A decision- theoretic model for M&A sale processes

A Work Project, presented as part of the requirements for the Award of a Masters Double Degree in Economics and International Business from the NOVA – School of Business and Economics and Insper Instituto de Ensino e Pesquisa

Sonication of removed breast implants for improved detection of subclinical infection.

BACKGROUND: Capsular fibrosis is a severe complication after breast implantation with an uncertain etiology. Microbial colonization of the prosthesis is hypothesized as a possible reason for the low-grade infection and subsequent capsular fibrosis. Current diagnostic tests consist of intraoperative swabs and tissue biopsies. Sonication of removed implants may improve the diagnosis of implant infection by detachment of biofilms from the implant surface. METHODS: Breast implants removed from patients with Baker grades 3 and 4 capsular contracture were analyzed by sonication, and the resulting sonication fluid was quantitatively cultured. RESULTS: This study investigated 22 breast implants (6 implants with Baker 3 and 16 implants with Baker 4 capsular fibrosis) from 13 patients. The mean age of the patients was 49 years (range, 31-76 years). The mean implant indwelling time was 10.4 years (range, 3 months to 30 years). Of the 22 implants, 12 were used for breast reconstruction and 10 for aesthetic procedures. The implants were located subglandularly (n = 12), submuscularly (n = 6), and subcutaneously (n = 4). Coagulase-negative staphylococci, Propionibacterium acnes, or both were detected in the sonication fluid cultures of nine implants (41%), eight of which grew significant numbers of microorganisms (>100 colonies/ml of sonication fluid). CONCLUSIONS: Sonication detected bacteria in 41% of removed breast implants. The identified bacteria belonged to normal skin flora. Further investigation is needed to determine any causal relation between biofilms and capsular fibrosis.

Les temporalités des médicaments : trajectoires en soins palliatifs à l'hôpital

A partir d'un terrain ethnographique réalisé au sein d'une équipe mobile de soins palliatifs d'un hôpital universitaire, cette thèse de doctorat porte sur les médicaments dans le contexte de la fin de vie. Au carrefour d'une socio-anthropologie de la maladie grave, du mourir et des médicaments, elle interroge les rapports à la morphine, ainsi qu'à certains psychotropes et sédatifs utilisés en soins palliatifs. Entre temporalité vécue et temporalité institutionnelle, les manières d'investir le temps lorsqu'il est compté, y sont centrales. Dans une dimension microsociale, les résultats montrent que l'introduction de certains médicaments comme la morphine et l'entrée en scène d'une équipe mobile de soins palliatifs sont des points de repère et peuvent sonner comme une annonce, sorte de sanction, dans la trajectoire incertaine de la personne malade. En outre, les médicaments permettent d'agir sur « le temps qui reste » en plus de soulager les symptômes lorsque la maladie grave bascule en maladie incurable. Ils font l'objet d'usages détournés du but initial de soulagement des symptômes pour repousser, altérer ou accélérer la mort dans une perspective de maîtrise de sa fin de vie. Dans une dimension mésosociale, ce travail considère les médicaments à la base d'échanges entre groupements professionnels sur fond d'institutionnalisation des soins palliatifs par rapport à d'autres segments de la médecine actifs dans la gestion de la fin de vie. Dans une médecine caractérisée par l'incertitude et les décisions -avec une teinte toute particulière en Suisse où le suicide assisté est toléré - les médicaments en soins palliatifs peuvent être considérés comme des instruments de mort, qu'ils soient redoutés ou recherchés. Interrogeant les risques de reproduire un certain nombre d'inégalités de traitements à l'approche de la mort, qui s'accentuent dans un contexte de plus en plus favorable aux pratiques euthanasiques, ce travail se propose, en définitive, de discuter le temps contraint de la mort dans les institutions hospitalo-universitaires, entre acharnement et abstention thérapeutique.¦-¦Based on ethnographie fieldwork conducted within a palliative care mobile team in an academic hospital, this doctoral thesis focuses on medicines used in end of life contexts. At the intersection of a socio-anthropology of illness, dying and pharmaceuticals, the relations to morphine, as well as to some psychotropic and sedative drugs used in palliative care are questioned. Between "lived" experiences of temporality and institutional temporality, the ways by which actors invest time when it is counted, appeared to be central. In a microsocial dimension, the results showed that introducing drugs such as morphine, as well as the arrival of a palliative care mobile team, are landmarks and sound like an announcement, a sort of sanction, during the uncertain trajectory of the ill person. In addition, medicines can act on "the remaining time" when severe illness shifts into incurable illness. Indeed, medicines are being diverted from the initial aim of symptom relief in order to defer, alter or hasten death in a perspective of control over one's death. In a mesosocial dimension, pharmaceuticals are seen as core to professional exchanges and to palliative care institutionalisation compared to other active medical segments in end of life care. In a medical context characterised by uncertainty and decision-taking-with a special shade in Switzerland where assisted suicide is tolerated - palliative medicines can be seen as instruments of death, whether sought or feared. Questioning the risks of reproducing treatment inequalities at the approach of death, which are accentuated in a context increasingly favorable to euthanasia practices, this study aims, ultimately, at discussing death's constrained time in academic hospitals, between therapeutic intervention and abstention.

