Comorbidity and nutritional indices as predictors of morbidity after transurethral procedures: A prospective cohort study.

INTRODUCTION: Preoperative scores are widely used predictors of complications after major surgery. These scores, however, are not widely used in transurethral procedures. The aim of this study was to assess the value of the Charlson Comorbidity Index (CCI), the age-adjusted CCI, the American Society of Anesthesiologist score (ASA) and the Nutritional Risk Score (NRS) in predicting early morbidity after transurethral urological procedures. METHODS: Consecutive patients undergoing transurethral resection of the bladder or the prostate were prospectively enrolled. The scores were calculated preoperatively; 30-day complications were prospectively recorded according to the Dindo-Clavien classification. Univariate logistic regression was performed to investigate the value of each score and of other factors (i.e., age, sex, body mass index, anemia, smoking habit, type of operation and anaesthesia) as predictors of complications. A multivariate model was then calculated using these predictors. RESULTS: Overall, 197 patients were included. The mean age was 72 (standard deviation ± 10). In total, 26.9% patients had at least 1 complication. Using univariate analysis, we found that each score significantly predicted complications. In multivariate analysis, only the ASA (odds ration [OR] 2.11; 95% confidence interval [CI] 1.01-4.43) and the NRS (OR 2.42; 95% CI 1.56-3.74) remained independent predictors. The best model incorporated ASA, NRS and gender, and predicted morbidity with an area under the curve of 76%. Our study's main limitations are population heterogeneity and limited sample size. CONCLUSION: The ASA and the NRS are important and independent determinants of early morbidity after transurethral procedures. The use of these indices may assist clinicians in the decision-making process to balance the possible benefits of transurethral procedures with the potential risks.

Ability of different adiposity indicators to identify children with elevated blood pressure.

OBJECTIVE: Body composition measured by dual-energy X-ray absorptiometry (DXA) is believed to be superior to crude measures such as BMI or waist circumference (WC) to assess health risks associated with adiposity in adults. We compared the ability of BMI, WC, waist-to-height ratio (WHtR), percentage body fat from skinfold thickness, and measures of total and central fat assessed by DXA to identify children with elevated blood pressure (BP). STUDY DESIGN: The QUALITY Study follows 630 Caucasian families (father, mother, and child originally aged 8-10 years). BP, height, weight, WC, and skinfold thickness were measured according to standardized protocols. Elevated BP was defined as systolic or diastolic BP at least 90th age, sex, and height-specific percentile. Total and central fat were determined with DXA. The area under the receiver operating characteristic (ROC) curve (AUC) statistic was computed from logistic models that adjusted for age, sex, height, Tanner stage, and physical activity. RESULTS: All adiposity indicators were highly correlated. WC and WHtR did not show superior ability over BMI to identify children with elevated SBP (P = 0.421 and 0.473). Measures of total and central fat from DXA did not show an improved ability over BMI or WC to identify children with elevated SBP (P = 0.325-0.662). CONCLUSION: Results support the use of BMI in clinical and public health settings, at least in this age group. As all indicators had a limited ability to identify children with elevated BP, results also support measurement of BP in all children of this age independent of a weight status.

Competing risks to breast cancer mortality in Catalonia

Background: Breast cancer mortality has experienced important changes over the last century. Breast cancer occurs in the presence of other competing risks which can influence breast cancer incidence and mortality trends. The aim of the present work is: 1) to assess the impact of breast cancer deaths among mortality from all causes in Catalonia (Spain), by age and birth cohort and 2) to estimate the risk of death from other causes than breast cancer, one of the inputs needed to model breast cancer mortality reduction due to screening or therapeutic interventions. Methods: The multi-decrement life table methodology was used. First, all-cause mortality probabilities were obtained by age and cohort. Then mortality probability for breast cancer was subtracted from the all-cause mortality probabilities to obtain cohort life tables for causes other than breast cancer. These life tables, on one hand, provide an estimate of the risk of dying from competing risks, and on the other hand, permit to assess the impact of breast cancer deaths on all-cause mortality using the ratio of the probability of death for causes other than breast cancer by the all-cause probability of death. Results: There was an increasing impact of breast cancer on mortality in the first part of the 20th century, with a peak for cohorts born in 1945–54 in the 40–49 age groups (for which approximately 24% of mortality was due to breast cancer). Even though for cohorts born after 1955 there was only information for women under 50, it is also important to note that the impact of breast cancer on all-cause mortality decreased for those cohorts. Conclusion: We have quantified the effect of removing breast cancer mortality in different age groups and birth cohorts. Our results are consistent with US findings. We also have obtained an estimate of the risk of dying from competing-causes mortality, which will be used in the assessment of the effect of mammography screening on breast cancer mortality in Catalonia.

