA) is a smartphone tool created specifically for self-reinforcement for patients with cancer through the daily accounting of activity and nutrition and direct interaction with clinical dietitians. We hypothesize that use of MOCHA will improve the accountability of breast cancer survivors and help them reach their personalized goals. Patients and Methods Women with stages I to III breast cancer who were at least 6 months post–active treatment with a body mass index (BMI) greater than 25 kg/m2 were enrolled in a 4-week feasibility trial. The primary objective was to demonstrate adherence during weeks 2 and 3 of the 4-week study period (14 days total). The secondary objective was to determine the usability of MOCHA according to the system usability scale. The exploratory objective was to determine weight loss and dietitian-participant interaction. Results We enrolled 33 breast cancer survivors who had an average BMI of 31.6 kg/m2. Twenty-five survivors completed the study, and the average number of daily uses was approximately 3.5 (range, 0 to 12) times/day; participants lost an average of 2 lbs (+4 lbs to −10.6 lbs). The average score of usability (the second objective) was 77.4, which was greater than the acceptable level. More than 90% of patients found MOCHA easy to navigate, and 84% were motivated to use MOCHA daily. Conclusion This study emphasizes the importance of technology use to improve goal adherence for patients by providing real-time feedback and accountability with the health care team. MOCHA focuses on the engagement of the health care team and is integrated into clinical workflow. Future directions will use MOCHA in a long-term behavior modification study.

Resumen: Desde 2004 el derecho chileno cuenta con legislación especial aplicable a la responsabilidad del Estado originada en el desempeño de los organismos públicos en el campo sanitario, extendiendo al terreno hospitalario el sistema de la responsabilidad por falta de servicio. Este trabajo intenta una categorización de los casos que se presentan en la materia, tomando en cuenta las especificidades de la actividad hospitalaria pública.

Summary The production of liquid biofuels to blend with gasoline is of worldwide importance to secure the energy supply while reducing the use of fossil fuels, supporting the development of rural technology with knowledge‐based jobs and mitigating greenhouse gas emissions. Today, engineering for plant construction is accessible and new processes using agricultural residues and municipal solid wastes have reached a good degree of maturity and high conversion yields (almost 90% of polysaccharides are converted into monosaccharides ready for fermentation). For the complete success of the 2G technology, it is still necessary to overcome a number of limitations that prevent a first‐of‐a‐kind plant from operating at nominal capacity. We also claim that the triumph of 2G technology requires the development of favourable logistics to guarantee biomass supply and make all actors (farmers, investors, industrial entrepreneurs, government, others) aware that success relies on agreement advances. The growth of ethanol production for 2020 seems to be secured with a number of 2G plants, but public/private investments are still necessary to enable 2G technology to move on ahead from its very early stages to a more mature consolidated technology.

Petrol prices between December 2015 and January 2016 have been at their lowest in years. These more affordable gasoline prices encourage less efficient car‐based transportation and longer trips, which is, in turn, expected to lead to increased carbon dioxide emissions and increased greenhouse gas levels in the atmosphere. Terrestrial transport can represent up to 20% of all C emissions to the atmosphere (www.eea.europa.eu). In addition to emissions from terrestrial vehicles, about 2% of all human carbon dioxide emissions are the result of aircraft emissions – many of which represent vacation trips. The relationship between tourism, as a global industry, and energy use is often neglected (Becken, 2002). This is despite the fact that if tourism continues to grow at currently predicted rates, it will lead to considerable increases in aircraft emissions by 2050. At present, the Natural Resources Defense Council indicates that it is estimated that air travel emits more than 650 million metric tonnes of carbon dioxide annually – equivalent to the pollution from 136 million cars, making the increased use of sustainable biofuels critical for reducing its carbon footprint (Martinez, 2014). Kyoto Protocols and the most recent Paris Protocols are calling for the use of clean, green and renewable transportation fuels to replace gasoline, diesel and jet fuel (United Nations, 2016). Biofuels for motor vehicles are considered a potential alternative for carbon emission savings because biofuels are produced through processes that significantly reduce net emissions (Fargioni et al., 2008). A number of biofuel programmes have been implemented in the United States and the European Union with the aim of not only reducing emissions but also reducing the importation of fossil fuels and enhancing the security of fuel supply at a national level. Despite of these efforts, current estimates indicate that only about 1% of the energy used globally can be traced back to a biofuel source; therefore, there exists great opportunities to increase the use of renewable liquid fuels (Hill et al., 2006).

