Outcomes during and after long-term tocilizumab treatment in patients with giant cell arteritis

OBJECTIVE

To assess outcomes in giant cell arteritis (GCA) patients during and after long-term tocilizumab (TCZ) treatment.

METHODS

Retrospective analysis of GCA patients treated with TCZ at a single centre (2010-2022). Time to relapse and annualised relapse rate during and after TCZ treatment, prednisone use, and safety were assessed. Relapse was defined as reappearance of any GCA clinical manifestation that required treatment intensification, regardless of C reactive protein levels and erythrocyte sedimentation rate.

RESULTS

Sixty-five GCA patients were followed for a mean (SD) of 3.1 (1.6) years. The mean duration of the initial TCZ course was 1.9 (1.1) years. The Kaplan-Meier (KM)-estimated relapse rate at 18 months on TCZ was 15.5%. The first TCZ course was discontinued due to satisfactory remission achievement in 45 (69.2%) patients and adverse events in 6 (9.2%) patients. KM-estimated relapse rate at 18 months after TCZ discontinuation was 47.3%. Compared with patients stopping TCZ at or before 12 months of treatment, the multivariable adjusted HR (95% CI) for relapse in patients on TCZ beyond 12 months was 0.01 (0.00 to 0.28; p=0.005). Thirteen patients received >1 TCZ course. Multivariable adjusted annualised relapse rates (95% CI) in all periods on and off TCZ aggregated were 0.1 (0.1 to 0.2) and 0.4 (0.3 to 0.7), respectively (p=0.0004). Prednisone was discontinued in 76.9% of patients. During the study, 13 serious adverse events occurred in 11 (16.9%) patients.

CONCLUSION

Long-term TCZ treatment was associated with remission maintenance in most patients with GCA. The estimated relapse rate by 18 months after TCZ discontinuation was 47.3%.

Rethinking organizational performance management: a complexity theory perspective

Purpose

Traditional approaches to organizational performance management that emphasize objectivity, control and predictability are rapidly losing relevance in an environment characterized by increasing levels of complexity and dynamism. This paper draws on complexity theory to suggest a new paradigm for managing performance in organizations.

Design/methodology/approach

The paper draws on the common features of complex systems and the corresponding concept of emergence to revisit key themes in organizational performance management and propose a set of implications for research and practice.

Findings

Understanding organizations as complex systems and performance as an emergent property of such systems leads to a set of new research questions, the adoption of alternative methods and the formulation of novel propositions. It also has various implications for both academic research and managerial practice, from moving away from the traditional notion of organizational alignment to adopting a more explicit stakeholder-based view in the design and use of measurement systems.

Originality/value

The paper highlights the great potential of complexity theory for addressing contemporary issues in the field of organizational performance management and charting the landscape for its future development.

POS0267 OUTCOMES DURING AND AFTER LONG-TERM TOCILIZUMAB TREATMENT IN PATIENTS WITH GIANT CELL ARTERITIS

Background

Data on the long-term efficacy and safety of tocilizumab (TCZ) for giant cell arteritis (GCA), including incidence and timing of disease relapse after TCZ discontinuation, is limited.

Objectives

We aimed to evaluate the long-term outcomes of GCA patients treated with TCZ in a real-world setting.

Methods

Retrospective analysis of GCA patients treated with TCZ for >9 months at a single center between 2010-2021. Time to relapse and annualized relapse rate during and after TCZ treatment, prednisone use and safety were assessed. Relapse was defined as the re-appearance of clinical manifestations of GCA that required treatment intensification regardless of the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) levels. The duration of TCZ treatment was determined as per the best clinical judgement of the treating rheumatologist.

Results

A total of 57 GCA patients were followed for a mean (SD) period of 3.4 (1.7) years. Baseline characteristics and treatments received are shown in Table 1. Patients were maintained on their initial TCZ course for a mean (SD) period of 2.0 (1.3) years. The initial TCZ course lasted >12 months in 50 (88%) patients. During the initial TCZ course, 8 (14.0%) patients relapsed. Kaplan-Meier (KM) estimated relapse rates on TCZ were 10.5% and 14.9% at 12 and 18 months, respectively (Figure 1A). TCZ was discontinued due to long-term remission in 37 (64.9%) patients and after an adverse event in 6 (10.5%) patients. Of the 43 patients stopping TCZ due to remission or adverse event, 19 (44.2%) subsequently relapsed. KM estimated relapse rates after TCZ discontinuation were 30.4% and 44.0% at 12 and 18 months, respectively (Figure 1B). Overall, 12 patients received more than one TCZ course. The aggregation of all TCZ courses (mean 2.5 years) and all periods off TCZ following the initial TCZ treatment (mean 0.9 years) showed that 11 (19.3%) patients relapsed while on TCZ and 20 (35.1%) patients relapsed during time off TCZ. An analysis adjusting for age, sex, prednisone dose at initiation of first TCZ course, and disease type (new onset vs. relapsing) at initiation of first TCZ course showed an annualized relapse rate (95% CI) of 0.1 (0.0-0.2) during TCZ treatment and 0.4 (0.3-0.7) off TCZ (rate ratio 0.2, p<0.0001). By the end of follow up, 42 (73.7%) patients were able to wean off prednisone. During the study, 12 serious adverse events occurred in 11 (19.3%) patients. Among those 12 events, 3 (25%) were related or possibly related to TCZ exclusively (i.e., soft tissue infection, bacteremia, and COVID-19), 3 (25%) to prednisone exclusively (i.e., osteoporotic fracture, diabetic ketoacidosis and stroke), and 2 (16.7%) to either TCZ or prednisone (i.e., pneumonia and sepsis).