Risks in R&D Collaboration between Small and Large Firms

The main aim of this thesis was to find out what kinds of risks arise from collabo-ration in R&D between small and large firms. The suitability and gain of some buyer/supplier risk frameworks in examining of R&D collaboration has been in-vestigated. A risk model has been based on the buyer/supplier risks models found in the literature. Its applicability has been tested empirically by means of theme interviews with firm representatives. The risk classification framework received some confirmation. But the study also showed that the theoretical framework was not completely adequate, as a new risk class arose from communication. Collaboration causes risks, and these risks should be taken into account when R&D collaboration is planned. The advantage of risk examination is the possibility to decrease failures and losses, and to in-crease possibilities for success and economical benefits. This study should be used as a managerial analysis tool in trying to understand the form and concept of risk in risk expectancy.

Identification and Management of Operational Risks in IT Organization of Financial Service Provider

Työn tavoitteena on tunnistaa toiminnallisia riskitekijöitä rahoituspalveluita tarjoavan yrityksen IT-organisaatiossa sekä löytää arkipäiväisiä keinoja hallita näitä riskejä. Työssä riskejä on myös tarkasteltu mahdollisen ulkoistuksen yhteydessä. Fuusiot ovat yleisiä rahoitusalan yrityksissä. Yhteenliittymien tuloksena yritysten IT-arkkitehtuuri voi olla monimutkainen ja kulttuurierot yrityksessä suuria. Synergia- ja mittakaavaetuja saadakseen yritys keskittää toimintojaan ja IT-ratkaisujaan. Riskien tunnistaminen on riskienhallintaprosessin tärkein vaihe. Tässä tutkimuksessa riskit ja riskitekijät tunnistettiin itsearvioinnin avulla kysymyssarjoja hyväksikäyttäen. Monet riskitekijät liittyivät sisäisen valvonnan ja seurannan puutteisiin. Myöhemmin näille riskeille pohdittiin työryhmässä käytännönläheisiä hallintakeinoja. Yritys voi siirtää tai jakaa IT -riskejä ulkoistamalla. Ulkoistaminen voi kuitenkin tuoda mukaan myös uusia riskitekijöitä. Ennen ulkoistamispäätöstä yrityksen sisäisten prosessien ja organisaation on oltava järjestyksessä, jotta sopimuksen kannattavuutta voidaan verrata luotettavasti saman palvelun tuottamiseen sisäisesti.

An overview on the Brazilian orange juice production chain

Brazil is the world's largest producer of oranges and uses more than 70% of the harvested fruits in the production of juices. The amount of processed orange is growing about 10% per year, confirming the trend of the Brazilian citrus for juice production. This research aimed to investigate the Brazilian orange juice production chain from 2005 to 2009. Data from the amount of frozen juice produced and exported, international price of orange juice, and intermediate transactions were assessed in order to make possible selection of all interveners involved in the chain. The study using the Social Network Analysis (SNA) showed that the densest relationships in the network are from exporters to importers and from orange growers to the orange processing industry. No difference was found in the values of the network geodesic distance or the clustering coefficients from 2005 to 2009. The degree of centrality increased steadily throughout the years indicating that the processing industry attempts to minimize the risks by centralizing the actions. A decrease in export of orange juice from 2007 (2.07 10(6) t) to 2008 (2.05 10(6) t) was found, probably due to the world's financial crisis with recovery in 2009. Since 2004, there has been an increase of nearly 10% per year in the market preference of concentrate juice (OFCJ) when compared to the "not from concentrated" juice (NFC). Nowadays the NFC market represents nearly 50% of all Brazilian export which impacted in the logistic distribution and transportation issues.

Performance Tuning of Fenix Logistic Systems

Työn tavoitteena oli selvittää Stora Enso Oyj:llä käytössä olevan Fenix myynnin- ja logistiikanhallintajärjestelmän logistiikkapalveluiden suorituskyky, tuottaa asiakasohjelmisto suorituskykymittauksista muodostuneen tiedon hallintaan sekä tuottaa toteuttamissuunnitelma suorituskyvyn parantamiseksi. Suorituskyky mitattiin käyttämällä TUXEDOn tarjoamia ominaisuuksia. Suorituskykymittausten tuloksien arviointia varten rakennettiin asiakasohjelmisto, jolla pystyttiin tuottamaan tarvittavat yhteenvetotiedot palveluiden kestoista ja rakenteista. Valmiita ratkaisuja ei ollut tarjolla, joten kaikki tarvittavat ohjelmistot on rakennettu osana tätä työtä. Kaikki komponenttiliittymät toteutettiin siten, että myös muitakin kuin logistiikkaan liittyviä palveluita voidaan tarvittaessa mitata. Mittausten tuloksena saatuja keskimääräisiä suoritusaikoja käytettiin hyväksi toteuttamissuunnitelmaa tehdessä. Toteutussuunnitelma sisältää useiden logistiikka-alueiden kehittämisideoita, joilla Fenixin logistiikkapalveluiden suorituskykyä voidaan tehostaa., ja nykyinen järjestelmän toimintanopeus pystytään säilyttämään tulevaisuudessa. Toteuttamissuunnitelmassa esitettyjä toimenpiteitä tullaan toteuttamaan TietoEnator Oyj:ssä vuoden 2003 aikana.

