Työvoimakoulutusraportti Pirkanmaa 2016 : Seuranta- ja ennakointitietoa työvoimakoulutuksen suunnitteluun

Työvoimakoulutusraportti Pirkanmaa 2016 – Seuranta- ja ennakointitietoa työvoimakoulutuksen suunnitteluun on Pirkanmaan elinkeino-, liikenne- ja ympäristökeskuksen sekä Ramboll Management Consulting Oy:n yhteistyössä laatima selvitys ammattialojen ja työllisyyden kehitysnäkymistä. Raportti toimii työvoimakoulutuksen suunnittelun tukena tarjoten seurantatietoa Pirkanmaalla järjestetystä työvoimakoulutuksesta. Lisäksi raportti kokoaa yhteen ennakointitietoa ja ennusteita toimialojen ja ammattien tulevaisuudesta.

Understanding solid-state transformations during dehydration: new insights using vibrational spectroscopy and multivariate modelling

Many active pharmaceutical ingredients (APIs) have both anhydrate and hydrate forms. Due to the different physicochemical properties of solid forms, the changes in solid-state may result in therapeutic, pharmaceutical, legal and commercial problems. In order to obtain good solid dosage form quality and performance, there is a constant need to understand and control these phase transitions during manufacturing and storage. Thus it is important to detect and also quantify the possible transitions between the different forms. In recent years, vibrational spectroscopy has become an increasingly popular tool to characterise the solid-state forms and their phase transitions. It offers several advantages over other characterisation techniques including an ability to obtain molecular level information, minimal sample preparation, and the possibility of monitoring changes non-destructively in-line. Dehydration is the phase transition of hydrates which is frequently encountered during the dosage form production and storage. The aim of the present thesis was to investigate the dehydration behaviour of diverse pharmaceutical hydrates by near infrared (NIR), Raman and terahertz pulsed spectroscopic (TPS) monitoring together with multivariate data analysis. The goal was to reveal new perspectives for investigation of the dehydration at the molecular level. Solid-state transformations were monitored during dehydration of diverse hydrates on hot-stage. The results obtained from qualitative experiments were used to develop a method and perform the quantification of the solid-state forms during process induced dehydration in a fluidised bed dryer. Both in situ and in-line process monitoring and quantification was performed. This thesis demonstrated the utility of vibrational spectroscopy techniques and multivariate modelling to monitor and investigate dehydration behaviour in situ and during fluidised bed drying. All three spectroscopic methods proved complementary in the study of dehydration. NIR spectroscopy models could quantify the solid-state forms in the binary system, but were unable to quantify all the forms in the quaternary system. Raman spectroscopy models on the other hand could quantify all four solid-state forms that appeared upon isothermal dehydration. The speed of spectroscopic methods makes them applicable for monitoring dehydration and the quantification of multiple forms was performed during phase transition. Thus the solid-state structure information at the molecular level was directly obtained. TPS detected the intermolecular phonon modes and Raman spectroscopy detected mostly the changes in intramolecular vibrations. Both techniques revealed information about the crystal structure changes. NIR spectroscopy, on the other hand was more sensitive to water content and hydrogen bonding environment of water molecules. This study provides a basis for real time process monitoring using vibrational spectroscopy during pharmaceutical manufacturing.

Towards real-time understanding of processes in pharmaceutical powder technology

There is a need for better understanding of the processes and new ideas to develop traditional pharmaceutical powder manufacturing procedures. Process analytical technology (PAT) has been developed to improve understanding of the processes and establish methods to monitor and control processes. The interest is in maintaining and even improving the whole manufacturing process and the final products at real-time. Process understanding can be a foundation for innovation and continuous improvement in pharmaceutical development and manufacturing. New methods are craved for to increase the quality and safety of the final products faster and more efficiently than ever before. The real-time process monitoring demands tools, which enable fast and noninvasive measurements with sufficient accuracy. Traditional quality control methods have been laborious and time consuming and they are performed off line i.e. the analysis has been removed from process area. Vibrational spectroscopic methods are responding this challenge and their utilisation have increased a lot during the past few years. In addition, other methods such as colour analysis can be utilised in noninvasive real-time process monitoring. In this study three pharmaceutical processes were investigated: drying, mixing and tabletting. In addition tablet properties were evaluated. Real-time monitoring was performed with NIR and Raman spectroscopies, colour analysis, particle size analysis and compression data during tabletting was evaluated using mathematical modelling. These methods were suitable for real-time monitoring of pharmaceutical unit operations and increase the knowledge of the critical parameters in the processes and the phenomena occurring during operations. They can improve our process understanding and therefore, finally, enhance the quality of final products.

