French Swiss physicians' attitude toward palliative sedation: Influence of prognosis and type of suffering.

OBJECTIVE: Palliative sedation is a last resort medical act aimed at relieving intolerable suffering induced by intractable symptoms in patients at the end-of-life. This act is generally accepted as being medically indicated under certain circumstances. A controversy remains in the literature as to its ethical validity. There is a certain vagueness in the literature regarding the legitimacy of palliative sedation in cases of non-physical refractory symptoms, especially "existential suffering." This pilot study aims to measure the influence of two independent variables (short/long prognosis and physical/existential suffering) on the physicians' attitudes toward palliative sedation (dependent variable). METHODS: We used a 2 × 2 experimental design as described by Blondeau et al. Four clinical vignettes were developed (vignette 1: short prognosis/existential suffering; vignette 2: long prognosis/existential suffering; vignette 3: short prognosis/physical suffering; vignette 4: long prognosis/physical suffering). Each vignette presented a terminally ill patient with a summary description of his physical and psychological condition, medication, and family situation. The respondents' attitude towards sedation was assessed with a six-point Likert scale. A total of 240 vignettes were sent to selected Swiss physicians. RESULTS: 74 vignettes were completed (36%). The means scores for attitudes were 2.62 ± 2.06 (v1), 1.88 ± 1.54 (v2), 4.54 ± 1.67 (v3), and 4.75 ± 1.71 (v4). General linear model analyses indicated that only the type of suffering had a significant impact on the attitude towards sedation (F = 33.92, df = 1, p = 0.000). Significance of the results: The French Swiss physicians' attitude toward palliative sedation is more favorable in case of physical suffering than in existential suffering. These results are in line with those found in the study of Blondeau et al. with Canadian physicians and will be discussed in light of the arguments given by physicians to explain their decisions.

Superior diagnostic performance of perfusion-cardiovascular magnetic resonance versus SPECT to detect coronary artery disease: The secondary endpoints of the multicenter multivendor MR-IMPACT II (Magnetic Resonance Imaging for Myocardial Perfusion Assessment in Coronary Artery Disease Trial).

ABSTRACT: BACKGROUND: Perfusion-cardiovascular magnetic resonance (CMR) is generally accepted as an alternative to SPECT to assess myocardial ischemia non-invasively. However its performance vs gated-SPECT and in sub-populations is not fully established. The goal was to compare in a multicenter setting the diagnostic performance of perfusion-CMR and gated-SPECT for the detection of CAD in various populations using conventional x-ray coronary angiography (CXA) as the standard of reference. METHODS: In 33 centers (in US and Europe) 533 patients, eligible for CXA or SPECT, were enrolled in this multivendor trial. SPECT and CXA were performed within 4 weeks before or after CMR in all patients. Prevalence of CAD in the sample was 49% and 515 patients received MR contrast medium. Drop-out rates for CMR and SPECT were 5.6% and 3.7%, respectively (ns). The study was powered for the primary endpoint of non-inferiority of CMR vs SPECT for both, sensitivity and specificity for the detection of CAD (using a single-threshold reading), the results for the primary endpoint were reported elsewhere. In this article secondary endpoints are presented, i.e. the diagnostic performance of CMR versus SPECT in subpopulations such as multi-vessel disease (MVD), in men, in women, and in patients without prior myocardial infarction (MI). For diagnostic performance assessment the area under the receiver-operator-characteristics-curve (AUC) was calculated. Readers were blinded versus clinical data, CXA, and imaging results. RESULTS: The diagnostic performance (= area under ROC = AUC) of CMR was superior to SPECT (p = 0.0004, n = 425) and to gated-SPECT (p = 0.018, n = 253). CMR performed better than SPECT in MVD (p = 0.003 vs all SPECT, p = 0.04 vs gated-SPECT), in men (p = 0.004, n = 313) and in women (p = 0.03, n = 112) as well as in the non-infarct patients (p = 0.005, n = 186 in 1-3 vessel disease and p = 0.015, n = 140 in MVD). CONCLUSION: In this large multicenter, multivendor study the diagnostic performance of perfusion-CMR to detect CAD was superior to perfusion SPECT in the entire population and in sub-groups. Perfusion-CMR can be recommended as an alternative for SPECT imaging. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: NCT00977093.

