A multicenter, randomized, controlled trial of totally percutaneous access versus open femoral exposure for endovascular aortic aneurysm repair (the PEVAR trial)

ObjectiveThe first multicenter randomized controlled trial was designed and conducted to assess the safety and effectiveness of totally percutaneous endovascular aortic aneurysm repair (PEVAR) with use of a 21F endovascular stent graft system and either an 8F or 10F suture-mediated closure system (the PEVAR trial, NCT01070069). A noninferiority trial design was chosen to compare percutaneous access with standard open femoral exposure.MethodsBetween 2010 and 2012, 20 U.S. institutions participated in a prospective, Food and Drug Administration–approved randomized trial to evaluate percutaneous femoral artery access and closure by a “preclose” technique in conjunction with endovascular abdominal aortic aneurysm repair. A total of 151 patients were allocated by a 2:1 design to percutaneous access/closure (n = 101) or open femoral exposure (n = 50 [FE]). PEVAR procedures were performed with either the 8F Perclose ProGlide (n = 50 [PG]) or the 10F Prostar XL (n = 51 [PS]) closure devices. All endovascular abdominal aortic aneurysm repair procedures were performed with the Endologix 21F profile (outer diameter) sheath-based system. Patients were screened by computed tomography with three-dimensional reconstruction and independent physician review for anatomic suitability and adequate femoral artery anatomy for percutaneous access. The primary trial end point (treatment success) was defined as procedural technical success and absence of major adverse events and vascular complications at 30 days. An independent access closure substudy evaluated major access-related complications. Clinical utility and procedural outcomes, ankle-brachial index, blood laboratory analyses, and quality of life were also evaluated with continuing follow-up to 6 months.ResultsBaseline characteristics were similar among groups. Procedural technical success was 94% (PG), 88% (PS), and 98% (FE). One-month primary treatment success was 88% (PG), 78% (PS), and 78% (FE), demonstrating noninferiority vs FE for PG (P = .004) but not for PS (P = .102). Failure rates in the access closure substudy analyses demonstrated noninferiority of PG (6%; P = .005), but not of PS (12%; P = .100), vs FE (10%). Compared with FE, PG and PS yielded significantly shorter times to hemostasis and procedure completion and favorable trends in blood loss, groin pain, and overall quality of life. Initial noninferiority test results persist to 6 months, and no aneurysm rupture, conversion to open repair, device migration, or stent graft occlusion occurred.ConclusionsAmong trained operators, PEVAR with an adjunctive preclose technique using the ProGlide closure device is safe and effective, with minimal access-related complications, and it is noninferior to standard open femoral exposure. Training, experience, and careful application of the preclose technique are of paramount importance in ensuring successful, sustainable outcomes

Institutional assessment as an instrument of rationalization back to the school as a formal organisation

O papel central da avaliação, da avaliação institucional e dos processos de garantia da qualidade de escolas e universidades nas políticas educacionais é objeto de discussão, também considerando a reforma do Estado. As teorias da nova gestão pública e as perspectivas gestionárias são consideradas como algumas das principais fontes de inspiração e de legitimação no contexto dominante de uma educação contábil. Dados empíricos preliminares resultantes do processo de avaliação externa de escolas básicas e secundárias portuguesas são apresentados e interpretados de acordo com os principais conceitos e representações organizacionais de escola presentes nos relatórios externos. Examinando algumas das imagens e dos significados de escola, cultura de escola, autonomia, objetivos, liderança e eficácia presentes nos relatórios de avaliação, o autor releva a importância das imagens formais, racionais e burocráticas de escolas. Várias questões de investigação são apresentadas tendo por base aquilo a que o autor chama o processo da hiperburocratização das organizações educativas. Algumas dimensões do conceito de burocracia de Max Weber são revisitadas, em articulação com perspectivas neocientíficas de garantia da qualidade e com as tecnologias da informação e comunicação. O autor sugere que maior relevância deve ser atribuída aos modelos formais e racionais de interpretação das organizações educativas, pois os processos de avaliação e de garantia da qualidade estão a contribuir para a formalização de escolas e universidades e para a intensificação do seu processo de racionalização, isto é, para a emergência de uma imagem analítica das escolas como hiperburocracias.The central role of evaluation, institutional assessment and quality assurance processes of schools and universities in education policy is object of discussion also considering the reform of the state. New Public Management theories and managerialist perspectives are considered some of the main sources of inspiration and legitimation in the dominant context of an audit education. Preliminary empirical data from external assessment of Portuguese primary and secondary schools are introduced and interpreted according to the main concepts and organizational representations of school found in external reports. Examining some of the central organizational images and meanings of school, school culture, autonomy, goals, leadership and effectiveness included in the external reviews, the author stresses the importance of formal, rational and bureaucratic images of schools. Several new research questions are presented for further inquiry based on the hypothesis of what it is called by the author the process of hyperbureaucratization of educational organizations. Some of the main dimensions of the concept of bureaucracy as presented by Max Weber are revisited in close relation with neo-scientific approaches of quality assurance and taking in consideration the use of information and communication technologies. Accordingly the author suggests that much more importance must be given to formal and rational models of interpreting educational organizations because assessment and quality assurance procedures are contributing to the formalization of schools and universities and to the intensification of their process of rationalization, i. e., to the emergence of an analytic image of schools as hyperbureaucracies.(undefined