Extent of non-publication in cohorts of studies approved by research ethics committees or included in trial registries

BACKGROUND: The synthesis of published research in systematic reviews is essential when providing evidence to inform clinical and health policy decision-making. However, the validity of systematic reviews is threatened if journal publications represent a biased selection of all studies that have been conducted (dissemination bias). To investigate the extent of dissemination bias we conducted a systematic review that determined the proportion of studies published as peer-reviewed journal articles and investigated factors associated with full publication in cohorts of studies (i) approved by research ethics committees (RECs) or (ii) included in trial registries. METHODS AND FINDINGS: Four bibliographic databases were searched for methodological research projects (MRPs) without limitations for publication year, language or study location. The searches were supplemented by handsearching the references of included MRPs. We estimated the proportion of studies published using prediction intervals (PI) and a random effects meta-analysis. Pooled odds ratios (OR) were used to express associations between study characteristics and journal publication. Seventeen MRPs (23 publications) evaluated cohorts of studies approved by RECs; the proportion of published studies had a PI between 22% and 72% and the weighted pooled proportion when combining estimates would be 46.2% (95% CI 40.2%-52.4%, I2 = 94.4%). Twenty-two MRPs (22 publications) evaluated cohorts of studies included in trial registries; the PI of the proportion published ranged from 13% to 90% and the weighted pooled proportion would be 54.2% (95% CI 42.0%-65.9%, I2 = 98.9%). REC-approved studies with statistically significant results (compared with those without statistically significant results) were more likely to be published (pooled OR 2.8; 95% CI 2.2-3.5). Phase-III trials were also more likely to be published than phase II trials (pooled OR 2.0; 95% CI 1.6-2.5). The probability of publication within two years after study completion ranged from 7% to 30%. CONCLUSIONS: A substantial part of the studies approved by RECs or included in trial registries remains unpublished. Due to the large heterogeneity a prediction of the publication probability for a future study is very uncertain. Non-publication of research is not a random process, e.g., it is associated with the direction of study findings. Our findings suggest that the dissemination of research findings is biased.

Cost-effectiveness of low-molecular-weight heparin for secondary prophylaxis of cancer-related venous thromboembolism.

