domingo, 2 de enero de 2011

Computers That See You and Keep Watch Over You

Computers That See You and Keep Watch Over You

Hundreds of correctional officers from prisons across America descended last spring on a shuttered penitentiary in West Virginia for annual training exercises.

Smarter Than You Think

Keeping Watch
Articles in this series are examining the recent advances in artificial intelligence and robotics and their potential impact on society.


Some officers played the role of prisoners, acting like gang members and stirring up trouble, including a mock riot. The latest in prison gear got a workout — body armor, shields, riot helmets, smoke bombs, gas masks. And, at this year’s drill, computers that could see the action.
Perched above the prison yard, five cameras tracked the play-acting prisoners, and artificial-intelligence software analyzed the images to recognize faces, gestures and patterns of group behavior. When two groups of inmates moved toward each other, the experimental computer system sent an alert — a text message — to a corrections officer that warned of a potential incident and gave the location.
The computers cannot do anything more than officers who constantly watch surveillance monitors under ideal conditions. But in practice, officers are often distracted. When shifts change, an observation that is worth passing along may be forgotten. But machines do not blink or forget. They are tireless assistants.
The enthusiasm for such systems extends well beyond the nation’s prisons. High-resolution, low-cost cameras are proliferating, found in products like smartphones and laptop computers. The cost of storing images is dropping, and new software algorithms for mining, matching and scrutinizing the flood of visual data are progressing swiftly.
A computer-vision system can watch a hospital room and remind doctors and nurses to wash their hands, or warn of restless patients who are in danger of falling out of bed. It can, through a computer-equipped mirror, read a man’s face to detect his heart rate and other vital signs. It can analyze a woman’s expressions as she watches a movie trailer or shops online, and help marketers tailor their offerings accordingly. Computer vision can also be used at shopping malls, schoolyards, subway platforms, office complexes and stadiums.
All of which could be helpful — or alarming.
“Machines will definitely be able to observe us and understand us better,” said Hartmut Neven, a computer scientist and vision expert at Google. “Where that leads is uncertain.”
Google has been both at the forefront of the technology’s development and a source of the anxiety surrounding it. Its Street View service, which lets Internet users zoom in from above on a particular location, faced privacy complaints. Google will blur out people’s homes at their request.
Google has also introduced an application called Goggles, which allows people to take a picture with a smartphone and search the Internet for matching images. The company’s executives decided to exclude a facial-recognition feature, which they feared might be used to find personal information on people who did not know that they were being photographed.
Despite such qualms, computer vision is moving into the mainstream. With this technological evolution, scientists predict, people will increasingly be surrounded by machines that can not only see but also reason about what they are seeing, in their own limited way.
The uses, noted Frances Scott, an expert in surveillance technologies at the National Institute of Justice, the Justice Department’s research agency, could allow the authorities to spot a terrorist, identify a lost child or locate an Alzheimer’s patient who has wandered off.
The future of law enforcement, national security and military operations will most likely rely on observant machines. A few months ago, the Defense Advanced Research Projects Agency, the Pentagon’s research arm, awarded the first round of grants in a five-year research program called the Mind’s Eye. Its goal is to develop machines that can recognize, analyze and communicate what they see. Mounted on small robots or drones, these smart machines could replace human scouts. “These things, in a sense, could be team members,” said James Donlon, the program’s manager.
Millions of people now use products that show the progress that has been made in computer vision. In the last two years, the major online photo-sharing services — Picasa by Google, Windows Live Photo Gallery by Microsoft, Flickr by Yahoo and iPhoto by Apple — have all started using face recognition. A user puts a name to a face, and the service finds matches in other photographs. It is a popular tool for finding and organizing pictures.
Kinect, an add-on to Microsoft’s Xbox 360 gaming console, is a striking advance for computer vision in the marketplace. It uses a digital camera and sensors to recognize people and gestures; it also understands voice commands. Players control the computer with waves of the hand, and then move to make their on-screen animated stand-ins — known as avatars — run, jump, swing and dance. Since Kinect was introduced in November, game reviewers have applauded, and sales are surging.
To Microsoft, Kinect is not just a game, but a step toward the future of computing. “It’s a world where technology more fundamentally understands you, so you don’t have to understand it,” said Alex Kipman, an engineer on the team that designed Kinect.
‘Please Wash Your Hands’
A nurse walks into a hospital room while scanning a clipboard. She greets the patient and washes her hands. She checks and records his heart rate and blood pressure, adjusts the intravenous drip, turns him over to look for bed sores, then heads for the door but does not wash her hands again, as protocol requires. “Pardon the interruption,” declares a recorded women’s voice, with a slight British accent. “Please wash your hands.”
Three months ago, Bassett Medical Center in Cooperstown, N.Y., began an experiment with computer vision in a single hospital room. Three small cameras, mounted inconspicuously on the ceiling, monitor movements in Room 542, in a special care unit (a notch below intensive care) where patients are treated for conditions like severepneumonia, heart attacks and strokes. The cameras track people going in and out of the room as well as the patient’s movements in bed.
The first applications of the system, designed by scientists at General Electric, are immediate reminders and alerts. Doctors and nurses are supposed to wash their hands before and after touching a patient; lapses contribute significantly to hospital-acquired infections, research shows.