Table 1.

Baseline characteristics and treatments

GCA patients(n = 57)Age, mean (SD)70.1 (9.3)Female sex39 (68.4)New onset disease at TCZ initiation18 (31.6)Initial TCZ treatment 4 mg/Kg intravenously monthly2 (3.5) 8 mg/Kg intravenously monthly13 (22.8) 162 mg subcutaneously every 2 weeks6 (10.5) 162 mg subcutaneously weekly36 (63.2)On prednisone at TCZ initiation57 (100)Prednisone dose (mg) at TCZ initiation, mean (SD)32.3 (21.7)Patients receiving >1 TCZ course12 (21.1)Duration of initial TCZ course (years), mean (SD)2.0 (1.3)Total duration of TCZ treatment (years), mean (SD)2.5 (1.6)*

Values represent number and (%) unless otherwise specified. *Aggregated time on tocilizumab (TCZ)

for those patients that received more than 1 TCZ course. GCA, giant cell arteritis; SD, standard deviation.

Conclusion

Long-term TCZ treatment was efficacious in maintaining disease remission and sparing the use of prednisone in patients with GCA. Over 40% of patients stopping TCZ after long-term remission or adverse event relapsed following TCZ discontinuation.

Acknowledgements

This study was sponsored by Genentech, Inc.

Disclosure of Interests

Mark Matza: None declared, Nicholas Dagincourt Employee of: Working for Genentech, Inc., as employees of Everest Clinical Research, Shalini Mohan Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., Andrey Pavlov Employee of: Working for Genentech, Inc. as an employee of Everest Clinical Research, Jian Han Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., John H. Stone Consultant of: Roche, Grant/research support from: Roche, Sebastian Unizony Grant/research support from: Research funding from Genentech, Inc.

The role of performance measurement in aligning operations with strategy: sustaining cognitive processes of internal alignment

Purpose

This paper aims to address an important theoretical shortcoming in the conceptualization of internal alignment by investigating the cognitive processes involved in aligning operations with strategy and the role of performance measurement (PM) in sustaining these processes.

Design/methodology/approach

A theory-building study investigates the process of using PM to drive the implementation of a new strategy in a large beer manufacturer in Italy. The study uses a sensemaking perspective to theorize the findings. Data were collected through semi-structured interviews, field observations and company documents.

Findings

This study develops a theoretical model suggesting that establishing and maintaining internal alignment occurs through seeking, assembling, adjusting and finalizing the meaning of how strategic priorities inform local action. PM plays a central role in this process by providing interpretive support.

Research limitations/implications

This article advances a cognition-centred view of internal alignment that complements the behavioural aspect of the phenomenon emphasized in prior literature.

Practical implications

Using PM for aligning operations with strategy is a complex and iterative process that requires time and effort and generates temporary stability. Managers may need to complement traditional approaches to alignment with providing space for sensemaking.

Originality/value

The paper proposes a view of internal alignment as an ongoing interpretive process that is sustained by PM. This process brings about the consistency of meanings that generates strategy-consistent behaviours.

[EXPERIMENTAL STUDY OF THE ULTIMATE STRENGTH OF SAMPLES OF MATERIAL BASED ON POLYLACTIDE AND TRICALCIUM PHOSPHATE, PRODUCED BY 3D PRINTING WITH DIFFERENT POROSITIES, DEPENDING ON THE TIME OF HYDRATION]

