The effect of superiors' exogenous constraints on budget negotiations

In a world characterized by increasing pressure from financial and product markets, the question of how exogenous constraints affect internal coordination and control processes has become increasingly important. This experiment investigates how two exogenous constraints that superiors can face in budget negotiation settings, increased opportunity costs and financial pressure to meet unit targets, affect budget negotiations and subordinate effort. The results show that both constraints induce more cooperation, but in different ways. Financial pressure on the superior leads to more cooperative negotiation behavior by superiors and subordinates than increased opportunity costs. Specifically, subordinates do not take advantage of the superior's increased financial pressure to enforce lower budgets. After negotiation, both constraints strongly mitigate the negative effects of superior budget imposition on subordinate effort because exogenous constraints eliminate the effect of procedural fairness considerations on subordinate effort.

Robotic lobectomy: tips, pitfalls and troubleshooting

The robotic approach in thoracic surgery has rapidly gained popularity in recent years. As with the introduction of any new technology, this warrants not only adaptation of the operative technique itself, but also the evolution of appropriate troubleshooting strategies. A selected number of helpful tips and technical procedural manoeuvres have been compiled to prevent intraoperative problems, as well as to overcome challenging situations that can arise during robotic lobectomies. In robotic surgery, as opposed to open surgery or video-assisted thoracic surgery, these tips serve an important purpose for the operating surgeon, as well as the entire surgical team involved in the procedure. All the assembled recommendations have proved their effectiveness and have been successfully used by the authors in many procedures. Furthermore, these manoeuvres have been found to be of great importance in the training and proctoring of thoracic surgeons, fellows and residents (bed-side assistants). This guide of clearly arranged tips and troubleshooting strategies offers surgeons a useful tool to overcome difficult situations in robotic lobectomy and preferably improve the reproducibility and safety of their procedures.

Formatives Selbst- und Peer-Assessment im Unterricht peripher venöser Venenpunktion

Das Lernen einer Fertigkeit durch Demonstration und anschließendes Üben wird „Modeling“ genannt. Es basiert darauf, die Diskrepanz zwischen dem Soll-Zustand (Demonstration) und dem Ist-Zustand (Üben) zu erkennen und zu beheben. Dafür ist die exakte Analyse der eigenen Fertigkeiten beim Üben unentbehrlich. Entsprechend ist auch bekannt, dass formative Evaluationen wesentlich zum erfolgreichen Lernen beitragen. Wir haben deshalb im Kurs für periphere Venenpunktion im 3. Studienjahr formatives Selbst- und Peer-Assessment eingeführt. Die Struktur des Assessment entspricht einem DOPS (dircect observation of procedural skills). DOPS stammt aus dem Arbeitsplatz-basieren Assessment und beinhaltet die Beurteilung folgender Kriterien: Vorbereitung/Nachsorge, technische Fertigkeit, Asepsis/Sicherheit, klinische Urteilsfähigkeit, Organisation/Effizienz, professionelles Verhalten, Gesamteindruck. Diese Kriterien wurden für den Unterricht konkretisiert (z.B. Vorbereitung mit Beschriftung der Röhrchen, etc.) und den Studierenden als Merkblätter ausgeteilt. Die Studierenden beurteilten ihre eigene Performance bzw. die eines Kommilitonen, gaben sich Feedback und legten individuelle Lernziele zur Verbesserung fest. Dieses Vorgehen hat den Vorteil, dass sowohl der Übende, als auch der beobachtende Kommilitone, die optimale Ausführung der jeweiligen Tätigkeit reflektieren, welches für beide eine Möglichkeit zum Lernen bietet . Bei der Evaluation des Kurses wurden die Handouts mit den Kriterien der DOPS von Teilnehmern von 9 der 10 Gruppen positiv erwähnt. Im Rahmen eines Debriefing mit den studentischen Tutoren wurde jedoch kritisch angemerkt, dass der Prozess der formativen Selbst- und Fremdevaluation den Studierenden im 3. Studienjahr nicht vertraut war. Es war für die Teilnehmer schwierig konkretes Feedback zu geben und individuelle Lernziele festzulegen. Für das kommende Jahr planen wir in Bezug auf den Kurs folgendes: Die Kriterien der korrekten Durchführung einer Fertigkeit zu formulieren wird von den Teilnehmern als hilfreich empfunden und soll deshalb beibehalten werden. Die Studierenden, die dieses Jahr an dem Kurs teilnehmen, haben bereits ein Feedbacktraining absolviert. Der Kurs kann deshalb neu an Vorkenntnisse anknüpfen. Darüber hinaus soll der Prozess der Festlegung der individuellen Lernziele in der Schulung der studentischen Tutoren des Kurses mehr Gewicht erhalten, damit die Tutoren die Teilnehmer hier gezielt unterstützen können.