Methods for Region Based Paper Surface Roughness Measurement

Paperin pinnan karheus on yksi paperin laatukriteereistä. Sitä mitataan fyysisestipaperin pintaa mittaavien laitteiden ja optisten laitteiden avulla. Mittaukset vaativat laboratorioolosuhteita, mutta nopeammille, suoraan linjalla tapahtuville mittauksilla olisi tarvetta paperiteollisuudessa. Paperin pinnan karheus voidaan ilmaista yhtenä näytteelle kohdistuvana karheusarvona. Tässä työssä näyte on jaettu merkitseviin alueisiin, ja jokaiselle alueelle on laskettu erillinen karheusarvo. Karheuden mittaukseen on käytetty useita menetelmiä. Yleisesti hyväksyttyä tilastollista menetelmää on käytetty tässä työssä etäisyysmuunnoksen lisäksi. Paperin pinnan karheudenmittauksessa on ollut tarvetta jakaa analysoitava näyte karheuden perusteella alueisiin. Aluejaon avulla voidaan rajata näytteestä selvästi karheampana esiintyvät alueet. Etäisyysmuunnos tuottaa alueita, joita on analysoitu. Näistä alueista on muodostettu yhtenäisiä alueita erilaisilla segmentointimenetelmillä. PNN -menetelmään (Pairwise Nearest Neighbor) ja naapurialueiden yhdistämiseen perustuvia algoritmeja on käytetty.Alueiden jakamiseen ja yhdistämiseen perustuvaa lähestymistapaa on myös tarkasteltu. Segmentoitujen kuvien validointi on yleensä tapahtunut ihmisen tarkastelemana. Tämän työn lähestymistapa on verrata yleisesti hyväksyttyä tilastollista menetelmää segmentoinnin tuloksiin. Korkea korrelaatio näiden tulosten välillä osoittaa onnistunutta segmentointia. Eri kokeiden tuloksia on verrattu keskenään hypoteesin testauksella. Työssä on analysoitu kahta näytesarjaa, joidenmittaukset on suoritettu OptiTopolla ja profilometrillä. Etäisyysmuunnoksen aloitusparametrit, joita muutettiin kokeiden aikana, olivat aloituspisteiden määrä ja sijainti. Samat parametrimuutokset tehtiin kaikille algoritmeille, joita käytettiin alueiden yhdistämiseen. Etäisyysmuunnoksen jälkeen korrelaatio oli voimakkaampaa profilometrillä mitatuille näytteille kuin OptiTopolla mitatuille näytteille. Segmentoiduilla OptiTopo -näytteillä korrelaatio parantui voimakkaammin kuin profilometrinäytteillä. PNN -menetelmän tuottamilla tuloksilla korrelaatio oli paras.

Usages de l'eau à Gaya (Niger) : entre fortes potentialités et contraintes majeures