The advantage of polylactide-based implants is their rapid and complete biodegradation, followed by replacement of the defect with bone tissue. The disadvantage of materials with a high biodegradation rate is their low support ability. The admixture of ceramic materials increases the strength of the implants and reduces the rate of biodegradation. 3D printing technology allows you to reduce the negative factors of ceramic impurities through the manufacture of implants of various porosities. Target. Determine the ultimate strength of a composite material based on PLA and TCP, manufactured by 3D printing with different porosity options, depending on the duration of hydration. Were made 9 samples of material with a size of 10x10x10 mm with different porosity 40%, 30%, 20%. Samples of the material were hydrated in saline. Strength tests were carried out on days 2, 10, and 20 after hydration, 3 samples of material of each porosity. All samples were tested for compression. The carried out comparative analysis indicates that the tested samples are statistically significant (at the level of p <0.05) differ from each other depending on the value of porosity at all periods of hydration. Although the average values of the ultimate strength of samples of the same porosity tend to decrease depending on the period of their hydration, these changes do not acquire statistical significance even between the extreme periods of observation. This is confirmed by the values of the indicator of the statistical significance of the differences p equal to 0.07; 0.759 and 0.124 for specimens with porosity of 20%, 30% and 40%, respectively. The tensile strength of samples of material based on polylactide and tricalcium phosphate, made using 3D printing, directly depends on their porosity, the smaller the pore volume, the stronger the samples. The hydration of the samples in saline solution for 20 days does not entail statistically significant changes in their strength regardless of the pore volume, although the average values of the ultimate strength for all tested samples tend to decrease.

Treatment failure in giant cell arteritis

Objective

Identify predictors of treatment failure in patients with giant cell arteritis (GCA) receiving tocilizumab in combination with glucocorticoids and in patients with GCA receiving only glucocorticoids.

Methods

Posthoc analysis of the Giant-Cell Arteritis Actemra trial including 250 patients who received tocilizumab every week plus a 26-week prednisone taper (n=100), tocilizumab every-other-week plus a 26-week prednisone taper (n=49) or placebo plus a 26-week (n=50) or 52-week (n=51) prednisone taper in the intention-to-treat population. Responders for this analysis were patients who maintained remission (no GCA signs/symptoms and no erythrocyte sedimentation rate elevation) through week 52. Treatment failure was defined as inability to achieve remission by week 12 or relapse between weeks 12 and 52. Predictors investigated in univariate and multivariable analyses included patient characteristics, disease-related and treatment-related factors and patient-reported outcomes (PROs).

Results

149 patients received tocilizumab plus prednisone (TCZ/PDN) and 101 received placebo plus prednisone (PBO+PDN). After adjustment for confounders, treatment failure was significantly less likely in the TCZ/PDN group than the PBO/PDN group (OR, 0.2; 95% CI, 0.1 to 0.3; p<0.0001). Risk for treatment failure was significantly higher in women than men in the PBO/PDN group (OR, 5.2; 95% CI, 1.6 to 17.2; p=0.007) but not in the TCZ/PDN group. Predictors of treatment failure in the TCZ/PDN group included lower baseline prednisone doses and worse PROs at baseline.

Conclusion

The strongest risk factors for treatment failure in GCA are treatment with prednisone alone and female sex. Lower starting prednisone doses and impaired PROs are associated with failure to respond to tocilizumab.

Trial registration number

NCT01791153.

Active remote sensing of atmospheric dust using relationships between their depolarization ratios and reflectivity

The backscattered light from agglomerated debris particles shows that an approximate linear correlation exists between the logarithm of the geometric albedo $ \log(A )$ of polydispersions of agglomerated debris particles and their lidar linear or circular depolarization ratios, $ \unicode{x00B5}_L$ and $ \unicode{x00B5}_C$. The nature of the relationship depends on the complex refractive index of the particles in the distribution. This extension of the Umov law can be used for lidar and radar characterizations by placing constraints on the reflectivity of the particles. It suggests that an approximate inverse relationship exists between the lidar ratio and the lidar depolarization ratios whose scaling parameter depends on the refractive index of the aerosol population.

Tocilizumab vs placebo for the treatment of giant cell arteritis with polymyalgia rheumatica symptoms, cranial symptoms or both in a randomized trial

OBJECTIVE

The randomized, placebo (PBO)-controlled GiACTA trial demonstrated the efficacy and safety of tocilizumab (TCZ) in patients with giant cell arteritis (GCA). The present study evaluated the efficacy of TCZ in patients with GCA presenting with polymyalgia rheumatica (PMR) symptoms only, cranial symptoms only or both PMR and cranial symptoms in the GiACTA trial.

METHODS

In GiACTA, 250 patients with GCA received either TCZ weekly or every other week plus a 26-week prednisone taper or PBO plus a 26- or 52-week prednisone taper. This post hoc analysis assessed baseline characteristics, sustained remission rate, number of flares, annualized flare rate, time to flare, cumulative prednisone dose, methotrexate use and safety in patients with PMR symptoms only, cranial symptoms only or both at baseline.

RESULTS

Overall, 52 patients had PMR symptoms only, 94 had cranial symptoms only and 104 had both symptoms at baseline. At Week 52, rates of sustained remission were significantly higher with TCZ vs PBO in all 3 groups (PMR only, 45.2% vs 19.0%, P = 0.0446; cranial only, 60.3% vs 19.4%, P = 0.0001; PMR and cranial, 55.0% vs 11.4%, P < 0.0001). Smaller proportions of TCZ-treated patients experienced disease flare than PBO-treated patients across all groups (PMR only, 41.9% vs 57.1%; cranial only, 20.7% vs 47.2%; PMR and cranial, 31.7% vs 81.8%). Annualized flare rate and risk of flare were significantly lower with TCZ vs PBO for patients with cranial symptoms only and both symptoms; they were numerically lower, but did not reach statistical significance, in the smaller group of patients with PMR symptoms only.