The camera over the bed delivers images to software that is programmed to recognize movements that indicate when a patient is in danger of falling out of bed. The system would send an alert to a nearby nurse.
If the results at Bassett prove to be encouraging, more features can be added, like software that analyzes facial expressions for signs of severe pain, the onset of delirium or other hints of distress, said Kunter Akbay, a G.E. scientist.
Hospitals have an incentive to adopt tools that improve patient safety. Medicare and Medicaid are adjusting reimbursement rates to penalize hospitals that do not work to prevent falls and pressure ulcers, and whose doctors and nurses do not wash their hands enough. But it is too early to say whether computer vision, like the system being tried out at Bassett, will prove to be cost-effective.
Mirror, Mirror
Daniel J. McDuff, a graduate student, stood in front of a mirror at the Massachusetts Institute of Technology’s Media Lab. After 20 seconds or so, a figure — 65, the number of times his heart was beating per minute — appeared at the mirror’s bottom. Behind the two-way mirror was a Web camera, which fed images of Mr. McDuff to a computer whose software could track the blood flow in his face.
The software separates the video images into three channels — for the basic colors red, green and blue. Changes to the colors and to movements made by tiny contractions and expansions in blood vessels in the face are, of course, not apparent to the human eye, but the computer can see them.
“Your heart-rate signal is in your face,” said Ming-zher Poh, an M.I.T. graduate student. Other vital signs, including breathing rate, blood-oxygen level and blood pressure, should leave similar color and movement clues.
The pulse-measuring project, described in research published in May by Mr. Poh, Mr. McDuff and Rosalind W. Picard, a professor at the lab, is just the beginning, Mr. Poh said. Computer vision and clever software, he said, make it possible to monitor humans’ vital signs at a digital glance. Daily measurements can be analyzed to reveal that, for example, a person’s risk of heart trouble is rising. “This can happen, and in the future it will be in mirrors,” he said.
Faces can yield all sorts of information to watchful computers, and the M.I.T. students’ adviser, Dr. Picard, is a pioneer in the field, especially in the use of computing to measure and communicate emotions. For years, she and a research scientist at the university, Rana el-Kaliouby, have applied facial-expression analysis software to help young people withautism better recognize the emotional signals from others that they have such a hard time understanding.
The two women are the co-founders of Affectiva, a company in Waltham, Mass., that is beginning to market its facial-expression analysis software to manufacturers of consumer products, retailers, marketers and movie studios. Its mission is to mine consumers’ emotional responses to improve the designs and marketing campaigns of products.
John Ross, chief executive of Shopper Sciences, a marketing research company that is part of the Interpublic Group, said Affectiva’s technology promises to give marketers an impartial reading of the sequence of emotions that leads to a purchase, in a way that focus groups and customer surveys cannot. “You can see and analyze how people are reacting in real time, not what they are saying later, when they are often trying to be polite,” he said. The technology, he added, is more scientific and less costly than having humans look at store surveillance videos, which some retailers do.
The facial-analysis software, Mr. Ross said, could be used in store kiosks or with Webcams. Shopper Sciences, he said, is testing Affectiva’s software with a major retailer and an online dating service, neither of which he would name. The dating service, he said, was analyzing users’ expressions in search of “trigger words” in personal profiles that people found appealing or off-putting.
Watching the Watchers
Maria Sonin, 33, an office worker in Waltham, Mass., sat in front of a notebook computer looking at a movie trailer while Affectiva’s software, through the PC’s Webcam, calibrated her reaction. The trailer was for “Little Fockers,” starring Robert De Niro and Ben Stiller, which opened just before Christmas. The software measured her reactions by tracking movements on a couple of dozen points on her face — mostly along the eyes, eyebrows, nose and the perimeter of her lips.
To the human eye, Ms. Sonin appeared to be amused. The software agreed, said Dr. Kaliouby, though it used a finer-grained analysis, like recording that her smiles were symmetrical (signaling amusement, not embarrassment) and not smirks. The software, Ms. Kaliouby said, allows for continuous, objective measurement of viewers’ response to media, and in the future will do so in large numbers on the Web.
Ms. Sonin, an unpaid volunteer, said later that she did not think about being recorded by the Webcam. “It wasn’t as if it was a big camera in front of you,” she said.
Christopher Hamilton, a technical director of visual effects, has used specialized software to analyze facial expressions and recreate them on the screen. The films he has worked on include “King Kong,” “Charlotte’s Web” and “The Matrix Revolutions.” Using facial-expression analysis technology to gauge the reaction of viewers, who agree to be watched, may well become a valuable tool for movie makers, said Mr. Hamilton, who is not involved with Affectiva.