The Self-Expanding Symetis Acurate Does Not Increase Cerebral Microembolic Load When Compared to the Balloon-Expandable Edwards Sapien Prosthesis: A Transcranial Doppler Study in Patients Undergoing Transapical Aortic Valve Implantation

Objectives The aim of this study was to quantify potential differences in count, frequency and pattern of high-intensity transient signals (HITS) during transapical transcatheter aortic valve implantation (TA-TAVI), by comparing the Symetis Acurate TA (SA) with the balloon-expandable Edwards Sapien XT (ES) system. Background Recently, the Symetis Acurate TA revalving system has been introduced for TA-TAVI. The Symetis Acurate TA aortic bioprosthesis is self-expanding and is deployed by a specific two-step implantation technique. Whether this novel method increases the load of intraprocedural emboli, detected by transcranial Doppler ultrasound (TCD) as HITS, or not is not clear. Methods Twenty-two patients (n = 11 in each study arm, median logistic EuroScore 20%, median STS score 7%) displayed continuous TCD signals of good quality throughout the entire TA-TAVI procedure and were included in the final analysis. Data are presented as median with interquartile ranges. Results No significant differences were detected in total procedural or interval-related HITS load (SA: 303 [200; 594], ES: 499 [285; 941]; p = 0.16). With both devices, HITS peaked during prosthesis deployment (PD), whereas significantly fewer HITS occurred during instrumentation (SA: p = 0.002; ES: <0.001) or post-implantation PI (SA: p = 0.007; ES: <0.001). PD-associated HITS amounted to almost half of the total HITS load. One patient suffered new disabling stroke at 30 days. Thirty-day mortality amounted to 13.6% (3 of 22 patients). Conclusions Simplified transapical delivery using the self-expanding SA device does not increase HITS, despite of a two-step deployment technique with more interactions with the native aortic valve, when compared to the balloon-expandable ES valve. The similarity in HITS count, frequency and pattern with the two systems suggests a common mechanism for the release of cerebral microemboli.

Effectiveness of Justice-Based Measures in Managing Trust and Privacy Concerns on Social Networking Sites: Intercultural Perspective

The unprecedented success of social networking sites (SNSs) has been recently overshadowed by concerns about privacy risks. As SNS users grow weary of privacy breaches and thus develop distrust, they may restrict or even terminate their platform activities. In the long run, these developments endanger SNS platforms’ financial viability and undermine their ability to create individual and social value. By applying a justice perspective, this study aims to understand the means at the disposal of SNS providers to leverage the privacy concerns and trusting beliefs of their users—two important determinants of user participation on SNSs. Considering that SNSs have a global appeal, empirical tests assess the effectiveness of justice measures for three culturally distinct countries: Germany, Russia and Morocco. The results indicate that these measures are particularly suited to address trusting beliefs of SNS audience. Specifically, in all examined countries, procedural justice and the awareness dimension of informational justice improve perceptions of trust in the SNS provider. Privacy concerns, however, are not as easy to manage, because the impact of justice-based measures on privacy concerns is not universal. Beyond theoretical value, this research offers valuable practical insights into the use of justice-based measures to promote trust and mitigate privacy concerns in a cross-cultural setting.

Aspiration Thrombectomy for Treatment of ST-segment Elevation Myocardial Infarction: a Meta-analysis of 26 Randomized Trials in 11 943 Patients.

