First Reported Successful Femoral Valve-in-Valve Transcatheter Aortic Valve Replacement Using the Edwards Sapien 3 Valve.

OBJECTIVES: Management of degenerated aortic valve bioprosthesis classically requires redo surgery, but transcatheter aortic valve-in-valve implantation is becoming a valid alternative in selected cases. In the case of a degenerated Mitroflow bioprosthesis, TAVR is associated with an additional challenge due to a specific risk of coronary occlusion. We aimed to assess the safety and feasibility of transfemoral valve-in-valve implantation of the new Edwards Sapien 3 (Edwards Lifesciences) in a degenerated Mitroflow bioprosthesis (Sorin Group, Inc). METHODS: We report here the safety and feasibility of transfemoral valve-in-valve implantation of a 23 mm Edwards Sapien 3 in a degenerated 25 mm Mitroflow valve and describe the specific assessment of the risk of coronary obstruction using a multi-imaging modality. RESULTS: The final result showed an absence of aortic regurgitation and a mean transvalvular gradient of 14 mm Hg. The patient had no major adverse cardiovascular events at 30-day follow-up. CONCLUSION: Transcatheter valve-in-valve implantation of an Edwards Sapien 3 in a degenerated Mitroflow is feasible and safe, considering a careful assessment of the risk of coronary obstruction with Mitroflow bioprosthesis due to leaflets mounted externally to the stent.

Diffusion of Administrative Innovation: TQM Implementation and Effectiveness in a Global

The main objective of this dissertation is to create new knowledge on an administrative innovation, its adoption, diffusion and finally its effectiveness. In this dissertation the administrative innovation is approached through a widely utilized management philosophy, namely the total quality management (TQM) strategy. TQM operationalizes a self-assessment procedure, which is based on continual improvement principles and measuring the improvements. This dissertation also captures the theme of change management as it analyzes the adoption and diffusion of the administrative innovation. It identifies innovation characteristics as well as organisational and individual factors explaining the adoption and implementation. As a special feature, this study also explores the effectiveness of the innovation based on objective data. For studying the administrative innovation (TQM model), a multinational Case Company provides a versatile ground for a deep, longitudinal analysis. The Case Company started the adoption systematically in the mid 1980s in some of its units. As part of their strategic planning today, the procedure is in use throughout the entire global company. The empirical story begins from the innovation adoption decision that was made in the Case Company over 22 years ago. In order to be able to capture the right atmosphere and backgrounds leading to the adoption decision, key informants from that time were interviewed, since the main target was to clarify the dynamics of how an administrative innovation develops. In addition, archival material was collected and studied, available memos and data relating to the innovation, innovation adoption and later to the implementation contained altogether 20500 pages of documents. A survey was furthermore conducted at the end of 2006 focusing on questions related to the innovation, organization and leadership characteristics and the response rate totalled up to 54%. For measuring the effectiveness of the innovation implementation, the needed longitudinal objective performance data was collected. This data included the profit unit level experience of TQM, the development of the self assessment scores per profit unit and performance data per profit unit measured with profitability, productivity and customer satisfaction. The data covered the years 1995-2006. As a result, the prerequisites for the successful adoption of an administrative innovation were defined, such as the top management involvement, support of the change agents and effective tools for implementation and measurement. The factors with the greatest effect on the depth of the implementation were the timing of the adoption and formalization. The results also indicated that the TQM model does have an effect on the company performance measured with profitability, productivity and customer satisfaction. Consequently this thesis contributes to the present literature (i) by taking into its scope an administrative innovation and focusing on the whole innovation implementation process, from the adoption, through diffusion until its consequences, (ii) because the studied factors with an effect on the innovation adoption and diffusion are multifaceted and grouped into individual, organizational and environmental factors, and a strong emphasis is put on the role of the individual change agents and (iii) by measuring the depth and consistency of the administrative innovation. This deep analysis was possible due to the availability of longitudinal data with triangulation possibilities.