Today, sampling audience reaction before a movie is released typically means gathering a couple of hundred people at a preview screening. The audience members then answer questions and fill out surveys. Yet viewers, marketing experts say, are often inarticulate and imprecise about their emotional reactions.
The software “makes it possible to measure audience response with a scene-by-scene granularity that the current survey-and-questionnaire approach cannot,” Mr. Hamilton said. A director, he added, could find out, for example, that although audience members liked a movie over all, they did not like two or three scenes. Or he could learn that a particular character did not inspire the intended emotional response.
Emotion-sensing software, Mr. Hamilton said, might become part of the entertainment experience — especially as more people watch movies and programs on Internet-connected televisions, computers and portable devices. Viewers could share their emotional responses with friends using recommendation systems based on what scene — say, the protagonists’ dancing or a car chase — delivered the biggest emotional jolt.
Affectiva, Dr. Picard said, intends to offer its technology as “opt-in only,” meaning consumers have to be notified and have to agree to be watched online or in stores. Affectiva, she added, has turned down companies, which she declined to name, that wanted to use its software without notifying customers.
Darker Possibilities
Dr. Picard enunciates a principled stance, but one that could become problematic in other hands.
The challenge arises from the prospect of the rapid spread of less-expensive yet powerful computer-vision technologies.
At work or school, the technology opens the door to a computerized supervisor that is always watching. Are you paying attention, goofing off or daydreaming? In stores and shopping malls, smart surveillance could bring behavioral tracking into the physical world.
More subtle could be the effect of a person knowing that he is being watched — and how that awareness changes his thinking and actions. It could be beneficial: a person thinks twice and a crime goes uncommitted. But might it also lead to a society that is less spontaneous, less creative, less innovative?
“With every technology, there is a dark side,” said Hany Farid, a computer scientist at Dartmouth. “Sometimes you can predict it, but often you can’t.”
A decade ago, he noted, no one predicted that cellphones and text messaging would lead to traffic accidents caused by distracted drivers. And, he said, it was difficult to foresee that the rise of Facebook and Twitter and personal blogs would become troves of data to be collected and exploited in tracking people’s online behavior.
Often, a technology that is benign in one setting can cause harm in a different context. Google confronted that problem this year with its face-recognition software. In its Picasa photo-storing and sharing service, face recognition helps people find and organize pictures of family and friends.
But the company took a different approach with Goggles, which lets a person snap a photograph with a smartphone, setting off an Internet search. Take a picture of the Eiffel Tower and links to Web pages with background information and articles about it appear on the phone’s screen. Take a picture of a wine bottle and up come links to reviews of that vintage.
Google could have put face recognition into the Goggles application; indeed, many users have asked for it. But Google decided against it because smartphones can be used to take pictures of individuals without their knowledge, and a face match could retrieve all kinds of personal information — name, occupation, address, workplace.
“It was just too sensitive, and we didn’t want to go there,” said Eric E. Schmidt, the chief executive of Google. “You want to avoid enabling stalker behavior.”