Résumé: Le département de Gaya, cadre de notre étude, est situé au sud-ouest de la république du Niger. Il dispose d'un important potentiel hydrique composé des eaux de surface (une centaine de mares permanentes, le fleuve Niger sur 106 km) et de sept aquifères superposés comprenant des nappes de subsurface (affleurantes par endroit) et des nappes artésiennes. L'étude sur les usages de l'eau à Gaya a été menée à travers plusieurs axes centrés sur l'estimation et la répartition spatiale des ressources en eau, le cadre juridique et institutionnel régulant leur mise en valeur, les différents secteurs d'utilisation de l'eau ainsi que les contraintes affectant cette utilisation. L'usage de la cartographie à travers les SIG dans le traitement et l'analyse des données, couplée à notre expérience d'une dizaine d'année de travaux dans la région, a permis de dresser des synthèses richement illustrées permettant de mieux comprendre tous les enjeux liés à la problématique des usages de l'eau dans cette partie du Niger. Contrairement à la vision que l'on a traditionnellement du Sahel où le manque d'eau constitue une des contraintes majeures au développement, ici des conditions locales particulières contredisent ce cliché et transposent le débat sur un autre plan. Il s'agit de la maîtrise de l'eau au niveau local à travers l'élaboration d'une politique appropriée qui tienne compte non seulement des spécificités locales de la ressource, mais aussi des différents types d'usages. La politique de l'eau au Niger, définie selon le Schéma directeur de mise en valeur et de gestion des ressources en eau, à travers la mise en place d'un important arsenal juridique et institutionnel, a eu le mérite de tracer un canevas sur la question, mais a montré ses limites au niveau pratique après dix ans d'essai. En effet au niveau de Gaya, ni l'Etat ni les partenaires au développement (bailleurs de fonds extérieurs) n'ont tenu compte des caractéristiques locales de la ressource ou du contexte socioéconomique particulier de la région. Ce qui a entraîné la réalisation d'infrastructures inadaptées aux réalités hydrogéologiques locales ainsi que des choix inappropriés au niveau de certains aménagements. En dépit de l'abondance de la ressource, son accès tant au niveau quantitatif que qualitatif, reste difficile pour une grande partie des acteurs ruraux. Les différents handicaps rencontrés dans la mise en valeur des ressources en eau résultent de cette incohérence de la politique nationale de l'eau, mais aussi de la difficulté de son application sur le terrain où persiste un pluralisme juridique caractérisé par la cohabitation de deux systèmes de régulation à savoir les droits coutumiers et la législation moderne. Ces différents éléments mis en évidence dans cette étude sur la zone de Gaya pourraient servir de base pour un meilleur aménagement des ressources en eau dans le cadre plus large d'une politique d'aménagement du territoire prenant en compte tous les facteurs tant physiques que socioéconomiques de la région. Abstract: The department of Gaya, in which this study was done, is located in the SW area of the Republic of Niger. It has an important hydrological potential composed of surface water (approximately 100 permanent ponds, 106 km of the Niger River) and 7 bodies of underground water sources including sub-surface and artresan wells. This study of the exploitation of wtaer in Gaya has been carried out employing several parameters based on: the estimation and spacial distribution of water ressources, the juridic and institutional rules governing their utilisation and the various constraints affecting this exploitation. The use of mapping when treating and analysing data, coupled with ten years personel field experience, resulted in a richly illustrated synthesis of this data. This, in turn, led to a better comprehension of all the factors related to problems of water utilisation in this particular region of Niger. Contrary to the generally accepted view that the lack of water ressources is a major contributing factor to the lack of development in the Sahel, in Gaya the local conditions contradict this statement. In this region, and at the local level, the proper use of water is based on the elaboration of an appropriate policy which takes into account not only the local specifics of water ressources but the various types of water utilsation as well. Local use of water and water ressources are dependant on established rules. Water policy in Niger is defined by the General Schema based on an important institutional and judicary arsenal of rules and regulations. However, after a ten-year trial period, this system was shown to have its limitations. In Gaya, neither the State nor the development agencies took into consideration local characteristics nor the socio-economic context of the region. This, in turn, resulted in putting in place infrastructures that were not adapted to local hydrogeological realities as well as inappropriate choices in land planning and development. In spite of the abundance of water ressources, access to them remains difficult for most of the rural population. The various difficulties encountered are the result of incoherent water policies on a national level as well as the lack of practical application in this area. This is due to a double judicary system where two regulatory systems co-exist:traditional laws and modern legislation. the different elements brought out by this study could serve as a basis for a better utilisation of water ressources on a larger scale in which land planning and development policies would take into consideration all the physcial as well as the socio-economical factors of this region.

