Intraoperative adverse events during laparoscopic colorectal resection-better laparoscopic treatment but unchanged incidence. Lessons learnt from a Swiss multi-institutional analysis of 3,928 patients.

PURPOSE: Intraoperative adverse events significantly influence morbidity and mortality of laparoscopic colorectal resections. Over an 11-year period, the changes of occurrence of such intraoperative adverse events were assessed in this study. METHODS: Analysis of 3,928 patients undergoing elective laparoscopic colorectal resection based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery was performed. RESULTS: Overall, 377 intraoperative adverse events occurred in 329 patients (overall incidence of 8.4 %). Of 377 events, 163 (43 %) were surgical complications and 214 (57 %) were nonsurgical adverse events. Surgical complications were iatrogenic injury to solid organs (n = 63; incidence of 1.6 %), bleeding (n = 62; 1.6 %), lesion by puncture (n = 25; 0.6 %), and intraoperative anastomotic leakage (n = 13; 0.3 %). Of note, 11 % of intraoperative organ/puncture lesions requiring re-intervention were missed intraoperatively. Nonsurgical adverse events were problems with equipment (n = 127; 3.2 %), anesthetic problems (n = 30; 0.8 %), and various (n = 57; 1.5 %). Over time, the rate of intraoperative adverse events decreased, but not significantly. Bleeding complications significantly decreased (p = 0.015), and equipment problems increased (p = 0.036). However, the rate of adverse events requiring conversion significantly decreased with time (p < 0.001). Patients with an intraoperative adverse event had a significantly higher rate of postoperative local and general morbidity (41.2 and 32.9 % vs. 18.0 and 17.2 %, p < 0.001 and p < 0.001, respectively). CONCLUSIONS: Intraoperative surgical complications and adverse events in laparoscopic colorectal resections did not change significantly over time and are associated with an increased postoperative morbidity.

Are patients with non-invasive papillary thyroid carcinoma, follicular variant (niFV-PTC) and minimally invasive follicular thyroid carcinoma with capsular invasion only (miFTC-CIO) overtreated?An institutional experience

Background. Recently several meetings and position papers advocate a change in terminology regarding thyroid neoplasms with indolent behavior, proposing the term "tumor" instead of "carcinoma". This change concerns non-invasive papillary thyroid carcinoma, follicular variant (niFV-PTC) and minimally invasive follicular thyroid carcinoma with capsular invasion only (miFTC-CIO). The aim of our study was to evaluate the impact of considering niFV-PTC and miFTC-CIO as lesions of low malignant potential, and to see how this change would influence patient management at our institution. Methods. A 32 months retrospective review of all well differentiated thyroid carcinomas (WDTC) (papillary and follicular carcinomas) diagnosed at our institution was performed, excluding tumors of uncertain malignant potential as well as poorly differentiated and anaplastic carcinomas. We retrieved cases of niFV-PTC and miFTC-CIO, reviewed histological slides to confirm diagnosis and recorded patient treatment. Results. A total of 9 (7.3%) niFV-PTC (4 males and 5 females, aged between 30 and 68 years, mean: 50.8 years old) and 2 (1.6%) cases of miFTC-CIO (2 females, 31 and 51 years old) were identified out of 122 WDTC diagnosed in the study period. The initial treatment consisted in 5 lobectomies and 6 total thyroidectomies (3 because of a compressive goiter, 2 because of a fine-needle aspiration diagnosis of suspicious for papillary thyroid carcinoma and 1 because of a fine-needle aspiration diagnosis of papillary carcinoma). The treatment following the histological diagnosis consisted in 4 thyroidectomy completions among patients who underwent simple lobectomy (4/5, 80%) and 9/11 (82%) radioablations with I131. Conclusions. The incidence of niFV-PTC is low at our institution, probably because we apply strict diagnostic criteria for this lesion. Simple lobectomy with negative margins is the treatment of choice in cases diagnosed as niFV-PTC and miFTC-CIO, due to the indolent course of these neoplasms. All cases with thyroidectomy completions and radioablations could have been avoided. As a consequence, the change of such terminology heavily impacts the malignancy risk evaluated cytologically as well as patients' management.