Childhood and adolescent antecedents of work stress and early atherosclerosis

Work stress is after musculoskeletal disorders the second most common work-related health problem in the European Union, affecting 28% of EU employees. Furthermore, a 50% excessive cardiovascular disease risk among employees with work stress is reported. High job demands combined with low job control according to the Job Demands-Job Control model, or high effort combined with low rewards according to Effort-Reward Imbalance model, are likely to produce work stress in the majority of employees. Atherosclerotic wall thickening is a validated marker of an increased risk of cardiovascular disease. This study examined the role of childhood and adolescent factors as antecedents of work stress and early atherosclerosis, and in the relationship between them. The Cardiovascular Risk in Young Finns Study, (the CRYF project) started in 1980 when the participants were at the age of three to 18 years. Follow-ups have been conducted every three years until 1992, after that in 1997 and 2001, and the latest is ongoing in 2008. The participants parents reported their socioeconomic position in 1980 and 1983, and their life satisfaction in 1983. Biological risk factors were measured in 1980 and 2001. Type A behaviour was reported in 1986, 1989 and 2001. In the 2001 follow-up when the participants were aged 24 to 39, work stress was assessed from responses to questionnaires on job demands-job control and effort-reward imbalance, and education. Ultrasound measurement of the carotid intima-media thickness (CIMT) was used to assess atherosclerosis. There were 755, 746, 1014 and 494 participants in studies I-IV, respectively. The results showed that low parental socioeconomic position and parental life dissatisfaction during childhood and adolescence predicted higher levels of job strain 18 years later, and that education mediated the relationship between parental socioeconomic position and job strain. Childhood and adolescent family factors were not related to the effort-reward imbalance. Parental life satisfaction was associated with high rewards at work among the men, and high parental socioeconomic position was associated with high reward among the women. Among the men, the eagerness-energy component of Type A behaviour across different developmental periods predicted increased CIMT. Among the women, hard-driving component of Type A behaviour predicted decreased CIMT. Low leadership characteristic in adolescence and early adulthood was associated with both high job strain and increased CIMT, and attenuated the relationship between job strain and CIMT to non-significance in men. The current findings add to the literature on the relationship between job strain and health literature in adopting a developmental perspective. The results imply that work stress does not completely originate from work. There are childhood and adolescent environmental and dispositional effects on work stress and CIMT several years later, and these partly seem to operate through educational attainment.

Developmental origins of psychological vulnerability factors for mental disorders

Premature birth and associated small body size are known to affect health over the life course. Moreover, compelling evidence suggests that birth size throughout its whole range of variation is inversely associated with risk for cardiovascular disease and type 2 diabetes in subsequent life. To explain these findings, the Developmental Origins of Health and Disease (DOHaD) model has been introduced. Within this framework, restricted physical growth is, to a large extent, considered either a product of harmful environmental influences, such as suboptimal nutrition and alterations in the foetal hormonal milieu, or an adaptive reaction to the environment. Whether inverse associations exist between body size at birth and psychological vulnerability factors for mental disorders is poorly known. Thus, the aim of this thesis was to study in three large prospective cohorts whether prenatal and postnatal physical growth, across the whole range of variation, is associated with subsequent temperament/personality traits and psychological symptoms that are considered vulnerability factors for mental disorders. Weight and length at birth in full term infants showed quadratic associations with the temperamental trait of harm avoidance (Study I). The highest scores were characteristic of the smallest individuals, followed by the heaviest/longest. Linear associations between birth size and psychological outcomes were found such that lower weight and thinness at birth predicted more pronounced trait anxiety in late adulthood (Study II); lower birth weight, placental size, and head circumference at 12 months predicted a more pronounced positive schitzotypal trait in women (Study III); and thinness and smaller head circumference at birth associated with symptoms of attention-deficit hyperactivity disorder (ADHD) in children who were born at term (Study IV). These associations occured across the whole variation in birth size and after adjusting for several confounders. With respect to growth after birth, individuals with high trait anxiety scores in late adulthood were lighter in weight and thinner in infancy, and gained weight more rapidly between 7 and 11 years of age, but weighed less and were shorter in late adulthood in relation to weight and height measured at 11 years of age (Study II). These results suggest that a suboptimal prenatal environment reflected in smaller birth size may affect a variety of psychological vulnerability factors for mental disorders, such as the temperamental trait of harm avoidance, trait anxiety, schizotypal traits, and symptoms of ADHD. The smaller the birth size across the whole range of variation, the more pronounced were these psychological vulnerability factors. Moreover, some of these outcomes, such as trait anxiety, were also predicted by patterns of growth after birth. The findings are concordant with the DOHaD model, and emphasise the importance of prenatal factors in the aetiology of not only mental disorders but also their psychological vulnerability factors.