CONCLUSIONS

TCZ improved clinical outcomes in patients who presented with PMR symptoms only, cranial symptoms only or both at baseline, suggesting that TCZ is effective in patients with GCA regardless of the presenting clinical phenotype.

Corrigendum to "A New Method of Scanning Tunneling Spectroscopy for Study of the Energy Structure of Semiconductors and Free Electron Gas in Metals"

[This corrects the article DOI: 10.1002/sca.4950190702.].

Ultrasonographic modeling of diaphragm function: A novel approach to respiratory assessment

Objectives

Bedside ultrasound techniques have the unique ability to produce instantaneous, dynamic images, and have demonstrated widespread utility in both emergency and critical care settings. The aim of this article is to introduce a novel application of this imaging modality by utilizing an ultrasound based mathematical model to assess respiratory function. With validation, the proposed models have the potential to predict pulmonary function in patients who cannot adequately participate in standard spirometric techniques (inability to form tight seal with mouthpiece, etc.).

Methods

Ultrasound was used to measure diaphragm thickness (Tdi) in a small population of healthy, adult males at various points of the respiratory cycle. Each measurement corresponded to a generated negative inspiratory force (NIF), determined by a handheld meter. The data was analyzed using mixed models to produce two representative mathematical models.

Results

Two mathematical models represented the relationship between Tdi and NIF_max, or maximum inspiratory pressure (MIP), both of which were statistically significant with p-values <0.005: 1. log(NIF) = -1.32+4.02×log(Tdi); and 2. NIF = -8.19+(2.55 × Tdi)+(1.79×(Tdi²)).

Conclusions

With validation, these models intend to provide a method of estimating MIP, by way of diaphragm ultrasound measurements, thereby allowing evaluation of respiratory function in patients who may be unable to reliably participate in standard spirometric tests.

A giant exoplanet orbiting a very-low-mass star challenges planet formation models

Surveys have shown that super-Earth and Neptune-mass exoplanets are more frequent than gas giants around low-mass stars, as predicted by the core accretion theory of planet formation. We report the discovery of a giant planet around the very-low-mass star GJ 3512, as determined by optical and near-infrared radial-velocity observations. The planet has a minimum mass of 0.46 Jupiter masses, very high for such a small host star, and an eccentric 204-day orbit. Dynamical models show that the high eccentricity is most likely due to planet-planet interactions. We use simulations to demonstrate that the GJ 3512 planetary system challenges generally accepted formation theories, and that it puts constraints on the planet accretion and migration rates. Disk instabilities may be more efficient in forming planets than previously thought.

Fluoroquinolone Residues in Fish Collected from Farms and Retail Stores in Stara Zagora Region, Bulgaria

Background: Fluoroquinolones are among various antibiotic groups used in livestock husbandry. The aim of this screening study was to evaluate the presence of fluoroquinolone residues in fish samples of Stara Zagora region, Bulgaria. Methods: A total of 69 samples from freshwater, marine, and anadromous fish were collected randomly from fish farms and retail stores in Stara Zagora region, Bulgaria. Fluoroquinolone residues were determined using Enzyme-Linked Immunosorbent Assay method. Data were statistically processed using STATISTICA 10.0 software. Results: Fluoroquinolones were detected in 44.3% of freshwater and 42.9% of marine fish samples, with no significant difference (p>0.05). Their concentrations varied from 1.03 to 271.73 μg/kg for common carp, 1.43 to 12.63 μg/kg for rainbow trout, 1.17 to 1.94 μg/kg for silver carp, 1.00 to 1.82 μg/kg for rudd and 1.27 to 2.15 μg/kg for striped catfish. Among marine fish, fluoroquinolone positive samples were found in European sprat (1.68 μg/kg), Longtail southern cod (1.30 μg/kg), and European hake (1.83 μg/kg). Conclusion: High levels of fluoroquinolones were found in some fish samples of Stara Zagora region, Bulgaria. Regular monitoring of antibiotic residues is too necessary in fish distributed in this region.