Automated formulation of optimisation models for steel beam structures

Over 70% of the total costs of an end product are consequences of decisions that are made during the design process. A search for optimal cross-sections will often have only a marginal effect on the amount of material used if the geometry of a structure is fixed and if the cross-sectional characteristics of its elements are property designed by conventional methods. In recent years, optimalgeometry has become a central area of research in the automated design of structures. It is generally accepted that no single optimisation algorithm is suitable for all engineering design problems. An appropriate algorithm, therefore, mustbe selected individually for each optimisation situation. Modelling is the mosttime consuming phase in the optimisation of steel and metal structures. In thisresearch, the goal was to develop a method and computer program, which reduces the modelling and optimisation time for structural design. The program needed anoptimisation algorithm that is suitable for various engineering design problems. Because Finite Element modelling is commonly used in the design of steel and metal structures, the interaction between a finite element tool and optimisation tool needed a practical solution. The developed method and computer programs were tested with standard optimisation tests and practical design optimisation cases. Three generations of computer programs are developed. The programs combine anoptimisation problem modelling tool and FE-modelling program using three alternate methdos. The modelling and optimisation was demonstrated in the design of a new boom construction and steel structures of flat and ridge roofs. This thesis demonstrates that the most time consuming modelling time is significantly reduced. Modelling errors are reduced and the results are more reliable. A new selection rule for the evolution algorithm, which eliminates the need for constraint weight factors is tested with optimisation cases of the steel structures that include hundreds of constraints. It is seen that the tested algorithm can be used nearly as a black box without parameter settings and penalty factors of the constraints.

Welding time models for cost calculations in the early stages of the design process

It is generally accepted that between 70 and 80% of manufacturing costs can be attributed to design. Nevertheless, it is difficult for the designer to estimate manufacturing costs accurately, especially when alternative constructions are compared at the conceptual design phase, because of the lack of cost information and appropriate tools. In general, previous reports concerning optimisation of a welded structure have used the mass of the product as the basis for the cost comparison. However, it can easily be shown using a simple example that the use of product mass as the sole manufacturing cost estimator is unsatisfactory. This study describes a method of formulating welding time models for cost calculation, and presents the results of the models for particular sections, based on typical costs in Finland. This was achieved by collecting information concerning welded products from different companies. The data included 71 different welded assemblies taken from the mechanical engineering and construction industries. The welded assemblies contained in total 1 589 welded parts, 4 257 separate welds, and a total welded length of 3 188 metres. The data were modelled for statistical calculations, and models of welding time were derived by using linear regression analysis. Themodels were tested by using appropriate statistical methods, and were found to be accurate. General welding time models have been developed, valid for welding in Finland, as well as specific, more accurate models for particular companies. The models are presented in such a form that they can be used easily by a designer, enabling the cost calculation to be automated.

En torno a la integración de lo interno y lo externo en los estudios historiográficos de la lengua inglesa

Aquest estudi és una aproximació crítica a la dicotomia establerta per Saussure entre la lingüística interna i la lingüística externa i l'aplicació que se n'ha fet als tractats historiogràfics de la llengua anglesa. Pel caràcter ontològic de la investigació diacrònica, aquestes consideracions saussurianes posen les bases empíriques per teoritzar sobre el canvi lingüístic en la llengua anglesa. D'altra banda, la distinció més o menys explícita entre la història interna de la llengua anglesa i l'externa és un fet comunament acceptat i utilitzat pels tractats historiogràfics consultats. A l'hora de dur a terme la investigació diacrònica, però, la història interna necessita, per a la delimitació cronològica, les aportacions de l'externa; així, encara que els condicionants sociològics es considerin marginals, els factors externs adquireixen importància no només pel fet d'incloure el context social on s'emmarquen els fenòmens lingüístics, sinó també per les consideracions de tipus sociolingüístic que en resulten, les quals aporten noves línies de recerca historiogràfica, basada en els models de variacions en el registre escrit de la llengua anglesa.