Around the World in 12 Months

Around the World in 12 Months


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Una vida sustentable

A Sustainable Life

Heads of State
It’s the day after New Year’s— broken your resolutions yet? No guilt necessary. After all, it’s hard enough to make it through a day, never mind a year, of good intentions. The problem is often with the resolutions themselves: Stay financially upright. Be loving to your spouse. Eat better. Recycle. Easy to say, but hard to do. So here, a guide on making those resolutions stick — and keeping the guilt at bay.
SUSTAINABLE LOVE

The Happy Marriage Is the ‘Me’ Marriage

For a long, fulfilling partnership: give your partner a chance to e-x-p-a-n-d.
SUSTAINABLE MONEY

Why a Budget Is Like a Diet — Ineffective

The battle, financial experts say, is finding ways to close the gap between good intentions and human nature.
SUSTAINABLE FOOD

Chop, Fry, Boil: Eating for One, or 6 Billion

Three basic recipes to help change the way we eat and live.
SUSTAINABLE FOOD

A Diet for an Invaded Planet: Invasive Species

On the menu, pests we can’t get rid of: kudzu, lionfish and Asian carp.
SUSTAINABLE TECH

Getting Over Our Two-Year Itch

That cellphone you loved in 2009 suddenly seems so yesterday. But is the trash bin the only answer?

Public Workers Facing Outrage as Budget Crises Grow

Public Workers Facing Outrage as Budget Crises Grow

FLEMINGTON, N.J. — Ever since Marie Corfield’s confrontation with Gov. Chris Christie this fall over the state’s education cuts became a YouTube classic, she has received a stream of vituperative e-mails and Facebook postings.
Laura Pedrick for The New York Times
Marie Corfield, a teacher in Flemington, N.J., challenged Gov. Chris Christie over state education cuts at a town hall meeting in September. Their tense exchange was posted on YouTube.
Sabina Louise Pierce for The New York Times
Bill Rahl, a retiree, says people shouldn’t have to give up a pension.