CORRELATIONS BETWEEN PERSONAL CHARACTERISTICS AND PHYSICAL FITNESS IN HEALTHY STUDENTS AND STUDENTS WITH CHRONIC DISEASES

Aim. The article deals with establishing correlations between personal characteristics and physical fitness in healthy students and students with chronic diseases. Materials and Methods. 426 first-year male and female students from the Irkutsk State University took part in the study. In all first-year students, we studied personal psychological characteristics: personal adaptation potential, motivation to success, anthropometric data (body weight, body height, BMI). We also studied the parameters of physical fitness. Results. In healthy female students, we revealed a direct correlation between physical fitness (pull ups) and personal adaptation potential. In females with chronic diseases, we established a direct correlation between abdominal muscles strength and personal adaptation potential. In healthy males, we found out the dependence between BMI and motivation to success. Conclusion. In first-year students (male and female), we revealed the positive correlations between personal characteristics and physical fitness.

Lasing threshold of the bound states in the continuum in the plasmonic lattices

Distributed feedback plasmonic laser based on the periodic array of holes in the silver half-space and covered with gain medium is considered. Square, hexagonal and several rectangular lattices are studied. It is demonstrated that the bound states in the continuum provide substantially lower threshold than radiating modes. Moreover, it is shown that while the hole size increases the lasing threshold of some modes decreases. Among the studied types of lattices, lasing in the hexagonal lattice requires the lowest material gain of only 18 cm^-1. Our results pave the way to the development of the efficient low-threshold distributed feedback plasmonic lasers.

Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial

IMPORTANCE

More than half of patients with acute ischemic stroke have minor neurologic deficits (National Institutes of Health Stroke Scale [NIHSS] score of 0-5) at presentation. Although prior major trials of alteplase included patients with low NIHSS scores, few without clearly disabling deficits were enrolled.

OBJECTIVE

To evaluate the efficacy and safety of alteplase in patients with NIHSS scores of 0 to 5 whose deficits are not clearly disabling.

DESIGN, SETTING, AND PARTICIPANTS

The PRISMS trial was designed as a 948-patient, phase 3b, double-blind, double-placebo, multicenter randomized clinical trial of alteplase compared with aspirin for emergent stroke at 75 stroke hospital networks in the United States. Patients with acute ischemic stroke whose deficits were scored as 0 to 5 on the NIHSS and judged not clearly disabling and in whom study treatment could be initiated within 3 hours of onset were eligible and enrolled from May 30, 2014, to December 20, 2016, with final follow-up on March 22, 2017.

INTERVENTIONS

Participants were randomized to receive intravenous alteplase at the standard dose (0.9 mg/kg) with oral placebo (n = 156) or oral aspirin, 325 mg, with intravenous placebo (n = 157).

MAIN OUTCOMES AND MEASURES

The primary outcome was the difference in favorable functional outcome, defined as a modified Rankin Scale score of 0 or 1 at 90 days via Cochran-Mantel-Haenszel test stratified by pretreatment NIHSS score, age, and time from onset to treatment. Because of early termination of the trial, prior to unblinding or interim analyses, the plan was revised to examine the risk difference of the primary outcome by a linear model adjusted for the same factors. The primary safety end point was symptomatic intracranial hemorrhage (sICH) within 36 hours of intravenous study treatment.

RESULTS

Among 313 patients enrolled at 53 stroke networks (mean age, 62 [SD, 13] years; 144 [46%] women; median NIHSS score, 2 [interquartile range {IQR}, 1-3]; median time to treatment, 2.7 hours [IQR, 2.1-2.9]), 281 (89.8%) completed the trial. At 90 days, 122 patients (78.2%) in the alteplase group vs 128 (81.5%) in the aspirin group achieved a favorable outcome (adjusted risk difference, -1.1%; 95% CI, -9.4% to 7.3%). Five alteplase-treated patients (3.2%) vs 0 aspirin-treated patients had sICH (risk difference, 3.3%; 95% CI, 0.8%-7.4%).

CONCLUSIONS AND RELEVANCE

Among patients with minor nondisabling acute ischemic stroke, treatment with alteplase vs aspirin did not increase the likelihood of favorable functional outcome at 90 days. However, the very early study termination precludes any definitive conclusions, and additional research may be warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02072226.

AG-1031 and AG-1503 improve cognitive deficits by promoting apoptosis and inhibiting autophagy in C6 glioma model rats

High-grade gliomas (HGGs; grades III and IV) are the most common and aggressive adult primary brain tumors, and their invasive nature ranks them the fourth in the incidence of cancer death. In our previous study, we found that AG-1031 and AG-1503 showed inhibitory effects on several cancer cell lines. In this study, C6 glioma-bearing rats were treated with AG-1031 or AG-1503. Western blot results of autophagy-associated protein (LC3 II/I, Beclin-1) and apoptosis-associated proteins (caspase-3, Bcl-2, Bax) revealed that AG-1031 could activate apoptotic signal pathway via inhibiting autophagy process in cancer cells. HE staining indicated that the tumor volumes were significantly decreased in AG-1031 and AG-1503 treated rats compared to non-treated C6 glioma-bearing rats. Meanwhile, AG-1031 and AG-1503 significantly decreased the expression of VEGF, a marker of invasion ability of tumor, in tumor tissue. The novel object recognition test showed that cognitive functions in C6 glioma-bearing rats were considerably damaged, whereas AG-1031 and AG-1503 significantly impeded the cognitive impairment. AG-1031 and AG-1503 efficiently alleviated the glioma-induced impairments of long-term potentiation (LTP), which was damaged in C6 glioma-bearing rats. Furthermore, AG-1031 and AG-1503 augmented the expression of synaptophysin (SYP), which were decreased in glioma rats. In conclusion, our results suggest that AG-1031 and AG-1503 can inhibit the expansion of glioma, and improve the cognitive impairment caused by glioma in glioma-bearing rats.