Institutional legacies, employment and professional integration of non EU/EEA doctors in France

Internationally, policies for attracting highly-skilled migrants have become the guidelines mainly used by the Organisation for Economic Co-operation and Development (OECD) countries. Governments are implementing specific procedures to capture and facilitate their mobility. However, all professions are not equal when it comes to welcoming highly-skilled migrants. The medical profession, as a protective market, is one of these. Taking the case of non-EU/EEA doctors in France, this paper shows that the medical profession defined as the closed labour market, remains the most controversial in terms of professional integration of migrants, protectionist barriers to migrant competition and challenge of medical shortage. Based on the path-dependency approach, this paper argues that non-EU/EEA doctors' issues in France derive from a complex historical process of interaction between standards settled in the past, particularly the historical power of medical corporatism, the unexpected long-term effects of French hospital reforms of 1958, and budgetary pressures. Theoretically, this paper shows two significant findings. Firstly, the French medical system has undergone a series of transformations unthinkable in the strict sense of a path-dependence approach: an opening of the medical profession to foreign physicians in the context of the Europeanisation of public policy, acceptance of non-EU/EEA doctors in a context of medical shortage and budgetary pressures. Secondly, there is no change of the overall paradigm: significantly, the recruitment policies of non-EU/EEA doctors continue to highlight the imprint of the past and reveal a significant persistence of prejudices. Non-EU/EEA doctors are not considered legitimate doctors even if they have the qualifications of physicians which are legitimate in their country and which can be recognised in other receiving countries.

Innovations of ageing and societal transition : Dynamics of change of the socio-technical regime of ageing

