Day Surgery in Finland : randomized and cross-sectional studies on treatment, quality, and outcome

The aims of this study were to describe Finnish day surgery practice at present and to evaluate quality of care by assessing postdischarge minor morbidity and quality indicators. Potential treatment options were approached by investigating the role of oral dexamethasone as a part of multimodal analgesia and the feasibility of day surgery in patients aged 65 years and older. Over a 2-month period, all patient cases at 14 Finnish day surgery or short-stay units were analyzed (Study I). Quality indicators included rates and reasons for overnight admission, readmission, reoperation, cancellations, and patient satisfaction. Recovery during the first postoperative week was assessed at two units (Study II). Altogether 2732 patients graded daily the intensity of predefined symptoms. To define risk factors of postdischarge symptoms, multinomial regression analysis was used. Sixty patients scheduled to undergo day surgery for hallux valgus were randomized to receive twice perioperatively dexamethasone 9 mg or placebo (Study III). Paracetamol 1 g was administered 3 times daily. Rescue medication (oxycodone) consumption during 0-3 postoperative days (POD), maximal pain scores and adverse effects were documented. Medically stable patients aged 65 years or older, scheduled for open inguinal hernia repair, were randomized to receive treatment either as day cases or inpatients (Study IV). Complications, unplanned admissions, healthcare visits, and patients’ acceptance of the type of care provided were assessed during 2 weeks postoperatively. In Study I, unplanned overnight admissions were reported in 5.9%, return hospital visits during PODs 1-28 in 3.7%, and readmissions in 0.7% of patients. Patient satisfaction was high. In Study II, pain was the most common symptom in adult patients (57%). Postdischarge symptoms were more frequent in adults aged < 40 years, children aged ≥ 7 years, females, and following a longer duration of surgery. In Study III, the total median (range) oxycodone consumption during the study period was 45 (0–165) mg in the dexamethasone group, compared with 78 (15–175) mg in the placebo group (P < 0.049). On PODs 0-1, patients in the dexamethasone group reported significantly lower pain scores. Following inguinal hernia repair, no significant differences in outcome measures were seen between the study groups. Patient satisfaction was equally high in day cases and inpatients (Study IV). Finnish day surgery units provide good-quality services. Minor postdischarge symptoms are common, and they are influenced by several patient-, surgery-, and anesthesia-related factors. Oral dexamethasone combined with paracetamol improves pain relief and reduces the need for oxycodone rescue medication following correction of hallux valgus. Day surgery for open inguinal hernia repair is safe and well accepted by patients aged 65 years or older and can be recommended as the primary choice of care for medically stable patients.

Zr4+ doping in Li4Ti5O12 anode for lithium-ion batteries: Open Li+ diffusion paths through structural imperfection

One-dimensional nanomaterials have short Li+ diffusion paths and promising structural stability, which results in a long cycle life during Li+ insertion and extraction processes in lithium rechargeable batteries. In this study, we fabricated one-dimensional spinel Li 4Ti5O12 (LTO) nanofibers using an electrospinning technique and studied the Zr4+ doping effect on the lattice, electronic structure, and resultant electrochemical properties of Li-ion batteries (LIBs). Accommodating a small fraction of Zr4+ ions in the Ti4+ sites of the LTO structure gave rise to enhanced LIB performance, which was due to structural distortion through an increase in the average lattice constant and thereby enlarged Li+ diffusion paths rather than changes to the electronic structure. Insulating ZrO2 nanoparticles present between the LTO grains due to the low Zr4+ solubility had a negative effect on the Li+ extraction capacity, however. These results could provide key design elements for LTO anodes based on atomic level insights that can pave the way to an optimal protocol to achieve particular functionalities. Distorted lattice: Zr4+ is doped into a 1 D spinel Li4Ti5O12 (LTO) nanostructure and the resulting electrochemical properties are explored through a combined theoretical and experimental investigation. The improved electrochemical performance resulting from incorporation of Zr4+ in the LTO is due to lattice distortion and, thereby, enlarged Li+ diffusion paths rather than to a change in the electronic structure.