Tilintarkastuksen odotuskuilu

Tutkimuksen tarkoitus on selvittää millaista tilintarkastuksen odotuskuilu on, mitkä syyt siihen johtavat ja miten odotuskuilua voidaan kaventaa. Aluksi käydään läpi tilintarkastusta, hyvää tilintarkastustapaa, mitä lakisääteiseen tilintarkastukseen sekä konsultointiin kuuluu ja mitä erikoisuuksia pk-yritysten tilintarkastamiseen kuuluu. Sen jälkeen käsitellään tilintarkastuksen odotuskuilua kirjallisuuden ja artikkelien perusteella. Tässä käydään tarkemmin läpi mitä tilintarkastuksen odotuskuilu on, mitkä syyt siihen johtavat sekä miten sitä voidaan kaventaa. Tämän jälkeen käydään tutkimuksen empiiristä osiota läpi, jossa auktorisoidut tilintarkastajat ovat vastanneet tilintarkastuksen odotuskuilua koskeviin kysymyksiin. Voidaan sanoa, että tilintarkastuksen odotuskuilu on kuilu yleisön odotuksista tilintarkastuksesta verrattuna siihen, mitä lakisääteinen tilintarkastus itse asiassa on. Odotuskuiluun on monia syitä, muun muassa tilintarkastuksen todennäköinen luonne ja yleisön ylisuuret odotukset. Odotuskuilua voidaan kaventaa kahdella tavalla: valistamalla yleisöä tai muuttamalla tilintarkastuksen luonnetta vastaamaan yleisön odotuksia.

Thomas-Fermi theory for atomic nuclei revisited

The recently developed semiclassical variational Wigner-Kirkwood (VWK) approach is applied to finite nuclei using external potentials and self-consistent mean fields derived from Skyrme inter-actions and from relativistic mean field theory. VWK consist s of the Thomas-Fermi part plus a pure, perturbative h 2 correction. In external potentials, VWK passes through the average of the quantal values of the accumulated level density and total en energy as a function of the Fermi energy. However, there is a problem of overbinding when the energy per particle is displayed as a function of the particle number. The situation is analyzed comparing spherical and deformed harmonic oscillator potentials. In the self-consistent case, we show for Skyrme forces that VWK binding energies are very close to those obtained from extended Thomas-Fermi functionals of h 4 order, pointing to the rapid convergence of the VWK theory. This satisfying result, however, does not cure the overbinding problem, i.e., the semiclassical energies show more binding than they should. This feature is more pronounced in the case of Skyrme forces than with the relativistic mean field approach. However, even in the latter case the shell correction energy for e.g.208 Pb turns out to be only ∼ −6 MeV what is about a factor two or three off the generally accepted value. As an adhoc remedy, increasing the kinetic energy by 2.5%, leads to shell correction energies well acceptable throughout the periodic table. The general importance of the present studies for other finite Fermi systems, self-bound or in external potentials, is pointed out.

Cost evaluation and comparison of three decision strategies for cardiac revascularization : results of the suspected CAD protocol of the European CMR registry

Background: The public health burden of coronary artery disease (CAD) is important. Perfusion cardiac magnetic resonance (CMR) is generally accepted to detect and monitor CAD. Few studies have so far addressed its costs and costeffectiveness. Objectives: To compare in a large CMR registry the costs of a CMR-guided strategy vs two hypothetical invasive strategies for the diagnosis and the treatment of patients with suspected CAD. Methods: In 3'647 patients with suspected CAD included prospectively in the EuroCMR Registry (59 centers; 18 countries) costs were calculated for diagnostic examinations, revascularizations as well as for complication management over a 1-year follow-up. Patients with ischemia-positive CMR underwent an invasive X-ray coronary angiography (CXA) and revascularization at the discretion of the treating physician (=CMR+CXA strategy). Ischemia was found in 20.9% of patients and 17.4% of them were revascularized. In ischemia-negative patients by CMR, cardiac death and non-fatal myocardial infarctions occurred in 0.38%/y. In a hypothetical invasive arm the costs were calculated for an initial CXA followed by FFR testing in vessels with ≥50% diameter stenoses (=CXA+FFR strategy). To model this hypothetical arm, the same proportion of ischemic patients and outcome was assumed as for the CMR+CXA strategy. The coronary stenosis - FFR relationship reported in the literature was used to derive the proportion of patients with ≥50% diameter stenoses (Psten) in the study cohort. The costs of a CXA-only strategy were also calculated. Calculations were performed from a third payer perspective for the German, UK, Swiss, and US healthcare systems.