The use of management control and performance measurement systems in SMEs

Purpose

The purpose of this paper is to respond to recent calls for understanding how multiple management control (MC) and performance measurement (PM) systems are used simultaneously for managing performance, particularly in the context of small- and medium-sized enterprises (SMEs).

Design/methodology/approach

Data are collected during an in-depth case study of MC and PM and management practices in a Dutch SME using multiple data sources and elicitation methods, including interviews and participant observations.

Findings

This study identifies managerial practices that enable the interplay of the four control systems – beliefs, boundaries, diagnostic and interactive – helping the organization manage organizational tensions in relation to short- and long-term focus, predictable goal achievement and search for new opportunities, internal and external focus, and control and creativity.

Research limitations/implications

This paper advances the research on integrating multiple aspects of performance management, particularly technical and social. This research is based on a single case study; future qualitative and quantitative studies could explore the interplay between the four control systems in other settings and explore the relationship between control systems and leadership style.

Practical implications

Managing performance requires active and continuous use of all four control systems. This is particularly salient in SMEs where less formal controls play a key role and where balance needs to be ensured despite the lack of managerial processes and capabilities.

Originality/value

The findings advance PM and management theory and practice in the context of SMEs.

An evaluation of risk factors for major adverse cardiovascular events during tocilizumab therapy

OBJECTIVE

To evaluate associations between lipid levels, inflammation, and rheumatoid arthritis (RA) disease activity, at baseline and during treatment, with the risk of major adverse cardiovascular events (MACE) in tocilizumab-treated patients with RA.

METHODS

In retrospective post hoc analyses, data were pooled for 3,986 adult patients with moderate to severe RA who received ≥1 dose of tocilizumab (4 mg/kg or 8 mg/kg) intravenously every 4 weeks in randomized controlled trials and extension studies. Cox proportional hazards modeling was used to evaluate associations between baseline characteristics and posttreatment changes in laboratory and disease characteristics (week 24) and change in disease activity and laboratory values from baseline to week 24 with the risk of future MACE during extended followup.

RESULTS

We identified 50 independently adjudicated cases of MACE during 14,683 patient-years of followup (0.34 MACE cases/100 patient-years). At baseline, age, a history of cardiac disorders, the Disease Activity Score in 28 joints (DAS28), and the total cholesterol:high-density lipoprotein cholesterol ratio were independently associated with MACE in multivariable models (P < 0.05 for all). During treatment, a higher DAS28 and higher swollen and tender joint counts at week 24 were associated with future MACE. In separate models, greater reductions in the DAS28 and joint counts from baseline to week 24 were inversely associated with future MACE; changes in lipid parameters were not statistically significantly associated with the risk of MACE.

CONCLUSION

In this population of patients treated with tocilizumab, an association was observed between the baseline total cholesterol:high-density lipoprotein cholesterol ratio and an increased risk of MACE. The risk of MACE while receiving treatment, however, was associated with control of disease activity but not lipid changes. Larger studies are needed to confirm these findings.

Upgrading Metallurgical Grade Silicon to Solar Grade Silicon

<p>he photovoltaics (PV) is a method of direct conversion of solar energy to electricity using semicon-ductor solar cells. In terms of globally installed capacity, PV remains third the most important renewable energy source after hydro and wind powers. 31.1 GW of PV systems were installed around the world in 2012 and up from 30.4 GW in 2011.There is a rapid growth of PV cell production and it is expected to increase further. However PV technology have to cost effective in comparison to hydro or wind powers and other sources of renewable energy. It has to reach the “grid parity” i.e. less or equal price for generated electricity <br />power. More than 85% of solar cells (SC) are made from solar grade silicon (SoGSi). SoGSi is produced by purification of metallurgy grade silicon (MGSi) which is produced by carbon recovering silicon from quartz. Also Quartz is an initial and essential material for obtaining SoGSi and SC. Rich resource of quartz <br />Sarykol located at southern part of Kazakhstan where the main factory for MG Si production «Каzsilicon» is situated. Upgrading of MGSi up to SoGSi consists is a number of technological steps and SoGSi is basis for PV industry. Therefore the cost of SoGSi determines the competitiveness of PV technology compared to <br />other energy sources. There are several chemical and metallurgical technologies for SoGSi production. This paper briefly describes these technologies and shows main advantages of metallurgical technologies based on slag refining (oxygenation). Considered technologies are the basis for industrial production of SoGSi, <br />solar cells with an efficiency of 15.8-17.1% and solar panels. The 1st power plant made from solar panels in Kazakhstan was launched in December 25, 2012 by «AstanaSolar» with a total capacity of 250 kW.</p>