The theory of expanded, extended, and enhanced opportunities for youth physical activity promotion

Background Physical activity interventions targeting children and adolescents (≤18 years) often focus on complex intra- and inter-personal behavioral constructs, social-ecological frameworks, or some combination of both. Recently published meta-analytical reviews and large-scale randomized controlled trials have demonstrated that these intervention approaches have largely produced minimal or no improvements in young people\u27s physical activity levels. Discussion In this paper, we propose that the main reason for previous studies\u27 limited effects is that fundamental mechanisms that lead to change in youth physical activity have often been overlooked or misunderstood. Evidence from observational and experimental studies is presented to support the development of a new theory positing that the primary mechanisms of change in many youth physical activity interventions are approaches that fall into one of the following three categories: (a) the expansion of opportunities for youth to be active by the inclusion of a new occasion to be active, (b) the extension of an existing physical activity opportunity by increasing the amount of time allocated for that opportunity, and/or (c) the enhancement of existing physical activity opportunities through strategies designed to increase physical activity above routine practice. Their application and considerations for intervention design and interpretation are presented. Summary The utility of these mechanisms, referred to as the Theory of Expanded, Extended, and Enhanced Opportunities (TEO), is demonstrated in their parsimony, logical appeal, support with empirical evidence, and the direct and immediate application to numerous settings and contexts. The TEO offers a new way to understand youth physical activity behaviors and provides a common taxonomy by which interventionists can identify appropriate targets for interventions across different settings and contexts. We believe the formalization of the TEO concepts will propel them to the forefront in the design of future intervention studies and through their use, lead to a greater impact on youth activity behaviors than what has been demonstrated in previous studies

Early life child micronutrient status, maternal reasoning, and a nurturing household environment have persistent influences on child cognitive development at age 5 years: Results from MAL-ED

Background: Child cognitive development is influenced by early-life insults and protective factors. To what extent these factors have a long-term legacy on child development and hence fulfillment of cognitive potential is unknown. Objective: The aim of this study was to examine the relation between early-life factors (birth to 2 y) and cognitive development at 5 y. Methods: Observational follow-up visits were made of children at 5 y, previously enrolled in the community-based MAL-ED longitudinal cohort. The burden of enteropathogens, prevalence of illness, complementary diet intake, micronutrient status, and household and maternal factors from birth to 2 y were extensively measured and their relation with the Wechsler Preschool Primary Scales of Intelligence at 5 y was examined through use of linear regression. Results: Cognitive T-scores from 813 of 1198 (68%) children were examined and 5 variables had significant associations in multivariable models: mean child plasma transferrin receptor concentration (β: −1.81, 95% CI: −2.75, −0.86), number of years of maternal education (β: 0.27, 95% CI: 0.08, 0.45), maternal cognitive reasoning score (β: 0.09, 95% CI: 0.03, 0.15), household assets score (β: 0.64, 95% CI: 0.24, 1.04), and HOME child cleanliness factor (β: 0.60, 95% CI: 0.05, 1.15). In multivariable models, the mean rate of enteropathogen detections, burden of illness, and complementary food intakes between birth and 2 y were not significantly related to 5-y cognition. Conclusions: A nurturing home context in terms of a healthy/clean environment and household wealth, provision of adequate micronutrients, maternal education, and cognitive reasoning have a strong and persistent influence on child cognitive development. Efforts addressing aspects of poverty around micronutrient status, nurturing caregiving, and enabling home environments are likely to have lasting positive impacts on child cognitive development.publishedVersio

