Dissertations / Theses on the topic 'Intracavitaire'

Introduction. L’efficacité de la chimiothérapie intracavitaire dépend de la pénétration du produit au sein du péritoine (CHIP) ou de la plèvre. L’hyperthermie et l’hyperpression peuvent augmenter cette pénétration. Ce travail étudie leur effet intrapéritonéal, puis établit la méthode optimale pour les délivrer. L’étude de la faisabilité et de la tolérance d’une hyperpression intrapleurale est essentielle pour transposer ces bénéfices à la cavité thoracique. Méthodes. Quatre groupes de porcs ont reçu une CHIP ouverte avec de l’oxaliplatine à une concentration constante (150 mg/l) pendant 30 minutes en normothermie ou hyperthermie (42-43°C) ; et en pression atmosphérique ou hyperpression (25 cmH2O). Deux groupes ont reçu une procédure fermée en hyperthermie et hyperpression ou forte hyperpression (40 cmH2O). L’absorption systémique et tissulaire d’oxaliplatine a été étudiée. La tolérance d’une perfusion pleurale a été étudiée chez 21 porcs avec ou sans résection associée, avec ou sans chimiothérapie (cisplatine + gemcitabine), à divers niveaux de pression de 15 à 25 cmH2O. Résultats. L’hyperthermie augmente les concentrations de platine dans les surfaces viscérales (p=0.0014), alors que l’hyperpression l’augmente dans les surfaces viscérales et pariétales (respectivement p= 0.0058 et p= 0.0044). L’association des deux facteurs permet d’obtenir les concentrations les plus importantes dans le péritoine viscéral (p= 0.00001) et pariétal (p= 0.0003). Les concentrations obtenues lors des procédures fermées sont inférieures à celles obtenues en ouvert, même lorsque la pression atteint 40 cmH2O. Une chimiothérapie intrapleurale à 20 cmH2O sans résection associée est le niveau maximal toléré durant 60 minutes. Conclusion. Au cours d’une CHIP, l’hyperthermie augmente la pénétration d’oxaliplatine dans le péritoine viscéral, alors que l’hyperpression est efficace dans le péritoine viscéral et pariétal. Leur association est synergique et la procédure ouverte semble la meilleure pour la délivrer. Une chimiothérapie intrapleurale est faisable à 20 cmH2O dans ce modèle<br>Introduction. In order to achieve a good effect, chemotherapy drugs need to penetrate into the peritoneal (HIPEC) or pleural tissue. Hyperthermia and high-pressure may enhance this penetration. The aim of this study was to evaluate their peritoneal effect and to establish the best technique to it. A feasibility study of an intrapleural high-pressure was an essential step to export these effects to the thoracic space. Methods. Four groups of pigs underwent an open HIPEC with a constant concentration (150 mg/l) of oxaliplatin during 30 minutes either in normothermia, or in hyperthermia (42-43°C); and either with atmospheric pressure or with high-pressure (25 cmH2O). Two more groups underwent a closed procedure with hyperthermia and either high-pressure or very high-pressure (40 cmH2O). The systemic and tissue absorption of oxaliplatin were studied. The haemodynamic and respiratory tolerance of a pleural infusion was also tested in 21 pigs with and without associated resection; with and without chemotherapy infusion (cisplatin + gemcitabin) and at various levels of pressure (from 15 to 25 cmH2O). Results. Hyperthermia enhances the concentrations of platinum in visceral surfaces (p=0.0014), whereas high-pressure enhances it both in visceral and in parietal surfaces (p= 0.0058 and p= 0.0044, respectively). Their association obtains the highest concentrations both in the visceral (p= 0.00001) and the parietal peritoneum (p= 0.0003). The concentrations obtained during closed procedure are lower than those achieved with the open technique, even with 40 cmH2O of pressure. A 60-minutes intrapleural chemotherapy perfusion with 20 cmH2O of pressure without any lung resection was the maximal tolerated level. Conclusion. During HIPEC, hyperthermia improves the penetration of oxaliplatin in the visceral peritoneum, whereas high-pressure is effective in both peritoneal surfaces. Their association is synergic and the open technique seems to be the best one to deliver it. An intrapleural chemotherapy with a 20 cmH2O pressure is feasible in this model

Le travail présenté dans cette thèse concerne l'étude, la réalisation et la caractérisation des sondes ultrasonores pour le traitement des tumeurs cancéreuses vaginales, prostatiques ou du rectum; par hyperthermie intra cavitaire. La première partie présente l'approche théorique des caractéristiques des différentes céramiques utilisées. Nous avons étudié le rendement, l'impédance électrique et le circuit électrique équivalent. Un algorithme, utilisant la méthode d'intégration de Simpson, permet le calcul numérique du diagramme de rayonnement. La deuxième partie présente la méthodologie et les résultats expérimentaux. La distribution spatiale de l'intensité acoustique dans l'eau et le glycérol a été mesurée par un détecteur piézo-électrique de petite taille. Ainsi la directivité et la profondeur de pénétration des faisceaux ultrasonores ont été déterminées. Il est montré qu'une vobulation permet d'améliorer l'homogénéité du faisceau sur toute son ouverture. Ainsi ont été étudiées les variations des gradients thermiques dans l'espace, en fonction du temps et de la puissance d'émission. Le refroidissement des applicateurs en surface permet de produire un échauffement en profondeur.

