Effect of waiting time on health outcomes and service utilization : A prospective randomized study on patients admitted to hospital for hip or knee replacement

Although the principle of equal access to medically justified treatment has been promoted by official health policies in many Western health care systems, practices do not completely meet policy targets. Waiting times for elective surgery vary between patient groups and regions, and growing problems in the availability of services threaten equal access to treatment. Waiting times have come to the attention of decision-makers, and several policy initiatives have been introduced to ensure the availability of care within a reasonable time. In Finland, for example, the treatment guarantee came into force in 2005. However, no consensus exists on optimal waiting time for different patient groups. The purpose of this multi-centre randomized controlled trial was to analyse health-related quality of life, pain and physical function in total hip or knee replacement patients during the waiting time and to evaluate whether the waiting time is associated with patients health outcomes at admission. This study also assessed whether the length of waiting time is associated with social and health services utilization in patients awaiting total hip or knee replacement. In addition, patients health-related quality of life was compared with that of the general population. Consecutive patients with a need for a primary total hip or knee replacement due to osteoarthritis were placed on the waiting list between August 2002 and November 2003. Patients were randomly assigned to a short waiting time (maximum 3 months) or a non-fixed waiting time (waiting time not fixed in advance, instead the patient followed the hospitals routine practice). Patients health-related quality of life was measured upon being placed on the waiting list and again at hospital admission using the generic 15D instrument. Pain and physical function were evaluated using the self-report Harris Hip Score for hip patients and a scale modified from the Knee Society Clinical Rating System for knee patients. Utilization measures were the use of home health care, rehabilitation and social services, physician visits and inpatient care. Health and social services use was low in both waiting time groups. The most common services used while waiting were rehabilitation services and informal care, including unpaid care provided by relatives, neighbours and volunteers. Although patients suffered from clear restrictions in usual activities and physical functioning, they seemed primarily to lean on informal care and personal networks instead of professional care. While longer waiting time did not result in poorer health-related quality of life at admission and use of services during the waiting time was similar to that at the time of placement on the list, there is likely to be higher costs of waiting by people who wait longer simply because they are using services for a longer period. In economic terms, this would represent a negative impact of waiting. Only a few reports have been published of the health-related quality of life of patients awaiting total hip or knee replacement. These findings demonstrate that, in addition to physical dimensions of health, patients suffered from restrictions in psychological well-being such as depression, distress and reduced vitality. This raises the question of how to support patients who suffer from psychological distress during the waiting time and how to develop strategies to improve patients initiatives to reduce symptoms and the burden of waiting. Key words: waiting time, total hip replacement, total knee replacement, health-related quality of life, randomized controlled trial, outcome assessment, social service, utilization of health services

Ammatti, ihminen ja maailmankuva murroksessa : Tutkimus yliopistokirjastoista ja kirjastonhoitajista tietoyhteiskuntakaudella 1970-2005