Currently the chemical industry is largely petroleum based and although the number of ongoing large‐scale biocatalytic processes are relatively low, a trend in growth is expected and the Organization for Economic Co‐operation and Development (OECD) and other agencies aim to have 30% of the total chemical industry based on renewable sources by 2050 (Philp et al., 2013). At present a good number of bio‐based products (bioethanol, acids such as lactic, succinic, itaconic and others) are derived from corn syrup and other sugar sources (Geiser et al., 2016; Ramos et al., 2016a); however, because of the food v fuel controversy new trends have been directed towards the production of bioproducts/biofuels from lignocellulosic biomass—the most abundant and important renewable source for alternative petrol derivatives. We discuss here the bases for sustainable bioenergy production.

To describe the characteristics and the evolution of patients with solid tumours admitted to the ICU and to identify factors associated with hospital mortality and to evaluate three illness severity scores.Descriptive study including 132 patients with solid tumour admitted to the ICU (2010-2016). Demographics and cancer-related data, organ failures, life-supporting therapies and severity scores: APACHE II, SOFA and ICU Cancer Mortality Model (ICMM) were collected.There were 58 patients admitted for medical reasons and 74 for scheduled surgery. The ICU and hospital mortality rate were 12.9% and 19.7%, respectively. The medical reason for admission, the number of organ failures, and the need of life-supporting therapies were significantly associated with a higher mortality (p0.05). In the logistic regression analysis, the three severity scores: SOFA (OR 1.18, 95% IC 1.14-1.48), APACHE II (OR 1.11, 95% CI 1.09-1.27), and ICMM (OR 1.03, 95% CI 1.02-1.07) were independently associated with a higher mortality (p0.05). To evaluate the discrimination, the area under the receiver operating characteristics curves (AUROC) were calculated: APACHE II (0.795, 95% CI 0.69-0.9), SOFA (0.77, 95% CI 0.69-0.864) and ICMM (0.794, 95% CI 0.697-0.891). The comparison of AUC ROC after DeLong's test showed no difference between them.Hospital mortality was associated with the type and severity of acute illness. The three severity scores were useful to assess outcome and accurate in the discrimination, but we did not find a significant difference between them.

Under Chilean public law, liability of a public hospital appears when the institution fails to accomplish its mandatory duties or incurs in negligence. As in private law liability, this system requires to determine the duties of hospitals and, in case of a medical accident, professional standards or duties. This paper explores the two main categories of medical malpractice, namely erroneous diagnosis and treatment failures based on public law theory and judiciary methods.

AIMS The aim of this study was to evaluate the effectiveness of local low-dose urokinase thrombolysis (LLDUT) in haemodynamically stable pulmonary embolism with right ventricular dysfunction (RVD). METHODS AND RESULTS This was a prospective study. LLDUT with a 200,000 IU bolus followed by a 100,000 IU/hr infusion was given. Treatment duration was determined through radiological control performed 48-72 hrs into treatment. A follow-up echocardiogram was performed within seven days after LLDUT completion. Evolution of thrombus burden, pulmonary artery pressures (PAP) and RVD were studied, and haemorrhagic complications and mortality were recorded. Eighty-seven patients were included (62.5±16.5 years). In 67 patients (77%), the baseline echocardiogram showed mild-to-severe RVD, a dilated right ventricle (diameter: 44.4±6.2 mm) and a decreased tricuspid annular plane systolic excursion (14 mm [12-17]). Seventy-six patients (87.4%) experienced radiological improvement. Initially high PAP (mmHg) decreased after LLDUT: systolic 52.4 vs. 35.2 (17.2 [95% CI: 14.5-19.9]; p