Tehdasmittausten varastointi moniulotteisella tietomallilla

Tietovarastoissa moniulotteinen tietomalli on tehokkain tapa esittää tietoa päätöksentekijöille. Sen toimivuus on hyväksi havaittu monissa eri liiketoimintaympäristöissä. Tehdasympäristöissä on tuhansia mittalaitteita, joista jokainen mittaa uniikkia valmistusprosessiin liittyvää piirrettä. Tässä työssä kehitettiin tietovarasto tehdasmittausten varastointiin käyttäen moniulotteista tietomallia. Havaittiin, että moniulotteisella mallilla tehdasmittaukset voidaan tallentaa joustavalla tavalla ja esittää käyttäjälle mielekkäässä muodossa. Moniulotteinen malli antaa myös erinomaiset keinot tiedon ryhmittelyyn ja vertailuun. Sillä ei kuitenkaan saada vastaavanlaisia hyötyjä kuin klassisissa kaupanalan tietovarastointi esimerkeissä, koska eri mittaukset ovat keskenään hyvin erilaisia. Vaikka mittaukset eivät olekaan aina vertailtavissa tai summattavissa keskenään, saadaan ne moniulotteisella mallilla tallennettua ja luokiteltua loogisesti siten, että käyttäjän on helppo löytää tarvitsemansa tieto. Lisäksi yleisesti tunnettu ja paljon käytetty tietovaraston suunnittelumalli takaa sen, että markkinoilta on saatavissa työkaluja tietovaraston käyttöön. Tietokannan toteutus tehtiin vapaasti levitettävän MySQLtiedonhallintajärjestelmän avulla. Sitä ei ole suunniteltu pääasiassa tietovarastokäyttöön, mutta halpa lisenssi ja hyvä skaalautuvuus tekevät siitä mielenkiintoisen vaihtoehdon. Sitä onkin käytetty luultua enemmän tietovarastoinnissa ja myös monien nimekkäiden organisaatioiden toimesta. Myös tässä työssä todettiin, että MySQL tarjoaa riittävät välineet tietovaraston kehittämiseen.

Weather and cardiovascular mortality.

Already in ancient Greece, Hippocrates postulated that disease showed a seasonal pattern characterised by excess winter mortality. Since then, several studies have confirmed this finding, and it was generally accepted that the increase in winter mortality was mostly due to respiratory infections and seasonal influenza. More recently, it was shown that cardiovascular disease (CVD) mortality also displayed such seasonality, and that the magnitude of the seasonal effect increased from the poles to the equator. The recent study by Yang et al assessed CVD mortality attributable to ambient temperature using daily data from 15 cities in China for years 2007-2013, including nearly two million CVD deaths. A high temperature variability between and within cities can be observed (figure 1). They used sophisticated statistical methodology to account for the complex temperature-mortality relationship; first, distributed lag non-linear models combined with quasi-Poisson regression to obtain city-specific estimates, taking into account temperature, relative humidity and atmospheric pressure; then, a meta-analysis to obtain the pooled estimates. The results confirm the winter excess mortality as reported by the Eurowinter3 and other4 groups, but they show that the magnitude of ambient temperature.

Cost-minimization analysis of three decision strategies for cardiac revascularization : results of the "suspected CAD"cohort of the european cardiovascular magnetic resonance registry.