A numerical study of the effect of loading conditions on tubular hydroforming

In this work, the mechanics of tubular hydroforming under various types of loading conditions is investigated. The main objective is to contrast the effects of prescribing fluid pressure or volume flow rate, in conjunction with axial displacement, on the stress and strain histories experienced by the tube and the process of bulging. To this end, axisymmetric finite element simulations of free hydroforming (without external die contact) of aluminium alloy tubes are carried out. Hill’s normally anisotropic yield theory along with material properties determined in a previous experimental study [A. Kulkarni, P. Biswas, R. Narasimhan, A. Luo, T. Stoughton, R. Mishra, A.K. Sachdev, An experimental and numerical study of necking initiation in aluminium alloy tubes during hydroforming, Int. J. Mech. Sci. 46 (2004) 1727–1746] are employed in the computations. It is found that while prescribed fluid pressure leads to highly non-proportional strain paths, specified fluid volume flow rate may result in almost proportional ones for the predominant portion of loading. The peak pressure increases with axial compression for the former, while the reverse trend applies under the latter. The implication of these results on failure by localized necking of the tube wall is addressed in a subsequent investigation.

Long-term results of obstetric brachial plexus surgery

Background: Brachial plexus birth palsy (BPBP) most often occurs as a result of foetal-maternal disproportion. The C5 and C6 nerve roots of the brachial plexus are most frequently affected. In contrast, roots from the C7 to Th1 that result in total injury together with C5 and C6 injury, are affected in fewer than half of the patients. BPBP was first described by Smellie in 1764. Erb published his classical description of the injury in 1874 and his name became linked with the paralysis that is associated with upper root injury. Since then, early results of brachial plexus surgery have been reasonably well documented. However, from a clinical point of view not all primary results are maintained and there is also a need for later follow-up results. In addition most of the studies that are published emanate from highly specialized clinics and no nation wide epidemiological reports are available. One of the plexus injuries is the avulsion type, in which the nerve root or roots are ruptured at the neural cord. It has been speculated whether this might cause injury to the whole neural system or whether shoulder asymmetry and upper limb inequality results in postural deformities of the spine. Alternatively, avulsion could manifest as other signs and symptoms of the whole musculoskeletal system. In addition, there is no available information covering activities of daily living after obstetric brachial plexus surgery. Patients and methods: This was a population-based cross-sectional study on all patients who had undergone brachial plexus surgery with at least 5 years of follow-up. An incidence of 3.05/1000 for BPBP was obtained from the registers for this study period. A total of 1706 BPBP patients needing hospital treatment out of 1 717 057 newborns were registered in Finland between 1971 and 1997 inclusive. Of these BPBP patients, 124 (7.3%) underwent brachial plexus surgery at a mean age of 2.8 months (range: 0.4―13.2 months). Surgery was most often performed by direct neuroraphy after neuroma resection (53%). Depending on the phase of the study, 105 to 112 patients (85-90%) participated in a clinical and radiological follow-up assessment. The mean follow up time exceeded 13 years (range: 5.0―31.5 years). Functional status of the upper extremity was evaluated using Mallet, Gilbert and Raimondi scales. Isometric strength of the upper limb, sensation of the hand and stereognosis were evaluated for both the affected and unaffected sides then the differences and their ratios were calculated and recorded. In addition to the upper extremity, assessment of the spine and lower extremities were performed. Activities of daily living (ADL), participation in normal physical activities, and the use of physiotherapy and occupational therapy were recorded in a questionnaire. Results: The unaffected limb functioned as the dominant hand in all, except four patients. The mean length of the affected upper limb was 6 cm (range: 1-13.5 cm) shorter in 106 (95%) patients. Shoulder function was recorded as a mean Mallet score of 3 (range: 2―4) which was moderate. Both elbow function and hand function were good. The mean