The purpose of this dissertation is to examine the dynamics of the socio-technical system in the field of ageing. The study stems from the notion that the ageing of the population as a powerful megatrend has wide societal effects, and is not just a matter for the social and health sector. The central topic in the study is change: not only the age structures and structures of society are changing, but also at the same time there is constant development, for instance, in technologies, infrastructures and cultural perceptions. The changing concept of innovation has widened the understanding of innovations related to ageing from medical and assistive technological innovations to service and social innovations, as well as systemic innovations at different levels, which means the intertwined and co-evolutionary change in technologies, structures, services and thinking models. By the same token, the perceptions of older people and old age are becoming more multi-faceted: old age is no longer equated to illnesses and decline, but visions of active ageing and a third age have emerged, which are framed by choices, opportunities, resources and consumption in later life. The research task in this study is to open up the processes and mechanisms of change in the field of ageing, which are studied as a complex, multi-level and interrelated socio-technical system. The question is about co-effective elements consisting of macro-level landscape changes, the existing socio-technical regime (the rule system, practices and structures) and bottom-up niche-innovations. Societal transitions do not account for the things inside the regime alone, or for the long-term changes in the landscape, nor for the radical innovations, but for the interplay between all these levels. The research problem is studied through five research articles, which offer micro-level case studies to macro-level phenomenon. Each of the articles focus on different aspects related to ageing and change, and utilise various datasets. The framework of this study leans on the studies of socio-technical systems and multi-level perspective on transitions mainly developed by Frank Geels. Essential factors in transition from one socio-technological regime to another are the co-evolutionary processes between landscape changes, regime level and experimental niches. Landscape level changes, like the ageing of the population, destabilise the regime in the forms of coming pressures. This destabilization offers windows for opportunity to niche-innovations outside or at fringe of the regime, which, through their breakthrough, accelerate the transition process. However, the change is not easy because of various kinds of lock-ins and inertia, which tend to maintain the stability of the regime. In this dissertation, a constructionist approach of society is applied leaning mainly to the ideas of Anthony Giddens’ theory of structuration, with the dual nature of structures. The change is taking place in the interplay between actors and structures: structures shape people’s practices, but at the same time these practices constitute and reproduce social systems. Technology and other material aspects, as part of socio-technical systems, and the use of them, also take part in the structuration process. The findings of the study point out that co-evolutionary and co-effective relationships between economic, cultural, technological and institutional fields, as well as relationships between landscape changes, changes in the local and regime-level practices and rule systems, are a very complex and multi-level dynamic socio-technical phenomenon. At the landscape level of ageing, which creates the pressures and triggers to the regime change, there are three remarkable megatrends: demographic change, changes in the global economy and the development of technologies. These exert pressures to the socio-technical regime, which as a rule system is experiencing changes in the form of new markets and consumer habits, new ways of perceiving ageing, new models of organising the health care and other services and as new ways of considering innovation and innovativeness. There are also inner dynamics in the relationships between these aspects within the regime. These are interrelated and coconstructed: the prevailing perceptions of ageing and innovation, for instance, reflect the ageing policies, innovation policies, societal structures, organising models, technology and scientific discussion, and vice versa. Technology is part of the inner dynamics of the sociotechnological regime. Physical properties of the artefacts set limitations and opportunities with regard to their functions and uses. The use of and discussion about technology, contributes producing and reproducing the perceptions of old age. For societal transition, micro-level changes are also needed, in form of niche-innovations, for instance new services, organisational models or new technologies, Regimes, as stabilitystriven systems, tend to generate incremental innovations, but radically new innovations are generated in experimental niches protected from ‘normal’ market selection. The windows of opportunity for radical novelties may be opened if the circumstances are favourable for instance by tensions in the socio-technical regime affected by landscape level changes. This dissertation indicates that a change is taking place, firstly, in the dynamic interactionbetween levels, as a result of purposive action and governance to some extent. Breaking the inertia and using the window of opportunity for change and innovation offered by dynamics between levels, presupposes the actors’ special capabilities and actions such as dynamic capabilities and distance management. Secondly, the change is taking place the socio-technological negotiations inside the regime: interaction between technological and social, which is embodied in the use of technology. The use of technology includes small-level contextual scripts that also participate in forming broader societal scripts (for instance defining old age at the society level), which in their turn affect the formation of policies for innovation and ageing. Thirdly, the change is taking place by the means of active formation of the multi-actor innovation networks, where the role of distance management is crucial to facilitate the communication between actors coming from different backgrounds as well as to help the niches born outside the regime to utilise the window of opportunity offered by regime destabilisation. This dissertation has both theoretical and practical contributions. This study participates in the discussion of action-oriented view on transition by opening up of the socio-technological, coevolutionary processes of the multi-faceted phenomenon of ageing, which has lacked systematic analyses. The focus of this study, however, is not on the large-scale coordination and governance, but rather on opening up the incremental elements and structuration processes, which contribute to the transition little by little, and which can be affected to. This increases the practical importance of this dissertation, by highlighting the importance of very tiny, everyday elements in the change processes in the long run.

Managing Change: An Organizational Outline for Reimagining the Digital Repository Infrastructure at The Ohio State University Libraries

Poster at Open Repositories 2014, Helsinki, Finland, June 9-13, 2014

Institutional environment in North Korea: market structure and overcoming institutional voids