La curiethérapie est une technique ancienne utilisant des sources scellées de faible ou moyenne énergie, toujours pertinente aux plans thérapeutique et économique et toujours en évolution (e.g. curiethérapie à Haut Débit de Dose (HDD)). Cette modalité de traitement permet de délivrer une forte dose d'irradiation dans un volume-cible limité, et permet de minimiser le risque de cancer radio-induit en préservant les Organes à Risques (OAR). Cependant, elle génère des gradients de dose élevés rendant la dosimétrie in vivo délicate à mettre en oeuvre. Les écarts constatés entre doses délivrées et prescrites sont ainsi fréquemment supérieurs à l'écart maximal toléré par la réglementation (± 5%) en usage pour la radiothérapie externe conventionnelle et rendue obligatoire en France par décret depuis 2011. Ce travail de thèse s'est déroulé dans le cadre du projet ANR-TECSAN INTRADOSE et exploite les acquis technologiques antérieurs démontrés à l'issue du projet Européen MAESTRO et du projet ANR-TECSAN CODOFER, en particulier une instrumentation RL/OSL (Radioluminescence - Optically Stimulated Luminescence) multivoies réalisée et validée au plan préclinique dans le cadre du projet MAESTRO. Le projet INTRADOSE a pour objectif de démontrer la faisabilité d'une Dosimétrie In Vivo (DIV) intracavitaire par cathéter dosimétriques à fibres optiques et cristaux d'alumine Al2O3:C dans le but d'améliorer la sécurité des patients traités par Curiethérapie HDD. Ce nouveau type de détecteur permet de mesurer une distribution de doses (mulitpoints) proche des OAR, il présente un petit diamètre (<br>The brachytherapy is an old technique using sealed radioactive sources of low or average energy. This technique is still therapeutically and economically relevant today and always evolving (e.g. High Dose Rate (HDR) brachytherapy). This treatment enables to deliver a high dose of irradiation in a limited tumoral volume and enables to minimize the risk of radiation-induced cancer as preserving the Organs at Risks (OAR). However, this technique generates high dose gradients, which makes in vivo dosimetry difficult to implement. Hence, the deviations observed between doses delivered and prescribed are often up to the maximal deviation tolerated by the nuclear safety regulations (± 5%) in conformational radiotherapy. Those regulations have been made mandatory in France since 2011. This thesis has been done within the framework of the ANR-TECSAN INTRADOSE project and is based on the past technological benefits demonstrated during the MAESTRO European project and the ANR-TECSAN CODOFER project, in particular a RL/OSL multichannel instrumentation (Radioluminescence - Optically Stimulated Luminescence) made and validated in preclinical evaluation during the MAESTRO project. The purpose of the INTRADOSE project is to demonstrate the feasibility of the intracavitary In Vivo Dosimetry (IVD) by dosimetric catheter using optical fibers and alumina crystals Al2O3:C with the aim of improving the safety of patients treated by HDR brachytherapy. This new probe enables to measure a dose distribution (several points) close to the OAR, it offers a little diameter (

Les tumeurs cérébrales primitives de haut grade représentent un enjeu de soins depremière importance. En effet, les plus fréquentes d’entre elles ; les glioblastomes (GBM) sont incurables. Leur médiane de survie est d’une quinzaine de mois lorsque les patients ont bénéficié d’une chirurgie d’exérèse optimale suivie des traitements adjuvants recommandés que sont la radiothérapie et la chimiothérapie. Malgré ces traitements, la récidive est la règle,et ce la plupart du temps à proximité de la cavité d’exérèse initiale. De nouvelles techniques ont vu le jour afin d’améliorer le contrôle local de la tumeur, citons l’implantation des pastilles de carmustine au sein de la cavité chirurgicale. Toutefois le bénéfice de ce type de thérapeutique complémentaire reste limité.C’est dans ce contexte que l’idée d’appliquer la thérapie photodynamique (PDT) aux GBM a émergé. Ce traitement repose sur la présence synchrone de trois éléments : une molécule photosensibilisante, de l’oxygène et l’illumination à une longueur d’onde spécifique déclenchant une cascade métabolique favorisant la mort des cellules gliales cancéreuses.Grâce au développement de photosensibilisant plus spécifique des cellules cancéreuses (PpIX 5-ALA), et notamment gliales, la thérapie photodynamique cérébrale apparaît comme une thérapie additionnelle prometteuse, ayant potentiellement un effet synergique avec les traitements adjuvants recommandés.Dans le cadre de GBM opérables, la PDT intracavitaire a pu être évaluée par notre équipe lors d’un essai clinique de phase I (INDYGO), démontrant sa sécurité d’usage et confirmant des résultats oncologiques encourageants. L’évaluation de la dose de lumière optimale permettant de traiter plus en profondeur reste à réaliser. Un essai de phase II(DOSYNDIGO) y est dédié et est en cours de période d’inclusion.Toutefois, certaines lésions de par leur topographie ne peuvent être opérées sans engendrer des déficits neurologiques permanents et péjoratifs pour le pronostic du patient.L’absence de chirurgie d’exérèse initiale grève d’autant plus le pronostic ultérieur de la maladie en réduisant la période de survie sans progression et survie globale. Dans le cas des patients ne pouvant bénéficier d’une chirurgie d’exérèse, la PDT intracavitaire ne pouvait avoir lieu.C’est dans ce contexte que nous avons mené nos travaux de recherche en direction de la PDT interstitielle (iPDT). Ce traitement minimalement invasif consiste en l’introduction d’une ou plusieurs fibres optiques en conditions stéréotaxiques au sein de la tumeur ou à proximité