PROFESSION, PERSON AND WORLDVIEW AT A TURNING POINT A Study of University Libraries and Library Staff in the Information Age 1970 - 2005 The incongruity between commonly held ideas of libraries and librarians and the changes that have occurred in libraries since 2000 provided the impulse for this work. The object is to find out if the changes of the last few decades have penetrated to a deeper level, that is, if they have caused changes in the values and world views of library staff and management. The study focuses on Finnish university libraries and the people who work in them. The theoretical framework is provided by the concepts of world view (values, the concept of time, man and self, the experience of the supernatural and the holy, community and leadership). The viewpoint, framework and methods of the study place it in the area of Comparative Religion by applying the world view framework. The time frame is the information age, which has deeply affected Finnish society and scholarly communication from 1970 to 2005. The source material of the study comprises 30 life stories; somewhat more than half of the stories come from the University of Helsinki, and the rest from the other eight universities. Written sources include library journals, planning documents and historical accounts of libraries. The experiences and research diaries of the research worker are also used as source material. The world view questions are discussed on different levels: 1) recognition of the differences and similarities in the values of the library sphere and the university sphere, 2) examination of the world view elements, community and leadership based on the life stories, and 3) the three phases of the effects of information technology on the university libraries and those who work in them. In comparing the values of the library sphere and the university sphere, the appreciation of creative work and culture as well as the founding principles of science and research are jointly held values. The main difference between the values in the university and library spheres concerns competition and service. Competition is part of the university as an institution of research work. The core value of the library sphere is service, which creates the essential ethos of library work. The ethical principles of the library sphere also include the values of democracy and equality as well as the value of intellectual freedom. There is also a difference between an essential value in the university sphere, the value of autonomy and academic freedom on the one hand, and the global value of the library sphere - organizing operations in a practical and efficient way on the other hand. Implementing this value can also create tension between the research community and the library. Based on the life stories, similarities can be found in the values of the library staff members. The value of service seems to be of primary importance for all who are committed to library work and who find it interesting and rewarding. The service role of the library staff can be extended from information services provider to include the roles of teacher, listener and even therapist, all needed in a competitive research community. The values of democracy and equality also emerge fairly strongly. The information age development has progressed in three phases in the libraries from the 1960s onward. In the third phase beginning in the mid 1990s, the increased usage of electronic resources has set fundamental changes in motion. The changes have affected basic values and the concept of time as well as the hierarchies and valuations within the library community. In addition to and as a replacement for the library possessing a local identity and operational model, a networked, global library is emerging. The changes have brought tension both to the library communities and to the relationship between the university community and the library. Future orientation can be said to be the key concept for change; it affects where the ideals and models for operations are taken from. Future orientation manifests itself as changes in metaphors, changes in the model of a good librarian and as communal valuations. Tension between the libraries and research communities can arise if the research community pictures the library primarily as a traditional library building with a local identity, whereas the 21st century library staff and directors are affected by future orientation and membership in a networked library sphere, working proactively to develop their libraries.

Mechanisms and molecular regulation of mammalian tooth replacement

In most non-mammalian vertebrates, such as fish and reptiles, teeth are replaced continuously. However, tooth replacement in most mammals, including human, takes place only once and further renewal is apparently inhibited. It is not known how tooth replacement is genetically regulated, and little is known on the physiological mechanism and evolutionary reduction of tooth replacement in mammals. In this study I have attempted to address these questions. In a rare human condition cleidocranial dysplasia, caused by a mutation in a Runt domain transcription factor Runx2, tooth replacement is continued. Runx2 mutant mice were used to investigate the molecular mechanisms of Runx2 function. Microarray analysis from dissected embryonic day 14 Runx2 mutant and wild type dental mesenchymes revealed many downstream targets of Runx2, which were validated using in situ hybridization and tissue culture methods. Wnt signaling inhibitor Dkk1 was identified as a candidate target, and in tissue culture conditions it was shown that Dkk1 is induced by FGF4 and this induction is Runx2 dependent. These experiments demonstrated a connection between Runx2, FGF and Wnt signaling in tooth development and possibly also in tooth replacement. The role of Wnt signaling in tooth replacement was further investigated by using a transgenic mouse model where Wnt signaling mediator β-catenin is continuously stabilized in dental epithelium. This stabilization led to activated Wnt signaling and to the formation of multiple enamel knots. In vitro and transplantation experiments were performed to examine the process of extra tooth formation. We showed that new teeth were continuously generated and that new teeth form from pre-existing teeth. A morphodynamic activator-inhibitor model was used to simulate enamel knot formation. By increasing the intrinsic production rate of the activator (β-catenin), the multiple enamel knot phenotype was reproduced by computer simulations. It was thus concluded that β-catenin acts as an upstream activator of enamel knots, closely linking Wnt signaling to the regulation of tooth renewal. As mice do not normally replace teeth, we used other model animals to investigate the physiological and genetic mechanisms of tooth replacement. Sorex araneus, the common shrew was earlier reported to have non-functional tooth replacement in all antemolar tooth positions. We showed by histological and gene expression studies that there is tooth replacement only in one position, the premolar 4 and that the deciduous tooth is diminished in size and disappears during embryogenesis without becoming functional. The growth rates of deciduous and permanent premolar 4 were measured and it was shown by competence inference that the early initiation of the replacement tooth in relation to the developmental stage of the deciduous tooth led to the inhibition of deciduous tooth morphogenesis. It was concluded that the evolutionary loss of deciduous teeth may involve the early activation of replacement teeth, which in turn suppress their predecessors. Mustela putorius furo, the ferret, has a dentition that resembles that of the human as ferrets have teeth that belong to all four tooth families, and all the antemolar teeth are replaced once. To investigate the replacement mechanism, histological serial sections from different embryonic stages were analyzed. It was noticed that tooth replacement is a process which involves the growth and detachment of the dental lamina from the lingual cervical loop of the deciduous tooth. Detachment of the deciduous tooth leads to a free successional dental lamina, which grows deeper into the mesenchyme, and later buds the replacement tooth. A careful 3D analysis of serial histological sections was performed and it was shown that replacement teeth are initiated from the successional dental lamina and not from the epithelium of the deciduous tooth. The molecular regulation of tooth replacement was studied and it was shown by examination of expression patterns of candidate regulatory genes that BMP/Wnt inhibitor Sostdc1 was strongly expressed in the buccal aspect of the dental lamina, and in the intersection between the detaching deciduous tooth and the successional dental lamina, suggesting a role for Sostdc1 in the process of detachment. Shh was expressed in the enamel knot and in the inner enamel epithelium in both generations of teeth supporting the view that the morphogenesis of both generations of teeth is regulated by similar mechanisms. In summary, histological and molecular studies on different model animals and transgenic mouse models were used to investigate tooth replacement. This thesis work has significantly contributed to the knowledge on the physiological mechanisms and molecular regulation of tooth replacement and its evolutionary suppression in mammals.