Tutkimus sai innoituksensa, kun tutkija huomasi tarpeen liiketaloudelliselle, ajantasaiselle ja realistiselle tutkimukselle Pohjois-Korean markkinoista, joka kuvailisi markkinoiden olemassaolevia ja puuttuvia rakenteita sekä tutkisi mahdollisuuksia ylittää puuttuvat rakenteet. Institutionaalinen teoria valittiin sopivaksi viitekehykseksi kuvailla ja tutkia markkinarakennetta. Tutkimuskysymys muotoiltiin seuraavasti: “Miten ulkomaiset yritykset voivat reagoida puuttuviin markkinarakenteisiin Pohjois-Koreassa?”. Tutkimuskysymys jaettiin kolmeen osakysymykseen: (1) Millainen on Pohjois-Korean markkinoiden institutionaalinen ympäristö? (2) Mitkä ovat merkittävimmät puuttuvat markkinarakenteet Pohjois-Koreassa? (3) Mitä mahdollisuuksia ulkomaisilla yrityksillä voisi olla reagoida puuttuviin markkinarakenteisiin? Tutkimus toteutettiin kvalitatiivisena, koska tutkimuskysymys on deskriptiivinen. Aineisto kerättiin asiantuntijahaastattelun ja kvalitatiivisen sisällönanalyysin keinoin. Primääriaineiston muodostavat 2 asiantuntijahaastattelua ja sekundääriaineiston muodostavat 95 artikkelia, jotka kerättiin 40 lähteestä. Aineisto analysoitiin kvalitatiivisen sisällönanalyysin keinoin. Aineisto koodattiin, luokiteltiin ja esitettiin kokonaisuuksina luokittelurungon avulla, joka laadittiin tutkimusta varten muodostetun teoreettisen viitekehyksen mukaan. Tulokset ja johtopäätökset voidaan tiivistää seuraavasti. (1) Pohjois-Korean markkinan instituutioihin vaikuttaa kaksoisrakenne, jossa muodollinen, sosialistinen rakenne ja epämuodollinen, markkinalähtöinen rakenne toimivat päällekkäin. (2) Puuttuvia rakenteita on sekä markkinan kontekstissa että markkinatasolla. Puutteet ovat osittain seurausta vanhojen rakenteiden korvaantumisesta uusilla, jotka eivät ole institutionalisoituneet. (3) Yritykset voivat käyttää samoja mahdollisuuuksia reagoida puuttuviin markkinarakenteisiin Pohjois-Koreassa, joita kehittyvien markkinoiden yhteydessä on esitetty. Sen tulkittiin vähentävän käsitystä, jonka mukaan Pohjois-Korean markkina on liian erikoinen yritystoiminnalle. (4) Kasvava keskiluokka sekä yrittäjyyden ja naisten yhä merkittävämpi rooli liike-elämässä aiheuttavat alhaalta ylöspäin suuntautuvaa kehitystä markkinoilla. Nämä ovat merkkejä viimeaikaisesta kehityksestä, jotka eivät ole saaneet laajaa huomiota länsimaisessa mediassa. Se korostaa tarvetta liiketaloudelliselle, ajantasaiselle jatkotutkimukselle Pohjois-Korean markkinoista.

Institutional environment in North Korea: market structure and overcoming institutional voids

The research was sparked by an exchange in South Korea, as the author identified a gap in research that provides economic, up to date and realistic information about the North Korean market in English language. A need for a research was identified that would describe the market’s existing and missing market structures and explore possibilities to overcome the missing market structures. Institutional theory was chosen as a suitable framework to describe and explore the market. The research question was formulated as follows: “How can foreign companies overcome institutional voids in the North Korean market?”. To answer the research question, it was divided into three sub-questions as follows: (1) What is the institutional environment in North Korea like? (2) What are the major institutional voids in the North Korean market? (3) What possibilities do foreign companies have to overcome institutional voids? The research is qualitative by nature due to the descriptive and exploratory nature of the research question. Data collection consisted of expert interview and content analysis, resulting in primary data of two interviews and secondary data of 95 articles from 40 different sources. The data was analyzed with the systematical technique of content analysis. The data was coded, classified and presented as concepts with the help of a classification system that was build following the theoretical framework adapted for this study. The findings can be summarized as follows. (1) The market institutions are characterized by an overlapping dual system of formal, socialist structures and informal, market-oriented structures. (2) Institutional voids prevail on both the market’s contextual and on the market level. They are partly result of old institutions being replaced by new institutions that lack institutionalization. (3) Identified possibilities to overcome institutional voids correspond with possibilities drawn from previous research. This decreases the image of North Korea as an impossibly unique market to operate in. (4) Emerging middle class, rapidly growing entrepreneurial activities and women’s increasing role in business drive a down-to-up change in the market. This signals the recent development of the market, yet has been overlooked in the Western media. Thus there is a need for further economic, up to date research concerning North Korea.