immédiate afin de délivrer l’illumination requise sans réaliser de craniotomie ni de dissection du parenchyme cérébral. L’iPDT pourrait être indiqué pour les patients nouvellement diagnostiqués non opérables, mais aussi à la récidive. L’iPDT viendrait en complément des standards de soins, sans les modifier. Nous avons rapporté les données de la littérature concernant l’iPDT, puis nous avons proposé des données originales décrivant une procédure clinique standardisée basée sur un algorithme dosimétrique dédié, avant d’entrevoir un essai clinique de phase I<br>High-grade primary brain tumors represent a major care issue. Indeed, the mostfrequent of these tumors, glioblastoma (GBM), have an appalling prognosis. Their mediansurvival is about 15 months when patients have undergone optimal excision surgery followedby the recommended adjuvant treatments of radiotherapy and chemotherapy. In spite of thesetreatments, recurrence is the rule, and most of the time close to the initial excision cavity. Newtechniques have been developed to improve local control of the tumor, such as the implantationof carmustine wafers in the surgical cavity. However, the benefit of this type of complementarytherapy is limited.It is in this context that the idea of applying photodynamic therapy (PDT) to GBM hasemerged. This treatment is based on the synchronous presence of three elements: aphotosensitizer molecule, oxygen and illumination at a specific wavelength triggering ametabolic cascade promoting the death of cancerous glial cells. Thanks to the development ofphotosensitizers specific to cancer cells (PpIX 5-ALA), especially glial cells, brain PDT appearsto be a promising additional therapy, potentially having a synergistic effect with gold-standardadjuvant treatments.In the context of operable GBM, intracavitary PDT has been evaluated by our team ina phase I clinical trial (INDYGO), demonstrating its safety and confirming encouragingoncological results. The evaluation of the optimal light dose for deeper treatment remains tobe done. A phase II trial (DOSYNDIGO) is dedicated to this and is currently in the inclusionperiod.However, some lesions, because of their topography, cannot be operated on withoutcausing permanent neurological deficits that are disabling for the patient prognosis. Theabsence of initial excisional surgery further compromises the prognosis of the disease byreducing the period of progression-free survival and total survival. In patients who could notbenefit from excisional surgery, this additional intra-cavity treatment could not take place. Thisis why we conducted our research work towards interstitial PDT. This involves introducing oneor more optical fibers under stereotactic conditions into the tumor or in its immediate vicinity inorder to deliver the required illumination without performing a craniotomy or dissecting thebrain parenchyma. This minimally invasive treatment represents a real opportunity for allpatients who cannot be operated on, either at the initial diagnosis of their GBM or at recurrence.This interstitial treatment would complement standard of care without modifying it. We reportedthe current data regarding iPDT available in the literature, then we proposed original data witha standardized clinical procedure based on a dedicated dosimetry algorithm, before lookingforward to a phase I clinical trial

Las señales electrocardiográficas, ya sea adquiridas en la piel del paciente (electrocardiogamas de superficie, ECG) o de forma invasiva mediante cateterismo (electrocardiogramas intracavitarios, iECG) ayudan a explorar la condición y función cardíacas del paciente, dada su capacidad para representar la actividad eléctrica del corazón. Sin embargo, la interpretación de las señales de ECG e iECG es una tarea difícil que requiere años de experiencia, con criterios diagnósticos complejos para personal clínico no especialista, que en muchos casos deben ser interpretados durante situaciones de gran estrés o carga de trabajo como en la unidad de cuidados intensivos, o durante procedimientos de ablación por radiofrecuencia (ARF) donde el cardiólogo tiene que interpretar cientos o miles de señales individuales. Desde el punto de vista computacional, el desarrollo de herramientas de alto rendimiento mediante técnicas de análisis basadas en datos adolece de la falta de bases de datos anotadas a gran escala y de la naturaleza de “caja negra” que están asociados con los algoritmos considerados estado del arte en la actualidad. Esta tesis trata sobre el entrenamiento de algoritmos de aprendizaje automático que ayuden al personal clínico en la interpretación automática de ECG e iECG. Esta tesis tiene cuatro contribuciones principales. En primer lugar, se ha desarrollado una herramienta de delineación del ECG para la predicción de los inicios y finales de las principales ondas cardíacas (ondas P, QRS y T) en registros compuestos de cualquier configuración de derivaciones. En segundo lugar, se ha desarrollado un algoritmo de generación de datos sintéticos que es capaz de paliar el impacto del reducido tamaño de las bases de datos existentes para el desarrollo de algoritmos de delineación. En tercer lugar, la metodología de análisis de datos de ECG se aplicó a datos similares, en registros electrocardiográficos intracavitarios, con el mismo objetivo de marcar inicios y finales de activaciones locales y de campo lejano para facilitar la localización de sitios de ablación adecuados en procedimientos de ARF. Para este propósito, el algoritmo de delineación del ECG de superficie desarrollado previamente fue empleado para preprocesar los datos y marcar la detección del complejo QRS. En cuarto y último lugar, el algoritmo de delineación de ECG de superficie fue empleado, junto con un algoritmo de reducción de dimensionalidad, Multiple Kernel Learning, para agregar la información del ECG de 12 derivaciones y lograr la identificación de marcadores que permitan la estratificación del riesgo de muerte súbita cardíaca en pacientes con cardiomiopatía hipertrófica.