Readers' Comments

Readers shared their thoughts on this article.
“People I don’t even know are calling me horrible names,” said Ms. Corfield, an art teacher who had pleaded the case of struggling teachers. “The mantra is that the problem is the unions, the unions, the unions.”
Across the nation, a rising irritation with public employee unions is palpable, as a wounded economy has blown gaping holes in state, city and town budgets, and revealed that some public pension funds dangle perilously close to bankruptcy. In California, New York, Michigan and New Jersey, states where public unions wield much power and the culture historically tends to be pro-labor, even longtime liberal political leaders have demanded concessions — wage freezes, benefit cuts and tougher work rules.
It is an angry conversation. Union chiefs, who sometimes persuaded members to take pension sweeteners in lieu of raises, are loath to surrender ground. Taxpayers are split between those who want cuts and those who hope that rising tax receipts might bring easier choices.
And a growing cadre of political leaders and municipal finance experts argue that much of the edifice of municipal and state finance is jury-rigged and, without new revenue, perhaps unsustainable. Too many political leaders, they argue, acted too irresponsibly, failing to either raise taxes or cut spending.
A brutal reckoning awaits, they say.
These battles play out in many corners, but few are more passionate than in New Jersey, where politics tend toward the moderately liberal and nearly 20 percent of the work force is unionized (compared with less than 14 percent nationally). From tony horse-country towns to middle-class suburbs to hard-edged cities, property tax and unemployment rates are high, and budgets are pools of red ink.
A new regime in state politics is venting frustration less atGoldman Sachs executives (Governor Christie vetoed a proposed “millionaire’s tax” this year) than at unions. Newark recently laid off police officers after they refused to accept cuts, and Camden has threatened to lay off half of its officers in January.
Fred Siegel, a historian at the conservative-leaning Manhattan Institute, has written of the “New Tammany Hall,” which he describes as the incestuous alliance between public officials and labor.
“Public unions have had no natural adversary; they give politicians political support and get good contracts back,” Mr. Siegel said. “It’s uniquely dysfunctional.”
Even if that is so, this battle comes woven with complications. Across the nation in the last two years, public workers have experienced furloughs and pay cuts. Local governments shed 212,000 jobs last year.
A raft of recent studies found that public salaries, even with benefits included, are equivalent to or lag slightly behind those of private sector workers. The Manhattan Institute, which is not terribly sympathetic to unions, studied New Jersey and concluded that teachers earned wages roughly comparable to people in the private sector with a similar education.
Benefits tend to be the sorest point. From Illinois to New Jersey, politicians have refused to pay into pension funds, creating deeper and deeper shortfalls.
In California, pension costs now crowd out spending for parks, public schools and state universities; in Illinois, spiraling pension costs threaten the state with insolvency.
And taxpayer resentment simmers.
Trouble in New Jersey
To venture into Washington Township in southern New Jersey is to walk the frayed line between taxpayer and public employees, and to hear anger and ambivalence. So many Philadelphians have flocked here over the years that locals call it “South Philly with grass.”
These expatriates tend to be Democrats and union members, or sons and daughters of the same. But property taxes are rising fast, and voters favored Governor Christie, a Republican. Bill Rahl, a graying plug of a retiree, squints and holds his hand against his throat. “I’m up to here with taxes, I can’t breathe, O.K.?” he says. “I don’t know about asking anyone to give up a pension. Just don’t ask for no more.”
Governor Christie faced a vast deficit when he took office last January, and much of the federal stimulus aid for schools was exhausted by June. So he cut deeply into state aid for education; Washington Township lost $900,000. That forced the town to rely principally on property taxes. (Few states lean as heavily on property taxes to finance education; New Jersey ranks 45th in state aid to education.) The town turned its construction office over to a private contractor and shed a few employees.
Sabina Louise Pierce for The New York Times
Michael Tini, left, a card dealer in Atlantic City, N.J., thinks public school teachers should take their fair share of the pain.