Aromatic compounds such as l-phenylalanine, 2-phenylethanol and trans-cinnamate are aromatic compounds of industrial interest. Current trends support replacement of chemical synthesis of these compounds by 'green' alternatives produced in microbial cell factories. The solvent-tolerant Pseudomonas putida DOT-T1E strain was genetically modified to produce up to 1 g l-1 of l-phenylalanine. In order to engineer this strain, we carried out the following stepwise process: (1) we selected random mutants that are resistant to toxic phenylalanine analogues; (2) we then deleted up to five genes belonging to phenylalanine metabolism pathways, which greatly diminished the internal metabolism of phenylalanine; and (3) in these mutants, we overexpressed the pheAfbr gene, which encodes a recombinant variant of PheA that is insensitive to feedback inhibition by phenylalanine. Furthermore, by introducing new genes, we were able to further extend the diversity of compounds produced. Introduction of histidinol phosphate transferase (PP_0967), phenylpyruvate decarboxylase (kdc) and an alcohol dehydrogenase (adh) enabled the strain to produce up to 180 mg l-1 2-phenylethanol. When phenylalanine ammonia lyase (pal) was introduced, the resulting strain produced up to 200 mg l-1 of trans-cinnamate. These results demonstrate that P. putida can serve as a promising microbial cell factory for the production of l-phenylalanine and related compounds.

Infections due Scedosporium spp. in lung transplant recipients are associated with disseminated disease with high mortality rates. The adjunctive local antifungal therapy may be a useful option when systemic treatment is insufficient and/or surgery is not feasible. We present a case of mixed disseminated infection due Scedosporium apiospermum and S. prolificans in a lung transplant recipient. Combined local and systemic antifungal therapy provided an unusual long-term survival in the intensive care unit. Sí

Lung cancer is the leading cause of cancer-related death in the United States, with more than half of the cancers are located peripherally. Computed tomography (CT) has been utilized in the last decade to detect early peripheral lung cancer. However, due to the high false diagnosis rate of CT, further biopsy is often necessary to confirm cancerous cases. This renders intervention for peripheral lung nodules (especially for small peripheral lung cancer) difficult and time-consuming, and it is highly desirable to develop new, on-the-spot earlier lung cancer diagnosis and treatment strategies.The objective of this study is to develop a minimally invasive multimodality image-guided (MIMIG) intervention system to detect lesions, confirm small peripheral lung cancer, and potentially guide on-the-spot treatment at an early stage. Accurate image guidance and real-time optical imaging of nodules are thus the key techniques to be explored in this work.The MIMIG system uses CT images and electromagnetic (EM) tracking to help interventional radiologists target the lesion efficiently. After targeting the lesion, a fiber-optic probe coupled with optical molecular imaging contrast agents is used to confirm the existence of cancerous tissues on-site at microscopic resolution. Using the software developed, pulmonary vessels, airways, and nodules can be segmented and visualized for surgical planning; the segmented results are then transformed onto the intra-procedural CT for interventional guidance using EM tracking. Endomicroscopy through a fiber-optic probe is then performed to visualize tumor tissues. Experiments using IntegriSense 680 fluorescent contrast agent labeling αvβ3 integrin were carried out for rabbit lung cancer models. Confirmed cancers could then be treated on-the-spot using radio-frequency ablation (RFA).The prototype system is evaluated using the rabbit VX2 lung cancer model to evaluate the targeting accuracy, guidance efficiency, and performance of molecular imaging. Using this system, we achieved an average targeting accuracy of 3.04 mm, and the IntegriSense signals within the VX2 tumors were found to be at least two-fold higher than those of normal tissues. The results demonstrate great potential for applying the system in human trials in the future if an optical molecular imaging agent is approved by the Food and Drug Administration (FDA).The MIMIG system was developed for on-the-spot interventional diagnosis of peripheral lung tumors by combining image-guidance and molecular imaging. The system can be potentially applied to human trials on diagnosing and treating earlier stage lung cancer. For current clinical applications, where a biopsy is unavoidable, the MIMIG system without contrast agents could be used for biopsy guidance to improve the accuracy and efficiency.

