Surgical treatment of hamstring injuries and disorders – the clinical spectrum from chronic tendinopathy to complete rupture

Hamstring muscle injuries and tendon disorders are common, especially in sports. They can be severe and difficult to treat, often resulting in impaired athletic performance and long rehabilitation times. Previous studies considering treatment of these problems are scarce. The current study was designed to investigate the effect of surgery on different types of hamstring muscle injuries and on proximal hamstring tendinopathy. In addition, we wanted to study the typical histopathological findings relating to proximal hamstring tendinopathy. In the study of complete (all three muscles torn) proximal hamstring avulsions (41 patients), our results showed that early operative treatment gives significantly better results than late surgery, and is therefore recommended. Despite this, considerable improvement of symptoms could also be achieved in chronic cases. In the study of partial (one or two muscles torn) proximal hamstring tears (47 patients), we observed that these injuries can cause significant functional deficit and impaired performance in athletes. The main finding was that after surgical repair most of the patients were able to return to their pre-injury level of sports. In the study of distal hamstring tears (18 patients), the results showed that surgical treatment had a good effect in the majority of these cases. In proximal hamstring tendinopathy, the main problem is pain which limits sports. In this study (90 patients), we found that after unsuccessful conservative treatment, surgery was a good treatment option resulting in full return to sports in most cases. In tendinopathic hamstring tendons, the morphological changes of tendinosis were largely identical to those previously described in other common (e.g. Achilles and patellar) tendinopathies. In chronic proximal hamstring avulsions, and also in reoperations, a large defect between distally retracted tendons and the ischial tuberosity may occasionally prevent anatomic reinsertion. We have described a reconstruction method using fascia lata autograft augmentation to be used in these most challenging repairs. This technique was utilized in the treatment of five patients, with encouraging results.

Sales and Operations Planning Implementation

The master’s thesis focused on implementing a sales and operations planning process. The main objectives were to create planning methods and tools for the implementation. The ultimate goal of the process, beyond this master’s thesis, is to balance the supply of products with customer demand, with optimized profitability. The theoretical part focused on giving a thorough view on the sales and operations planning process. The basis for a monthly planning cycle was identified. Methods, tools, and metrics for demand forecasting and operations planning were also introduced. Based on the theoretical part, a method for forecasting, a forecast spreadsheet, and a forecast accuracy metric were designed. A spreadsheet tool and methods were also designed for the monthly planning of production volumes, capacity, and inventory. The implementation progress was reviewed for two product families for three months. The sales and operations planning process was able to successfully identify a demand peak for the product families. Suggestions for the future of sales and operations planning were also made.

Surgical Treatment of Colorectal Cancer. Controversial Issues

Aims: This study was carried out to evaluate surgical treatment of colorectal cancer (CRC) with special interest in present status and controversial issues: stenting as a palliative procedure for metastasized CRC (I), duration of thromboprophylaxis after the surgical treatment of CRC (II), treatment of the increasing population of elderly people (III) and the quality of life (QoL) after surgery for rectal cancer with special reference to pelvic floor dysfunction (IV). Materials and methods: The material consisted of patients with CRC operated on at Turku University Hospital between 2003 and 2008. In study II the data was collected retrospectively from electronic archives. In other studies the follow-up data was collected at postoperative control visits. In study IV the RAND-36 standardized questionnaire and additional questions assessing urinary, sexual and anorectal dysfunction were used. Results: The results of the current study showed that self-expanding metallic stents provided an alternative to palliative surgery in the treatment of obstructive CRC. Low molecular heparin given s.c. for a median of 11 days until hospital discharge seemed to provide sufficient thromboprophylaxis after surgery. With preoperative selection elderly patients with rectal cancer were suitable for major surgery for rectal cancer with morbidity and mortality rates comparable to those in younger patients. There was no difference between preoperative and one year postoperative general QoL for operated rectal cancer patients. Postoperative pelvic dysfunction was associated with an impaired QoL in some dimensions. Conclusions: Many individual factors regarding the patient and the disease must be taken into account when making treatment decisions in CRC to ensure successful treatment of CRC, patient satisfaction and QoL.