Part I: Enzyme replacement versus neurotrophic factor viral vector-mediated gene therapy of Parkinson’s disease, Part II: The effects of orally dosed tolcapone and entacapone on dopamine metabolism in the dorsal striatum and nucleus accumbens in rats

Part I: Parkinson’s disease is a slowly progressive neurodegenerative disorder in which particularly the dopaminergic neurons of the substantia nigra pars compacta degenerate and die. Current conventional treatment is based on restraining symptoms but it has no effect on the progression of the disease. Gene therapy research has focused on the possibility of restoring the lost brain function by at least two means: substitution of critical enzymes needed for the synthesis of dopamine and slowing down the progression of the disease by supporting the functions of the remaining nigral dopaminergic neurons by neurotrophic factors. The striatal levels of enzymes such as tyrosine hydroxylase, dopadecarboxylase and GTP-CH1 are decreased as the disease progresses. By replacing one or all of the enzymes, dopamine levels in the striatum may be restored to normal and behavioral impairments caused by the disease may be ameliorated especially in the later stages of the disease. The neurotrophic factors glial cell derived neurotrophic factor (GDNF) and neurturin have shown to protect and restore functions of dopaminergic cell somas and terminals as well as improve behavior in animal lesion models. This therapy may be best suited at the early stages of the disease when there are more dopaminergic neurons for neurotrophic factors to reach. Viral vector-mediated gene transfer provides a tool to deliver proteins with complex structures into specific brain locations and provides long-term protein over-expression. Part II: The aim of our study was to investigate the effects of two orally dosed COMT inhibitors entacapone (10 and 30 mg/kg) and tolcapone (10 and 30 mg/kg) with a subsequent administration of a peripheral dopadecarboxylase inhibitor carbidopa (30 mg/kg) and L- dopa (30 mg/kg) on dopamine and its metabolite levels in the dorsal striatum and nucleus accumbens of freely moving rats using dual-probe in vivo microdialysis. Earlier similarly designed studies have only been conducted in the dorsal striatum. We also confirmed the result of earlier ex vivo studies regarding the effects of intraperitoneally dosed tolcapone (30 mg/kg) and entacapone (30 mg/kg) on striatal and hepatic COMT activity. The results obtained from the dorsal striatum were generally in line with earlier studies, where tolcapone tended to increase dopamine and DOPAC levels and decrease HVA levels. Entacapone tended to keep striatal dopamine and HVA levels elevated longer than in controls and also tended to elevate the levels of DOPAC. Surprisingly in the nucleus accumbens, dopamine levels after either dose of entacapone or tolcapone were not elevated. Accumbal DOPAC levels, especially in the tolcapone 30 mg/kg group, were elevated nearly to the same extent as measured in the dorsal striatum. Entacapone 10 mg/kg elevated accumbal HVA levels more than the dose of 30 mg/kg and the effect was more pronounced in the nucleus accumbens than in the dorsal striatum. This suggests that entacapone 30 mg/kg has minor central effects. Also our ex vivo study results obtained from the dorsal striatum suggest that entacapone 30 mg/kg has minor and transient central effects, even though central HVA levels were not suppressed below those of the control group in either brain area in the microdialysis study. Both entacapone and tolcapone suppressed hepatic COMT activity more than striatal COMT activity. Tolcapone was more effective than entacapone in the dorsal striatum. The differences between dopamine and its metabolite levels in the dorsal striatum and nucleus accumbens may be due to different properties of the two brain areas.