BACKGROUND: Coronary artery disease (CAD) continues to be one of the top public health burden. Perfusion cardiovascular magnetic resonance (CMR) is generally accepted to detect CAD, while data on its cost effectiveness are scarce. Therefore, the goal of the study was to compare the costs of a CMR-guided strategy vs two invasive strategies in a large CMR registry. METHODS: In 3'647 patients with suspected CAD of the EuroCMR-registry (59 centers/18 countries) costs were calculated for diagnostic examinations (CMR, X-ray coronary angiography (CXA) with/without FFR), revascularizations, and complications during a 1-year follow-up. Patients with ischemia-positive CMR underwent an invasive CXA and revascularization at the discretion of the treating physician (=CMR + CXA-strategy). In the hypothetical invasive arm, costs were calculated for an initial CXA and a FFR in vessels with ≥50 % stenoses (=CXA + FFR-strategy) and the same proportion of revascularizations and complications were applied as in the CMR + CXA-strategy. In the CXA-only strategy, costs included those for CXA and for revascularizations of all ≥50 % stenoses. To calculate the proportion of patients with ≥50 % stenoses, the stenosis-FFR relationship from the literature was used. Costs of the three strategies were determined based on a third payer perspective in 4 healthcare systems. RESULTS: Revascularizations were performed in 6.2 %, 4.5 %, and 12.9 % of all patients, patients with atypical chest pain (n = 1'786), and typical angina (n = 582), respectively; whereas complications (=all-cause death and non-fatal infarction) occurred in 1.3 %, 1.1 %, and 1.5 %, respectively. The CMR + CXA-strategy reduced costs by 14 %, 34 %, 27 %, and 24 % in the German, UK, Swiss, and US context, respectively, when compared to the CXA + FFR-strategy; and by 59 %, 52 %, 61 % and 71 %, respectively, versus the CXA-only strategy. In patients with typical angina, cost savings by CMR + CXA vs CXA + FFR were minimal in the German (2.3 %), intermediate in the US and Swiss (11.6 % and 12.8 %, respectively), and remained substantial in the UK (18.9 %) systems. Sensitivity analyses proved the robustness of results. CONCLUSIONS: A CMR + CXA-strategy for patients with suspected CAD provides substantial cost reduction compared to a hypothetical CXA + FFR-strategy in patients with low to intermediate disease prevalence. However, in the subgroup of patients with typical angina, cost savings were only minimal to moderate.

Interdependency management in universities: a case study

There remains uncertainty in scientific discussions regarding the governance of universities in new public management regimes in terms of who actually 'rules' in the university. Apparently, a strengthened management leadership is confronted with continuing elements of academic self-regulation and professional autonomy in knowledge production and diffusion. Organisational and academic rationales coexist in today's management of universities. This article endeavours to clarify some of the ambiguities pertaining to the coexistence of two authorities by demonstrating the working of 'interdependency management' that is taking place within universities. For this purpose, the authors have scrutinised research, teaching and recruitment policies in one Swiss university that is subject to such ambiguities. The study confirms existing research in that a command-and-control system is not applied. Policymaking in universities is instead based on a mix of negotiations in faculties that are taking place in the 'shadow of hierarchy', negotiated bargaining between faculties and leaders and occasional unilateral decisions of leaders. This mitigates latent conflicts between management and the academic community: strategic orientations of the university are generally accepted by the academic community while the academic community has influence on policy formulation and maintains defining powers over policy substance.

Earnings quality and performance in the banking industry: a profit frontier approach

The analysis of efficiency and productivity in banking has received a great deal of attention for almost three decades now. However, most of the literature to date has not explicitly accounted for risk when measuring efficiency. We propose an analysis of profit efficiency taking into account how the inclusion of a variety of bank risk measures might bias efficiency scores. Our measures of risk are partly inspired by the literature on earnings management and earnings quality, keeping in mind that loan loss provisions, as a generally accepted proxy for risk, can be adjusted to manage earnings and regulatory capital. We also consider some variants of traditional models of profit efficiency where different regimes are stipulated so that financial institutions can be evaluated in different dimensions—i.e., prices, quantities, or prices and quantities simultaneously. We perform this analysis on the Spanish banking industry, whose institutions have been deeply affected by the current international financial crisis, and where re-regulation is taking place. Our results can be explored in multiple dimensions but, in general, they indicate that the impact of earnings management on profit efficiency is of less magnitude than what might a priori be expected, and that on the whole, savings banks have performed less well than commercial banks. However, savings banks are adapting to the new regulatory scenario and rapidly catching up with commercial banks, especially in some dimensions of performance.