Although extended secondary prophylaxis with low-molecular-weight heparin was recently shown to be more effective than warfarin for cancer-related venous thromboembolism, its cost-effectiveness compared to traditional prophylaxis with warfarin is uncertain. We built a decision analytic model to evaluate the clinical and economic outcomes of a 6-month course of low-molecular-weight heparin or warfarin therapy in 65-year-old patients with cancer-related venous thromboembolism. We used probability estimates and utilities reported in the literature and published cost data. Using a US societal perspective, we compared strategies based on quality-adjusted life-years (QALYs) and lifetime costs. The incremental cost-effectiveness ratio of low-molecular-weight heparin compared with warfarin was 149,865 dollars/QALY. Low-molecular-weight heparin yielded a quality-adjusted life expectancy of 1.097 QALYs at the cost of 15,329 dollars. Overall, 46% (7108 dollars) of the total costs associated with low-molecular-weight heparin were attributable to pharmacy costs. Although the low-molecular-weigh heparin strategy achieved a higher incremental quality-adjusted life expectancy than the warfarin strategy (difference of 0.051 QALYs), this clinical benefit was offset by a substantial cost increment of 7,609 dollars. Cost-effectiveness results were sensitive to variation of the early mortality risks associated with low-molecular-weight heparin and warfarin and the pharmacy costs for low-molecular-weight heparin. Based on the best available evidence, secondary prophylaxis with low-molecular-weight heparin is more effective than warfarin for cancer-related venous thromboembolism. However, because of the substantial pharmacy costs of extended low-molecular-weight heparin prophylaxis in the US, this treatment is relatively expensive compared with warfarin.

Delirium: guidelines for general hospitals.

OBJECTIVE: Delirium is highly prevalent in general hospitals but remains underrecognized and undertreated despite its association with increased morbidity, mortality, and health services utilization. To enhance its management, we developed guidelines covering all aspects, from risk factor identification to preventive, diagnostic, and therapeutic interventions in adult patients. METHODS: Guidelines, systematic reviews, randomized controlled trials (RCT), and cohort studies were systematically searched and evaluated. Based on a synthesis of retrieved high-quality documents, recommendation items were submitted to a multidisciplinary expert panel. Experts scored the appropriateness of recommendation items, using an evidence-based, explicit, multidisciplinary panel approach. Each recommendation was graded according to this process' results. RESULTS: Rated recommendations were mostly supported by a low level of evidence (1.3% RCT and systematic reviews, 14.3% nonrandomized trials vs. 84.4% observational studies or expert opinions). Nevertheless, 71.1% of recommendations were considered appropriate by the experts. Prevention of delirium and its nonpharmacological management should be fostered. Haloperidol remains the first-choice drug, whereas the role of atypical antipsychotics is still uncertain. CONCLUSIONS: While many topics addressed in these guidelines have not yet been adequately studied, an explicit panel and evidence-based approach allowed the proposal of comprehensive recommendations for the prevention and management of delirium in general hospitals.

Survey on current practices for neurological prognostication after cardiac arrest.

PURPOSE: To investigate current practices and timing of neurological prognostication in comatose cardiac arrest patients. METHODS: An anonymous questionnaire was distributed to the 8000 members of the European Society of Intensive Care Medicine during September and October 2012. The survey had 27 questions divided into three categories: background data, clinical data, decision-making and consequences. RESULTS: A total of 1025 respondents (13%) answered the survey with complete forms in more than 90%. Twenty per cent of respondents practiced outside of Europe. Overall, 22% answered that they had national recommendations, with the highest percentage in the Netherlands (>80%). Eighty-nine per cent used induced hypothermia (32-34 °C) for comatose cardiac arrest patients, while 11% did not. Twenty per cent had separate prognostication protocols for hypothermia patients. Seventy-nine per cent recognized that neurological examination alone is not enough to predict outcome and a similar number (76%) used additional methods. Intermittent electroencephalography (EEG), brain computed tomography (CT) scan and evoked potentials (EP) were considered most useful. Poor prognosis was defined as cerebral performance category (CPC) 3-5 (58%) or CPC 4-5 (39%) or other (3%). When prognosis was considered poor, 73% would actively withdraw intensive care while 20% would not and 7% were uncertain. CONCLUSION: National recommendations for neurological prognostication after cardiac arrest are uncommon and only one physician out of five uses a separate protocol for hypothermia treated patients. A neurological examination alone was considered insufficient to predict outcome in comatose patients and most respondents advocated a multimodal approach: EEG, brain CT and EP were considered most useful. Uncertainty regarding neurological prognostication and decisions on level of care was substantial.