INTRODUCTION AND OBJECTIVES There is continued debate about the routine use of aspiration thrombectomy in patients with ST-segment elevation myocardial infarction. Our aim was to evaluate clinical and procedural outcomes of aspiration thrombectomy-assisted primary percutaneous coronary intervention compared with conventional primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. METHODS We performed a meta-analysis of 26 randomized controlled trials with a total of 11 943 patients. Clinical outcomes were extracted up to maximum follow-up and random effect models were used to assess differences in outcomes. RESULTS We observed no difference in the risk of all-cause death (pooled risk ratio = 0.88; 95% confidence interval, 0.74-1.04; P = .124), reinfarction (pooled risk ratio = 0.85; 95% confidence interval, 0.67-1.08; P = .176), target vessel revascularization (pooled risk ratio = 0.86; 95% confidence interval, 0.73-1.00; P = .052), or definite stent thrombosis (pooled risk ratio = 0.76; 95% confidence interval, 0.49-1.16; P = .202) between the 2 groups at a mean weighted follow-up time of 10.4 months. There were significant reductions in failure to reach Thrombolysis In Myocardial Infarction 3 flow (pooled risk ratio = 0.70; 95% confidence interval, 0.60-0.81; P < .001) or myocardial blush grade 3 (pooled risk ratio = 0.76; 95% confidence interval, 0.65-0.89; P = .001), incomplete ST-segment resolution (pooled risk ratio = 0.72; 95% confidence interval, 0.62-0.84; P < .001), and evidence of distal embolization (pooled risk ratio = 0.61; 95% confidence interval, 0.46-0.81; P = .001) with aspiration thrombectomy but estimates were heterogeneous between trials. CONCLUSIONS Among unselected patients with ST-segment elevation myocardial infarction, aspiration thrombectomy-assisted primary percutaneous coronary intervention does not improve clinical outcomes, despite improved epicardial and myocardial parameters of reperfusion. Full English text available from:www.revespcardiol.org/en.

Hormonal and Clinical Predictors for Post-egg Retrieval Pain in Women Undergoing Assisted Reproductive Technology Procedures

OBJECTIVES The intensity of post-egg retrieval pain is underestimated, with few studies examining post-procedural pain and predictors to identify women at risk for severe pain. We evaluated the influence of pre-procedural hormonal levels, ovarian factors, as well as mechanical temporal summation (mTS) as predictors for post-egg retrieval pain in women undergoing in vitro fertilization (IVF). METHODS Eighteen women scheduled for ultrasound-guided egg retrieval under standardized anesthesia and post-procedural analgesia were enrolled. Pre-procedural mTS, questionnaires, clinical data related to anesthesia and the procedure itself, post-procedural pain scores and pain medication for breakthrough pain were recorded. Statistical analysis included Pearson product moment correlations, Mann-Whitney U tests and multiple linear regressions. RESULTS Average peak post-egg retrieval pain during the first 24 hours was 5.0±1.6 on an NRS scale (0=no pain, 10=worst pain imaginable). Peak post-egg retrieval pain was correlated with basal antimullerian hormone (AMH) (r=0.549, P=0.018), pre-procedural peak estradiol (r=0.582, P=0.011), total number of follicles (r=0.517, P=0.028) and number of retrieved eggs (r=0.510, P=0.031). Ovarian hyperstimulation syndrome (OHSS) (n=4) was associated with higher basal AMH (P=0.004), higher peak pain scores (P=0.049), but not with peak estradiol (P=0.13). The mTS did not correlate with peak post-procedural pain (r=0.266, P=0.286), or peak estradiol level (r=0.090, P=0.899). DISCUSSION Peak post-egg retrieval pain intensity was higher than anticipated. Our results suggest that post-egg retrieval pain can be predicted by baseline AMH, high peak estradiol, and OHSS. Further studies to evaluate intra- and post-procedural pain in this population are needed, as well as clinical trials to assess post-procedural analgesia in women presenting with high hormonal levels.

