Does improvisation lead to outcome deviation? A conceptual framework of improvisation, its antecedents and outcome deviation

Management and organization literature has extensively noticed the crucial role that improvisation assumes in organizations, both as a learning process (Miner, Bassoff & Moorman, 2001), a creative process (Fisher & Amabile, 2008), a capability (Vera & Crossan, 2005), and a personal disposition (Hmielesky & Corbett, 2006; 2008). My dissertation aims to contribute to the existing literature on improvisation, addressing two general research questions: 1) How does improvisation unfold at an individual level? 2) What are the potential antecedents and consequences of individual proclivity to improvise? This dissertation is based on a mixed methodology that allowed me to deal with these two general research questions and enabled a constant interaction between the theoretical framework and the empirical results. The selected empirical field is haute cuisine and the respondents are the executive chefs of the restaurants awarded by Michelin Guide in 2010 in Italy. The qualitative section of the dissertation is based on the analysis of 26 inductive case studies and offers a multifaceted contribution. First, I describe how improvisation works both as a learning and creative process. Second, I introduce a new categorization of individual improvisational scenarios (demanded creative improvisation, problem solving improvisation, and pure creative improvisation). Third, I describe the differences between improvisation and other creative processes detected in the field (experimentation, brainstorming, trial and error through analytical procedure, trial and error, and imagination). The quantitative inquiry is founded on a Structural Equation Model, which allowed me to test simultaneously the relationships between proclivity to improvise and its antecedents and consequences. In particular, using a newly developed scale to measure individual proclivity to improvise, I test the positive influence of industry experience, self-efficacy, and age on proclivity to improvise and the negative impact of proclivity to improvise on outcome deviation. Theoretical contributions and practical implications of the results are discussed.

Untersuchung der physiologischen Rolle des Wilms-Tumorgens 1 (WT1) im Rahmen der Generierung muriner in-vivo-Modelle für die Wilms-Tumorerkrankung