<br>Electrocardiographic signals, either acquired on the patient’s skin (surface electrocardiogam, ECG) or invasively through catheterization (intracavitary electrocardiogram, iECG) offer a rich insight into the patient’s cardiac condition and function given their ability to represent the electrical activity of the heart. However, the interpretation of ECG and iECG signals is a complex task that requires years of experience, difficulting the correct diagnosis for non-specialists, during stress-related situations such as in the intensive care unit, or in radiofrequency ablation (RFA) procedures where the physician has to interpret hundreds or thousands of individual signals. From the computational point of view, the development of high-performing pipelines from data analysis suffer from lack of large-scale annotated databases and from the “black-box” nature of state-of-the-art analysis approaches. This thesis attempts at developing machine learning-based algorithms that aid physicians in the task of automatic ECG and iECG interpretation. The contributions of this thesis are fourfold. Firstly, an ECG delineation tool has been developed for the markup of the onsets and offsets of the main cardiac waves (P, QRS and T waves) in recordings comprising any configuration of leads. Secondly, a novel synthetic data augmentation algorithm has been developed for palliating the impact of small-scale datasets in the development of robust delineation algorithms. Thirdly, this methodology was applied to similar data, intracavitary electrocardiographic recordings, with the objective of marking the onsets and offsets of events for facilitating the localization of suitable ablation sites. For this purpose, the ECG delineation algorithm previously developed was employed to pre-process the data and mark the QRS detection fiducials. Finally, the ECG delineation approach was employed alongside a dimensionality reduction algorithm, Multiple Kernel Learning, for aggregating the information of 12-lead ECGs with the objective of developing a pipeline for risk stratification of sudden cardiac death in patients with hypertrophic cardiomyopathy.

Intracavitary ultrasound hyperthermia applicators have the potential to better heat certain tumor sites, especially in the pelvic region, than external techniques. To allow deep, controlled heating, an intracavitary phased array has been developed. The hardware required to drive the array was also developed; including amplifiers, phase shifters, power meters and matching circuits. The entire system is computer controlled and capable of driving up to 64 individual ultrasound transducers. This system was used to conduct acoustic field measurements and in vivo perfused kidney experiments with the phased arrays. These results show that these arrays focus as predicted, and are capable of controlling the heating field by electrically controlling the position of the focus.

Trezentos pacientes portadores de colonização intracavitária pulmonar (pelos exames soro lógico e/ou tecidual) foram investigados num período de 10 anos. Os casos foram classificados como: Aspergillus fumigatus (246 casos); Ao niger (21 casos); A. flavus (7 casos); Pseudallescheria boydii (1 caso); colonização fúngica não especificada (21 casos) e colonização actinomicética (4 casos). os grupos A. niger (çasos)e A. fumigatus (controles) foram comparados a respeito de variáveis clínicas e laboratoriais, por serem os mais freqUentes e pela pobreza da literatura sobre A. niger. Esta análise mostrou associações estatisticamente significativas com o A. niger para;sexo masculino (Razão de Chances = 3,28; p <0,05); infecção nosocomial, ocorrendo em hospitais de conservação precária (RC = 150,8; p< 0,001); tuberculose ativa (RC = 8,03; P <0,001); diabete mélito tipo 11 (RC = 10,67; p<O,OOl); e êxito letal (RC = 3,1; p<0,02). Por outro lado, cristais de oxalato de cálcio no escarro e oxalose sitêmica só ocorreram no grupo A.niger. As implicações etiológicas e diagnósticas destes achados sao discutidas, enfatizando o papel do ambiente externo, da oxalose, do acúmulo de ácidos e da tuberculose ativa na etiopatogenia do A. niger.<br>Three hundred patients with intracavitary pulmonary colonization (by serologic and/or tissue examinations) were analysed during a ten years period. The cases were classified as: Aspergillus fumigatus (246 cases); A. niger (21 cases); A. flavus (7cases); Pseudallescheria boydii (1 case); fungal colonization not especified (21 cases) and actinomycetic colonization (4 cases). Due to their frequency and the scarcity of literature about A. niger, the groups A. niger (cases) and A. fumigatus (controls) were compared with respect to clinical and laboratorial variables. This analysis showed statistically significant associations with A. niger for: male sex (Odds Ratio = 3,28; p< 0,05); nosocomial infection, which occurred.in hospitaIs in poor state of repair (aR = 150.8; p<O,ooU; active tuberculosis (aR = 8,03; p<O,OOl); type 11 diabete mellitus (aR = 10,67; p<O,ooU; and lethal outcome (aR = 3, 1; p < o, 02). On the other hand, calcium oxalate crystals in the sputum and sistemic oxalosis occured only in A. niger group. The etiologic and diagnostic implications of these findings are discussed, with emphasis on the role of the externa 1 environernent, oxalosis, acid acurnulation and ative tuberculosis in the etiopathogenesis of A. niger.