Depression and its assessment among stroke patients and their caregivers

Approximately one-third of stroke patients experience depression. Stroke also has a profound effect on the lives of caregivers of stroke survivors. However, depression in this latter population has received little attention. In this study the objectives were to determine which factors are associated with and can be used to predict depression at different points in time after stroke; to compare different depression assessment methods among stroke patients; and to determine the prevalence, course and associated factors of depression among the caregivers of stroke patients. A total of 100 consecutive hospital-admitted patients no older than 70 years of age were followed for 18 months after having their first ischaemic stroke. Depression was assessed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), Beck Depression Inventory (BDI), Hamilton Rating Scale (HRSD), Visual Analogue Mood Scale (VAMS), Clinical Global Impression (CGI) and caregiver ratings. Neurological assessments and a comprehensive neuropsychological test battery were performed. Depression in caregivers was assessed by BDI. Depressive symptoms had early onsets in most cases. Mild depressive symptoms were often persistent with little change during the 18-month follow-up, although there was an increase in major depression over the same time interval. Stroke severity was associated with depression especially from 6 to 12 months post-stroke. At the acute phase, older patients were at higher risk of depression, and a higher proportion of men were depressed at 18 months post-stroke. Of the various depression assessment methods, none stood clearly apart from the others. The feasibility of each did not differ greatly, but prevalence rates differed widely according to the different criteria. When compared against DSM-III-R criteria, sensitivity and specificity were acceptable for the CGI, BDI, and HRSD. The CGI and BDI had better sensitivity than the more specific HRSD. The VAMS seemed not to be a reliable method for assessing depression among stroke patients. The caregivers often rated patients depression as more severe than did the patients themselves. Moreover, their ratings seemed to be influenced by their own depression. Of the caregivers, 30-33% were depressed. At the acute phase, caregiver depression was associated with the severity of the stroke and the older age of the patient. The best predictor of caregiver depression at later follow-up was caregiver depression at the acute phase. The results suggest that depression should be assessed during the early post-stroke period and that the follow-up of those at risk of poor emotional outcome should be extended beyond the first year post-stroke. Further, the assessment of well-being of the caregivers of stroke patients should be included as a part of a rehabilitation plan for stroke patients.

Kokemuksia tieteellisten jatko-opintojen ohjauksesta Teknillisen korkeakoulun Tuotantotalouden osastolla : Tavoitteeksi suunnitelmallinen ohjaus jatko-opiskelijan kasvun tueksi