Variability of seed traits and properties of soluble mucilages in lines of the flax genetic collection of Vavilov Institute

Upon hydration, flax seeds secrete mucilages whose content and physico-chemical properties vary according to the genotype and environment. The aim of the work was to investigate the complex genetic relationships between the vegetative period, colour, size and production of seed, the composition (polysaccharides and proteins) and physico-chemical properties of soluble mucilages collected at 28 °C from seeds of 18 lines grown in St Petersburg area. The vegetative period duration was found to impact the size and production of seeds, the yield of mucilages, including the polysaccharides, and the galactosidase enzymes, as well as their composition (mainly the rhamnogalacturonan I moieties) and some of their properties (mainly viscosity). Data allowed to significantly distinguish 6 fibre lines with mucilages enriched in rhamnogalacturonan I, 6 lines with mucilages enriched in arabinoxylan including 5 linseeds and 1 mutated fibre-line, and 5 lines with mucilages enriched in homogalacturonan-like polymer including 4 fibre lines and 1 brown linseed. Seven fibre lines had mucilages particularly rich in galactose. High to very high variability was found for 14 traits. Relatively independent characters (form/shape, protein and galactosidase) were identified and could be combined by breeding, with a focus on mucilage yield, composition and properties. Main-component analyses of line characters showed a large diversity in linseeds mainly due to their different origin but small variation in Russian fibre lines with brown seeds.

Inappropriate discharge on bronchodilators and acid-blocking medications after ICU admission: importance of medication reconciliation

BACKGROUND

Previous studies suggest that some medications, including proton pump inhibitors and β-agonist inhalers, are administered to hospitalized patients and sometimes continued without indications. Medication reconciliation has been offered as one mechanism to reduce the frequency of such medication errors and is now mandated by the Joint Commission (NPSG.03.06.01). We hypothesized that (1) β agonists and acid-blocking medications are prescribed following critical illness without indications, and (2) medication reconciliation can reduce the frequency of inappropriate continuation of these agents. The study was carried out in a 414-bed community teaching hospital affiliated with the University of Connecticut Medical School. All subjects were admitted to the ICU between February and April 2012 (physician-driven reconciliation) and between July and September 2012, just following implementation of pharmacy technician-driven medication reconciliation. This was a retrospective cohort study.

METHODS

Medical records of all subjects were reviewed using a uniform data extraction tool. Demographic information, clinical data, in-patient and out-patient medications (before and following hospital discharge), and outcomes were recorded.

RESULTS

Prior to pharmacy technician-administered, physician-confirmed medication reconciliation, 253 ICU subjects were compared to 291 subjects admitted to the ICU after initiation of this process. There were no differences in admission type, stay, history of coronary artery disease, requirements for mechanical ventilation, or length of mechanical ventilation between groups. Rates of discharge on bronchodilators (8.9 vs. 4.2%, P = .09) or acid blockers (19.1 vs. 11.2%, P = .05) without clinical indications were lower with pharmacy technician-driven, physician-confirmed medication reconciliation than with routine physician-driven medication reconciliation. Multiple logistic regression analyses demonstrated a significant association of mechanical ventilation with inappropriate discharge on both bronchodilators and acid blockers. Pharmacy technician-driven medication reconciliation tended to reduce these errors.

CONCLUSIONS

In our hospital, acid blockers and bronchodilators were often continued inappropriately following critical illness. The specific pharmacy technician-driven method of medication reconciliation deployed in our hospital reduced by half but did not eliminate this medication error.

Using quality improvement principles to improve the care of patients with severe sepsis and septic shock

BACKGROUND

Sepsis, an inflammatory response to an infection that may lead to severe organ dysfunction and death, is the leading cause of death in medical intensive care units. The Society of Critical Care Medicine has issued guidelines and promoted protocols to improve the management of patients with severe sepsis and septic shock. Generally, the medical community has been slow to adopt these guidelines because of the system challenges associated with protocol implementation. We describe an interdisciplinary team approach to the development and implementation of management protocols for treating patients with severe sepsis and septic shock.

METHODS

To determine the effectiveness of the bundled emergency department and critical care order sets developed by the Sepsis Steering Committee, we performed a case review of 1,105 sequential patients admitted to a large academic tertiary referral hospital with a diagnosis of severe sepsis or septic shock between July 2008 and January 2012.