Secondary victimization of crime victims by criminal proceedings

It is conceivable that criminal proceedings cause psychological harm to the crime victims involved, that is, cause secondary victimization. To investigate this hypothesis, negative and positive effects of criminal proceedings were investigated, as perceived by 137 victims of violent crimes who were involved in trials several years previously. Trial outcome and procedure variables were measured as potential causes of secondary victimization. Results show a high proportion of victims reporting overall negative effects. Powerful predictors were outcome satisfaction and procedural justice, but not subjective punishment severity, interactional justice, and psychological stress by criminal proceedings. The practical implications of the results pertain to whether victims should be advised to report the crime to the police or not, and to appropriate prevention and intervention measures of secondary victimization by criminal proceedings.

Transcarotid aortic valve-in-valve implantation for degenerated stentless aortic root conduits with severe regurgitation: a case series

OBJECTIVES Transcatheter aortic valve implantation (TAVI) is routinely performed via the transfemoral and the transapical route. Subclavian and direct aortic access are described alternatives for TAVI. Recently, the transcarotid approach has been shown to be feasible among patients with limited vascular access and severe native aortic valve stenosis. We aim to investigate the feasibility of transcatheter aortic valve-in-valve implantation via the transcarotid access in patients with severe aortic regurgitation due to degenerated stentless Shelhigh conduits using the 29 mm Medtronic CoreValve bioprosthesis. METHODS Three patients with complex vascular anatomy undergoing transcatheter valve-in-valve implantation via the transcarotid route were enrolled in the study. The procedure was performed under general anaesthesia using surgical cut-down to facilitate vascular access. Immediate procedural results as well as echocardiographic and clinical outcomes after 30 days and 6 months of the follow-up were recorded and analysed. RESULTS All three patients underwent unproblematic TAVI and experienced dramatic improvement of symptoms. Mean transvalvular gradient was 3, 6 and 11 mmHg, respectively. Effective orifice area ranged between 1.7 and 2.2 cm(2). Only mild paravalvular regurgitation was detected by echocardiography after 30 days of the follow-up. CONCLUSIONS The transcarotid approach can be safely performed for valve-in-valve procedures using the Medtronic CoreValve in patients with limited vascular access. It enables accurate positioning and implantation of the prosthesis.

Risk Factors for Sternal Wound Infection After Open Heart Operations Vary According to Type of Operation

BACKGROUND This study evaluated whether risk factors for sternal wound infections vary with the type of surgical procedure in cardiac operations. METHODS This was a university hospital surveillance study of 3,249 consecutive patients (28% women) from 2006 to 2010 (median age, 69 years [interquartile range, 60 to 76]; median additive European System for Cardiac Operative Risk Evaluation score, 5 [interquartile range, 3 to 8]) after (1) isolated coronary artery bypass grafting (CABG), (2) isolated valve repair or replacement, or (3) combined valve procedures and CABG. All other operations were excluded. Univariate and multivariate binary logistic regression were conducted to identify independent predictors for development of sternal wound infections. RESULTS We detected 122 sternal wound infections (3.8%) in 3,249 patients: 74 of 1,857 patients (4.0%) after CABG, 19 of 799 (2.4%) after valve operations, and 29 of 593 (4.9%) after combined procedures. In CABG patients, bilateral internal thoracic artery harvest, procedural duration exceeding 300 minutes, diabetes, obesity, chronic obstructive pulmonary disease, and female sex (model 1) were independent predictors for sternal wound infection. A second model (model 2), using the European System for Cardiac Operative Risk Evaluation, revealed bilateral internal thoracic artery harvest, diabetes, obesity, and the second and third quartiles of the European System for Cardiac Operative Risk Evaluation were independent predictors. In valve patients, model 1 showed only revision for bleeding as an independent predictor for sternal infection, and model 2 yielded both revision for bleeding and diabetes. For combined valve and CABG operations, both regression models demonstrated revision for bleeding and duration of operation exceeding 300 minutes were independent predictors for sternal infection. CONCLUSIONS Risk factors for sternal wound infections after cardiac operations vary with the type of surgical procedure. In patients undergoing valve operations or combined operations, procedure-related risk factors (revision for bleeding, duration of operation) independently predict infection. In patients undergoing CABG, not only procedure-related risk factors but also bilateral internal thoracic artery harvest and patient characteristics (diabetes, chronic obstructive pulmonary disease, obesity, female sex) are predictive of sternal wound infection. Preventive interventions may be justified according to the type of operation.