Adaptive MCMC methods with applications in environmental and geophysical models

This work presents new, efficient Markov chain Monte Carlo (MCMC) simulation methods for statistical analysis in various modelling applications. When using MCMC methods, the model is simulated repeatedly to explore the probability distribution describing the uncertainties in model parameters and predictions. In adaptive MCMC methods based on the Metropolis-Hastings algorithm, the proposal distribution needed by the algorithm learns from the target distribution as the simulation proceeds. Adaptive MCMC methods have been subject of intensive research lately, as they open a way for essentially easier use of the methodology. The lack of user-friendly computer programs has been a main obstacle for wider acceptance of the methods. This work provides two new adaptive MCMC methods: DRAM and AARJ. The DRAM method has been built especially to work in high dimensional and non-linear problems. The AARJ method is an extension to DRAM for model selection problems, where the mathematical formulation of the model is uncertain and we want simultaneously to fit several different models to the same observations. The methods were developed while keeping in mind the needs of modelling applications typical in environmental sciences. The development work has been pursued while working with several application projects. The applications presented in this work are: a winter time oxygen concentration model for Lake Tuusulanjärvi and adaptive control of the aerator; a nutrition model for Lake Pyhäjärvi and lake management planning; validation of the algorithms of the GOMOS ozone remote sensing instrument on board the Envisat satellite of European Space Agency and the study of the effects of aerosol model selection on the GOMOS algorithm.

Verrucous Carcinoma of the Vulva: A Case Report and Review of the Literature.

Verrucous carcinoma of the vulva is a rare lesion (1). Affecting essentially postmenopausal women, this lesion is a distinct and particular entity in vulval carcinoma classification and its scalability is uncertain and unpredictable. Here, we present a case concerning a 48-year-old patient, without follow-up after a condyloma acuminate of the vulva (large left lip). The origin of this case will be discussed in this article. The treatment decided was only surgical. A review of literature shows the rarity of this lesion of the female genital tract.

Self-deception as affective coping. An empirical perspective on philosophical issues.

In the philosophical literature, self-deception is mainly approached through the analysis of paradoxes. Yet, it is agreed that self-deception is motivated by protection from distress. In this paper, we argue, with the help of findings from cognitive neuroscience and psychology, that self-deception is a type of affective coping. First, we criticize the main solutions to the paradoxes of self-deception. We then present a new approach to self-deception. Self-deception, we argue, involves three appraisals of the distressing evidence: (a) appraisal of the strength of evidence as uncertain, (b) low coping potential and (c) negative anticipation along the lines of Damasio's somatic marker hypothesis. At the same time, desire impacts the treatment of flattering evidence via dopamine. Our main proposal is that self-deception involves emotional mechanisms provoking a preference for immediate reward despite possible long-term negative repercussions. In the last part, we use this emotional model to revisit the philosophical paradoxes.

"I like my beer cold, my TV loud, and my homosexuals flaming!" : preference for stereotype consistency as a function of a person x situation interaction /