Tutkimuksen tarkoituksena oli selvittää Teknillisen korkeakoulun Tuotantotalouden osaston jatko-opintojenohjauksen nykykäytännöt ja kartoittaa jatko-opiskelijoiden kokemuksia jatko-opintojen ohjauksesta. Lisäksi haluttiin kehittää ohjauksen käytäntöjä. Tutkimusote oli kvalitatiivinen ja pääasialliset tutkimusmenetelmät olivat grounded theory ja teemahaastattelu. Jatko-opiskelijoita haastateltiin yhteensä 18 Tuotantotaloudenosaston kaikilta jatkokoulutuslinjoilta: perinteiseltä linjalta, valtakunnallisesta tohtoriohjelmasta ja teollisuuden tohtoriohjelmasta ExIMasta. Tutkimuksen teoriapohjana olivat konstruktivistinen oppimiskäsitys ja sosiaalikonstruktivismi. Tutkimuksessa pyrittiin löytämään tutkimuksen teon elementit ja selvittämään, kuinka tutkijankoulutusprosessia tulisi konstruktivistisen oppimiskäsityksen mukaisesti tukea. Tieteellisen tiedon tuottamista sosiaalisena prosessina ja ryhmän tukea tutkimuksen teossa käsiteltiin sosiaalikonstruktivistisen teorian avulla. Tutkimuksen päätulokseksi saatiin, että jatko-opiskelijan tutkimusprosessin ohjaamiseen kaivataan suunnitelmallisuutta ja struktuuria. Tutkimuksen tuloksena esitetyn ohjausmallin mukaan opiskelija halutaan aktivoida pohtimaan omia tavoitteitaan ja tutkimuksen teon etenemistä sekä ohjaustarpeitaan jatahoja, joista ohjausta voi hakea. Tämän prosessin tueksi sekä jatko-opiskelijan ja ohjaajan avuksi tutkimuksessa esitetään käytännön työkalu, ohjaussuunnitelma. Yksilöohjauksen järjestäminen on kaikilla jatkokoulutuslinjoilla opiskelijan omalla vastuulla, ja usein ohjaustilanteiden järjestäminen koetaan vaikeaksi. Jatko-opiskelijoilla on useita ohjaustahoja, esimerkiksi oman korkeakoulun ja muiden korkeakoulujen professorien lisäksi tutkijakollegat ja teollisuuden edustajat. Yksilöohjaus on menetelmä- ja sisältötukea, henkistä tukea, kannustusta, keskustelua, ideoita ja ajatusten jäsennystä. Vertaisohjaukseen kuuluu näiden lisäksi samassa tilanteessa olevien ihmisten tuki, palaute ja kritiikki. Hyvän ohjauksen elementtejä ovat kannustaminen ja innostaminen, neuvominen ja jäsentäminen sekä seuranta ja säännöllisyys. Ohjauksessa tulisi lisäksi ottaa huomioon jatkotutkinnon erilainen merkitys eri opiskelijoille. Jatkotutkinto merkitsee joillekin ajokorttia akateemiseen maailmaan, toisille ammatillista kehitystä teollisuudessa. Tutkimuksen teon eri vaiheissa tarvitaan erilaista ohjausta: alkuvaiheessa tiukkaa ohjausta, jotta tutkimuksen oikeat urat löytyvät, raakatyön vaiheessa tukea ja kannustusta, jotta aineistonkeruu ja analyysi onnistuvat, ja loppuvaiheessa tutkimusraportin kommentointia. Tutkimuksessa todetaan lisäksi, että tieto- ja viestintätekniikkaa hyödyntäen voidaan hoitaa joitakin ohjausalueita paremmin kuin nykykäytännöillä. Tutkimuksen tärkeimpiä lähteitä olivat grounded theoryn osalta Strauss & Corbinin(1990) teos, ohjauksen osalta Aittolan (1995), Aittolan & Määtän (1997, 1998) tutkimukset ja Ackerin,Hillin & Blackin (1994) tutkimukset sekä konstruktivismin osalta von Wrightin (1996) ja Tynjälän (1999) tutkimukset. Avainsanat: Tieteelliset jatko-opinnot, teollisuuden tohtoriohjelma, ohjaus, tutorointi, mentorointi, konstruktivismi, sosiaalikonstruktivismi, grounded theory Keywords: Postgraduate education, Ph.D. studies, industry-university collaboration in Ph.D. studies, constructivism, social constructivism, grounded theory, tutoring, mentoring, supervision

Feeling Better, Performing Better? Holistically-Oriented Top Performance and Well-Being (HOPE) : Performance Enhancement and Its Perceived Impacts on Musicians

Most musicians choose a career in music based on their love of the art and a desire to share it with others. However, being a performing musician is highly demanding. Despite considerable evidence of the great frequency of performance-related problems (e.g. debilitating performance anxiety) among professional musicians or aspiring musicians in the current Western classical music tradition these problems are seldom discussed openly. The existing system offers musicians very little help in learning how to build sustainable performance success into their musical career. This study it is first of its kind in Finland which addresses the issue on larger scale in a systematic way. I devised the HOPE intervention (Holistically-Oriented Top Performance and Well-Being Enhancement), in order to learn how to integrate professional peak performance and a sense of personal well-being into the lives and careers of musicians. Unlike most interventions in previous research, the HOPE intervention is explicitly holistic and aims at enhancing the whole musician, not just alleviating performance anxiety. Earlier research has not in principle focused on musicians´ psychological well-being or on their subjective perceptions. The main purpose of the study is to understand the perceived impacts of the specially devised HOPE intervention on the participants and particularly in four key areas: performing, playing or singing well-being, and overall (performing, playing or singing and well-being combined). Furthermore, it is hoped that a deeper understanding of performers´ development will be gained. The research method is interdisciplinary and mainly qualitative. The primary data consist of a series of linked questionnaires (before and after the intervention) and semi-structured follow-up interviews collected during action research-oriented HOPE intervention courses for music majors in the Sibelius Academy. With the longitudinal group called Hope 1, the core data were collected during a nine month HOPE intervention course and from follow-up interviews conducted six months later in 2003-2004. The core data of Hope 1 (nine participants) are compared with the perceived impacts on fifty-three other participants in the HOPE courses during the period since their inception, 2001-2006. The focus is particularly on participants´ subjective perceptions. Results of the study suggest that the HOPE intervention is beneficial in enhancing overall performance capacity, including music performance, and a personal sense of well-being in a music university setting. The findings indicate that within all key areas significant positive changes take place between the beginning and the end of a HOPE intervention course. The longitudinal data imply that the perceived positive changes are still ongoing six months after the HOPE intervention course is finished. The biggest change takes place within the area of performing and the smallest, in participants´ perception of their playing or singing. The main impacts include reduced feelings of stress and anxiety (an enhanced sense of well-being) as well as increased sense of direction and control in one's life. Since the results of the present research gave no other reason to believe otherwise, it is to be expected that the HOPE intervention and the results of the study can be exploited in other areas of human activity as well, especially where continuous professional top performance is a prerequisite such as in business or sports. Keywords: performance enhancement, professional top performance, subjective well-being, subjective perceptions, holism, coaching, music performance anxiety, studying music, music.