Assemblyman Paul D. Moriarty, a liberal Democrat, served four years as mayor of Washington Township. As the bill for pension and health benefits for town employees soared, he struggled to explain this to constituents.
“We really should not receive benefits any better than the people we serve,” he says. “It leads to a lot of resentment against public employees.”
All of which sounds logical, except that, as Mr. Moriarty also acknowledges, such thinking also “leads to a race to the bottom.” That is, as businesses cut private sector benefits, pressure grows on government to cut pay and benefits for its employees.
Robert Master, political director for the Communication Workers of America District 1, which represents 40,000 state workers, speaks to that difficulty.
“The subtext of Christie’s message to a lot of people is that ‘you’re paying for benefits you’ll never have,’ ” he says. “Our challenge is how to defend middle-class health and retirement security, not just for our members but for all working families, when over the past 30 years retirement and health care in the private sector have been essentially demolished.”
This said, some union officials privately say that the teachers’ union, in its battle against cuts to salaries and benefits, misread Mr. Christie and the public temperament. Better to endorse a wage freeze, they say, than to argue that teachers should be held harmless against the economic storm.
In the past, union leaders, too, have proven adept at winning gains not just at the bargaining table. In 2000, union lobbyists persuaded legislators to cut five years off the retirement age for police and firefighters — a move criticized as a budget-buster by a state pension commission. The next year, the budget still was flush and union leaders persuaded the Republican dominated legislature to approve a 9 percent increase in pension benefits. (The legislators added a sweetener for their own pensions.)
Those labor leaders, however, proved less successful in persuading their legislative allies to pay for such benefits. For much of the last two decades, New Jersey has shortchanged its pension contribution.
Governor Christie talked about tough choices this past year — then skipped the state’s required $3.1 billion payment. Now New Jersey has a $53.9 billion unfunded pension liability.
A recent Monmouth University/Gannett New Jersey poll found a narrow plurality of respondents in the state in favor of ditching the pensions for a 401(k)-type program. Public pensions, however, run the gamut, from modest (the average local government pensioner makes less than $20,000 a year while teachers draw about $46,000) to the gilded variety for police and firefighters, some of whom collect six figures. And then there’s the political class, which has made an art form of pension collection.
Some politicians draw multiple pensions as county legislators, called freeholders, and as prosecutors or union leaders. Back in Washington Township, people tend to talk of state government as a casino with fixed craps tables.
A white-haired retired undercover police officer, whose wrap-around shades match his black Harley-Davidson jacket, pauses outside the Washington Township municipal building to consider the many targets. He did not want to give his name.
“Christie has all the good intentions in the world but has he hit the right people?” he says. “I understand pulling in belts, but you talking about janitors and cops, or the free-loading freeholder?”
Good Jobs, at What Cost?
So how much is too much? On their face, New Jersey’s public salaries are not exorbitant. The state has one of the highest per-capita incomes in the country, and the average teacher makes $66,597, which even with benefits is on par with or slightly behind similarly educated private sector workers, according to Jeffrey H. Keefe, a Rutgers professor who studied the issue for the liberal-leaning Economic Policy Institute.
Mr. Keefe, however, uncovered some intriguing class splits. Blue-collar public workers make more money than their private sector counterparts. For such jobs, public unions have established a higher wage floor.
The sense that public workers enjoy certain advantages is not a mirage. Public employees pay into their pension funds, but health benefits often come at a fraction of the cost of most private sector packages.
Government employment also tends to be more secure. When the economy crashed, federal stimulus dollars safeguarded many public jobs. The alternative, many economists point out, was to force towns and cities into extensive layoffs, even as unemployment hovered around 10 percent and millions of Americans sought help from public agencies.
But it accentuated the perception that public workers, however tenuously, inhabited a protected class. That’s a tough sell in Washington Township.
Ask Michael Tini, 54, who works as a card dealer in Atlantic City, about teacher salaries and benefits and he taps his head, not unsympathetically.
“Look, I understand that teachers are the brains of the operation, O.K.? But my hours are cut, and my taxes are killing me.”
He taps his head again. “They have got to take it in the ear, too.”

En este día...

On This Day in HistorySunday, January 02nd
The 002nd day of 2011.
There are 363 days left in the year.
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Today's Highlights in History
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NYT Front PageSee a larger version of this front page.
On Jan. 2, 1905, Japanese Gen. Nogi received from Russian Gen. Stoessel at 9 o'clock P.M. a letter formally offering to surrender, ending the Russo-Japanese War. (Go to article.)On Jan. 21920Isaac Asimovthe immensely popular science fiction writer, was born. Following his death on April 61992his obituary appeared in The Times. (Go to obit. |Other Birthdays)
Editorial Cartoon of the Day

On January 2, 1864Harper's Weekly featured a cartoon about the Civil War. (See the cartoon and read an explanation.)