Mechanical Thrombectomy for Isolated M2 Occlusions: A Post Hoc Analysis of the STAR, SWIFT, and SWIFT PRIME Studies.

BACKGROUND AND PURPOSE Mechanical thrombectomy is beneficial for patients with acute ischemic stroke and a proximal anterior occlusion, but it is unclear if these results can be extrapolated to patients with an M2 occlusion. The purpose of this study was to examine the technical aspects, safety, and outcomes of mechanical thrombectomy with a stent retriever in patients with an isolated M2 occlusion who were included in 3 large multicenter prospective studies. MATERIALS AND METHODS We included patients from the Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), Solitaire With the Intention For Thrombectomy (SWIFT), and Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) studies, 3 large multicenter prospective studies on thrombectomy for ischemic stroke. We compared outcomes and technical details of patients with an M2 with those with an M1 occlusion. All patients were treated with a stent retriever. Imaging data and outcomes were scored by an independent core laboratory. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score of 2b/3. RESULTS We included 50 patients with an M2 and 249 patients with an M1 occlusion. Patients with an M2 occlusion were older (mean age, 71 versus 67 years; P = .04) and had a lower NIHSS score (median, 13 versus 17; P < .001) compared with those with an M1 occlusion. Procedural time was nonsignificantly shorter in patients with an M2 occlusion (median, 29 versus 35 minutes; P = .41). The average number of passes with a stent retriever was also nonsignificantly lower in patients with an M2 occlusion (mean, 1.4 versus 1.7; P = .07). There were no significant differences in successful reperfusion (85% versus 82%, P = .82), symptomatic intracerebral hemorrhages (2% versus 2%, P = 1.0), device-related serious adverse events (6% versus 4%, P = .46), or modified Rankin Scale score 0-2 at follow-up (60% versus 56%, P = .64). CONCLUSIONS Endovascular reperfusion therapy appears to be feasible in selected patients with ischemic stroke and an M2 occlusion.

Effects of dialysis modality on blood loss, bleeding complications and transfusion requirements in critically ill patients with dialysis-dependent acute renal failure.

Blood loss and bleeding complications may often be observed in critically ill patients on renal replacement therapies (RRT). Here we investigate procedural (i.e. RRT-related) and non-procedural blood loss as well as transfusion requirements in regard to the chosen mode of dialysis (i.e. intermittent haemodialysis [IHD] versus continuous veno-venous haemofiltration [CVVH]). Two hundred and fifty-two patients (122 CVVH, 159 male; aged 61.5±13.9 years) with dialysis-dependent acute renal failure were analysed in a sub-analysis of the prospective randomised controlled clinical trial-CONVINT-comparing IHD and CVVH. Bleeding complications including severity of bleeding and RRT-related blood loss were assessed. We observed that 3.6% of patients died related to severe bleeding episodes (between group P=0.94). Major all-cause bleeding complications were observed in 23% IHD versus 26% of CVVH group patients (P=0.95). Under CVVH, the rate of RRT-related blood loss events (57.4% versus 30.4%, P=0.01) and mean total blood volume lost was increased (222.3±291.9 versus 112.5±222.7 ml per patient, P <0.001). Overall, transfusion rates did not differ between the study groups. In patients with sepsis, transfusion rates of all blood products were significantly higher when compared to cardiogenic shock (all P <0.01) or other conditions. In conclusion, procedural and non-procedural blood loss may often be observed in critically ill patients on RRT. In CVVH-treated patients, procedural blood loss was increased but overall transfusion rates remained unchanged. Our data show that IHD and CVVH may be regarded as equivalent approaches in critically ill patients with dialysis-dependent acute renal failure in this regard.

Expanding Indications of Transcatheter Heart Valve Interventions.