Erityistä tukea tarvitsevien lasten polut esiopetuksesta alkuopetukseen : tukitoimet ja suoriutuminen

The purpose of this follow-up study is to analyse stages of learning and teaching of children with special needs in pre-school and the first two grades of elementary school. The target group included 270 children with special needs. The three year follow-up period for each child began during the pre-school year, and continued until the spring of the second grade in elementary school. Various diagnoses were detected among children in the study group. The disorders were categorised in six classes: the developmentally delayed, children with language development disorder, children with emotional and behavioural disorders, children with attention deficit, children with other non-cognitive disorders and children with extensive developmental disorders. The study's starting point was the situation in pre-school: how the children were placed in pre-school, and what kinds of support they were offered? The purpose of the study was to describe how children with special needs move from different types of groups in pre-school to the different types of classes in the first two grades of elementary school. I also examined how well the children with special needs succeeded in the first two grades of elementary school. An additional purpose was to find out what connections there may be between the paths taken by children with special needs when they move from pre-school to elementary school, the types of support they get, and how they succeed academically in elementary school. The data were gathered mainly by means of questionnaires. In addition the children were studied by means of tests designed to estimate their academic skills at the end of the second grade. In analysing the data I used both quantitative and qualitative methods. Six paths were identified among the children in the study group, based on whether a child was in a group or a class given special teaching or in an ordinary group or class during pre-school and the first two grades of elementary school. In this study, about 53% of the children with special needs moved from pre-school to a regular class in elementary school, and about 47% of the children received special education in elementary school. Among the ordinary groups (n = 69) in pre-school the majority of children (73 %) moved to a regular class in elementary school. Among the children receiving special education (n = 201) in pre-school, 46% moved to a regular class in elementary school. That path turned out to be the one followed by the greatest number of children. Only rarely did children move from an ordinary group in pre-school to a special education class in elementary school. Examination of the results according to the children's transition paths also links together with the viewpoint of integration and segregation. This study indicates that in pre-school special education groups, a significantly greater number of methods supporting children's development were used than in the conventional education groups. The difference was at its greatest inconnection with the use of so-called special rehabilitation methods. A quite wide range of variation was observed in how the children succeeded in elementary school. Success in the tests designed to estimate the children's academic skills was poor for 31% of the children (n = 230) in the first grade study group. For 69 % of the children, however, success in the tests was at least satisfactory. In the second grade study group 34 % of the children (N = 216) got through all the three tests estimating academic skills acceptably. According to this study, a number of children with special needs require special support throughout pre-school and the first two grades of elementary school. The results show that if the children received special support during the pre-school year, a number were able to participate in regular education in elementary school. Keywords: a child with special needs, measures of support, transitions, achievements in school

Milk casein-derived tripeptides : A special focus on blood pressure and vascular function