Previous research on the effects of intracranial stents on arterial hemodynamics has involved computational hemodynamics (CHD) simulations applied to artificially generated stent models. In this study, accurate geometric reconstructions of in-vitro (PTFE tube) and ex-vivo (canine artery) deployed stents based on ultra-high resolution MicroCT imaging were used. The primary goal was to compare the hemodynamic effects of deployment in these two different models and to identify flow perturbations due to deployment anomalies such as stent malapposition and strut prolapse, important adverse mechanics occurring in clinical practice, but not considered in studies using idealized stent models. Ultra-high resolution MicroCT data provided detailed visualization of deployment characteristics allowing for accurate in-stent flow simulation. For stent cells that are regularly and symmetrically deployed, the near wall flow velocities and wall shear stresses were similar to previously published results derived from idealized models. In-stent hemodynamics were significantly altered by misaligned or malapposed stent cells, important effects not realistically captured in previous models. This research shows the feasibility and value of an ex-vivo stent model for MicroCT based CHD studies. It validates previous in-vitro studies and further contributes to the understanding of in-stent hemodynamics associated with adverse mechanics of self-expanding intracranial stents.

The aim of this study was to report the emergence of linezolid-resistant coagulase-negative staphylococci (CoNS) in an intensive care unit.An observational study was conducted in critically ill patients with colonization or infection by linezolid-resistant CoNS between January 2010 and December 2014. We analyzed the epidemiological and clinical features, and the mechanism of resistance to linezolid. We also evaluated the association between the incidence of linezolid-resistant CoNS strains and the consumption of linezolid in the study period.During the study period 49 patients had a linezolid-resistant CoNS strain isolated from clinical samples (blood in 42 cases, urine in 6, peritoneal fluid in 1). Molecular study showed a combination of mechanisms of resistance. Most patients were critically ill (APACHE II score = 21.9 ± 8.3) and nearly all had undergone surgery and invasive procedures, and had prior exposure to antibiotics. Linezolid-resistant CoNS were considered to be contaminants in 42 patients and associated with infection in 7 patients, comprising bacteremia and septic shock in most of them. They were successfully treated with glycopeptides or daptomycin. A modest significant correlation was observed between the decrease in linezolid consumption and the lower incidence of resistant isolates.Linezolid-resistant CoNS had emerged in critically ill patients with severe underlying diseases and prior antibiotic exposure. Most isolates represented colonization; however, linezolid-resistant CoNS can produce serious infections in critically ill patients. Glycopeptides and daptomycin seem to provide useful alternatives for therapy of these infections. A relationship was found between linezolid consumption and the incidence of linezolid-resistant CoNS strains.

espanolDesde fines de 2009 la Corte Suprema ha promovido la idea del “decaimiento del procedimiento administrativo sancionador” como un medio tendiente a limitar la potestad sancionadora de la administracion. En pocas palabras, esta idea consiste en que si una resolucion condenatoria tarda demasiado tiempo en ser adoptada, no tiene valor juridico. La nocion fue rapidamente difundida en el medio legal, dando origen a una jurisprudencia frondosa. Este articulo, sin embargo, cuestiona los fundamentos juridicos de esta doctrina y postula que los remedios que el derecho arbitre para enfrentar la morosidad administrativa no pueden concebirse sin atender al interes general que justifica la potestad sancionadora de la administracion EnglishSince the end of 2009, the Supreme Court has promoted the idea of a "decline in the administrative inquest procedure" as a means to limit the sanctioning authority of the Administration. Briefly explained, if a decision on a sanction takes too long to be adopted, it is of no legal value. The idea spread quickly in the legal environment, giving rise to abundant jurisprudence. However, this article questions the legal basis for this doctrine and postulates that the remedies afforded by law to confront tardy administrative action cannot be conceived without regard to the general interest justifying the sanctioning authority of the Administration.