This study investigated the design concepts and development of two types of intracavitary ultrasound applicators for use in hyperthermia cancer treatment. Acoustic field calculations, thermal simulations, bench experiments, and in vivo and in vitro studies were utilized to determine and then evaluate the final designs. Each of these devices appears to offer a significant improvement over the existing RF and microwave intracavitary hyperthermia methods. The first type of applicator consisted of a multielement array with the power level to each element independently controlled. This is an important feature in that it allows the power deposition along the length of the array to be modified during a treatment to account for changes in blood perfusion or local heating rates. A temperature regulated water bolus provided acoustic coupling and additional control over the depth of the maximum temperature from the cavity wall. These applicators were tested in vivo and in vitro and were able to induce controlled transrectal heating at depths of 2-3 cm in the canine rectum and prostate gland. The second type of applicator to be developed was an electrically focused array. Computer simulations were used to perform a parametric study of the design of such arrays. These results have indicated that cylindrical arrays of a practical size (7.5 cm long, 1.5 cm O.D.), resonating at 0.5 MHz with individual elements that are up to 1.5 mm wide, can preferentially heat regions 2-5 cm from the array surface. In addition, it was shown that the temperature distribution can be further controlled by scanning the focal position within the target volume, producing heated regions up to 4 cm wide. A practical design was developed and a prototype 0.5 MHz array was constructed and tested in degassed water. These results were in good agreement with the corresponding theoretical simulations.

La tachicardia sopraventricolare da rientro nel nodo atrioventricolare (AVNRT) è la forma più comune di tachicardia parossistica sopraventricolare riscontrata nella pratica clinica, costituendone circa i due terzi dei casi, con incidenza maggiore nei giovani adulti e nel sesso femminile. Il trattamento d’elezione per la risoluzione definitiva dell’AVNRT attualmente è rappresentato dall’ablazione transcatetere a radiofrequenza della via lenta. La via lenta è situata tra l'ostio del seno coronarico e l'anulus tricuspidale, posizione che garantisce un maggiore margine di sicurezza, con riduzione dei casi di blocco atrioventricolare completo inferiori all’ 1 %, poiché più distante dal nodo atrio-ventricolare (AV) compatto e dal fascio di His rispetto alla via rapida, che in passato costituiva il target dell’ablazione con complicazioni nel 20% dei casi. Sebbene il rischio di sviluppare un blocco AV completo si sia notevolmente ridotto con il cambio del target di ablazione, nei rari casi in cui ancora oggi si verifica può essere necessario l’impianto di un pacemaker. Nel seguente progetto di tesi è stato sviluppato un algoritmo di elaborazione dei segnali intracavitari, registrati durante lo studio elettrofisiologico, in grado di identificare con chiarezza l’attivazione del fascio di His nel segnale intracavitario registrato dal catetere posto in prossimità del fascio, anche in situazioni che non lo consentono a causa dell’influenza delle attivazioni atriali e ventricolari. Ciò consente di individuare con maggiore stabilità un punto di protezione della struttura sensibile dal quale occorre mantenere una certa distanza durante l’erogazione dell’energia a radiofrequenza. Il risultato ottenuto rappresenta il primo passo di un approccio, che potrebbe essere ulteriormente ottimizzato in sviluppi futuri, contribuendo ad una significativa riduzione del rischio in termini di sviluppo di blocco atrioventricolare completo durante la procedura.

Thesis (S.M.)--Massachusetts Institute of Technology, Dept. of Electrical Engineering and Computer Science, 1999.<br>Includes bibliographical references (p. 76-82).<br>by Shunmugavelu D. Sokka.<br>S.M.

Thesis (M.Eng.)--Massachusetts Institute of Technology, Dept. of Electrical Engineering and Computer Science, 1998.<br>Includes bibliographical references (leaf 102).<br>Heat transfer in tissue during induced hyperthettnia treatments for prostate disease can be modeled as a multi-input multi-output (MIMO) system. For both focused and unfocused ultrasound arrays, the control of this MIMO system can follow either of two paths. First, a method of system identification can be used to derive a system model from which a gain matrix for a controller can be calculated with methods like that of the linear quadratic regulator (LQR). Second, a trial and error controller can be designed and tuned for each new treatment. Although the first option has clear benefits, this work shows that, with MRI thermometry, the ti.me delay in the temperature feedback loop is sufficient to make any method of system identification difficult within the ti.me constraints of a clinical setting. A proportional plus integrator plus derivative (PID) controller was designed to control the system in computer simulations. This single-input, single-output (SISO) controller was weighted to better control the system by providing parameters scaled to compensate for the geometry of the treatment and thermal coupling of tissue. While the controller performed very well under the conditions for which it was tuned, the level of performance decreased when the parameters of the simulation, such as the rate of perfusion in the tissue were altered. For the unfocused array, a program was written in C++ to run the array and implement the controller for a hyperthermia treatment using MRI thermometry for the feedback signal.<br>by N. Katherine Merrilees.<br>M.Eng.