Der Wilms-Tumor ist eine embryonale Tumorerkrankung der Niere, als deren Ursprung Nierenvorläuferzellen des metanephrischen Mesenchyms gelten, deren Differenzierung während der frühen Nephrogenese ausbleibt und aus denen nachfolgend durch eine maligne Transformation Wilms-Tumore entstehen. Zwei Gene, die an der Wilms-Tumorgenese beteiligt zu sein scheinen, sind WT1 (Wilms-Tumorgen 1) und CTNNB1 (Catenin, cadherin-associated protein, beta 1). Während WT1 u.a. die Differenzierung des metanephrischen Mesenchyms steuert, begünstigen aktivierende Mutationen von CTNNB1 und eine dadurch bedingte Akkumulation seines Proteins β-Catenin die Tumorgenese vieler Organe. So verwundert es nicht, dass eine alleinige heterozygote Keimbahnmutation von WT1, die einen dominant-negativen Effekt auf funktionsfähiges WT1 ausübt, häufig zur Entstehung von Wilms-Tumoren in Patienten mit Denys-Drash-Syndrom (DDS) führt, sowie in etwa 15 % aller sporadischen Wilms-Tumore WT1 und CTNNB1 mutiert sind.rnDer Mechanismus der Entstehung von Wilms-Tumoren ist weitgehend unbekannt, was u.a. daran liegt, dass homozygote Wt1-Mutationen in der Maus embryonal (~ Tag 13,5 d.p.c.) letal sind. In der vorliegenden Arbeit sollten daher mit Hilfe einer Wt1 k.o.-Effektormaus (WE2) vier murine konditional reversible Wilms-Tumor-Modelle auf Basis des Tet off-Systems hergestellt werden. Dadurch lag in den zu generierenden Tieren Wt1 durch die Integration des WE2-Transgens zwar nur heterozygot mutiert vor, doch durch den endogenen Wt1-Promotor des Transgens sollte es zur zeitlichen und räumlichen Wt1-analogen Expression eines tetrazyklinabhängigen Transaktivators (tTA) kommen, der ohne die Gabe von Doxycyclin Tet-regulierbare Transgene in Wt1-exprimierenden Zellen aktivieren kann, die einen positiven Einfluss auf die Wilms-Tumorgenese haben könnten. So sollte durch das WE2 DDS-Modell ein DDS simuliert werden und es in Tieren der Modelle WE2 TC bCat∆Ex3, WE2 LC bCat∆Ex3 und WE2 Wnt1 zur Akkumulation von β-Catenin in Wt1-exprimierenden Nierenvorläuferzellen kommen, so dass deren Differenzierung ausbleibt und es durch eine maligne Transformation zur Entstehung eines Wilms-Tumors kommt.rnrnMit Hilfe von histologischen Analysen an entsprechenden Responder-Linien konnte zunächst gezeigt werden, dass die embryonale und adulte Expressionsdomäne des WE2-Effektors mit der von endogenen Wt1 übereinstimmt. Gleichzeitig wurden aber auch neue Expressionsorte von Wt1 nachgewiesen. So konnte die Expression des WE2-Effektors z.B. im Endothel der dorsalen Aorta detektiert werden, der als Entstehungsort von hämatopoetischen Stammzellen gilt. Anschließende hier vorgestellte Experimente zeigten, dass Wt1 direkt an diesem Prozess beteiligt ist und belegten eine noch nicht beschriebene Funktion von Wt1 in der frühen Hämatopoese.rnEs war jedoch mit keinem System möglich, eine Wilms-Tumorerkrankung zu simulieren. Während Tiere des WE2 DDS-Modells trotz nachweisbarer Induktion keinen Phänotyp aufwiesen, war wohl in den anderen Modellen eine konstitutive β-Catenin-Aktivierung in der Frühschwangerschaft nicht mit dem embryonalen Überleben vereinbar. Dabei schienen alle tripeltransgenen bzw. doppeltransgenen Embryonen, in denen durch einen frühen Doxycyclinentzug die Entstehung von Wilms-Tumoren möglich gewesen wäre, intrauterin zu sterben. Wurde dagegen Doxycyclin erst in der dritten Lebenswoche entzogen, so entwickelten die Tiere durch eine Wt1-vermittelte β-Catenin-Aktivierung Granulosazelltumore, polyzystische Nieren und Veränderungen der Hoden. Da alle diese organischen Veränderungen während der prä- bis frühen postnatalen Phase induziert wurden, schien die Doxycyclinmenge nicht auszureichen, um eine β-Catenin-Aktivierung zu verhindern. Es hätte also auch zur Entstehung von Wilms-Tumoren kommen können, so dass diese Ergebnisse darauf hinweisen, dass eine β-Catenin-Aktivierung wahrscheinlich nicht der physiologisch entscheidende Schritt bei der Entstehung eines Wilms-Tumors ist.rnrnDie Charakterisierung der WE2-Effektormaus und die Herstellung und Analysen der Systeme geben damit Einblick in die WT1- bzw. WT1/CTNNB1-assoziierte Wilms-Tumorgenese und ermöglichen die weitere Erforschung von Granulosazelltumoren, polyzystsischen Nieren, Veränderungen von Hoden und der Rolle von WT1 in der frühen Hämatopoese.rn

90 Nb: potential radionuclide for application in immuno-PET : development of appropriate production strategy and first in vivo evaluation of 90 Nb-labeled monoclonal antibody