The study centers on the power of Right-Wing Authoritarianism (RWA) and Social Dominance Orientation (SDO) as predictors of prejudice against stereotypical and nonstereotypical homosexuals under the threat of death and the threat of uncertainty. Right-wing authoritarianism (RWA) is an individual difference variable that measures the tendency for individuals to unquestionably follow those perceived to be authorities. Social Dominance Orientation (SDO) is an individual difference variable that measures the degree to which an individual prefers inequality among social groups. The RWA and SDO Scales are considered to be two of the strongest predictors of prejudice, such as prejudice against homosexuals. The study focuses on the unique predictive power of these two variables in predicting prejudice against homosexuals. The study also examines the role of situational threat in prejudice, specifically the threat of death (mortality salience) and the threat of uncertainty (uncertainty salience). Competing predictions from theories involving the threat of death (Terror Management Theory) and the threat of uncertainty (Uncertainty Management Theory) are also tested. The preference for expected information in the form of stereotypes concerning male homosexuals (that is, a stereotypical or non-stereotypical homosexual) were tested. The difference between the predictive power ofRWA and SDO was examined by measuring how these variables predict liking of a stereotypical or non-stereotypical homosexual under the threat of death, the threat of uncertainty, or a control condition. Along with completing a measure for RWA and a measure for SDO, participants were asked to think of their own death, of their being uncertain or about watching television then were asked to read about a week in the life of either a stereotypical or non-stereotypical male homosexual. Participants were then asked to evaluate the individual and his essay. Based on the participants' evaluations, results from 180 heterosexual university students show that RWA and SDO are strong predictors for disliking of a stereotypical homosexual under the threat of uncertainty and disliking of a non-stereotypical homosexual under the threat of death. Furthermore, however, results show that RWA is a particularly strong predictor of disliking of a stereotypical homosexual under the threat of uncertainty, whereas SDO is an exceptionally strong predictor of disliking of the non-stereotypical homosexual under the threat of death. This further adds to the notion that RWA and SDO are indeed unique predictors of prejudice. Implications are also explored, including the fact that the study simuhaneously examined the role of individual difference variables and situational threat variables, as well as exploratory analysis on Dominating Authoritarians.

Legitimacy in question : elite-mass relations, constitutional reform and Canadian democracy /

During the 1980s and 1990s, Canadian political authority orientations underwent a significant transformation. Canadians are no longer deferential towards their political elites. Instead, they are autonomous, challenging, and increasingly participatory, and this continuing trend has brought the procedural legitimacy of the Canadian political process into question. The following study of elite-mass relations within Canadian democracy attempts to provide insight into the meaning of this change and how it should be addressed. An attitudinalbehavioural analysis ofthe electorate presents evidence that popular cynicism and alienation is rooted more deeply in a dissatisfaction with political institutions and traditions than with politicians. A structural analysis of the elected political elite reveals the failure of consociational traditions to provide effective representation as well as the minimal impact which the aforementioned orientation shift has had upon this elite. An event-decisional analysis, or case study, ofelite-mass relations in the arena of constitutional politics augments these complementary profiles and illustrates how the transformed electorate has significantly restricted the elected political elite's role in constitutional reform. The study concludes that the lack ofresponsiveness, representativeness, and inclusiveness ofCanada's elected political elite, political institutions, and political traditions has substantially eroded the procedural legitimacy of Canadian democracy during the 1980s and 1990s. Remedying these three deficiencies in the political system, which are the objects of increasing public demand, may restore legitimacy, but the likelihood that such reforms will be adopted is presently uncertain in the face of formidable difficulties and obstacles.

Reproduction in the temperate crayfish, Orconectes rusticus: intermale aggression, copulatary behaviour, and sperm competition

The chelipeds of Orconectes rusticus are sexually dimorphic; males possessing the larger. Males use their chelae in intermale aggressive interactions, both to threaten, and assault opponents. In dyadic interactions males with larger chelae were dominant over otherwise physically similar opponents. A high frequency of attack behaviour, coupled with a low frequency of threats during these interactions indicates that actual physical contact is required for opponent assessment. Large clawed males oriented females into the copulatory position faster than small clawed males. Females more frequently escaped the precopulatory-grasp attempts of small clawed males. Additionally, male-female pairs that included a large clawed male remained in copula longer than pairs that included a small clawed male. Sperm of the second male to mate took precedence over the sperm of the primary male. Sperm precedence was incomplete; about 900/0 paternity accrued to the second male.