Gilbert elbow scale value was 3 (range: -1―5) and the mean Raimondi hand scale was 4 (range:1―5). One-third of the patients experienced pain in the affected limb including all those patients (n=9) who had clavicular non-union resulting from surgery. A total of 61 patients (57%) had an active shoulder external rotation of less than 0° and an active elbow extension deficiency was noted in 82 patients (77%) giving a mean of 26° (range: 5°―80°). In all, expect two patients, shoulder external rotation strength at a mean ratio 35% (range: 0―83%) and in all patients elbow flexion strength at a mean ratio of 41% (range: 0―79%) were impaired compared to the unaffected side. According to radiographs, incongruence of the glenohumeral joint was noted in 15 (16%) patients, whereas incongruence of the radiohumeral joint was found in 20 (21%) patients. Fine sensation was normal for 34/49 (69%) patients with C5-6 injury, for 15/31 (48%) with C5-7 and for only 8/25 (32%) of patients with total injury. Loss of protective sensation or absent sensation was noted in some palmar areas of the hand for 12/105 patients (11%). Normal stereognosis was recorded for 88/105 patients (84%). No significant inequalities in leg length were found and the incidence of structural scoliosis (1.7%) did not differ from that of the reference population. Nearly half of the patients (43%) had asynchronous motion of the upper limbs during gait, which was associated with impaired upper limb function. Data obtained from the completed questionnaires indicated that two thirds (63%) of the patients were satisfied with the functional outcome of the affected hand although one third of all patients needed help with ADL. Only a few patients were unable to participate in physical activities such as: bicycling, cross-country skiing or swimming. However, 71% of the patients reported problems related to the affected upper limb, such as muscle weakness and/or joint stiffness during the aforementioned activities. Incongruity of the radiohumeral joints, extent of the injury, avulsion type injury, age less than three months of age at the time of plexus surgery and inexperience of the surgeon was related to poor results as determined by multivariate analyses. Conclusions: Most of the patients had persistent sequelae, especially of shoulder function. Almost all measurements for the total injury group were poorer compared with those of the C5-6 type injury group. Most of the patients had asymmetry of the shoulder region and a shorter affected upper limb, which is a probable reason for having an abnormal gait. However, BPBP did not have an effect on normal growth of the lower extremities or the spine. Although, participation in physical activities was similar to that of the normal population, two-thirds of the patients reported problems. One-third of the patients needed help with ADL. During the period covered by this study, 7.3% BPBP of patients that needed hospital treatment had a brachial plexus operation, which amounts to fewer than 10 operations per year in Finland. It seems that better results of obstetric plexus surgery and more careful follow-up including opportunities for late reconstructive procedures will be expected, if the treatment is solely concentrated on by a few specialised teams.

Profiling k-Iteration Paths : A Generalization of the Ball-Larus Profiling Algorithm

The Ball-Larus path-profiling algorithm is an efficient technique to collect acyclic path frequencies of a program. However, longer paths -those extending across loop iterations - describe the runtime behaviour of programs better. We generalize the Ball-Larus profiling algorithm for profiling k-iteration paths - paths that can span up to to k iterations of a loop. We show that it is possible to number suchk-iteration paths perfectly, thus allowing for an efficient profiling algorithm for such longer paths. We also describe a scheme for mixed-mode profiling: profiling different parts of a procedure with different path lengths. Experimental results show that k-iteration profiling is realistic.

Optimal multicommodity flow through the complete graph with random edge capacities

We consider a multicommodity flow problem on a complete graph whose edges have random, independent, and identically distributed capacities. We show that, as the number of nodes tends to infinity, the maximumutility, given by the average of a concave function of each commodity How, has an almost-sure limit. Furthermore, the asymptotically optimal flow uses only direct and two-hop paths, and can be obtained in a distributed manner.