Die Nuklearmedizin ist ein modernes und effektives Werkzeug zur Erkennung und Behandlung von onkologischen Erkrankungen. Molekulare Bildgebung, die auf dem Einsatz von Radiopharmaka basiert, beinhaltet die Einzel-Photonen-Emissions-Tomographie (SPECT) und Positronenemissions¬tomographie (PET) und ermöglicht die nicht-invasive Visualisierung von Tumoren auf nano-und picomolarer Ebene.rnDerzeit werden viele neue Tracer für die genauere Lokalisierung von kleinen Tumoren und Metastasen eingeführt und hinsichtlich ihrer Eignung untersucht. Die meisten von ihnen sind Protein-basierte Biomoleküle, die die Natur selbst als Antigene für die Tumorzellen produziert. Dabei spielen Antikörper und Antikörper-Fragmente eine wichtige Rolle in der Tumor-Diagnostik und Behandlung. Die PET-Bildgebung mit Antikörpern und Antikörperfragmenten bezeichnet man als immuno-PET. Ein wichtiger Aspekt hierbei ist, dass entsprechende Radiopharmaka benötigt werden, deren Halbwertszeit mit der Halbwertszeit der Biomoleküle korreliert ist.rnIn neueren Arbeiten wird 90Nb als potenzieller Kandidat für die Anwendung in der immuno-PET vorgeschlagen. Seine Halbwertszeit von 14,6 Stunden ist geeignet für die Anwendung mit Antikörperfragmenten und einige intakten Antikörpern. 90Nb hat eine relativ hohen Anteil an Positronenemission von 53% und eine optimale Energie für die β+-Emission von 0,35 MeV, die sowohl eine hohe Qualität der Bildgebung als auch eine niedrige Aktivitätsmenge des Radionuklids ermöglicht.rnErsten grundlegende Untersuchungen zeigten: i) dass 90Nb in ausreichender Menge und Reinheit durch Protonen-Bombardierung des natürlichen Zirkonium Targets produziert, ii) aus dem Targetmaterial in entsprechender radiochemischer Reinheit isoliert und iii) zur Markierung des monoklonalen Antikörpers (Rituximab) verwendet werden kann und iv) dieser 90Nb-markierte mAb eine hohe in vitro Stabilität besitzt. Desweiteren wurde eine alternative und schnelle Abtrennungsmethode entwickelt, die es erlaubt 90Nb, mit einer geeigneten radiochemischen und radionuklidischen Reinheit für eine anschließende Markierung von Biomolekülen in einer Stunde zu aufzureinigen. Schließlich wurden erstmals 90Nb-markierte Biomolekülen in vivo untersucht. Desweiteren wurden auch Experimente durchgeführt, um den optimalen bifunktionellen Chelatbildner (BFC) für 90Niob zu finden. Mehrere BFC wurden hinsichtlich Komplexbildung mit NbV untersucht. Desferrioxamin (Df) erwies sich als geeignetster Chelator für 90Nb. Der monoklonale Antikörper Bevacizumab (Avastin®) wurde mit 90Nb markiert und eine Biodistributionsstudie und eine PET-Untersuchung durchgeführt. Alle diese Ergebnisse zeigten, dass 90Nb ein vielversprechendes Radionuklid für die Immuno-PET ist, welches sogar für weitere kommerzielle Anwendungen in der klinischen Routine geeignet zu sein scheint.rn

First contact imaging of nanoparticular siRNA – From synthesis to application of a prodye concept

Delivery of therapeutic nucleic acid based drugs is still very demanding and difficult to manage and monitor. For this reason, a precise method for the monitoring of RNAi pathways is necessary. This thesis explores a new approach for sensing of potentially therapeutic nucleic acids, using the interaction of so called prodyes with intracellular enzymes in a prodrug manner. To realize this concept, some non-fluorescent, fluorescein based asymmetric dyes were synthesized and their spectroscopic characteristics were studied. Azide-alkyne Click chemistry was applied for conjugation purposes, using a new protocol at weak acidic pH to get intact prodye constructs. Both, an electrophoretic mobility shift assay with polyacrylamide gels and in-cuvette experiments showed remarkable OFF-to-ON behavior of these new siRNA constructs under physiological conditions. After salt-free purification, subsequent hybridization to double-stranded ribonucleic acids and nanoformulation to lipoplexes, the prodye conjugated siRNA was examined in cellular uptake studies for First Contact Imaging. The investigated siRNA-prodye conjugates showed strong sensitivity to esterases, being hydrolyzed at the biolabile function and developing a strong fluorescence which was verified in bulk. As an optimization, a new profluorescent molecule system was designed and synthesized, which has a carbonate as biolabile 6’ protecting group and a highly water soluble 3’ clickable linker. This new non-fluorescent but colored prodye showed 12 - 320 times increased fluorescence intensities between OFF- and ON- states, depending to the deprotection method. This is the first reported molecule model of an asymmetric profluorescent fluorescein, having the very favorable 3’ & 6’ functions.