The intrinsic mechanisms of softwood fiber damage in brown stock fiber line unit operations Lappeenranta 2010

The effects of pulp processing on softwood fiber properties strongly influence the properties of wet and dry paper webs. Pulp strength delivery studies have provided observations that much of the strength potential of long fibered pulp is lost during brown stock fiber line operations where the pulp is merely washed and transferred to the subsequent processing stages. The objective of this work was to study the intrinsic mechanisms which maycause fiber damage in the different unit operations of modern softwood brown stock processing. The work was conducted by studying the effects of industrial machinery on pulp properties with some actions of unit operations simulated in laboratory scale devices under controlled conditions. An optical imaging system was created and used to study the orientation of fibers in the internal flows during pulp fluidization in mixers and the passage of fibers through the screen openings during screening. The qualitative changes in fibers were evaluated with existing and standardized techniques. The results showed that each process stage has its characteristic effects on fiber properties: Pulp washing and mat formation in displacement washers introduced fiber deformations especially if the fibers entering the stage were intact, but it did not decrease the pulp strength properties. However, storage chests and pulp transfer after displacement washers contributed to strength deterioration. Pulp screening proved to be quite gentle, having the potential of slightly evening out fiber deformations from very deformed pulps and vice versa inflicting a marginal increase in the deformation indices if the fibers were previously intact. Pulp mixing in fluidizing industrial mixers did not have detrimental effects on pulp strength and had the potential of slightly evening out the deformations, provided that the intensity of fluidization was high enough to allow fiber orientation with the flow and that the time of mixing was short. The chemical and mechanical actions of oxygen delignification had two distinct effects on pulp properties: chemical treatment clearly reduced pulp strength with and without mechanical treatment, and the mechanical actions of process machinery introduced more conformability to pulp fibers, but did not clearly contribute to a further decrease in pulp strength. The chemical composition of fibers entering the oxygen stage was also found to affect the susceptibility of fibers to damage during oxygen delignification. Fibers with the smallest content of xylan were found to be more prone to irreversibledeformations accompanied with a lower tensile strength of the pulp. Fibers poor in glucomannan exhibited a lower fiber strength while wet after oxygen delignification as compared to the reference pulp. Pulps with the smallest lignin content on the other hand exhibited improved strength properties as compared to the references.

Quality and analysis of administration processes in server operations

IT outsourcing refers to the way companies focus on their core competencies and buy the supporting functions from other companies specialized in that area. Service is the total outcome of numerous of activities by employees and other resources to provide solutions to customers' problems. Outsourcing and service business have their unique characteristics. Service Level Agreements quantify the minimum acceptable service to the user. The service quality has to be objectively quantified so that its achievement or non-achievement of it can be monitored. Usually offshoring refers to the transferring of tasks to low-cost nations. Offshoring presents a lot of challenges that require special attention and they need to be assessed thoroughly. IT Infrastructure management refers to installation and basic usability assistance of operating systems, network and server tools and utilities. ITIL defines the industry best practices for organizing IT processes. This thesis did an analysis of server operations service and the customers’ perception of the quality of daily operations. The agreed workflows and processes should be followed better. Service providers’ processes are thoroughly defined but both the customer and the service provider might disobey them. Service provider should review the workflows regarding customer functions. Customer facing functions require persistent skill development, as they communicate the quality to the customer. Service provider needs to provide better organized communication and knowledge exchange methods between the specialists in different geographical locations.

Pharmacokinetics of Oxycodone and Paracetamol in the Elderly. Clinical Pharmacokinetic Study on Orthopaedic Surgical Patients and Healthy Volunteers

The proportion of elderly people over 65 years of age in Finland is expected to grow to over 25% by the 2025. It has been estimated that elderly people today consume nearly 40% of all drugs. Age brings about number of physiological changes that may affect the disposition, metabolism and excretion of drugs. The function of heart, lungs, liver and kidneys decreases even in healthy people, as they get older. The proportion of total body water decreases and the relative fat percentage increases. Also several other factors such as concurrent diseases, concomitant medication and nutritional factors have an effect on drug therapy in elderly. Age increases the risk of adverse drug reactions, which most often are dose-dependent. Despite all this there are not enough studies involving the elderly people and the elderly are most often excluded from clinical trials. Oxycodone is a strong opioid analgesic, which is used to treat moderate or severe pain. Paracetamol is a widely used nonopioid analgesic, which has become popular in the treatment of pain in many patient groups. In this series of studies the pharmacokinetics of oral and intravenous oxicodone as well as intravenous paracetamol in the elderly and young adult patients were investigated. Also a study investigating the interaction of oral antibiotic clarityhromycin, a known cytochrome P450 (CYP) 3A4 inhibitor, with oxycodone pharmacokinetics and pharmacodynamics in elderly and young healthy volunteers was carried out. The pharmacokinetics of oxycodone showed a clear age depency. Patients over 70 years had 50-80% higher mean exposure to oral oxycodone and a twofold greater plasma concentration than young adults 12 h after ingestion of the drug. Elderly patients had 40-80% greater exposure to intravenous oxycodone and patients over 80 years had over twofold greater plasma concentrations 8 h post dose than the young adults. The elderly patients had also greater exposure to intra venous paracetamol compared to young adults. Clarithromycin increased the exposure to oral oxycodone in both young and elderly volunteers. The elderly had marked interindividual variation in the pharmacokinetics and pharmacodynamics when clarithromycin was given concomitantly with oxycodone. Because the pharmacokinetics of oxycodone and intravenous paracetamol depend on the age of the subject, it is important to titrate the analgesic dose individually in the elderly.

