@phdthesis{Bauer2023,
  author    = {Bauer, Carsten},
  title     = {Learning Curve Effects in Hospitals as Highly Specialized Expert Organizations},
  doi       = {10.25972/OPUS-32871},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-328717},
  school      = {Universit{\"a}t W{\"u}rzburg},
  year      = {2023},
  abstract  = {The collection at hand is concerned with learning curve effects in hospitals as highly specialized expert organizations and comprises four papers, each focusing on a different aspect of the topic. Three papers are concerned with surgeons, and one is concerned with the staff of the emergency room in a conservative treatment. The preface compactly addresses the steadily increasing health care costs and economic pressure, the hospital landscape in Germany as well as its development. Furthermore, the DRG lump-sum compensation and the characteristics of the health sector, which is strongly regulated by the state and in which ethical aspects must be omnipresent, are outlined. Besides, the benefit of knowing about learning curve effects in order to cut costs and to keep quality stable or even improve it, is addressed. The first paper of the collection investigates the learning effects in a hospital which has specialized on endoprosthetics (total hip and knee replacement). Doing so, the specialized as well as the non-specialized interventions are studied. Costs are not investigated directly, but cost indicators. The indicator of costs in the short term are operating room times. The one of medium- to long-term costs is quality. It is operationalized by complications in the post-anesthesia care unit. The study estimates regression models (OLS and logit). The results indicate that the specialization comes along with advantages due to learning effects in terms of shorter operating room times and lower complication rates in endoprosthetic interventions. For the non-specialized interventions, the results are the same. There are no possibly negative effects of specialization on non-specialized surgeries, but advantageous spillover effects. Altogether, the specialization can be regarded as reasonable, as it cuts costs of all surgeries in the short, medium, and long term. The authors are Carsten Bauer, Nele M{\"o}bs, Oliver Unger, Andrea Szczesny, and Christian Ernst. In the second paper surgeons' learning curves effects in a teamwork vs. an individual work setting are in the focus of interest. Thus, the study combines learning curve effects with teamwork in health care, an issue increasingly discussed in recent literature. The investigated interventions are tonsillectomies (surgical excision of the palatine tonsils), a standard intervention. The indicator of costs in the short and medium to long term are again operating room times and complications as a proxy for quality respectively. Complications are secondary bleedings, which usually occur a few days after surgery. The study estimates regression models (OLS and logit). The results show that operating room times decrease with increasing surgeon's experience. Surgeons who also operate in teams learn faster than the ones always operating on their own. Thus, operating room times are shorter for surgeons who also take part in team interventions. As a special feature, the data set contains the costs per case. This enables assuring that the assumed cost indicators are valid. The findings recommend team surgeries especially for resident physicians. The authors are Carsten Bauer, Oliver Unger, and Martin Holderried. The third paper is dedicated to stapes surgery, a therapy for conductive hearing loss caused by otosclerosis (overflow bone growth). It is conceptually simple, but technically difficult. Therefore, it is regarded as the optimum to study learning curve effects in surgery. The paper seeks a comprehensive investigation. Thus, operating room times are employed as short-term cost indicator and quality as the medium to long term one. To measure quality, the postoperative difference between air and bone conduction threshold as well as a combination of this difference and the absence of complications. This paper also estimates different regression models (OLS and logit). Besides investigating the effects on department level, the study also considers the individual level, this means operating room times and quality are investigated for individual surgeons. This improves the comparison of learning curves, as the surgeons worked under widely identical conditions. It becomes apparent that the operating room times initially decrease with increasing experience. The marginal effect of additional experience gets smaller until the direction of the effect changes and the operating room times increase with increasing experience, probably caused by the allocation of difficult cases to the most experienced surgeons. Regarding quality, no learning curve effects are observed. The authors are Carsten Bauer, Johannes Taeger, and Kristen Rak. The fourth paper is a systematic literature review on learning effects in the treatment of ischemic strokes. In case of stroke, every minute counts. Therefore, there is the inherent need to reduce the time from symptom