Novel application of a discrete choice experiment to identify preferences for a national healthcare-associated infection surveillance programme: A cross-sectional study

Objective: To identify key stakeholder preferences and priorities when considering a national healthcare-associated infection (HAI) surveillance programme through the use of a discrete choice experiment (DCE). Setting: Australia does not have a national HAI surveillance programme. An online web-based DCE was developed and made available to participants in Australia. Participants: A sample of 184 purposively selected healthcare workers based on their senior leadership role in infection prevention in Australia. Primary and secondary outcomes: A DCE requiring respondents to select 1 HAI surveillance programme over another based on 5 different characteristics (or attributes) in repeated hypothetical scenarios. Data were analysed using a mixed logit model to evaluate preferences and identify the relative importance of each attribute. Results: A total of 122 participants completed the survey (response rate 66%) over a 5-week period. Excluding 22 who mismatched a duplicate choice scenario, analysis was conducted on 100 responses. The key findings included: 72% of stakeholders exhibited a preference for a surveillance programme with continuous mandatory core components (mean coefficient 0.640 (p<0.01)), 65% for a standard surveillance protocol where patient-level data are collected on infected and non-infected patients (mean coefficient 0.641 (p<0.01)), and 92% for hospital-level data that are publicly reported on a website and not associated with financial penalties (mean coefficient 1.663 (p<0.01)). Conclusions: The use of the DCE has provided a unique insight to key stakeholder priorities when considering a national HAI surveillance programme. The application of a DCE offers a meaningful method to explore and quantify preferences in this setting.

Handling sectional views in volume-based approach to automatically construct 3D solid from 2D views

This paper presents an algorithm for solid model reconstruction from 2D sectional views based on volume-based approach. None of the existing work in automatic reconstruction from 2D orthographic views have addressed sectional views in detail. It is believed that the volume-based approach is better suited to handle different types of sectional views. The volume-based approach constructs the 3D solid by a boolean combination of elementary solids. The elementary solids are formed by sweep operation on loops identified in the input views. The only adjustment to be made for the presence of sectional views is in the identification of loops that would form the elemental solids. In the algorithm, the conventions of engineering drawing for sectional views, are used to identify the loops correctly. The algorithm is simple and intuitive in nature. Results have been obtained for full sections, offset sections and half sections. Future work will address other types of sectional views such as removed and revolved sections and broken-out sections. (C) 2004 Elsevier Ltd. All rights reserved.

Pathways to health : Determinants of health, health behaviour and health inequalities in early adulthood