Hyponatremia associated coma due to pituitary apoplexy in early pregnancy: a case report

Pituitary apoplexy in pregnancy is rare. Its clinical features may range from unspecific complaints to panhypopituitarism resulting even in coma and death. Therefore, alertness to signs and symptoms of acute loss of pituitary function in pregnancy is mandatory. We report a woman in her 7th week of her first gestation presenting with sudden coma due to severe hyponatremia. Secondary adrenal insufficiency could be identified as the underlying cause. Panhypopituitarism including central diabetes insipidus and spontaneous abortion developed during the follow-up. Magnetic resonance imaging showed pituitary apoplexy without a pre-existing pituitary mass. The clinical course was notable for severe complications, including neurological deficits through cerebral ischemia, but eventual recovery could be achieved. We discuss the diagnostic difficulties in the evaluation of pituitary disease in pregnancy.

Simultaneous bilateral hip replacement reveals superior outcome and fewer complications than two-stage procedures: a prospective study including 1819 patients and 5801 follow-ups from a total joint replacement registry

Background Total joint replacements represent a considerable part of day-to-day orthopaedic routine and a substantial proportion of patients undergoing unilateral total hip arthroplasty require a contralateral treatment after the first operation. This report compares complications and functional outcome of simultaneous versus early and delayed two-stage bilateral THA over a five-year follow-up period. Methods The study is a post hoc analysis of prospectively collected data in the framework of the European IDES hip registry. The database query resulted in 1819 patients with 5801 follow-ups treated with bilateral THA between 1965 and 2002. According to the timing of the two operations the sample was divided into three groups: I) 247 patients with simultaneous bilateral THA, II) 737 patients with two-stage bilateral THA within six months, III) 835 patients with two-stage bilateral THA between six months and five years. Results Whereas postoperative hip pain and flexion did not differ between the groups, the best walking capacity was observed in group I and the worst in group III. The rate of intraoperative complications in the first group was comparable to that of the second. The frequency of postoperative local and systemic complication in group I was the lowest of the three groups. The highest rate of complications was observed in group III. Conclusions From the point of view of possible intra- and postoperative complications, one-stage bilateral THA is equally safe or safer than two-stage interventions. Additionally, from an outcome perspective the one-stage procedure can be considered to be advantageous.

The association between early hemodynamic variables and outcome in normothermic comatose patients following cardiac arrest

Currently, few data exist on the association between post-cardiac arrest hemodynamic function and outcome. In this explorative, retrospective analysis, the association between hemodynamic variables during the first 24 h after intensive care unit admission and functional outcome at day 28 was evaluated in 153 normothermic comatose patients following a cardiac arrest.

Risk assessment in the first fifteen minutes: a prospective cohort study of a simple physiological scoring system in the emergency department