Increased consumption of low-fat milk products is inversely associated with the risk of hypertension. The beneficial effect of milk on blood pressure is attributed to high calcium and potassium content but also to specific peptide sequences, which are cleaved from milk protein during gastrointestinal digestion, fermentation of milk with proteolytic starter cultures or enzymatic hydrolysis. Milk products fermented with Lactobacillus helveticus contain casein-derived tripeptides isoleucine-proline-proline (Ile-Pro-Pro) and valine-proline-proline (Val-Pro-Pro), which have been shown to possess antihypertensive effects in humans and in experimental animals. The aim of the present series of studies was to investigate the effects of tripeptides Ile-Pro-Pro and Val-Pro-Pro or fermented milk products containing them on vascular function and blood pressure and to elucidate the mechanisms behind them by using different experimental models of hypertension. Another aim was to characterize the acute effects of tripeptides on blood pressure and arterial stiffness in mildly hypertensive humans. Ile-Pro-Pro and Val-Pro-Pro or fermented milk products containing them attenuated the development of hypertension in two experimental models of hypertension, spontaneously hypertensive rat (SHR) and type 2 diabetic Goto-Kakizaki (GK) rat fed with high-salt diet. Significant differences in systolic blood pressure (SBP) were seen after 8 weeks treatment with tripeptide-containing products compared to control product. Plant sterols did not enhance this effect. Two differently produced tripeptide powders produced a similar attenuating effect on SBP in SHR. In mildly hypertensive subjects, a single administration of tripeptide- and plant sterol-containing fermented milk product decreased both SBP and diastolic blood pressure (DBP) over a period of 8 hours. Protective effect of tripeptides Ile-Pro-Pro and Val-Pro-Pro and fermented milk products containing them on vascular function was demonstrated in in vitro studies and long-term experimental studies. The effect was shown to be endothelium-dependent and possibly involving endothelium-derived hyperpolarizing factor (EDHF). In the clinical study, single administration of tripeptide-containing fermented milk product did not affect measures of arterial stiffness. Long-term treatment with fermented milk product containing Ile-Pro-Pro and Val-Pro-Pro inhibited angiotensin-converting enzyme (ACE) and decreased aldosterone levels thus showing beneficial effects on the renin-angiotensin system (RAS) in SHR and GK. No changes in the components of RAS were observed by the single administration of the same product in mildly hypertensive subjects. Increased levels of cGMP, NOx and citrulline suggest increased nitric oxide (NO) production by the tripeptides. Taken together, Ile-Pro-Pro and Val-Pro-Pro -containing products attenuate the development of hypertension after long-term treatment in experimental models of hypertension and possess an acute antihypertensive effect in mildly hypertensive subjects. In addition, these tripeptides show endothelium-mediated beneficial effects on vascular function. Attenuation of blood pressure increase by the tripeptides in experimental animals involves RAS, but its role in the antihypertensive effect in humans remains to be elucidated.

Arresting occlusal enamel caries lesions with pit and fissure sealants

The aim of this study was to evaluate the feasibility of pit and fissure sealants and the effectiveness of the two sealant methods applied in every-day practice in public dental health care in Finland. Two sealant methods were evaluated according to their effectiveness in preventing dentin caries and sealant retention. Application time with these sealant methods was compared. The survival rate of sealed first and second molars was followed for nine and 13 year periods, respectively. Caries risk evaluation and observed increased caries risk were the basis for considering sealant application. A questionnaire, sent to all public dental health centers in Finland, monitored the attitudes of the dental profession towards sealant application and explored the current policies used as well as changes noted in the sealant application protocol. DMFT (Decayed, Missing or Filled Teeth) index values collected from the health centers were evaluated. The difference in caries rate between two methods investigated was highly significant. When compared to the glass ionomer sealant method (GIC), the effectiveness of the resin-based method (RB) in preventing dentin caries was 74% and the rate difference 3%. The relative risk for RB-sealed surfaces vs. GIC-sealed surfaces of having detectable dentin caries was 0.3 (95% CI 0.12, 0.57). The retention rate of sealants was higher with RB than GIC (P<0.001). Application of RB sealant material was less time-consuming than application of GIC sealant. Occlusal dentin caries lesions were found in 4% and proximal caries in less than 2% of sealed teeth. The majority of respondents reported application of sealants on a systematic basis along with caries-risk evaluation. Those health centers sealing over suspected or detected enamel caries had lower average DMFT index values (1.0) when compared to DMFT values (1.2) of health centers applying sealants by alternative criteria. It is concluded that the RB sealant method is more effective than the GIC sealant method in preventing dentin caries. Sealant maintenance may increase the costs of a sealant program. Occlusal caries management may be improved if the applied sealant policies are changed towards an interceptive approach i.e. applying the sealants over detected or suspected enamel caries lesions instead of sealing sound teeth in a preventive manner.