Orientador: Orlando Petrucci Junior<br>Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas<br>Made available in DSpace on 2018-08-11T10:51:42Z (GMT). No. of bitstreams: 1 Souza_FernandoSergioOlivade_D.pdf: 1025341 bytes, checksum: 15ba5e4c6177129ac03b697eb1f59cb9 (MD5) Previous issue date: 2008<br>Resumo: A estimulação elétrica biventricular apresenta bons resultados no tratamento da insuficiência cardíaca congestiva refratária em portadores de cardiomiopatia dilatada com distúrbios de condução interventricular. OBJETIVO: Apresentar proposição utilizando técnica original simplificada para o implante de eletrodo de estimulação ventricular esquerda epicárdica, baseado na anatomia radiológica e no eletrograma intracavitário,enfatizando o componente atrial, demonstrando o resultado, complicações, ressaltando tempo total de utilização de fluoroscópio. CASUÍSTICA E MÉTODO: De Outubro de 2001 a Março de 2007 foram realizados 234 implantes de marca-passo biventricular em pacientes previamente selecionados, utilizando-se anatomia radiológica e observação de eletrograma intracavitário, dando-se prioridade ao componente atrial, demonstrando a taxa de sucesso, complicações e tempo total de utilização de radioscopia. RESULTADOS: O implante do sistema, utilizando-se a estimulação do ventrículo esquerdo via seio coronariano não foi possível em 19(8,1%) pacientes. Em 30(12,8%) pacientes foram observadas dificuldades na canulação do óstio coronário e em 52(22%) pacientes observaram-se dificuldades de progressão do eletrodo através do seio coronário. O tempo médio de utilização de radioscopia foi 18,69(±15,2) min. CONCLUSÃO: A utilização da técnica simplificada para cateterização do seio coronário sem utilização de bainha, baseada na anatomia radiológica e no eletrograma intracavitário, enfatizando o componente atrial, no tratamento de portadores de cardiomiopatia dilatada avançada, pela terapia de ressincronização cardíaca, demonstrou resultado satisfatório, índice de complicações pequeno, e baixa exposição do operador a radiação ionizante<br>Abstract: Biventricular pacing has present good results in treatment of congestive cardiac heart failure in patients with dilated miocardyopathy and interventricular conduction disturbance. PURPOSE: to present a proposal of using a original simplified technique for left epicardial ventricular lead stimulation, based on the radiological imaging of the anatomy and intracavitary electrogram, emphasizing the atrial component, showing the results, complications, highlighting the total fluoro time. METHODS: From October, 2001 up to March, 2007, 234 biventricular pacemaker implantations were performed in previously selected patients, using radiological anatomy and observation of the intracavitary electrogram, focusing on the atrial component, and showing the success rate, complications and total time of radioscopy utilization. RESULTS: The implantation of the system using left ventricular pacing via coronary sinus was not possible in 19(8,1%) patients. Difficulties on the cannulation of the coronary ostium were felt in 30(12,8%) patients and difficulties of lead advancement through the coronary sinus were felt in 52(22%) patients. The mean time of radioscopy utilization was 18.69(±15,2) min. CONCLUSION: the use of a simplified technique for coronary sinus cannulation without the aid of a sheath, based on the radiological imaging of the anatomy and intracavitary electrogram, emphasizing the atrial component, for the treatment of advanced dilated cardiomyopathy patients with cardiac resynchronization therapy, has shown satisfactory results, low incidence of complications, and low exposure of the operator to ionizing radiation<br>Doutorado<br>Cirurgia<br>Doutor em Cirurgia

Introducció: En l'actualitat, la prostatectomia radical és el tractament d'elecció pels homes amb càncer de pròstata localitzat, però, alguns pacients pateixen d'incontinència urinària (IU) després de la cirurgia. Aquesta pèrdua d'orina es converteix en un problema físic, emocional, psicosocial i econòmic. La fisioteràpia del sòl pelvià és un tractament conservador, indolor i econòmic per a aquesta situació en concret, i dins de la mateixa trobem com a tècniques habituals l'entrenament de la musculatura del sòl pelvià i l'electroestimulació muscular perineal. Com a objectiu principal es pretén comparar l'eficàcia del tractament amb electroestimulació perineal de superfície versus el mateix tractament aplicat de manera intra-cavitària, en la reducció de la IU secundària a prostatectomia radical, i la seva repercussió sobre la qualitat de vida. Material i mètodes: Es va realitzar un assaig clínic controlat i aleatoritzat d'equivalència a simple cec. Es va generar una seqüència d'assignació aleatòria a raó 1: 1 i es va realitzar una inclusió consecutiva fins arribar a un total de 70 pacients. Els grups van rebre 1 sessió setmanal durant 10 setmanes consecutives. El grup intervenció (GI) va realitzar la tècnica amb elèctrodes de superfície i el grup control (GC) amb sonda intraanal. Es van recollir les dades basals, en les setmanes 5 i 10, i als 6 mesos posteriors a la finalització del tractament. Els grams d'orina perduts mesurats amb el Pad Test 24h va ser considerada la variable principal. Altres variables d'estudi van ser la qualitat de vida relacionada amb la salut (QVRS) mesura amb els qüestionaris ICIQ-SF, I-QOL i SF-12, l'estat de la musculatura del sòl pelvià, la continuïtat i adherència a el tractament, els efectes adversos i la satisfacció amb el tractament. Resultats: Es van incloure un total de 70 homes amb una mitjana d'edat de 62,8 (DE 9,4) anys. Tots havien estat intervinguts quirúrgicament de prostatectomia radical i posteriorment van presentar IU derivada d'aquesta cirurgia. Els participants van presentar un Pad Test 24h basal mitjà de 328,3 (DE 426,1) grams. El Pad Test mostrar una disminució significativa dels grams d'orina perduts a les 5 setmanes (121,7 gr en el GC i 