Introduction The survival of patients admitted to an emergency department is determined by the severity of acute illness and the quality of care provided. The high number and the wide spectrum of severity of illness of admitted patients make an immediate assessment of all patients unrealistic. The aim of this study is to evaluate a scoring system based on readily available physiological parameters immediately after admission to an emergency department (ED) for the purpose of identification of at-risk patients. Methods This prospective observational cohort study includes 4,388 consecutive adult patients admitted via the ED of a 960-bed tertiary referral hospital over a period of six months. Occurrence of each of seven potential vital sign abnormalities (threat to airway, abnormal respiratory rate, oxygen saturation, systolic blood pressure, heart rate, low Glasgow Coma Scale and seizures) was collected and added up to generate the vital sign score (VSS). VSSinitial was defined as the VSS in the first 15 minutes after admission, VSSmax as the maximum VSS throughout the stay in ED. Occurrence of single vital sign abnormalities in the first 15 minutes and VSSinitial and VSSmax were evaluated as potential predictors of hospital mortality. Results Logistic regression analysis identified all evaluated single vital sign abnormalities except seizures and abnormal respiratory rate to be independent predictors of hospital mortality. Increasing VSSinitial and VSSmax were significantly correlated to hospital mortality (odds ratio (OR) 2.80, 95% confidence interval (CI) 2.50 to 3.14, P < 0.0001 for VSSinitial; OR 2.36, 95% CI 2.15 to 2.60, P < 0.0001 for VSSmax). The predictive power of VSS was highest if collected in the first 15 minutes after ED admission (log rank Chi-square 468.1, P < 0.0001 for VSSinitial;,log rank Chi square 361.5, P < 0.0001 for VSSmax). Conclusions Vital sign abnormalities and VSS collected in the first minutes after ED admission can identify patients at risk of an unfavourable outcome.

Prevalence, predictors, and consequences of long-term refusal of antipsychotic treatment in first-episode psychosis

Studies investigating medication adherence in psychosis are limited by the need of a certain degree of medication adherence and the inclusion of mostly multiple-episode patients. By contrast, noninformed consent, epidemiological studies in first-episode psychosis (FEP) allow the assessment of an important subgroup of patients who persistently refuse antipsychotic medication and thereby never receive an adequate antipsychotic trial. The present study aims to assess the prevalence and predictors of such a "medication refusal" subgroup and its association with illness outcome.

Prevalence and impact of cannabis use disorders in adolescents with early onset first episode psychosis

Previous studies on the impact of cannabis use disorders (CU) on outcome in psychosis were predominantly based on non representative samples, often have not controlled for confounders and rarely focused on adolescent patients. Thus, the aims of the present study were to assess: (i) prevalence of CU; (ii) baseline and pretreatment differences between CU and those without CU (NCU); (iii) the impact of baseline and course of CU on 18-month outcomes in a representative cohort of adolescents with early onset first episode psychosis (EOP).

Distress related to myocardial infarction and cardiovascular outcome: a retrospective observational study

Background During acute coronary syndromes patients perceive intense distress. We hypothesized that retrospective ratings of patients' MI-related fear of dying, helplessness, or pain, all assessed within the first year post-MI, are associated with poor cardiovascular outcome. Methods We studied 304 patients (61 ± 11 years, 85% men) who after a median of 52 days (range 12-365 days) after index MI retrospectively rated the level of distress in the form of fear of dying, helplessness, or pain they had perceived at the time of MI on a numeric scale ranging from 0 ("no distress") to 10 ("extreme distress"). Non-fatal hospital readmissions due to cardiovascular disease (CVD) related events (i.e., recurrent MI, elective and non-elective stent implantation, bypass surgery, pacemaker implantation, cerebrovascular incidents) were assessed at follow-up. The relative CVD event risk was computed for a (clinically meaningful) 2-point increase of distress using Cox proportional hazard models. Results During a median follow-up of 32 months (range 16-45), 45 patients (14.8%) experienced a CVD-related event requiring hospital readmission. Greater fear of dying (HR 1.21, 95% CI 1.03-1.43), helplessness (HR 1.22, 95% CI 1.04-1.44), or pain (HR 1.27, 95% CI 1.02-1.58) were significantly associated with an increased CVD risk without adjustment for covariates. A similarly increased relative risk emerged in patients with an unscheduled CVD-related hospital readmission, i.e., when excluding patients with elective stenting (fear of dying: HR 1.26, 95% CI 1.05-1.51; helplessness: 1.26, 95% CI 1.05-1.52; pain: HR 1.30, 95% CI 1.01-1.66). In the fully-adjusted models controlling for age, the number of diseased coronary vessels, hypertension, and smoking, HRs were 1.24 (95% CI 1.04-1.46) for fear of dying, 1.26 (95% CI 1.06-1.50) for helplessness, and 1.26 (95% CI 1.01-1.57) for pain. Conclusions Retrospectively perceived MI-related distress in the form of fear of dying, helplessness, or pain was associated with non-fatal cardiovascular outcome independent of other important prognostic factors.