[ES] El dibujo es una herramienta imprescindible para profundizar en el conocimiento de los objetos estudiados. Esta herramienta se ha visto ampliada y potenciada con el rápido desarrollo de las tecnologías de modelado 3D y renderizado foto realista, ya que el nivel de conocimiento que podemos extraer de los objetos es mayor al ofrecernos muchos más recursos gráficos. La recreación del castillo de Montefrío en época nazarí es un ejemplo de uso de las técnicas infográficas aplicadas al conocimiento histórico y a su difusión. Para este proyecto de animación 3D se ha empleado el renderizado por elementos, el cual se basa en "deconstruir" el render en sus elementos principales, permitiendo un gran control y flexibilidad en el flujo de trabajo del proyecto y durante la fase de postproducción de las imágenes CG., [EN] Drawing is a necessary tool to deepen in the knowledge of the objects studied. This tool has been widened and favoured with the fast development of the 3Dmodeling technologies and realistic photo rendering, because the level of knowledge we can extract from the objects is higher when we are offered far more graphical resources. The recreation of the castle of Montefrío in the nazarí age is an instance of the use of the infographic techniques applied to the historical knowledge and its diffusion. For this project of 3D animation the render elements have been used , which is based on de-built the render in its main elements, allowing a great control and flexibility in the workflow of the project and during the phase of postproduction of CG images.

Introduccion y objetivos La escasez de donantes cardiacos limita la expansion de los programas de trasplante. Nuestro objetivo es valorar el impacto de las diferentes causas de exclusion de la donacion cardiaca y analizar potenciales aspectos superables. Pacientes y metodo Estudio descriptivo, retrospectivo, en el que se incluye a los donantes de organos de un hospital durante 10 anos. Consideramos como potenciales donantes cardiacos a los varones menores de 50 anos y a las mujeres menores de 55 anos. Analizamos las causas de muerte encefalica y las razones de exclusion inicial de la donacion o su posterior rechazo. Resultados Evaluamos a 130 donantes, 69 de ellos considerados potenciales donantes cardiacos. En total 39 fueron donantes efectivos de corazon (el 30% de todos los donantes y el 56,5% de los que, por criterios de edad, podrian haber llegado a serlo). Trece donantes fueron excluidos por antecedentes de cardiopatia, la mayoria en el grupo fallecido por accidente cerebrovascular (ACVA), excepto los que tenian rotura de aneurisma o malformacion (p Conclusiones La disfuncion ventricular supone el 30% de las exclusiones de la donacion cardiaca. La prevencion o reversion de este fenomeno podria aumentar la reserva de donantes cardiacos.

To determine the efficacy of antioxidants in reducing amyloid-beta-induced oxidative stress, and the neuroinflammatory response in the central nervous system (CNS) in vivo, three injections of fibrillar amyloid-beta (fAbeta) or artificial cerebrospinal fluid (aCSF) into the CA1 region of the hippocampus of the rat were made. Concomitantly, one of the three free radical scavengers, i.e. melatonin, vitamin C, or vitamin E was also administered. Besides being a free radical scavenger, melatonin also has immunomodulatory functions. Antioxidant treatment reduced significantly oxidative stress and pro-inflammatory cytokines. There were no marked differences between melatonin, vitamin C, and vitamin E regarding their capacity to reduce nitrites and lipoperoxides. However, melatonin exhibited a superior capacity to reduce the pro-inflammatory response induced by fAbeta.

Medical imaging provides internal anatomical information of the human body to facilitate minimally invasive interventional procedures. Ideally, image-guided intervention requires both the device tracking and imaging to be performed in real time, and recent development of medical imaging and device-tracking techniques makes it possible to visualize both devices and patients’ anatomy during intervention. However, when real-time imaging is not applicable, patient motion tracking and image registration or motion compensation play important roles in generating more realistic image roadmaps for the guidance. Following discussion of the traditional techniques for multimodality image-guided intervention, this chapter focuses on how to integrate device tracking with multimodality imaging and introduces data fusion and dynamic image guidance in the context of image-guided bronchoscopy and percutaneous lung cancer intervention. It is expected that with advanced sensors and dynamic image modeling, more accurate real-time estimation about the interventional roadmap and more efficient, accurate, and safer intervention procedures can be achieved.