On this date in:
1492The leader of the last Arab stronghold in Spain surrendered to Spanish forces loyal to King Ferdinand II and Queen Isabella I.
1788Georgia became the fourth state to ratify the U.S. Constitution.
1900Secretary of State John Hay announced the Open Door Policy to prompt trade with China.
1935Bruno Hauptmann went on trial in Flemington, N.J., on charges of kidnapping and murdering the infant son of Charles and Anne Lindbergh. (He was found guilty and executed.)
1960Sen. John F. Kennedy of Massachusetts announced his candidacy for the Democratic presidential nomination.
1965The New York Jets signed University of Alabama quarterback Joe Namath for a reported $400,000.
1974President Richard Nixon signed legislation requiring states to limit highway speeds to 55 mph.
1991Sharon Pratt Dixon was sworn in as mayor of Washington, D.C., becoming the first African-American woman to head a city of Washington's size and prominence.
2006A methane gas explosion at the Sago Mine in West Virginia trapped 13 miners underground for more than 40 hours; only one survived.
2008Oil prices soared to $100 a barrel for the first time.

Current Birthdays
Kate Bosworth turns 28 years old today.

AP Photo/Peter Kramer Actress Kate Bosworth turns 28 years old today.

71Jim Bakker
Former TV evangelist
69Dennis Hastert
Former House speaker
64Jack Hanna
TV host
44Tia Carrere
Actress
43Cuba Gooding Jr.
Actor
42Christy Turlington
Model
40Taye Diggs
Actor
36Dax Shepard
Actor
35Paz Vega
Actress
Historic Birthdays
Isaac Asimov
 
1/2/1920 - 4/6/1992
American science fiction author 

(Go to obit.)

32James Wolfe
1/2/1727 - 9/13/1759
English general who captured Quebec

67Johann Daniel Titius
1/2/1729 - 12/11/1796
Prussian astronomer and physicist

66Rudolf Clausius
1/2/1822 - 8/24/1888
German mathematical physicist

66Justin Winsor
1/2/1831 - 10/22/1897
American librarian and historian

68Ernst Barlach
1/2/1870 - 10/24/1938
German sculpture and playwright

58/59Tex Rickard
1/2/1870/71 - 1/6/1929
American fight promoter and gambler

79Albert Coombs Barnes
1/2/1872 - 7/24/1951
American inventor and art collector

24Saint Theresa of Lisieux
1/2/1873 - 9/30/1897
French Carmelite nun

53Count Folke Bernadotte
1/2/1895 - 9/17/1948
Swedish diplomat, humanitarian

75Sally Rand
1/2/1904 - 8/31/1979
American actress and fan dancer

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SOURCE: The Associated Press
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Tratamiento del dolor en el paciente cirrótico y Avances en el tratamiento de la cirrosis hepática


Tratamiento del dolor en el paciente cirrótico
Pain Management in the Cirrhotic Patient: The Clinical Challenge
Natasha Chandok, and Kymberly S. Watt.
Mayo Clin Proc. 2010;85(5):451-45
Pain management in patients with cirrhosis is a difficult clinical challenge for health care professionals, and few prospective studies have offered an evidence-based approach. In patients with end stage liver disease, adverse events from analgesics are frequent, potentially fatal, and often avoidable. Severe complications from analgesia in these patients include hepatic encephalopathy, hepatorenal syndrome, and gastrointestinal bleeding, which can result in substantial morbidity and even death. In general, acetaminophen at reduced dosing is a safe option. In patients with cirrhosis, nonsteroidal anti-inflammatory drugs should be avoided to avert renal failure, and opiates should be avoided or used sparingly, with low and infrequent dosing, to prevent encephalopathy. For this review, we searched the available literature using PubMed and MedlIne with no limits.