159,1 al GI) i 10 setmanes (235,8 gr en el GC i 248,5 al GI) de tractament en ambdós grups (GC p <0,001 i GI p <0,001). La diferència va deixar de ser significativa un cop finalitzat el tractament durant els 6 mesos posteriors (17,3 gr en el GC, p = 0,230 i 11,7 gr en el GI, p = 0,438). Els qüestionaris ICIQ-SF, I-QOL i SF-12 també van mostrar una millora significativa en la QVRS en els diferents períodes d'avaluació. En l'anàlisi de les diferències entre els dos tractaments, en relació a la variable principal (Pad Test 24h) i en relació a la resta de variables recollides mitjançant els qüestionaris de QVRS, s'observa l'absència de significació estadística. Conclusions: Els resultats sobre l'equivalència terapèutica de la EEM aplicada amb elèctrodes de superfície i la EEM aplicada amb sonda intraanal no són concloents i, per tant, no permeten establir l'equivalència terapèutica entre les dues modalitats de tractament. No obstant això, la disminució en els grams d'orina perduts al llarg de la teràpia és clínica i estadísticament significativa en ambdós grups; a més, les diferències en les pèrdues d'orina entre el grup intraanal i el grup de superfície no són significatives, és a dir, la EEM sembla ser eficaç i l'eficàcia de les dues formes d'administració no son diferent des del punt de vista estadístic. La utilització de la EEM millora significativament la QVRS dels participants des de l'inici al final del tractament en les dues modalitats.<br>Introducción: En la actualidad, la prostatectomía radical es el tratamiento de elección para los hombres con cáncer de próstata localizado,sin embargo, algunos pacientes sufren de incontinencia urinaria (IU) después de la cirugía. Esta pérdida de orina se convierte en un problema físico, emocional, psicosocial y económico. La fisioterapia del suelo pelviano es un tratamiento conservador, indoloro y económico para esta situación en concreto, y dentro de la misma encontramos como técnicas habituales el entrenamiento de la musculatura del suelo pelviano y la electroestimulación muscular perineal. Como objetivo principal se pretende comparar la eficacia del tratamiento con electroestimulación perineal de superficie versus el mismo tratamiento aplicado de manera intra-cavitaria, en la reducción de la IU secundaria a prostatectomía radical, y su repercusión sobre la calidad de vida. Material y métodos: Se realizó un ensayo clínico controlado y aleatorizado de equivalencia a simple ciego. Se genero&#769; una secuencia de asignación aleatoria a razón 1:1 y se realizo&#769; una inclusión consecutiva hasta alcanzar un total de 70 pacientes. Los grupos recibieron 1 sesión semanal durante 10 semanas consecutivas. El grupo intervención (GI) realizó la técnica con electrodos de superficie y el grupo control (GC) con sonda intraanal. Se recogieron los datos basales, en las semanas 5 y 10, y a los 6 meses posteriores a la finalización del tratamiento. Los gramos de orina perdidos medidos con el Pad Test 24h fue considerada la variable principal. Otras variables de estudio fueron la calidad de vida relacionada con la salud (CVRS) medida con los cuestionarios ICIQ-SF, I-QOL y SF-12, el estado de la musculatura del suelo pelviano, la continuidad y adherencia al tratamiento, los efectos adversos y la satisfacción con la terapia. Resultados: Se incluyeron un total de 70 hombres con una media de edad de 62,8 (DE 9,4) años. Todos habían sido intervenidos quirúrgicamente de prostatectomía radical y posteriormente presentaron IU derivada de esta cirugía. Los participantes presentaron un Pad Test 24h basal medio de 328,3 (DE 426,1) gramos. El Pad Test mostró una disminución significativa de los gramos de orina perdidos a las 5 semanas (121,7 gr en el GC y 159,1 en el GI) y 10 semanas (235,8 gr en el GC y 248,5 en el GI) de tratamiento en ambos grupos (GC p<0,001 y GI p<0,001). La diferencia dejó de ser significativa una vez finalizado el tratamiento durante los 6 meses posteriores (17,3 gr en el GC, p=0,230 y 11,7 gr en el GI, p=0,438). Los cuestionarios ICIQ-SF, I-QOL y SF-12 también mostraron una mejora significativa en la CVRS en los diferentes periodos de evaluación. En el análisis de las diferencias entre los dos tratamientos, en relación a la variable principal (Pad Test 24h) y en relación al resto de variables con valores recogidos mediante los cuestionarios de CVRS, se observa la ausencia de significación estadística. Conclusiones: Los resultados sobre la equivalencia terapéutica de la EEM aplicada con electrodos de superficie y la EEM aplicada con sonda intraanal no son concluyentes y, por tanto, no permiten establecer la equivalencia terapéutica entre ambas modalidades de tratamiento. Sin embargo, la disminución en los gramos de orina perdidos a lo largo de la terapia es clínica y estadísticamente significativa en ambos grupos; además, las diferencias en las pérdidas de orina entre el grupo intraanal y el grupo de superficie no son significativas, es decir, la EEM parece ser eficaz y la eficacia de las dos formas de administración no ser diferente desde el punto de vista estadístico. La utilización de la EEM mejora significativamente la CVRS de los participantes desde el inicio al final del tratamiento con los dos modos de aplicación.