onset to treatment. The article is concerned with the reduction of the time from arrival at the hospital to thrombolysis treatment, the so-called "door-to-needle time". In the literature, there are studies on learning in a broader sense caused by a quality improvement program as well as learning in a narrower sense, in which learning curve effects are evaluated. Besides, studies on the time differences between low-volume and high-volume hospitals are considered, as the differences are probably the result of learning and economies of scale. Virtually all the 165 evaluated articles report improvements regarding the time to treatment. Furthermore, the clinical results substantiate the common association of shorter times from arrival to treatment with improved clinical outcomes. The review additionally discusses the economic implications of the results. The author is Carsten Bauer. The preface brings forward that after the measurement of learning curve effects, further efforts are necessary for using them in order to increase efficiency, as the issue does not admit of easy, standardized solutions. Furthermore, the postface emphasizes the importance of multiperspectivity in research for the patient outcome, the health care system, and society.},
  subject      = {Lernkurve},
  language  = {en}
}
@article{KolbMaeurerGoebelerMaeurer2015,
  author    = {Kolb-M{\"a}urer, Annette and Goebeler, Matthias and M{\"a}urer, Mathias},
  title     = {Cutaneous adverse events associated with interferon-\(\beta\) treatment of multiple sclerosis},
  series = {International Journal of Molecular Sciences},
  volume    = {16},
  journal   = {International Journal of Molecular Sciences},
  doi       = {10.3390/ijms160714951},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-148451},
  pages     = {14951-14960},
  year      = {2015},
  abstract  = {Interferons are widely used platform therapies as disease-modifying treatment of patients with multiple sclerosis. Although interferons are usually safe and well tolerated, they frequently cause dermatological side effects. Here, we present a multiple sclerosis (MS) patient treated with interferon-\(\beta\) who developed new-onset psoriasis. Both her MS as well as her psoriasis finally responded to treatment with fumarates. This case illustrates that interferons not only cause local but also systemic adverse events of the skin. These systemic side effects might indicate that the Th17/IL-17 axis plays a prominent role in the immunopathogenesis of this individual case and that the autoimmune process might be deteriorated by further administration of interferons. In conclusion, we think that neurologists should be aware of systemic cutaneous side effects and have a closer look on interferon-associated skin lesions. Detection of psoriasiform lesions might indicate that interferons are probably not beneficial in the individual situation. We suggest that skin lesions may serve as biomarkers to allocate MS patients to adequate disease-modifying drugs.},
  language  = {en}
}
@article{LatoschikWienrich2022,
  author    = {Latoschik, Marc Erich and Wienrich, Carolin},
  title     = {Congruence and plausibility, not presence: pivotal conditions for XR experiences and effects, a novel approach},
  series = {Frontiers in Virtual Reality},
  volume    = {3},
  journal   = {Frontiers in Virtual Reality},
  issn      = {2673-4192},
  doi       = {10.3389/frvir.2022.694433},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-284787},
  year      = {2022},
  abstract  = {Presence is often considered the most important quale describing the subjective feeling of being in a computer-generated and/or computer-mediated virtual environment. The identification and separation of orthogonal presence components, i.e., the place illusion and the plausibility illusion, has been an accepted theoretical model describing Virtual Reality (VR) experiences for some time. This perspective article challenges this presence-oriented VR theory. First, we argue that a place illusion cannot be the major construct to describe the much wider scope of virtual, augmented, and mixed reality (VR, AR, MR: or XR for short). Second, we argue that there is no plausibility illusion but merely plausibility, and we derive the place illusion caused by the congruent and plausible generation of spatial cues and similarly for all the current model's so-defined illusions. Finally, we propose congruence and plausibility to become the central essential conditions in a novel theoretical model describing XR experiences and effects.},
  language  = {en}
}
@article{LueckerathLapaAlbertetal.2015,
  author    = {L{\"u}ckerath, Katharina and Lapa, Constantin and Albert, Christa and Herrmann, Ken and J{\"o}rg, Gerhard and Samnick, Samuel and Einsele, Herrmann and Knop, Stefan and Buck, Andreas K.},
  title     = {\(^{11}\)C-Methionine-PET: a novel and sensitive tool for monitoring of early response to treatment in multiple myeloma},
  series = {Oncotarget},
  volume    = {6},
  journal   = {Oncotarget},
  number    = {10},
  doi       = {10.18632/oncotarget.3053},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-148688},
  pages     = {8418-8429},