Transcatheter aortic valve replacement (TAVR) has been established as a less invasive alternative to open-heart surgery in inoperable or high-risk patients presenting with symptomatic severe aortic valve stenosis. The feasibility and efficacy of valve-in-valve implantation in degenerated surgical aortic bioprostheses have also been described and can currently be considered a valuable treatment option in patients deemed unsuitable for repeat cardiac surgery. However, the clinical use of TAVR devices is not limited to the treatment of the tricuspid stenotic aortic valve. Several additional indications including treatment of the bicuspid stenotic aortic valve, aortic regurgitation, and valve-in-valve or valve-in-ring implantation in the mitral or tricuspid position as well as treatment of pure mitral, tricuspid, or pulmonary regurgitation have been described. The purpose of the present review is to summarize the available evidence concerning the emerging off-label use of TAVR devices in current clinical practice. Case examples have been selected to highlight the main procedural steps of each particular intervention.

Evaluation of Medical Students’ Attitudes and Performance of Basic Surgery Skills in a Training Program Using Fresh Human skin, Excised During Body Contouring Surgeries

BACKGROUND: Learning surgical skills in the operating room may be a challenge for medical students. Therefore, more approaches using simulation to enable students to develop their practical skills are required. OBJECTIVES: We hypothesized that (1) there would be a need for additional surgical training for medical students in the pre-final year, and (2) our basic surgery skills training program using fresh human skin would improve medical students' surgical skills. DESIGN: We conducted a preliminary survey of medical students to clarify the need for further training in basic surgery procedures. A new approach using simulation to teach surgical skills on human skin was set up. The procedural skills of 15 randomly selected students were assessed in the operating room before and after participation in the simulation, using Objective Structured Assessment of Technical Skills. Furthermore, subjective assessment was performed based on students' self-evaluation. The data were analyzed using SPSS, version 21 (SPSS, Inc., Chicago, IL). SETTING: The study took place at the Inselspital, Bern University Hospital. PARTICIPANTS: A total of 186 pre-final-year medical students were enrolled into the preliminary survey; 15 randomly selected medical students participated in the basic surgical skills training course on the fresh human skin operating room. RESULTS: The preliminary survey revealed the need for a surgical skills curriculum. The simulation approach we developed showed significant (p < 0.001) improvement for all 12 surgical skills, with mean cumulative precourse and postcourse values of 31.25 ± 5.013 and 45.38 ± 3.557, respectively. The self-evaluation contained positive feedback as well. CONCLUSION: Simulation of surgery using human tissue samples could help medical students become more proficient in handling surgical instruments before stepping into a real surgical situation. We suggest further studies evaluating our proposed teaching method and the possibility of integrating this simulation approach into the medical school curriculum.

Pulmonary Vein Isolation Versus Defragmentation: The CHASE-AF Clinical Trial

BACKGROUND Long-term success rates using ablation for persistent atrial fibrillation (AF) are disappointing and usually do not exceed 60%. OBJECTIVES This study sought to compare arrhythmia-free survival between pulmonary vein isolation (PVI) and a stepwise approach (full defrag) consisting of PVI, ablation of complex fractionated electrograms, and additional linear ablation lines in the setting of atrial tachycardias (AT) in patients with persistent AF after PVI. METHODS From November 2010 to February 2013, 205 patients (151 men; 61.7 ± 10.2 years of age) underwent de novo ablation for persistent AF. Subsequently, patients were prospectively randomized to either PVI alone (n = 78) or full defrag (n = 75), with 52 patients not randomized due to AF termination with the original PVI. The primary endpoint was recurrence of any AT after a blanking period of 3 months. RESULTS During the entire study, 241 ablations were performed (mean: 1.59 in the PVI-alone group, 1.55 in the full-defrag group). With the stepwise approach, termination of AF occurred in 45 (60%) patients. However, arrhythmia-free survival did not differ whether patients underwent single or multiple procedures (p = 0.468). Procedure duration, fluoroscopy time, and radiofrequency duration were significantly longer in the full-defrag group (all p < 0.001). CONCLUSIONS A stepwise approach aimed at AF termination does not seem to provide additional benefit over PVI alone in patients with persistent AF, but it is associated with significantly longer procedural and fluoroscopic duration as well as radiofrequency application time. (The Randomized Catheter Ablation of Persist End Atrial Fibrillation Study [CHASE-AF]; NCT01580124).