Assessing the adaptive capacity of the Ontario wine industry to climate change: A case study

The global wine industry is experiencing the impacts of climate change. Canada’s major wine sector, the Ontario Wine Industry (OWI) is no exception to this trend. Warmer winter and summer temperatures are affecting wine production. The industry needs to adapt to these challenges, but their capacity for this is unclear. To date, only a limited number of studies exist regarding the adaptive capacity of the wine industry to climate change. Accordingly, this study developed an adaptive capacity assessment framework for the wine industry. The OWI became the case study for the implementation of the assessment framework. Data was obtained by means of a questionnaire sent to grape growers, winemakers and supporting institutions in Ontario. The results indicated the OWI has adaptive capacity capabilities in financial, institutional, political, technological, perceptions, knowledge, diversity and social capital resources areas. Based on the OWI case study, this framework provides an effective means of assessing regional wine industries’ capacity to adapt to climate change.

Individual and Collective Responsiveness to Climate Change: A Response to Dwyer

Commentaire / Commentary

The institutional environment and its influence on political options to Protect Winnipeg’s Female garments Workers against the impact of globalization

The principal objective of this paper is to identify the relationship between the re­sults of the Canadian policies implemented to protect female workers against the impact of globalization on the garment industry and the institutional setting in which this labour market is immersed in Winnipeg. This research paper begins with a brief summary of the institutional theory appro­ach that sheds light on the analysis of the effects of institutions on the policy options to protect female workers of the Winnipeg garment industry. Next, this paper identi­fies the set of beliefs, formal procedures, routines, norms and conventions that cha­racterize the institutional environment of the female workers of Winnipeg’s garment industry. Subsequently, this paper descri­bes the impact of free trade policies on the garment industry of Winnipeg. Afterward, this paper presents an analysis of the ba­rriers that the institutional features of the garment sector in Winnipeg can set to the successful achievement of policy options addressed to protect the female workforce of this sector. Three policy options are considered: ethical purchasing; training/retraining programs and social engage­ment support for garment workers; and protection of migrated workers through promoting and facilitating bonds between Canada’s trade unions and trade unions of the labour sending countries. Finally, this paper concludes that the formation of isolated cultural groups inside of factories; the belief that there is gender and race discrimination on the part of the garment industry management against workers; the powerless social conditions of immi­grant women; the economic rationality of garment factories’ managers; and the lack of political will on the part of Canada and the labour sending countries to set effective bilateral agreements to protect migrate wor­kers, are the principal barriers that divide the actors involved in the garment industry in Winnipeg. This division among the prin­cipal actors of Winnipeg’s garment industry impedes the change toward more efficient institutions and, hence, the successful achievement of policy options addressed to protect women workers. 

Assessing the vulnerability of food crop systems in Africa to climate change

Africa is thought to be the region most vulnerable to the impacts of climate variability and change. Agriculture plays a dominant role in supporting rural livelihoods and economic growth over most of Africa. Three aspects of the vulnerability of food crop systems to climate change in Africa are discussed: the assessment of the sensitivity of crops to variability in climate, the adaptive capacity of farmers, and the role of institutions in adapting to climate change. The magnitude of projected impacts of climate change on food crops in Africa varies widely among different studies. These differences arise from the variety of climate and crop models used, and the different techniques used to match the scale of climate model output to that needed by crop models. Most studies show a negative impact of climate change on crop productivity in Africa. Farmers have proved highly adaptable in the past to short- and long-term variations in climate and in their environment. Key to the ability of farmers to adapt to climate variability and change will be access to relevant knowledge and information. It is important that governments put in place institutional and macro-economic conditions that support and facilitate adaptation and resilience to climate change at local, national and transnational level.

Ideational change in the WTO and its impacts on EU agricultural policy institutions and the CAP

This paper argues that the Uruguay Round Agreement on Agriculture (URAA) introduced the market liberal paradigm as the ideational underpinning of the new farm trade regime. Though the immediate consequences in terms of limitations on agricultural support and protection were very modest, the Agreement did impact on the way in which domestic farm policy evolves. It forced EU agricultural policy makers to consider the agricultural negotiations when reforming the Common Agricultural Policy (CAP). The new paradigm in global farm trade resulted in a process of institutional layering in which concerns raised in the World Trade Organization (WTO) were gradually incorporated in EU agricultural institutions. This has resulted in gradual reform of the CAP in which policy instruments have been changed in order to make the CAP more WTO compatible. The underlying paradigm, the state-assisted paradigm, has been sustained though it has been rephrased by introducing the concept of multifunctionality.