Targeted fluorescence imaging agents such as IntegriSense 680 can be used to label integrin α v β 3 expressed in tumor cells and to distinguish tumor from normal tissues. Coupled with endomicroscopy and image-guided intervention devices, fluorescence contrast captured from the fiber-optic imaging technique can be used in a Minimally Invasive Multimodality Image Guided (MIMIG) system for on-site peripheral lung cancer diagnosis. In this work, we propose an automatic quantification approach for IntegriSense-based fluorescence endomicroscopy image sequences. First, a sliding time-window is used to calculate the histogram of the frames at a given timepoint, also denoted as the IntegriSense signal. The intensity distributions of the endomicroscopy image sequences can be briefly classified into three groups: high, middle and low intensities, which might correspond to tumor, normal tissue, and background (air) tissues within the lungs, respectively. At a given time-point, the histogram calculated from the sliding time-window is fit with a Gaussian mixture model, and the average and standard deviation (std), as well as the weight of each Gaussian distribution can be identified. Finally, a threshold can be used to the weighting parameter of the high intensity group for tumor information detection. This algorithm can be used as an automatic tumor detection tool from IntegriSense-based endomicroscopy. In experiments, we validated the algorithm using 20 IntegriSense-based fluorescence endomicroscopy image sequences collected from 6 rabbit experiments, where VX2 tumor was implanted into the lung of each rabbit, and image-guided endomicroscopy was performed. The automatic classification results were compared with manual results, and high sensitivity and specificity were obtained.

Purpose To show the feasibility of computed tomography (CT) image-guided fiberoptic confocal fluorescence molecular imaging in a rabbit lung tumor model. Materials And Methods Eight lung tumor models were created by injection of a VX2 cell suspension. The fluorescent imaging agent IntegriSense 680 was given to the animals 3.5–4 hours before the procedure. CT images were obtained and transferred to the minimally invasive multimodality image-guided (MIMIG) system as a guidance map. A real-time electromagnetically tracked needle was inserted under the visual guidance of the MIMIG system. A second CT image was obtained to confirm the location of the needle tip. Next, fiberoptic fluorescence imaging was acquired along the needle track. Finally, tumor samples were obtained for histopathologic confirmation. Results All cases were performed during breath-hold. Tumor size was 12.5 mm ± 1.6; the distance from the chest wall was 2.1 mm ± 0.5. The needle tip reached the tumor in all cases with an accuracy of 3.3 mm ± 1.6. Only one skin entry point was necessary, and no needle adjustments were required. No pneumothorax was observed. At least two-fold α v β 3 integrin image contrast was detected in the tumor compared with normal lung tissue. Tumor samples were confirmed to have viable VX2 cells and contrast uptake. Conclusions The MIMIG system enables effective in situ fluorescence molecular imaging in a needle biopsy lung procedure. In situ α v β 3 integrin molecular imaging allows molecular characterization of lung tumors at multiple regions and can be used to guide biopsy procedures.

En este trabajo se advierte que la entrada en vigencia del Convenio 169 de la OIT en el derecho chileno suscita expectativas de evolucion en el estatus juridico y politico de los indigenas; no obstante, los desafios que despierta no son faciles de enfrentar. A juicio del autor, el discurso juridico centrado en los derechos humanos, que suele adoptarse en la promocion de los intereses indigenas, parece mostrarse inapropiado para describir la naturaleza de los instrumentos que contempla el Convenio. El riesgo principal que envuelve la falta de un analisis riguroso de estos instrumentos reside en una vulgarizacion del derecho que introduzca inseguridad en las relaciones y altere las instituciones republicanas. En circunstancias que la fuerza normativa de los instrumentos internacionales depende, en el derecho interno, de su puesta en practica mediante reglas precisas, se sugiere entonces mirar el Convenio 169 como una ocasion para deliberar conscientemente la forma en que los chilenos quieren reconocer juridicamente la especificidad de sus pueblos indigenas