Successful long-term ambulatory norepinephrine infusions in a patient with pure autonomic failure.

We present a case study of a patient with pure autonomic failure who was successfully treated with ambulatory norepinephrine (NE) infusions over a 9-year-period of time before death occurred unexpectedly. Given this patient's response to the NE infusion treatment, we discuss the option of ambulatory NE infusions as a treatment for severe orthostatic hypotension that is refractory to common treatments.

Successful Surgical Pulmonary Embolectomy for Massive Perinatal Embolism after Emergency Cesarean Section.

Pregnant women are exposed to an increased risk for developing pulmonary embolism (PE), a main cause for maternal mortality. Surgical pulmonary embolectomy is one important therapeutic and potential life-saving armamentarium, considering pregnancy as a relative contraindication for thrombolysis. We present a case of a 36-year-old woman with massive bilateral PE after emergent caesarean delivery, requiring reanimation by external heart massage. The onset of massive intrauterine bleeding contraindicated thrombolysis and emergency surgical pulmonary embolectomy, followed by a hysterectomy, were preformed successfully. Acute surgical pulmonary embolectomy may be an option in critically diseased high-risk patients, requiring a multiteam approach, and should be part of the therapeutic armamentarium of the attending cardiac surgeon.

Flocking behaviour: Agent-based simulation and hierarchical leadership.

We have studied how leaders emerge in a group as a consequence of interactions among its members. We propose that leaders can emerge as a consequence of a self-organized process based on local rules of dyadic interactions among individuals. Flocks are an example of self-organized behaviour in a group and properties similar to those observed in flocks might also explain some of the dynamics and organization of human groups. We developed an agent-based model that generated flocks in a virtual world and implemented it in a multi-agent simulation computer program that computed indices at each time step of the simulation to quantify the degree to which a group moved in a coordinated way (index of flocking behaviour) and the degree to which specific individuals led the group (index of hierarchical leadership). We ran several series of simulations in order to test our model and determine how these indices behaved under specific agent and world conditions. We identified the agent, world property, and model parameters that made stable, compact flocks emerge, and explored possible environmental properties that predicted the probability of becoming a leader.

Developing Launching Processes — A Case Study

New product launches are becoming more and more important to companies around the globe. Being first on the market is a good place to be, and it will mostly likely bring the best profits. Gaining that desired position requires a lot of work where cooperation inside as well as outside of the company need to be in line. This thesis discusses launching processes in a pharmaceutical firm. The topic is looked at from supply chain management's point of view where purchasing department's role is emphasized. Additionally, launching strategies related to launches are investigated and the idea of internal alignment is introduced. Moreover, the topic is examined in project and process management perspective; how with the tools of project and process management the launching processes could be improved. The main findings reveal that there are many improvement points in the current launching process. Problems in the areas of information exchange, leadership and internal alignment were discovered yet trust and confidence for the better future compound the interviewees. This study presents what are the most important factors for a successful product launch and how the current processes could be streamlined.

Successful embolization of a delayed splenic rupture following trauma in a child.

Delayed rupture of the spleen following trauma is an exceedingly rare phenomenon in children. In the case we have experienced, arterial embolization was successfully performed, surgery was avoided, and functional splenic tissue was preserved. Embolization is of value in the management of blunt splenic injuries in hemodynamically stable children, even after delayed rupture. The exact criteria for its use remain to be established.

Price rivalry in airline markets: A study of a successful strategy of a network carrier against a low-cost carrier

Competition in airline markets may be tough. In this context, network carriers have two alternative strategies to compete with low-cost carriers. First, they may establish a low-cost subsidiary. Second, they may try to reduce costs using the main brand. This paper examines a successful strategy of the first type implemented by Iberia in the Spanish domestic market. Our analysis of data and the estimation of a pricing equation show that Iberia has been able to charge lower prices than rivals with its low-cost subsidiary. The pricing policy of the Spanish network carrier has been particularly aggressive in less dense routes and shorter routes.

Aortic root morphology: a paradigm for successful reconstruction.