There is increasing evidence that the origins of poor adult health and health inequalities can be traced back to circumstances preceding current socioeconomic position and living conditions. The life-course approach to examining the determinants of health has emphasised that exposure to adverse social and economic circumstances in earlier life or concurrent adverse circumstances due to unfavourable living conditions in earlier life may lead to poor health, health-damaging behaviour, disease or even premature death in adulthood. There is, however, still a lack of knowledge about the contribution of social and economic circumstances in childhood and youth to adult health and health inequalities, and even less is known about how environmental and behavioural factors in adulthood mediate the effects of earlier adverse experiences. The main purpose of this study was to deepen our understanding of the development of poor health, health-damaging behaviours and health inequalities during the life-course. Its aim was to find out which factors in earlier and current circumstances determine health, the most detrimental indicators of health behaviour (smoking, heavy drinking and obesity as a proxy for the balance between nutrition and exercise), and educational health differences in young adults in Finland. Following the ideas of the social pathway theory, it was assumed that childhood environment affects adult health and its proximal determinants via different pathways, including educational, work and family careers. Early adulthood was studied as a significant phase of life when many behavioural patterns and living conditions relevant to health are established. In addition, socioeconomic health inequalities seem to emerge rapidly when moving into adulthood; they are very small or non-existent in childhood and adolescence, but very marked by early middle age. The data of this study were collected in 2000 2001 as part of the Health 2000 Survey (N = 9,922), a cross-sectional and nationally representative health interview and examination survey. The main subset of data used in this thesis was the one comprising the age group 18 29 years (N = 1,894), which included information collected by standardised structured computer-aided interviews and self-administered questionnaires. The survey had a very high participation rate at almost 90% for the core questions. According to the results of this study, childhood circumstances predict the health of young adults. Almost all the childhood adversities studied were found to be associated with poor self-rated health and psychological distress in early adulthood, although fewer associations were found with the somatic morbidity typical of young adults. These effects seemed to be more or less independent of the young adult s own education. Childhood circumstances also had a strong effect on smoking and heavy drinking, although current circumstances and education in particular, played a role in mediating this effect. Parental smoking and alcohol abuse had an influence on the corresponding behaviours of offspring. Childhood circumstances had a role in the development of obesity and, to a lesser extent, overweight, particularly in women. The findings support the notion that parental education has a strong effect on early adult obesity, even independently of the young adult s own educational level. There were marked educational differences in self-rated health in early adulthood: those in the lowest educational category were most likely to have average or poorer health. Childhood social circumstances seemed to explain a substantial part of these educational differences. In addition, daily smoking and heavy drinking contributed substantially to educational health differences. However, the contribution of childhood circumstances was largely shared with health behaviours adopted by early adulthood. Employment also shared the effects of childhood circumstances on educational health differences. The results indicate that childhood circumstances are important in determining health, health behaviour and health inequalities in early adulthood. Early recognition of childhood adversities followed by relevant support measures may play an important role in preventing the unfortunate pathways leading to the development of poor health, health-damaging behaviour and health inequalities. It is crucially important to recognise the needs of children living in adverse circumstances as well as children of substance abusing parents. In addition, single-parent families would benefit from support. Differences in health and health behaviours between different sub-groups of the population mean that we can expect to see ever greater health differences when today s generation of young adults grows older. This presents a formidable challenge to national health and social policy as well as health promotion. Young adults with no more than primary level education are at greatest risk of poor health. Preventive policies should emphasise the role of low educational level as a key determinant of health-damaging behaviours and poor health. Keywords: health, health behaviour, health inequalities, life-course, socioeconomic position, education, childhood circumstances, self-rated health, psychological distress, somatic morbidity, smoking, heavy drinking, BMI, early adulthood

Note on the locally product and almost locally product structures

This paper is concerned with a study of some of the properties of locally product and almost locally product structures on a differentiable manifold X n of class C k . Every locally product space has certain almost locally product structures which transform the local tangent space to X n at an arbitrary point P in a set fashion: this is studied in Theorem (2.2). Theorem (2.3) considers the nature of transformations that exist between two co-ordinate systems at a point whenever an almost locally product structure has the same local representation in each of these co-ordinate systems. A necessary and sufficient condition for X n to be a locally product manifold is obtained in terms of the pseudo-group of co-ordinate transformations on X n and the subpseudo-groups [cf., Theoren (2.1)]. Section 3 is entirely devoted to the study of integrable almost locally product structures.

Prevalence and Forms of Bullying among Business Professionals: A Comparison of Two Different Strategies for Measuring Bullying

The aim of this study was to analyse the prevalence and forms of workplace bullying among business professionals holding predominantly managerial or expert positions. A cross-sectional survey study was conducted among Finnish professionals with a university degree in business studies. In the study two different strategies for measuring bullying were used and compared. When provided a definition of bullying, 8.8% of the respondents reported that they had at least occasionally been bullied during the past 12 months. However, when using a slightly modified version of the Negative Acts Questionnaire (Einarsen & Hoel 2001), containing a list of 32 predefined negative and potentially harassing acts, as many as 24.1% of the respondents reported that they had been subjected to at least one of the negative acts on a weekly basis. The respondents had experienced predominantly work-related negative acts, e.g. that their opinions and views were ignored, that they were given unreasonable deadlines or that information was withheld. Although the prevalence rates reported with the two strategies varied considerably, there was still consistency between the two strategies in the sense that those who had classified themselves as bullied also reported higher exposure rates to almost all of the negative acts included.