Possibilities and challenges of longitudinal studies in operations management

Longitudinal studies are quite rare in the area of Operations Management. One reason might be the time needed to conduct such studies, and then the lack of experience and real-life examples and results. The aim of the thesis is to examine longitudinal studies in the area of OM and the possible advantages, challenges and pitfalls of such studies. A longitudinal benchmarking study, Made in Finland, was analyzed in terms of the study methodology and its outcomes. The timeline of this longitudinal study is interesting. The first study was made in 1993, the second in 2004 and the third in 2010. Between these studies some major changes occurred in the Finnish business environment. Between the first and second studies, Finland joined the ETA and the EU, and globalization started with the rise of the Internet era, while between the second and third studies financial turmoil started in 2007. The sample and cases used in this study were originally 23 manufacturing sites in Finland. These sites were interviewed in 1993, in 2004 and 2010. One important and interesting aspect is that all the original sites participated in 2004, and 19 sites were still able to participate in 2010. Four sites had been closed and/or moved abroad. All of this gave a good opportunity to study the changes that occurred in the Finnish manufacturing sites and their environment, and how they reacted to these changes, and the effects on their performance. It is very seldom, if ever, that the same manufacturing sites have been studied in a longitudinal setting by using three data points. The results of this study are thus unique, and the experience gained is valuable for practitioners.

Streamlining Launch Support Operations in a Product Platform

The new product development process is a massive investment to a company that aims to reduce their products’ time-to-market. Capability to shorter time-to market allows longer life-cycle to products which are introduced to market earlier but also give advantage to start product launch later while simultaneously learning from customer behavior and competitors. The product launch support operations are the last ramp-up activities before the product launching. This study defines what these operations mean in a product platform and how they can be streamlined to be more efficient. The methodology includes interviews, innovative group brainstorming and regular working group meetings. The challenges concerning the current situation of product launch support operations are allocated into four categories: General, Process, Project Resources and Project Management including altogether ten sub challenges. The challenges include issues related to technology and marketing management, branding strategy, organizing the global platform structure, harmonizing processes and clarifying handovers between shareholders in the process. The study makes a suggestion of a new Product Launch Support organization and clarification of its roles, responsibilities and tasks. In addition a new project management tool and Lessons Learned are suggested to improve the project management. The study can be seen as a pre-study when having an aim at combining technological and marketing know-how in the product ramp-up process before actual production. The future proceedings are suggested to include more detailed specifications and implementation in order to reach the long range target, reduced the time-to-market.

Hazard Risk Management in Large Nordic Companies' Operations in Russia

The objective of this research was to describe how Nordic companies manage hazard risks in their operations in Russia and how the local business environment is considered to affect the hazard risks. Research methods used in this research were literature review and expert interviews. Twelve Nordic industrial companies operating in different fields of industry were interviewed. Large Nordic companies typically guide risk management centralized from the parent company on behalf of the whole company group and the risk management standards and policies are integrated in all subsidiaries. Parent companies typically control hazard risk management in Russia by regular risk management reporting, auditing the Russian sites and by training local managers and employees to risk management work. Many companies have experienced several losses in the first years of operating in Russia before the risk management policies have been implemented in Russian subsidiaries. The companies have learned to take local characteristics better into account by experience and most companies are quite satisfied with their current risk management standards in Russia. The interviews indicate that companies experience especially the poor quality of infrastructure, some features in Russian organizational culture and high level of criminality to increase hazard risks in Russia. However, understanding these features and risks in the business environment makes the management of these risks possible. Risks related to infrastructure can be managed in advance by decreasing dependencies of infrastructure and considering the infrastructure quality already when planning the business operations. Also good local network is often considered critical in order to overcome the complications related to infrastructure. Russian personnel has typically different attitude towards risk management than Nordic personnel and neglecting safety and maintenance and concealing losses is more typical in Russia. By training and guiding the local personnel risk management and safety work and desired ways of actions these risks can be decreased. Criminality risks are often managed to certain extent by investing in security, increasing supervising and paying attention to reliability of the employees and other interest groups of the company.