Aortic root (AoR) components provide synchronous and precise 3D deformation of the aortic root during the cardiac cycle in order to ensure closure and opening of the three leaflets over a lifetime. Any deviation from the natural 3D morphology, such as with AoR annulus dilatation, enlarged sinuses and/or dilatation of the sinotubular junction, as in the case of ascending aortic dilatation, may result in disruption of the natural AoR function. Surgical treatment of AoR pathology has two modalities: the replacement of the aortic valve by artificial prosthesis or by preservation of the three leaflets and reconstruction of the aortic root components. Currently, there are two basic aortic root reconstruction procedures: aortic root sparing and aortic valve reimplantation techniques. Regardless of the technique used, the restoration of adequate cusp coaptation, is from a technical point of view, the most important element to consider. To achieve this, there are two requirements that need to be met: (i) the valve coaptation should be superior to the level of the aortic root base by at least 8 mm and (ii) the coaptation height per se has to be ≥5 mm. Successful restoration of the aortic root requires adequate technical skills, detailed knowledge of aortic root anatomy and topography, and also knowledge of the spatial pattern of AoR elements. Recently, there has been growing interest in aortic root reconstructive procedures as well their modifications. As such, the aim of this review is to analyse aortic root topography and 3D anatomy from a surgical point of view. The review also focuses on potential risk regions that one should be aware of before the surgical journey into the 'deep waters area' of the AoR begins.

Successful minimally invasive surgery for primary hyperparathyroidism: influence of preoperative imaging and intraoperative parathyroid hormone levels.

PURPOSE: Adenoma is the main parathyroid disorder leading to primary hyperparathyroidism (PHP). Minimally invasive parathyroidectomy (MIP) is recognized as a valid procedure for adenoma-related PHP. It requires precise preoperative localization combining Tc-99m-MIBI (methoxy-isobutyl-isonitrile) scintigraphy and single-photon emission computed tomography (SPECT) with x-ray computed tomography (CT) and intraoperative confirmation of successful excision by change in intact parathormone (iPTH) levels. The study aim was to assess the surgery success in relation to these two parameters. METHODS: All patients operated on for PHP from 2005 to mid-2014 at our institution were retrospectively reviewed. MIP was performed in case of precise preoperative adenoma localization on scintigraphy, absence of past cervical surgery, and absence of concomitant thyroid resection necessity. In these patients, iPTH levels were monitored intraoperatively. Confirmation criteria for iPTH values were a return to normal level or a decrease >50 % of basal iPTH level. RESULTS: There were 197 PHP operations during the study period: 118 MIP and 79 bilateral neck explorations (BNEs). The MIP success rate was 95 % (112/118) with a preoperative MIBI scan ± CT accurate in 94 % (111/118) of the patients and with correct iPTH in 90 % (106/118) of the cases. Among the 12 iPTH levels that did not meet the confirmation criteria, 10 returned to normal range by postoperative day 2. Treatment failure appeared in three patients (one BNE, two MIPs). CONCLUSIONS: Tc-99m-MIBI dual-phase scintigraphy with SPECT/CT is the key examination for functional and morphological parathyroid adenoma localization. If preoperative scintigraphy is obvious and intraoperative assessment is clear, one could possibly safely omit iPTH, as it may lead to unnecessary BNE in primary PHP.

Web and education, a successful open entanglement

E-learning, understood as the intensive use of Information and Communication Technologies in mainly but not only) distance education, has radically changed the meaning of the latter. E-learning is an overused term which has been applied to any use of technology in education. Today, the most widely accepted meaning ofe-learning coincides with the fourth generation described by Taylor (1999), where there is an asynchronousprocess that allows students and teachers to interact in an educational process expressly designed in accordance with these principles. We prefer to speak of Internet-Based Learning or, better still, Web-Based Learning, for example, to explain the fact that distance education is carried out using the Internet, with the appearance of the virtual learning environment concept, a web space where the teaching and learning process is generated and supported (Sangrà, 2002). This entails overcoming the barriers of space and time of brickand mortar education (although we prefer the term face-to-face) or of classical distance education using broadcasting and adopting a completely asynchronous model that allows access to education by many more users, at any level (including secondary education, but primarily higher education and lifelong learning).