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Avances en el tratamiento de la cirrosis hepática
M. Tejedor Bravo a, A. Albillos Martínez
Servicio de Gastroenterología. Hospital Universitario Ramón y Cajal. Universidad de Alcalá. CIBERehd. Instituto de Salud Carlos III. Madrid. España.
Medicine.2010; 10 :4708-15
La hipertensión portal es la causa de la mayoría de las complicaciones de la cirrosis: la hemorragia variceal, la ascitis y el síndrome hepatorrenal, la peritonitis bacteriana espontánea y la encefalopatía hepática. Los bloqueadores beta adrenérgicos no selectivos están indicados en los pacientes con mayor riesgo de hemorragia variceal, aquellos con varices esofágicas grandes o con varices pequeñas y signos rojos o Child-Pugh C, mientras que la ligadura con bandas es especialmente útil en los enfermos con varices grandes y la contraindicación o intolerancia a los bloqueadores beta. La combinación de los bloqueadores beta y la ligadura con bandas constituye la mejor opción para prevenir el resangrado variceal, reservando la derivación portosistémica percutánea intrahepática (DPPI) con prótesis recubierta para aquellos pacientes en los que fracasa tal tratamiento. El manejo del paciente con hemorragia variceal incluye la reposición enérgica de la volemia, el mantenimiento de una concentración de hemoglobina entre 7-8 g/dl, el empleo de un tratamiento hemostático primario consistente en somatostatina o de terlipresina, junto con una ligadura endoscópica con bandas de la variz sangrante, y en la administración profiláctica de antibióticos. La DPPI con prótesis recubierta está indicada en los pacientes con hemorragia refractaria o recidivante al tratamiento anterior. La implantación precoz (24-48 horas del ingreso) de una DPPI está también indicada en los pacientes con hemorragia variceal en los que la probabilidad de fracaso del tratamiento estándar es alta (Child-Pugh C hasta 13 puntos y Child-Pugh B con hemorragia activa). El síndrome hepatorrenal es la forma de insuficiencia renal más característica de la cirrosis, y su forma rápidamente progresiva (tipo 1) entraña una mortalidad elevada a corto plazo. La combinación de un vasoconstrictor esplácnico como la terlipresina y de la expansión de la volemia con infusión de albúmina revierte aproximadamente el 50% de los casos, y permite al enfermo disponer de un margen para recibir un trasplante hepático. La peritonitis bacteriana espontánea es otra complicación potencial de la cirrosis con ascitis, con una mortalidad que alcanza casi el 30% y que se concentra en los pacientes que desarrollan insuficiencia renal. De ahí que, además de las cefalosporinas de tercera generación, sea necesario prevenir aquella mediante la infusión de albúmina en los pacientes con alto riesgo de padecerla, aquellos con creatinina > 1 mg/dl o bilirrubina > 4 mg /dl. La profilaxis de la peritonitis bacteriana espontánea está indicada en los pacientes con ascitis y un episodio previo de peritonitis, con hemorragia digestiva alta y con proteínas en el líquido ascítico < 1,5 g/dl e insuficiencia renal (creatinina >1,2 mg/dl) o Child-Pugh #> 9. Varios ensayos clínicos controlados sugieren que la inhibición selectiva de inhibidores del receptor V2 de la vasopresina con fármacos como el tolvaptán puede ser útil para corregir la hiponatremia, que con frecuencia contribuye a aumentar la morbilidad del paciente con cirrosis y ascitis. Por último, mencionar la utilidad que ha demostrado la rifaximina, un antibiótico de amplio espectro no absorbible, para reducir la recurrencia de la encefalopatía hepática.


Atentamente
Anestesiología y Medicina del Dolor