Local Embeddedness and Knowledge Acquisition and How They Affect Finnish Business Operations in Russia

This pilot project aims examine the factors of the Finnish subsidiaries local embeddedness, their knowledge creation capabilities and the transfer mechanisms of new practices in the context of the Russian market. The research is designed as a multiple case study conducted with a qualitative approach. The empirical data consists of the interviews of the four Finnish case companies operating in the Kaluga region and three local partner companies. The deductive and inductive approaches were employed to conduct the analysis of the data. The propositions for the future study were developed in the conclusive chapters of the research, where we propose that the factor of the economy growth and industrialization matters in terms of subsidiaries’ role dedication, their knowledge creation capabilities, and direction of the knowledge flow within the local environment.

Reframing the relationship between service design and operations: a service engineering approach

The significance of services as business and human activities has increased dramatically throughout the world in the last three decades. Becoming a more and more competitive and efficient service provider while still being able to provide unique value opportunities for customers requires new knowledge and ideas. Part of this knowledge is created and utilized in daily activities in every service organization, but not all of it, and therefore an emerging phenomenon in the service context is information awareness. Terms like big data and Internet of things are not only modern buzz-words but they are also describing urgent requirements for a new type of competences and solutions. When the amount of information increases and the systems processing information become more efficient and intelligent, it is the human understanding and objectives that may get separated from the automated processes and technological innovations. This is an important challenge and the core driver for this dissertation: What kind of information is created, possessed and utilized in the service context, and even more importantly, what information exists but is not acknowledged or used? In this dissertation the focus is on the relationship between service design and service operations. Reframing this relationship refers to viewing the service system from the architectural perspective. The selected perspective allows analysing the relationship between design activities and operational activities as an information system while maintaining the tight connection to existing service research contributions and approaches. This type of an innovative approach is supported by research methodology that relies on design science theory. The methodological process supports the construction of a new design artifact based on existing theoretical knowledge, creation of new innovations and testing the design artifact components in real service contexts. The relationship between design and operations is analysed in the health care and social care service systems. The existing contributions in service research tend to abstract services and service systems as value creation, working or interactive systems. This dissertation adds an important information processing system perspective to the research. The main contribution focuses on the following argument: Only part of the service information system is automated and computerized, whereas a significant part of information processing is embedded in human activities, communication and ad-hoc reactions. The results indicate that the relationship between service design and service operations is more complex and dynamic than the existing scientific and managerial models tend to view it. Both activities create, utilize, mix and share information, making service information management a necessary but relatively unknown managerial task. On the architectural level, service system -specific elements seem to disappear, but access to more general information elements and processes can be found. While this dissertation focuses on conceptual-level design artifact construction, the results provide also very practical implications for service providers. Personal, visual and hidden activities of service, and more importantly all changes that take place in any service system have also an information dimension. Making this information dimension visual and prioritizing the processed information based on service dimensions is likely to provide new opportunities to increase activities and provide a new type of service potential for customers.

Anaesthesia and Pain Management for Use in Orthopaedic Day Surgery

Day surgery has gained a large popularity during the last decades. In Finland, 57% of the elective procedures, and 50% at Turku University Hospital, were already conducted on day basis during 2012. The steady growth of day surgery is mostly due to an increased safety in perioperative care and cost-effectiveness. The development of surgical techniques and anaesthetic methods has advanced the modern day surgery and extended the repertory of the procedures for use in day surgery operations. Day surgery also offers certain benefits like reduced risk for hospital-related infections, stress and confusion. Patient satisfaction, regarding several issues, is high. Most concerns and complaints are related to postoperative pain, nausea and vomiting pain and nausea. Pain can hamper recovery and pain management is a crucial factor for hospital discharge. Appropriate pain treatment is effective, safe, easy and economical. A procedure-specific approach and an individually planned, multimodal analgesia should be the basis of modern pain management. The main aim of this thesis was to evaluate the effectiveness and safety of anaesthetic technique and methods in pain treatment of orthopaedic day case surgery, and following conclusions were made. Unilateral spinal block was achieved using hyperbaric bupivacaine with a small dose of clonidine but clonidine prolonged the block. Continuous subacromial bupivacaine was found to be safe but conferring only moderate efficacy in pain care after shoulder arthroscopy. Transdermal fentanyl, 12 g/h, as part of multimodal analgesia, offered a safe and easy option to pain management in this patient group. However, after forefoot surgery, it did not reduce pain any further. In general, pain scores in all patient groups were low and the need for rescue opioid moderate.