ABSTRACT
The quality of cloud service is an important aspect to the success of any global business in today's world. The objective of this paper is to find the factors of the cloud service quality and assess the impact of service quality on customer satisfaction and loyalty. A survey of 419 cloud experts/users was conducted in India by means of an organized survey instrument/questionnaire based on Likert scale. The respondents were the cloud experts/users using the services of top 5 cloud service providers of India. Research hypotheses were tested using partial least squares structural equation modeling. The study found that agility, assurance of service, reliability, scalability, security, service responsiveness, and usability all have a positive and significant effect on overall cloud service quality. The research revealed the partial mediation effect of customer satisfaction amid service quality and customer loyalty. It is noticed that service quality has positive and significant link with customer loyalty and customer satisfaction. This establishes the partial mediation effect of customer satisfaction on the link between service quality and customer loyalty. Finally, the paper recommends cloud experts/users/service providers to give specific attention to these factors when migrating to cloud services.
ABSTRACT
Bioprosthetic mitral valves rarely obstruct. We present an older woman who presented with rapidly progressive dyspnea 4 years after bovine mitral replacement. Investigations demonstrated severe mitral stenosis with large, obstructive masses within the previous mitral prosthesis and an elevated eosinophil count. She underwent urgent reoperative mitral replacement and tricuspid valve repair through a 4-cm right minithoracotomy under hypothermic, fibrillatory arrest. Pathologic analysis revealed eosinophilic infiltrates in the obstructive masses and normal endomyocardial biopsies. She made an uneventful recovery and was discharged on steroids to suppress the eosinophilia. Repeat echocardiography demonstrated a well-functioning porcine valve without leaflet restriction or obstruction.
Subject(s)
Bioprosthesis , Heart Valve Prosthesis , Hypereosinophilic Syndrome/complications , Minimally Invasive Surgical Procedures/methods , Mitral Valve Insufficiency/surgery , Reoperation/methods , Aged , Diagnosis, Differential , Echocardiography , Female , Follow-Up Studies , Humans , Mitral Valve Insufficiency/diagnosis , Mitral Valve Insufficiency/etiologyABSTRACT
BACKGROUND: Most hospitals in Canada do not have percutaneous coronary intervention (PCI) facilities and use thrombolysis as reperfusion therapy for ST-elevation myocardial infarction (STEMI). Urgent PCI after thrombolysis may optimize reperfusion and prevent reinfarction and recurrent ischemia. OBJECTIVE: To determine the feasibility of transferring high-risk STEMI patients from community hospitals in Ontario to PCI centres for urgent PCI within 6 h of thrombolysis. METHODS: Patients with anterior or high-risk inferior STEMI received tenecteplase and were urgently transferred to PCI centres. PCI was performed if at least 70% stenosis was present in the infarct-related artery, regardless of flow, using coronary stents. Transfer of stable patients back to community hospitals was encouraged 24 h to 48 h after PCI. RESULTS: Eighteen patients were transferred and underwent PCI a median of 3.9 h (range 2.7 h to 6.4 h) after thrombolysis. No complications occurred during transfer. One death occurred that was related to failed reperfusion and cardiogenic shock. Minor access-site bleeding occurred in five patients. Fifteen patients were transferred back to their community hospitals within 24 h of PCI. There were no further deaths or reinfarctions at one-year follow-up. CONCLUSIONS: Transfer of high-risk STEMI patients for urgent PCI within 6 h after thrombolysis appears feasible. The randomized trial phase of the Trial of Routine ANgioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) will compare this strategy with standard treatment after thrombolysis.
Subject(s)
Angioplasty, Balloon, Coronary , Coronary Stenosis/therapy , Heart Conduction System/physiopathology , Myocardial Infarction/therapy , Patient Transfer , Thrombolytic Therapy , Adult , Aged , Blood Vessel Prosthesis Implantation , Coronary Angiography , Coronary Stenosis/complications , Coronary Stenosis/diagnostic imaging , Coronary Stenosis/physiopathology , Enoxaparin/therapeutic use , Feasibility Studies , Female , Fibrinolytic Agents/therapeutic use , Follow-Up Studies , Heparin/therapeutic use , Hospitals, Community , Humans , Length of Stay , Male , Middle Aged , Myocardial Infarction/diagnostic imaging , Myocardial Infarction/etiology , Myocardial Infarction/physiopathology , Myocardial Reperfusion , Ontario , Pilot Projects , Postoperative Complications/etiology , Stents , Tenecteplase , Thrombolytic Therapy/methods , Time Factors , Tissue Plasminogen Activator/therapeutic use , Treatment OutcomeABSTRACT
Non-ST segment elevation acute coronary syndromes (NSTE ACS) include a clinical spectrum that ranges from unstable angina to NSTE myocardial infarction. Management goals aim to prevent recurrent ACS and improve long-term outcomes by choosing a treatment strategy according to an estimate of the risk of an adverse outcome. Recent registry data suggest that patients with NSTE ACS frequently do not receive recommended treatment, and that risk stratification is not used to determine either the choice of treatment or the speed of access to coronary angiography. The present article evaluates the evidence for recommended treatment using information from recent trials and guidelines published by the major cardiac organizations in Europe and North America. Using this information, a multidisciplinary group developed a simplified algorithm that uses risk stratification to select an optimal early management strategy. Long-term outcomes are improved by a multi-faceted vascular protection strategy that is initiated at the time of hospitalization for NSTE ACS.