Routine Measurement of Health-Related Quality of Life in Assessing Cost-Effectiveness in Secondary Health Care

Aims: The aims of this study were 1) to identify and describe health economic studies that have used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL); 2) to test the feasibility of routine collection of health-related quality of life (HRQoL) data as an indicator of effectiveness of secondary health care; and 3) to establish and compare the cost-utility of three large-volume surgical procedures in a real-world setting in the Helsinki University Central Hospital, a large referral hospital providing secondary and tertiary health-care services for a population of approximately 1.4 million. Patients and methods: So as to identify studies that have used QALYs as an outcome measure, a systematic search of the literature was performed using the Medline, Embase, CINAHL, SCI and Cochrane Library electronic databases. Initial screening of the identified articles involved two reviewers independently reading the abstracts; the full-text articles were also evaluated independently by two reviewers, with a third reviewer used in cases where the two reviewers could not agree a consensus on which articles should be included. The feasibility of routinely evaluating the cost-effectiveness of secondary health care was tested by setting up a system for collecting HRQoL data on approximately 4 900 patients' HRQoL before and after operative treatments performed in the hospital. The HRQoL data used as an indicator of treatment effectiveness was combined with diagnostic and financial indicators routinely collected in the hospital. To compare the cost-effectiveness of three surgical interventions, 712 patients admitted for routine operative treatment completed the 15D HRQoL questionnaire before and also 3-12 months after the operation. QALYs were calculated using the obtained utility data and expected remaining life years of the patients. Direct hospital costs were obtained from the clinical patient administration database of the hospital and a cost-utility analysis was performed from the perspective of the provider of secondary health care services. Main results: The systematic review (Study I) showed that although QALYs gained are considered an important measure of the effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited. Of the reviewed full-text articles, only 70 reported QALYs based on actual before after measurements using a valid HRQoL instrument. Collection of simple cost-effectiveness data in secondary health care is feasible and could easily be expanded and performed on a routine basis (Study II). It allows meaningful comparisons between various treatments and provides a means for allocating limited health care resources. The cost per QALY gained was 2 770 for cervical operations and 1 740 for lumbar operations. In cases where surgery was delayed the cost per QALY was doubled (Study III). The cost per QALY ranges between subgroups in cataract surgery (Study IV). The cost per QALY gained was 5 130 for patients having both eyes operated on and 8 210 for patients with only one eye operated on during the 6-month follow-up. In patients whose first eye had been operated on previous to the study period, the mean HRQoL deteriorated after surgery, thus precluding the establishment of the cost per QALY. In arthroplasty patients (Study V) the mean cost per QALY gained in a one-year period was 6 710 for primary hip replacement, 52 270 for revision hip replacement, and 14 000 for primary knee replacement. Conclusions: Although the importance of cost-utility analyses has during recent years been stressed, there are only a limited number of studies in which the evaluation is based on patients own assessment of the treatment effectiveness. Most of the cost-effectiveness and cost-utility analyses are based on modeling that employs expert opinion regarding the outcome of treatment, not on patient-derived assessments. Routine collection of effectiveness information from patients entering treatment in secondary health care turned out to be easy enough and did not, for instance, require additional personnel on the wards in which the study was executed. The mean patient response rate was more than 70 %, suggesting that patients were happy to participate and appreciated the fact that the hospital showed an interest in their well-being even after the actual treatment episode had ended. Spinal surgery leads to a statistically significant and clinically important improvement in HRQoL. The cost per QALY gained was reasonable, at less than half of that observed for instance for hip replacement surgery. However, prolonged waiting for an operation approximately doubled the cost per QALY gained from the surgical intervention. The mean utility gain following routine cataract surgery in a real world setting was relatively small and confined mostly to patients who had had both eyes operated on. The cost of cataract surgery per QALY gained was higher than previously reported and was associated with considerable degree of uncertainty. Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is two-fold compared to hip replacement. Cost-utility results from the three studied specialties showed that there is great variation in the cost-utility of surgical interventions performed in a real-world setting even when only common, widely accepted interventions are considered. However, the cost per QALY of all the studied interventions, except for revision hip arthroplasty, was well below 50 000, this figure being sometimes cited in the literature as a threshold level for the cost-effectiveness of an intervention. Based on the present study it may be concluded that routine evaluation of the cost-utility of secondary health care is feasible and produces information essential for a rational and balanced allocation of scarce health care resources.