Catheter ablation of atrial fibrillation as first-line therapy--a single-centre experience

The aims of the study were (i) to assess the characteristics of patients selected for atrial fibrillation (AF) ablation as first-line therapy, (ii) to identify current clinical criteria for such a strategy, and (iii) to analyse the outcome compared with patients who had failure of antiarrhythmic drug (AAD) therapy prior to ablation.

Respiratory symptoms in preterm infants: burden of disease in the first year of life

Objective While respiratory symptoms in the first year of life are relatively well described for term infants, data for preterm infants are scarce. We aimed to describe the burden of respiratory disease in a group of preterm infants with and without bronchopulmonary dysplasia (BPD) and to assess the association of respiratory symptoms with perinatal, genetic and environmental risk factors. Methods Single centre birth cohort study: prospective recording of perinatal risk factors and retrospective assessment of respiratory symptoms during the first year of life by standardised questionnaires. Main outcome measures: Cough and wheeze (common symptoms), re-hospitalisation and need for inhalation therapy (severe outcomes). Patients: 126 preterms (median gestational age 28.7 weeks; 78 with, 48 without BPD) hospitalised at the University Children's Hospital of Bern, Switzerland 1999-2006. Results Cough occurred in 80%, wheeze in 44%, rehospitalisation in 25% and long term inhalation therapy in wheezers in 13% of the preterm infants. Using logistic regression, the main risk factor for common symptoms was frequent contact with other children. Severe outcomes were associated with maximal peak inspiratory pressure, arterial cord blood pH, APGAR and CRIB-Score. Conclusions Cough in preterm infants is as common as in term infants, whereas wheeze, inhalation therapy and re-hospitalisations occur more often. Severe outcomes are associated with perinatal risk factors. Preterm infants who did not qualify for BPD according to latest guidelines also showed a significant burden of respiratory disease in the first year of life.

Effectiveness of interventions to improve screening for syphilis in pregnancy: a systematic review and meta-analysis

About 2·1 million pregnant women have active syphilis every year. Without screening and treatment, 69% of these women will have an adverse outcome of pregnancy. The objectives of this study were to review the literature systematically to determine the effectiveness of screening interventions to prevent congenital syphilis and other adverse pregnancy outcomes.

Interaction of pregnancy and autoimmune rheumatic disease

During pregnancy, the fetus represents a natural allograft that is not normally rejected. While the maternal immune system retains the ability to respond to foreign antigens, tolerance mechanisms are up-regulated to protect the fetus from immunologic attacks by the mother. The profound immunologic adaptations during and after pregnancy do influence maternal autoimmune rheumatic diseases in several ways. One is triggering the onset of a rheumatic disease in the post partum period, the other influencing disease activity of established rheumatic disease. The review will discuss the mechanisms of increased susceptibility of rheumatoid arthritis (RA) in the first year post partum with a specific emphasis on the role of fetal cells or antigens persisting in the maternal circulation (so called microchimerism). Furthermore, the different influences of pregnancy on established rheumatic diseases will be highlighted. A marked beneficial effect of pregnancy is observed on RA whereas several other rheumatic diseases as ankylosing spondylitis (AS) and systemic lupus erythematosus (SLE) show either no particular effect or an aggravation of symptoms during pregnancy. Differences emerging in regard to modulation of disease symptoms during pregnancy seem related to response to hormones, the type of cytokine profile and immune response prevailing as well as further downstream interactions of molecular pathways that are important in disease pathogenesis.