  year      = {2015},
  abstract  = {Multiple myeloma (MM) remains an essentially incurable hematologic malignancy. However, new treatment modalities and novel drugs have been introduced and thus additional tools for therapy monitoring are increasingly needed. Therefore, we evaluated the radiotracers \(^{11}\)C-Methionine (paraprotein-biosynthesis) and \(^{18}\)F-FDG (glucose-utilization) for monitoring response to anti-myeloma-therapy and outcome prediction. Influence of proteasome-inhibition on radiotracer-uptake of different MM cell-lines and patient-derived CD138\(^{+}\) plasma cells was analyzed and related to tumor-biology. Mice xenotransplanted with MM. 1S tumors underwent MET- and FDG-\(\mu\)PET. Tumor-to-background ratios before and after 24 h, 8 and 15 days treatment with bortezomib were correlated to survival. Treatment reduced both MET and FDG uptake; changes in tracer-retention correlated with a switch from high to low CD138-expression. In xenotransplanted mice, MET-uptake significantly decreased by 30-79\% as early as 24 h after bortezomib injection. No significant differences were detected thus early with FDG. This finding was confirmed in patient-derived MM cells. Importantly, early reduction of MET-but not FDG-uptake correlated with improved survival and reduced tumor burden in mice. Our results suggest that MET is superior to FDG in very early assessment of response to anti-myeloma-therapy. Early changes in MET-uptake have predictive potential regarding response and survival. MET-PET holds promise to individualize therapies in MM in future.},
  language  = {en}
}
@article{ReichertsGerdesPaulietal.2016,
  author    = {Reicherts, Philipp and Gerdes, Antje B. M. and Pauli, Paul and Wieser, Matthias J.},
  title     = {Psychological placebo and nocebo effects on pain rely on expectation and previous experience},
  series = {Journal of Pain},
  volume    = {17},
  journal   = {Journal of Pain},
  number    = {2},
  doi       = {10.1016/j.jpain.2015.10.010},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-190962},
  pages     = {203-214},
  year      = {2016},
  abstract  = {Expectation and previous experience are both well established key mediators of placebo and nocebo effects. However, the investigation of their respective contribution to placebo and nocebo responses is rather difficult because most placebo and nocebo manipulations are contaminated by pre-existing treatment expectancies resulting from a learning history of previous medical interventions. To circumvent any resemblance to classical treatments, a purely psychological placebonocebo manipulation was established, namely, the "visual stripe pattern induced modulation of pain." To this end, experience and expectation regarding the effects of different visual cues (stripe patterns) on pain were varied across 3 different groups, with either only placebo instruction (expectation), placebo conditioning (experience), or both (expectation + experience) applied. Only the combined manipulation (expectation + experience) revealed significant behavioral and physiological placebo nocebo effects on pain. Two subsequent experiments, which, in addition to placebo and nocebo cues, included a neutral control condition further showed that especially nocebo responses were more easily induced by this psychological placebo and nocebo manipulation. The results emphasize the great effect of psychological processes on placebo and nocebo effects. Particularly, nocebo effects should be addressed more thoroughly and carefully considered in clinical practice to prevent the accidental induction of side effects.},
  language  = {en}
}
@phdthesis{Saverschek2010,
  author    = {Saverschek, Nicole},
  title     = {The influence of the symbiotic fungus on foraging decisions in leaf-cutting ants - Individual behavior and collective patterns},
  url       = {http://nbn-resolving.de/urn:nbn:de:bvb:20-opus-52087},
  school      = {Universit{\"a}t W{\"u}rzburg},
  year      = {2010},
  abstract  = {Foraging behavior is a particularly fascinating topic within the studies of social insects. Decisions made by individuals have effects not only on the individual level, but on the colony level as well. Social information available through foraging in a group modulates individual preferences and shapes the foraging pattern of a colony. Identifying parameters influencing foraging behavior in leaf-cutting ants is especially intriguing because they do not harvest for themselves, but for their symbiotic fungus which in turn influences their plant preferences after the incorporation of the substrate. To learn about the substrates' unsuitability for the fungus, ants need to be able to identify the incorporated substrate and associate it with detrimental effects on the fungus. Odor is an important plant characteristic known to be used as recognition key outside the nest in the context of foraging. Chapter 1 shows that foragers are able to recall information about the unsuitability of a substrate through odor alone and consequently reject the substrate, which leads to the conclusion that inside the nest, odor might be enough to indentify incorporated