RESULTS

Implementation of the protocol led to improved order set use over time, a significant decrease in the median time to antibiotics of 140 (range 1-820) minutes in 2008 to 72 (range 1-1,020) minutes in 2011 (P≤0.001), and a decrease in median length of stay from 8 days (range 1-54) in 2008 to 7 days (range 1-33) in 2011 (P=0.036).

CONCLUSION

A multidisciplinary team approach to sepsis management using protocols and early goal-directed therapy is feasible in a large academic medical center to improve the process of care and outcomes.

Comparative reliability of structured versus unstructured interviews in the admission process of a residency program

BACKGROUND

Although never directly compared, structured interviews are reported as being more reliable than unstructured interviews. This study compared the reliability of both types of interview when applied to a common pool of applicants for positions in an emergency medicine residency program.

METHODS

In 2008, one structured interview was added to the two unstructured interviews traditionally used in our resident selection process. A formal job analysis using the critical incident technique guided the development of the structured interview tool. This tool consisted of 7 scenarios assessing 4 of the domains deemed essential for success as a resident in this program. The traditional interview tool assessed 5 general criteria. In addition to these criteria, the unstructured panel members were asked to rate each candidate on the same 4 essential domains rated by the structured panel members. All 3 panels interviewed all candidates. Main outcomes were the overall, interitem, and interrater reliabilities, the correlations between interview panels, and the dimensionality of each interview tool.

RESULTS

Thirty candidates were interviewed. The overall reliability reached 0.43 for the structured interview, and 0.81 and 0.71 for the unstructured interviews. Analyses of the variance components showed a high interrater, low interitem reliability for the structured interview, and a high interrater, high interitem reliability for the unstructured interviews. The summary measures from the 2 unstructured interviews were significantly correlated, but neither was correlated with the structured interview. Only the structured interview was multidimensional.

CONCLUSIONS

A structured interview did not yield a higher overall reliability than both unstructured interviews. The lower reliability is explained by a lower interitem reliability, which in turn is due to the multidimensionality of the interview tool. Both unstructured panels consistently rated a single dimension, even when prompted to assess the 4 specific domains established as essential to succeed in this residency program.

Vitamins K and D status in stages 3-5 chronic kidney disease

BACKGROUND AND OBJECTIVES

Vitamin K, vitamin K-dependent proteins, and vitamin D may be involved in the regulation of calcification in chronic kidney disease (CKD).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Vitamin K and D status was measured as dietary intake, plasma phylloquinone, serum percent uncarboxylated osteocalcin (%ucOC), proteins induced by vitamin K absence (PIVKA-II), Vitamin K Epoxide Reductase single-nucleotide polymorphism, apolipoprotein E genotype, and plasma 25-hydroxyvitamin D (25(OH)D) in 172 subjects with stage 3 to 5 CKD. Nutritional status was determined by subjective global assessment.

RESULTS

Subclinical vitamin K deficiency criteria was met by 6% (phylloquinone), 60% (%ucOC), and 97% (PIVKA-II) of subjects, whereas 58.3% and 8.6% had 25(OH)D insufficiency and deficiency, respectively. Dietary vitamin K intake was associated with higher phylloquinone and lower PIVKA-II. There were positive correlations between phylloquinone and the presence of stable weight, and the absence of subcutaneous fat loss or muscle wasting. 25(OH)D levels were positively associated with stable weight and albumin (P < 0.001). PIVKA-II levels were associated with apolipoprotein E genotype. Higher %ucOC and lower 25(OH)D were similarly associated with CKD stage, parameters of mineral metabolism, and urine albumin to creatinine ratio.

CONCLUSIONS

These data indicate that a suboptimal vitamin K and D status is prevalent in patients with CKD. Sufficiency of both vitamins K and D was similarly predicted by measures of overall improved nutritional status. Proteinuria was associated with both a suboptimal vitamin D status as well as worse peripheral vitamin K status.

Hyoscyamine biosynthesis in Datura stramonium hairy root in vitro systems with different ploidy levels

Hyoscyamine biosynthesis in Datura stramonium hairy roots with different ploidy levels was investigated. For the first time, we report that hairy roots undergo endoreduplication and therefore consist mainly of cells with doupled sets of chromosomes of primary plant tissues, used for Agrobacterium transformation. The alkaloid profiles of hairy roots obtained from diploid and tetraploid plants were similar in terms of the major compounds, but they differed significantly with respect to the minor compounds (here defined as those that accounted for <1% of the total ion current of the alkaloid mixture in gas chromatography-mass spectrometric analyses). Significant differences in the effects of the main nutrients on the growth of the hairy roots obtained from diploid and tetraploid plants and their hyoscyamine contents were observed. The maximal yield of hyoscyamine (177 mg/L) was obtained when hairy roots from tetraploid plants were cultivated in Murashige-Skoog nutrient medium supplemented with 6% sucrose. Time courses of utilization of the main nutrients in the medium during cultivation of D. stramonium hairy root cultures are also presented.