Familial aggregation of type 1 diabetes and diabetic nephropathy in Finland

Type 1 diabetes (T1D) is a common, multifactorial disease with strong familial clustering. In Finland, the incidence of T1D among children aged 14 years or under is the highest in the world. The increase in incidence has been approximately 2.4% per year. Although most new T1D cases are sporadic the first-degree relatives are at an increased risk of developing the same disease. This study was designed to examine the familial aggregation of T1D and one of its serious complications, diabetic nephropathy (DN). More specifically the study aimed (1) to determine the concordance rates of T1D in monozygotic (MZ) and dizygotic (DZ) twins and to estimate the relative contributions of genetic and environmental factors to the variability in liability to T1D as well as to study the age at onset of diabetes in twins; (2) to obtain long-term empirical estimates of the risk of T1D among siblings of T1D patients and the factors related to this risk, especially the effect of age at onset of diabetes in the proband and the birth cohort effect; (3) to establish if DN is aggregating in a Finnish population-based cohort of families with multiple cases of T1D, and to assess its magnitude and particularly to find out whether the risk of DN in siblings is varying according to the severity of DN in the proband and/or the age at onset of T1D: (4) to assess the recurrence risk of T1D in the offspring of a Finnish population-based cohort of patients with childhood onset T1D, and to investigate potential sex-related effects in the transmission of T1D from the diabetic parents to their offspring as well as to study whether there is a temporal trend in the incidence. The study population comprised of the Finnish Young Twin Cohort (22,650 twin pairs), a population-based cohort of patients with T1D diagnosed at the age of 17 years or earlier between 1965 and 1979 (n=5,144) and all their siblings (n=10,168) and offspring (n=5,291). A polygenic, multifactorial liability model was fitted to the twin data. Kaplan-Meier analyses were used to provide the cumulative incidence for the development of T1D and DN. Cox s proportional hazards models were fitted to the data. Poisson regression analysis was used to evaluate temporal trends in incidence. Standardized incidence ratios (SIRs) between the first-degree relatives of T1D patients and background population were determined. The twin study showed that the vast majority of affected MZ twin pairs remained discordant. Pairwise concordance for T1D was 27.3% in MZ and 3.8% in DZ twins. The probandwise concordance estimates were 42.9% and 7.4%, respectively. The model with additive genetic and individual environmental effects was the best-fitting liability model to T1D, with 88% of the phenotypic variance due to genetic factors. The second paper showed that the 50-year cumulative incidence of T1D in the siblings of diabetic probands was 6.9%. A young age at diagnosis in the probands considerably increased the risk. If the proband was diagnosed at the age of 0-4, 5-9, 10-14, 15 or more, the corresponding 40-year cumulative risks were 13.2%, 7.8%, 4.7% and 3.4%. The cumulative incidence increased with increasing birth year. However, SIR among children aged 14 years or under was approximately 12 throughout the follow-up. The third paper showed that diabetic siblings of the probands with nephropathy had a 2.3 times higher risk of DN compared with siblings of probands free of nephropathy. The presence of end stage renal disease (ESRD) in the proband increases the risk three-fold for diabetic siblings. Being diagnosed with diabetes during puberty (10-14) or a few years before (5-9) increased the susceptibility for DN in the siblings. The fourth paper revealed that of the offspring of male probands, 7.8% were affected by the age of 20 compared with 5.3% of the offspring of female probands. Offspring of fathers with T1D have 1.7 times greater risk to be affected with T1D than the offspring of mothers with T1D. The excess risk in the offspring of male fathers manifested itself through the higher risk the younger the father was when diagnosed with T1D. Young age at onset of diabetes in fathers increased the risk of T1D greatly in the offspring, but no such pattern was seen in the offspring of diabetic mothers. The SIR among offspring aged 14 years or under remained fairly constant throughout the follow-up, approximately 10. The present study has provided new knowledge on T1D recurrence risk in the first-degree relatives and the risk factors modifying the risk. Twin data demonstrated high genetic liability for T1D and increased heritability. The vast majority of affected MZ twin pairs, however, remain discordant for T1D. This study confirmed the drastic impact of the young age at onset of diabetes in the probands on the increased risk of T1D in the first-degree relatives. The only exception was the absence of this pattern in the offspring of T1D mothers. Both the sibling and the offspring recurrence risk studies revealed dynamic changes in the cumulative incidence of T1D in the first-degree relatives. SIRs among the first-degree relatives of T1D patients seems to remain fairly constant. The study demonstrates that the penetrance of the susceptibility genes for T1D may be low, although strongly influenced by the environmental factors. Presence of familial aggregation of DN was confirmed for the first time in a population-based study. Although the majority of the sibling pairs with T1D were discordant for DN, its presence in one sibling doubles and presence of ESRD triples the risk of DN in the other diabetic sibling. An encouraging observation was that although the proportion of children to be diagnosed with T1D at the age of 4 or under is increasing, they seem to have a decreased risk of DN or at least delayed onset.