substrate. Identification of plant species is a key factor in the foraging success of leaf-cutting ants as they harvest a multitude of different plant species in a diverse environment and host plant availability and suitability changes throughout the year. Fixed plant preferences of individuals through innate tendencies are therefore only one factor influencing foraging decisions. On the individual as well as the colony level, foraging patterns are flexible and a result of an intricate interplay between the different members involved in the harvesting process: foragers, gardeners and the symbiotic fungus. In chapter 2 I identified several conditions necessary for na{\"i}ve foragers to learn about the unsuitability of substrate inside the nest. In order to exchange of information about the unsuitability of a substrate, the plant in question must be present in the fungus garden. Foragers can learn without own foraging experience and even without experiencing the effects of the substrate on the fungus, solely through the presence of experienced gardeners. The presence of experienced foragers alone on the other hand is not enough to lower the acceptance of substrate by na{\"i}ve foragers in the presence of na{\"i}ve gardeners, even if experienced foragers make up the majority of the workforce inside the nest. Experienced foragers are also able to reverse their previous negative experience and start accepting the substrate again. The individual behavior of foragers and gardeners with different experiential backgrounds in the presence of suitable or unsuitable substrate inside the fungus chamber was investigated in chapter 3 to shed some light on possible mechanisms involved in the flow of information about substrate suitability from the fungus to the ants. Gardeners as well as foragers are involved in the leaf processing and treatment of the applied leaf patches on the fungus. If the plant material is unsuitable, significantly more ants treat the plant patches, but foragers are less active overall. Contacts between workers initiated by either gardeners or foragers occur significantly more frequent and last longer if the substrate is unsuitable. Even though experienced gardeners increase na{\"i}ve foragers' contact rates and duration with other workers in the presence of suitable plant patches, na{\"i}ve foragers show no differences in the handling of the plant patches. This suggests that foragers gain information about plant suitability not only indirectly through the gardening workers, but might also be able to directly evaluate the effects of the substrate on the fungus themselves. Outside the nest, foragers influence each other the trail (chapter 4). Foraging in a group and the presence of social information is a decisive factor in the substrate choice of the individual and leads to a distinct and consentaneous colony response when encountering unfamiliar or unsuitable substrates. As leaf-cutting ants harvest different plant species simultaneously on several trails, foragers gain individual experiences concerning potential host plants. Preferences might vary among individuals of the same colony to the degree that foragers on the same trail perceive a certain substrate as either suitable or unsuitable. If the majority of foragers on the trail perceives one of the currently harvested substrates as unsuitable, na{\"i}ve foragers lower their acceptance within 4 hours. In the absence of a cue in the fungus, na{\"i}ve foragers harvesting by themselves still eventually (within 6 hours) reject the substrate as they encounter experienced gardeners during visits to the nest within foraging bouts. As foraging trails can be up to 100 m long and foragers spend a considerable amount of time away from the nest, learning indirectly from experienced foragers on the trail accelerates the distribution of information about substrate suitability. The level of rejection of a formerly unsuitable substrate after eight hours of foraging by na{\"i}ve foragers correlates with the average percentage of unladen experienced foragers active on the trail. This suggests that unladen experienced foragers might actively contact laden na{\"i}ve workers transmitting information about the unsuitability of the load they carry. Results from experiments were I observed individual laden foragers on their way back to the nest backed up this assumption as individuals were antennated and received bites into the leaf disk they carried. Individuals were contacted significantly more often by nestmates that perceived the carried leaf disk as unsuitable due to previous experience than by nestmates without this experience (chapter 6). Leaf-cutting ants constantly evaluate, learn and re-evaluate the suitability of harvested substrate and adjust their foraging activity accordingly. The importance of the different sources of information within the colony and their effect on the foraging pattern of the colony depend on the presence or absence of each of them as e.g. experienced foragers have a bigger influence on the plant preferences of na{\"i}ve foragers in the absence of a cue in the fungus garden.},
  subject      = {Blattschneiderameisen},
  language  = {en}
}