Sedimentology of the Sixteen Mile Creek Lagoon, Niagara Peninsula, Ontario, Canada

The effec s of relative water level changes in Lake Ontario were detected in the ysical, chemical and biological characteristics of the sediments of the Fifteen, Sixteen and Twenty Mile Creek lagoonal complexes. Regional environmental changes have occurred resulting in the following sequence of sediments in the three lagoons and marsh. From the base up they are; (I) Till,(2) Pink Clay, (3) Bottom Sand, (4) Gyttja, (5) Orange Sandy Silt, (6) Brown Clay and (7) Gray Clay. The till was only encountered in the marsh and channel; however, it is presumed to occur throughout the entire area. The presence of diatoms and sponge spicules, the vertical and ongitudinal uniformity of the sediment and the stratigr ic position of the Pink Clay indicate that it has a glacial or post-glacial lacustrine origin. Overl ng the Pink Clay or Till is a clayey, silty sand to gravel. The downstream fining and unsorted nature of this material indicate that it has a fluvial/deltaic origin. Water levels began rising in the lagoon 3,250 years ago resulting in the deposition of the Gyttja, a brown, organic-rich silty clay probably deposited in a shallow, stagnant environment as shown by the presence of pyrite in the organic material and relatively high proportions of benthic diatoms and grass pollen. Increase in the rate of deposition of the Gyttja on Twenty Mile Creek and a decrease in the same unit on Sixteen Mile Creek is possibly the result of a capture of the Sixteen Mile Creek by the Twenty Mile Creek. The rise in lake level responsible for the onset and transgression of this III unit may have been produced by isostatic rebound; however, the deposition also corresponds closely to a drop in the level of Lake Huron and increased flow through the lower lakes. The o ange Sandy Silt, present only in the marsh, appears to be a buried soil horizon as shown by oxidized roots, and may be the upland equivalant to the Gyttja. Additional deepening resulted in the deposition of Brown Clay, a unit which only occurs at the lakeward end of the three lagoons. The decrease in grass pollen and the relatively high proportion of pelagic diatoms are evidence for this. The deepening may be the result of isostatic rebound; however, the onset of its deposition at 1640 years B.P. is synchronous in the three lagoons and corresponds to the end of the subAtlantic climatic episode. The effects of the climatic change in southern Ontario is uncertain. Average deposition rates of the Brown Clay are similar to those in the upper Gyttja on Sixteen Mile Creek; however, Twenty Mile Creek shows lower rates of the Brown Clay than those in the upper Gyttja. The Gray Clay covers the present bottom of the three lagoons and also occurs in the marsh It is inter1aminated wi sand in the channels. Increases in the rates of deposi ion, high concentrations of Ca and Zn, an Ambrosia rise, and an increase in bioturbation possibly due to the activities of the carp, indicate th this unit is a recent deposit resulting from the activities of man.

Outcome Evaluation of a Campus-Based Quit and Win Contest

This study examined abstinence outcomes of a provincial, campus-based Quit and Win contest relative to contestants’ assessments of the prize, buddy support, social support network, and emails. Of the 288 participants providing baseline data, 201 self-reported their smoking and quitting behaviours, use of quit aides, and perceptions of contest components. On 5-point scales, perceived values of the contest prize, buddy support, social support network and email were 4.42, 3.95, 3.89, and 3.46 respectively. Intention to treat analysis showed 27.8% of participants achieved 6-week contest-period abstinence; 19.8% achieved 3-month sustained abstinence. Odds of achieving 3-month abstinence were influenced by age (OR = 1.10, CI =1.03, 1.18) and use of pharmacological quit aides (OR = 0.42, CI = 0.20, 0.88), but not smoking behaviours or contest components. Contest prizes and support were valued, but played an uncertain role in quitting success. Future research might examine their roles in contestant recruitment or retention.