Voting Paths

We consider a variant of the popular matching problem here. The input instance is a bipartite graph $G=(\mathcal{A}\cup\mathcal{P},E)$, where vertices in $\mathcal{A}$ are called applicants and vertices in $\mathcal{P}$ are called posts. Each applicant ranks a subset of posts in an order of preference, possibly involving ties. A matching $M$ is popular if there is no other matching $M'$ such that the number of applicants who prefer their partners in $M'$ to $M$ exceeds the number of applicants who prefer their partners in $M$ to $M'$. However, the “more popular than” relation is not transitive; hence this relation is not a partial order, and thus there need not be a maximal element here. Indeed, there are simple instances that do not admit popular matchings. The questions of whether an input instance $G$ admits a popular matching and how to compute one if it exists were studied earlier by Abraham et al. Here we study reachability questions among matchings in $G$, assuming that $G=(\mathcal{A}\cup\mathcal{P},E)$ admits a popular matching. A matching $M_k$ is reachable from $M_0$ if there is a sequence of matchings $\langle M_0,M_1,\dots,M_k\rangle$ such that each matching is more popular than its predecessor. Such a sequence is called a length-$k$ voting path from $M_0$ to $M_k$. We show an interesting property of reachability among matchings in $G$: there is always a voting path of length at most 2 from any matching to some popular matching. Given a bipartite graph $G=(\mathcal{A}\cup\mathcal{P},E)$ with $n$ vertices and $m$ edges and any matching $M_0$ in $G$, we give an $O(m\sqrt{n})$ algorithm to compute a shortest-length voting path from $M_0$ to a popular matching; when preference lists are strictly ordered, we have an $O(m+n)$ algorithm. This problem has applications in dynamic matching markets, where applicants and posts can enter and leave the market, and applicants can also change their preferences arbitrarily. After any change, the current matching may no longer be popular, in which case we are required to update it. However, our model demands that we switch from one matching to another only if there is consensus among the applicants to agree to the switch. Hence we need to update via a voting path that ends in a popular matching. Thus our algorithm has applications here.

Max-Coloring Paths: Tight Bounds and Extensions

The max-coloring problem is to compute a legal coloring of the vertices of a graph G = (V, E) with a non-negative weight function w on V such that Sigma(k)(i=1) max(v epsilon Ci) w(v(i)) is minimized, where C-1, ... , C-k are the various color classes. Max-coloring general graphs is as hard as the classical vertex coloring problem, a special case where vertices have unit weight. In fact, in some cases it can even be harder: for example, no polynomial time algorithm is known for max-coloring trees. In this paper we consider the problem of max-coloring paths and its generalization, max-coloring abroad class of trees and show it can be solved in time O(vertical bar V vertical bar+time for sorting the vertex weights). When vertex weights belong to R, we show a matching lower bound of Omega(vertical bar V vertical bar log vertical bar V vertical bar) in the algebraic computation tree model.

Faster Algorithms for All-pairs Approximate Shortest Paths in Undirected Graphs

Let G - (V, E) be a weighted undirected graph having nonnegative edge weights. An estimate (delta) over cap (u, v) of the actual distance d( u, v) between u, v is an element of V is said to be of stretch t if and only if delta(u, v) <= (delta) over cap (u, v) <= t . delta(u, v). Computing all-pairs small stretch distances efficiently ( both in terms of time and space) is a well-studied problem in graph algorithms. We present a simple, novel, and generic scheme for all-pairs approximate shortest paths. Using this scheme and some new ideas and tools, we design faster algorithms for all-pairs t-stretch distances for a whole range of stretch t, and we also answer an open question posed by Thorup and Zwick in their seminal paper [J. ACM, 52 (2005), pp. 1-24].