Creating a research network for a successful e-portfolio design and implementation

The presence of e-portfolios in educational centres, companies and administrations has emergedstrongly during the last years by creating very different practices coming from different objectives and purposes. This situation has led researchers and practitioners to design and implement e-portfolios with little reference to previous knowledge of them; consequently, developments are disparate with many of the processes and dimensions used both in development and use being unnecessary complex. In order to minimize the inconveniences, unify these developmental processes and improve the resultsof implementation and use of e-portfolios, it seemed necessary to create a network of researchers, teachers and trainers coming from different universities and institutions of different kinds who are interested in the investigation and the practice of e-portfolios in Spain. Therefore, The Network on e-portfoliowas created in 2006, funded by the Spanish Ministry of Education and led by the UniversitatOberta de Catalunya. Besides the goals associatedwith the creation of this network and which wewanted to share with other European researchers and experts of other continents, we will also present in this paper some data concerned with the first study carried out on the use of e-portfolios in our country that shows where we are and which trends are the most important for the near future.

Henkilöstön johtamisen haasteet organisaation muutosprosessissa. Case: Etelä-Karjalan sosiaali- ja terveyspiiri

Tutkimuksen tavoitteena oli selvittää, miten henkilöstö johdetaan onnistuneesti muutoksen kautta uuteen organisaatioon ja miten henkilöstö tällä hetkellä kokee tulevan organisaatiomuutoksen. Tutkimuksen teoriaosassa keskitytään organisaatiomuutokseen ilmiönä ja siihen liittyviin asioihin sekä tarkastellaan henkilöstön ja esimiestyön roolia muutosprosessissa. Tutkimuksen empiirisen aineiston muodostavat Etelä-Karjalan sosiaali- ja terveyspiirin valmisteluorganisaation kymmenen henkilöstöedustajan haastattelut. Haastatteluaineisto kerättiin ja analysoitiin laadullisella tutkimusmenetelmällä. Tutkimustulokset osoittavat, että organisaatiossa kaivataan enemmän avointa ja toimivaa tiedonkulkua koskien muutosta. Henkilöstö on tällä hetkellä epävarma tulevaisuudesta, ja heitä tulisi ottaa enemmän mukaan muutosprosessiin. Työntekijät kaipaavat myös enemmän tietoa, tukea ja ohjausta esimiehiltään. Muutoksen onnistumisessa osaavalle ja tehokkaalle esimiestyöskentelylle asetettiin paljon painoarvoa. Vaikka tutkimustulokset eivät annakaan yhtä oikeaa tapaa toteuttaa muutosta, tuovat ne hyvin esille asiat, jotka tulisi huomioida muutosta eteenpäin vietäessä.

Successful therapies for Alzheimer's disease: why so many in animal models and none in humans?

Peering into the field of Alzheimer's disease (AD), the outsider realizes that many of the therapeutic strategies tested (in animal models) have been successful. One also may notice that there is a deficit in translational research, i.e., to take a successful drug in mice and translate it to the patient. Efforts are still focused on novel projects to expand the therapeutic arsenal to 'cure mice.' Scientific reasons behind so many successful strategies are not obvious. This article aims to review the current approaches to combat AD and to open a debate on common mechanisms of cognitive enhancement and neuroprotection. In short, either the rodent models are not good and should be discontinued, or we should extract the most useful information from those models. An example of a question that may be debated for the advancement in AD therapy is: In addition to reducing amyloid and tau pathologies, would it be necessary to boost synaptic strength and cognition? The debate could provide clues to turn around the current negative output in generating effective drugs for patients. Furthermore, discovery of biomarkers in human body fluids, and a clear distinction between cognitive enhancers and disease modifying strategies, should be instrumental for advancing in anti-AD drug discovery.