Players' beliefs in extensive form games

The epistemic program in game theory uses formal models of interactive reasoning to provide foundations for various game-theoretic solution concepts. Much of this work is based around the (static) Aumann structure model of interactive epistemology, but more recently dynamic models of interactive reasoning have been developed, most notably by Stalnaker (Economics and Philosophy 1996) and Battigalli and Siniscalchi (Journal of Economic Theory 1999), and used to analyze rational play in extensive form games. But while the properties of Aumann structures are well un- derstood, without a formal language in which belief and belief revision statements can be expressed, it is unclear exactly what are the properties of these dynamic models. In chapter 1, "Dynamic In- teractive Epistemology", we investigate this question by defining such a language. A semantics and syntax are presented, with soundness and completeness theorems linking the two. Chapter 2, "Algorithmic Characterization of Ratioalizability in Extensive Form Games", uses the framework of chapter 1 to construct a dynamic epistemic model for extensive form games, which generates a hierarchy of beliefs for each player over her opponents' strategies and beliefs, and tells us how those beliefs will be revised as the game proceeds. We use the model to analyze the implications of the assumption that the players possess common (true) belief in rationality, thus extending the concept of rationalizability to extensive form games. Chapter 3, "The Equivalence of Bayes and Causal Rationality in Games", takes as its starting point a seminal paper of Aumann (Econometrica 1987), which showed how the choices of rational players could be analyzed in a unified state space framework. His innovation was to include the choices of the players in the description of the states, thus abolishing Savage's distinction between acts and consequences. But this simplification comes at a price: Aumann's notion of Bayes ratio­ nality does not allow players to evaluate what would happen were they to deviate from their actual choices. We show how the addition of a causal structure to the framework enables us to analyze such counterfactual statements, and use it to introduce a notion of causal rationality. Under a plausible causal independence condition, the two notions are shown to be equivalent. If we are prepared to accept this condition we can dispense with the causal apparatus and retain Aumann's original framework. In chapter 4, "The Deception of the Greeks", it is argued that the standard model of an extensive form game rules out an important phenomenon in situations of strategic interaction: deception. Using examples from the world of ancient Greece and from modern-day Wall Street, we show how the model can be generalized to incorporate this phenomenon. Deception takes place when the action observed by a player is different from the action actually taken. The standard model does allow imperfect information (modeled by non-singleton information sets), but not deception: the actual action taken is never ruled out. Our extension of extensive form games relaxes the assumption that the information sets partition the set of nodes, so that the set of nodes considered possible after a certain action is taken might not include the actual node. We discuss the implications of this relaxation, and show that in certain games deception is inconsistent with common knowledge of rationality even along the backward induction path.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Players' beliefs in extensive form games

The epistemic program in game theory uses formal models of interactive reasoning to provide foundations for various game-theoretic solution concepts. Much of this work is based around the (static) Aumann structure model of interactive epistemology, but more recently dynamic models of interactive reasoning have been developed, most notably by Stalnaker (Economics and Philosophy 1996) and Battigalli and Siniscalchi (Journal of Economic Theory 1999), and used to analyze rational play in extensive form games. But while the properties of Aumann structures are well un- derstood, without a formal language in which belief and belief revision statements can be expressed, it is unclear exactly what are the properties of these dynamic models. In chapter 1, "Dynamic In- teractive Epistemology", we investigate this question by defining such a language. A semantics and syntax are presented, with soundness and completeness theorems linking the two. Chapter 2, "Algorithmic Characterization of Ratioalizability in Extensive Form Games", uses the framework of chapter 1 to construct a dynamic epistemic model for extensive form games, which generates a hierarchy of beliefs for each player over her opponents' strategies and beliefs, and tells us how those beliefs will be revised as the game proceeds. We use the model to analyze the implications of the assumption that the players possess common (true) belief in rationality, thus extending the concept of rationalizability to extensive form games. Chapter 3, "The Equivalence of Bayes and Causal Rationality in Games", takes as its starting point a seminal paper of Aumann (Econometrica 1987), which showed how the choices of rational players could be analyzed in a unified state space framework. His innovation was to include the choices of the players in the description of the states, thus abolishing Savage's distinction between acts and consequences. But this simplification comes at a price: Aumann's notion of Bayes ratio­ nality does not allow players to evaluate what would happen were they to deviate from their actual choices. We show how the addition of a causal structure to the framework enables us to analyze such counterfactual statements, and use it to introduce a notion of causal rationality. Under a plausible causal independence condition, the two notions are shown to be equivalent. If we are prepared to accept this condition we can dispense with the causal apparatus and retain Aumann's original framework. In chapter 4, "The Deception of the Greeks", it is argued that the standard model of an extensive form game rules out an important phenomenon in situations of strategic interaction: deception. Using examples from the world of ancient Greece and from modern-day Wall Street, we show how the model can be generalized to incorporate this phenomenon. Deception takes place when the action observed by a player is different from the action actually taken. The standard model does allow imperfect information (modeled by non-singleton information sets), but not deception: the actual action taken is never ruled out. Our extension of extensive form games relaxes the assumption that the information sets partition the set of nodes, so that the set of nodes considered possible after a certain action is taken might not include the actual node. We discuss the implications of this relaxation, and show that in certain games deception is inconsistent with common knowledge of rationality even along the backward induction path.</p