Rationale and Objectives Small metallic stents are increasingly used in the treatment of cerebral aneurysms and for revascularization in ischemic strokes. Realistic three-dimensional datasets of a stent were obtained by using three x-ray–based imaging methods in current clinical use. Multislice-CT (MS-CT), C-arm flat detector-CT (C-arm CT, ACT), and flat panel-CT (FP-CT) were compared with high-resolution laboratory MicroCT scans that served as a reference standard. The purpose was to assess and compare the quality and accuracy of current clinical three-dimensional reconstructions of a vascular stents. Material & Methods A 3 × 20 mm Cypher stent was deployed in a straight polytetrafluoroethylene tube and filled with nondiluted iodine contrast and BaSO4. MS-CT images of the static tube phantom and stent were acquired using GE LightSpeed VCT Series, C-arm CT images were obtained using Artis (DynaCT, Siemens), FP-CT were obtained using a preclinical research CT (GE), and MicroCT images were obtained using eXplore Locus SP (GE). DICOM datasets were analyzed using Amira and Matlab. Results Because of blooming effects, the maximum intensity projections (MIPs) and volume renderings generated from MS-CT showed significantly increased strut dimensions with no distinction between the regular struts and connector struts while the lumen diameter is artificially reduced. The shape of the reconstructed stent surface differed remarkably from the real stent. C-arm CT and FP-CT volume renderings more accurately represented the struts. Consistently capturing the structure of the connectors and the strut shape definition was highly threshold dependent. The stent lumen was about 30% underestimated by MS-CT when compared to MicroCT. Conclusion The spatial resolution of current clinical CT for imaging of small metallic stents is insufficient to visualize fine geometrical details. Further improvement in the spatial resolution of clinical imaging technologies combined with better software and hardware for image postprocessing will be necessary for detailed structural analysis, evaluation of the stent lumen in vivo, and to permit accurate assessment of stent patency and early detection potential in-stent stenosis.

We designed and evaluated a real time 3D CT Image Guided Intervention system that integrates in-vivo microendoscopic imaging for on-the-spot visualization of ICG contrast uptake by tumor vessel in peripheral lung tumors. The performance of the system was evaluated in seven rabbits where VX2 cells were implanted in the chest to create peripheral lung tumors. Two weeks later the animal underwent a chest CT scan which was used for creating a real time 3D vision and navigation tracking. ICG was injected fifteen minutes prior to the needle puncture to allow adequate contrast leakage inside the tumor and plasma clearance. After the needle puncture, the microendoscope was introduced inside the tumor for imaging. Visualization of tumor leaky vasculature was possible in all the tumors. The experiment demonstrated that real-time microendoscopy of deep solid organs under a 3D CT image-guided system is possible while providing enough accuracy in reaching tumors without complications.

In multimodality image-guided intervention for cancer diagnosis, a needle with cannula is first punctured using CT or MRI -guided system to target the tumor, then microendoscopy can be performed using an optical fiber through the same cannula. With real-time optical imaging, the operator can directly determine the malignance of the tumor or perform fine needle aspiration biopsy for further diagnosis. During this operation, stable microendoscopy image series are needed to quantify the tissue properties, but they are often affected by respiratory and heart systole motion even when the interventional probe is held steadily. This paper proposes a microendoscopy motion correction (MMC) algorithm using normalized mutual information (NMI)-based registration and a nonlinear system to model the longitudinal global transformations. Cubature Kalman filter is thus used to solve the underlying longitudinal transformations, which yields more stable and robust motion estimation. After global motion correction, longitudinal deformations among the image sequences are calculated to further refine the local tissue motion. Experimental results showed that compared to global and deformable image registrations, MMC yields more accurate alignment results for both simulated and real data.