Causation, counterfactuals and competitive advantage

Causation is still poorly understood in strategy research, and confusion prevails around key concepts such as competitive advantage. In this paper, we define epistemological conditions that help to dispel some of this confusion and to provide a basis for more developed approaches. In particular, we argue that a counterfactual approach – that builds on a systematic analysis of ‘what-if’ questions – can advance our understanding of key causal mechanisms in strategy research. We offer two concrete methodologies – counterfactual history and causal modeling – as useful solutions. We also show that these methodologies open up new avenues in research on competitive advantage. Counterfactual history can add to our understanding of the context-specific construction of resource-based competitive advantage and path dependence, and causal modeling can help to reconceptualize the relationships between resources and performance. In particular, resource properties can be regarded as mediating mechanisms in these causal relationships.

Bullying and organisational politics in competitive and rapidly changing work environments

This paper argues that workplace bullying can in some cases be a form of organisational politics, that is, a deliberate, competitive strategy from the perspective of the individual perpetrator. A cross-sectional study conducted among business professionals revealed that there was a correlation between a politicised and competitive climate and bullying. This finding implies that globalisation, increased pressures for efficiency, and restructuring, which limits the number of management positions and thereby contributes to increased internal competition, may lead to more bullying. The findings have important implications for management, since the possible political aspects of bullying must be taken into account in order to be able to undertake successful prevention and intervention measures.

Causation, counterfactuals and competitive advantage

Causation is still poorly understood in strategy research, and confusion prevails around key concepts such as competitive advantage. In this paper, we define epistemological conditions that help to dispel some of this confusion and to provide a basis for more developed approaches. In particular, we argue that a counterfactual approach – that builds on a systematic analysis of ‘what-if’ questions – can advance our understanding of key causal mechanisms in strategy research. We offer two concrete methodologies – counterfactual history and causal modeling – as useful solutions. We also show that these methodologies open up new avenues in research on competitive advantage. Counterfactual history can add to our understanding of the context-specific construction of resource-based competitive advantage and path dependence, and causal modeling can help to reconceptualize the relationships between resources and performance. In particular, resource properties can be regarded as mediating mechanisms in these causal relationships.

Fishes of the Darkness : Water colour-regulated competitive interactions in humic lakes

Humic lakes are abundant in the temperate and cold regions of the Boreal Zone. High levels of water colour and strong thermal stratification of humic lakes limit the potential fish habitats and give a special role to the intraspecific and interspecific interactions. Water colour has different effects on species depending on species-specific life-history traits and trophic interactions. Fish species whose success in predation is based on visual cues are more susceptible to suffer in competition. The main aim of the thesis was to demonstrate the effects of water colour on European perch (Perca fluviatilis) in humic lakes. The contribution of water colour to diet, feeding, growth and competitive interactions of fish was studied both in laboratory and in small humic lakes with varying levels of water colour. The main findings of the thesis were that water colour has different effects on species, depending on species-specific life-history traits and trophic interactions. Water colour affected visually-oriented perch feeding and growth negatively, and the prolonged benthic feeding phase of perch resulting from the increased water colour could increase intraspecific competition in perch populations and may result in a partial bottleneck in growth for perch. Moreover, water colour may act as a proximate factor behind the population dependency of sexual growth dimorphism in perch.