<br>Introduction: Radical prostatectomy is the gold standard treatment for men with localized prostate cancer. This technique is associated with post-operative urinary incontinence. Pelvic floor physiotherapy is a conservative, painless and economical treatment for this specific situation. Kegel exercises and perineal electrostimulation are common techniques to train pelvic floor muscles. The perineal electrostimulation can be applied to the patient with surface electrodes or by an intra-cavitary anal probe. The main objective is to compare the efficacy of the treatment with transcutaneous perineal electrostimulation versus the same intra-cavitary treatment to reduce the magnitude of urinary incontinence after radical prostatectomy, and the impact on the quality of life. Material and method: An equivalence, single-blind, randomized controlled trial was conducted. The groups received 1 weekly therapy session for 10 consecutive weeks. The intervention group (IG) performed the technique with surface electrodes and the control group (CG) with intraanal probe. Data were collected at baseline, at weeks 5 and 10, and 6 months after the end of treatment. Grams of urine lost, measured with the 24h Pad Test, was considered the main variable. Other study variables were health-related quality of life (HRQoL) measured with the ICIQ-SF, I-QOL and SF-12 questionnaires, pelvic floor musculature condition, continuity, adherence to treatment, adverse effects, and satisfaction with treatment. Results: A total of 70 men were included with a mean age of 62.8 (SD 9.4) years. All had undergone radical prostatectomy surgery and subsequently presented UI derived from this surgery. The participants presented a mean baseline 24h Pad Test of 328.3 (SD 426.1) grams. The Pad Test showed a significant decrease in the urine lost grams at 5 weeks (121.7 g in the CG and 159.1 g in the IG; p<0.001) and 10 weeks (235.8 g in the CG and 248.5 g in the IG; p<0.001) of treatment. The difference was no longer significant once the treatment was finished during the subsequent 6 months (17.3 g in the CG, p=0.230 and 11.7 g in the IG, p=0.438). The ICIQ-SF, I-QOL and SF-12 questionnaires also showed a significant improvement in HRQoL in the different evaluation periods. In the CG, an increase of 4.1 points in the ICIQ-SF, an increase of 21.1 points in the I-QOL, a decrease of 1.6 points in the mental and a decrease of 2.7 points in the physical dimensions of SF-12 were observed. In the IG, an increase of 3.8 points in the ICIQ-SF, an increase of 25.1 points in the I-QOL, a decrease of 1.6 points in the mental and a decrease of 2 points in the physical dimensions of SF-12 were also noted. In the analysis of the differences between the two treatments, in relation to the main variable (Pad Test 24h) and to the rest of variables collected through the HRQoL questionnaires, absence of statistical significance was found. Conclusions: The results on the therapeutic equivalence of perineal MES applied with surface electrodes and that applied with an intraanal probe are not conclusive and, therefore, do not allow establishing the therapeutic equivalence between both treatment modalities. However, the decrease in the grams of urine lost throughout the therapy is clinically and statistically significant in both groups (after 5 weeks of treatment and after 10 weeks of treatment); furthermore, the differences in urine losses between the intraanal group and the surface group are not significant, that is, MES seems to be effective and the efficacy of the two forms of administration not to be different from a statistical point of view. The use of electrostimulation improves significantly the HRQoL of the participants from the beginning to the end of the treatment with both modes of application.<br>Universitat Autònoma de Barcelona. Programa de Doctorat en Metodologia de la Recerca Biomèdica i Salut Pública

博士<br>國立清華大學<br>核子工程與科學研究所<br>103<br>This study included two parts: (1) Dose distributions of an 192Ir brachytherapy source in different media ; (2) Influence of metal of the applicator on the dose distribution during brachytherapy. The AAPM TG-43 report provides dose calculation formula and dose parameters for brachytherapy. Although it can be used to evaluate the radiation dose received by the soft tissue, the human organs such as nasopharynx, esophagus, bronchi, lungs and bones are of different densities. AAPM TG-43 does not provide the corresponding dose parameters, therefore, the dose in these tissues can’t be assessed accurately. This may result in tumor recurrence or severe side effects in normal tissues. The MCNPX code is used to investigate the 192Ir dose distribution in water, bone and lung tissue. The glass dosimeter measurement was performed to verify the calculation results. It is found that dose rate constant, radial dose function and anisotropy function in water agreed well with previous literatures. The lung dose near the source, however, would be overestimated by up to 12% if water was used as the lung material. The result implies that if tumor is located in lung, the tumor dose will be overestimated if the difference in material density is not taken into consideration. The calculated results from this study could offer as a clinical reference for improving the accuracy of dose delivered for brachytherapy within the patient of lung cancer. The 2nd part explores how the metal materials of the applicator influence the dose distribution when performing brachytherapy for cervical cancer. (1) 192Ir source located at a single position: For dose distribution in water with the presence of the tandem, differences among measurement, MCNPX calculation and treatment planning system results are < 5%. For dose distribution in water with the presence of the ovoid, the MCNPX result agrees with the measurement. But the doses calculated from treatment planning system were overestimated by up to a factor of 4. This is due to the shielding effect of the metal materials in the applicator not being considered in the treatment planning system. (2) Multiple 192Ir source dwell positions: When the applicator was used in treatment, the absolute dose difference between the TLD results and the MCNPX simulation results agreed within ~ 6 %. Compared with the MCNPX results, the TPS overestimated the ICRU rectum and bladder reference dose point by 58% and 50%, respectively. This result shows that the dose distribution calculated by TPS would be affected due to the use of applicator containing metal material, which suggests that the TPS result should be modified to take into account the shielding effect of the applicator to ensure the accuracy of the dose delivery.