Logistic Solutions of Imported Renovation Materials

Tämän diplomityön tavoitteena oli tutkia saneeraus- ja remontoimistuotteiden osalta maahantuontia Suomeen ja transitoliikennettä Suomen kautta Venäjälle. Lähtökohtana oli Suomen logistinen asema ja mahdolliset kilpailukykyyn vaikuttavat tekijät, joista on luotu potentiaalisia tulevaisuuden kuvia. Kaikki tulokset johdettiin LOADER/CLIENT –tutkimusprojektin yhteyksistä. Tutkimuksen tavoitteisiin päästiin empiiristä tutkimusta varten kootun teorian kautta, joka koostuu toimitusketjun hallinnasta ja tämänhetkisestä parhaimmasta käytännöstä eli ns. kolmen A:n menetelmästä. Lisäksi teoriaosuudessa tarkasteltiin toimitusketjun yritysten välisiä suhteita, kansainväliseen toimitusketjuun liittyviä tekijöitä sekä tulevaisuuden haasteita. Työn empiiristä tutkimustietoa kerättiin pääasiassa haastattelujen, mutta myös muiden tutkimuksen tuloksien kautta. Tutkimusmenetelmä oli laadullinen puolistrukturoitu teemahaastattelu, jota varten ryhmä remontoimiseen ja saneeraukseen liittyviä yrityksiä ja heidän käyttämiä logistisia operaattoreita sekä projektin johtoryhmää haastateltiin. Tutkimuksen tulosten mukaan suurin osa haastatelluista yrityksistä näkee Suomen logistisen aseman hyvänä tällä hetkellä ja lähivuosina. Etenkin arvotavaroiden transito- kuljetuksissa Suomen asema nähdään vahvana vuosien kokemuksen ansiosta. Tällä hetkellä arvotavaroiden toimitusaika ja kokonaiskustannukset varastoimisineen ja käsittelyineen ovat vastaavia tai jopa edullisempia verrattuna esimerkiksi reitteihin Baltian maiden kautta. Baltian maiden kehitys voi heikentää Suomen kilpailukykyä hetkellisesti, mutta todennäköisesti ei pidemmällä aikavälillä. Haastateltujen henkilöiden mielestä Suomen logistiseen kilpailukykyyn tulevaisuudessa vaikuttaa eniten kaksi kriittistä tekijää. Suomen tulisi ensinnäkin keskittyä ja kehittää arvotavaran transitokuljetuksia. Toiseksi, säilyttääkseen kilpailukykynsä, Suomen satamien palveluiden kuten tullin ja ahtaajien tulisi olla joustavasti käytettävissä 24 tuntia vuorokaudessa vuoden jokaisena päivänä.

Product Launch in Industrial Markets – Financial Risks in New AMD Elevator Door Launch

Tuotekehitys ja uusien tuotteiden lanseeraus on teollisen yrityksen menestyksekkään liiketoiminnan elinehtoja tämän päivän kilpailussa. Teollisuusyrityksen tuotteiden innovaatioaikakausia on ollut lukuisia, samoin kuin uuden tuotteen lanseerauksen lähtökohtia. Aikakausista, jolloin tuotteita kehitettiin yrityksen omista lähtökohdista, kuten valmistuksellisista eduista, on edetty tilanteeseen, jossa markkinoiden tarpeita tulee ottaa yhä enemmän huomioon. Kuitenkin, teollisuudessa esitellään tuotteita yhä puhtaasti tuotantolähtöisesti, ja tutkimuksen tavoitteena on selvittää taloudellisia riskejä, joita liittyy puhtaasti teknologiavetoiseen tuotteiden kehitystyöhön, valmistukseen ja lanseeraukseen. Normatiivisena tutkimuksena työ pyrkii asiakastarpeita ja teollisuusyrityksen loppuasiakkaiden näkökulmia huomioon ottaen osoittamaan markkinoinnin keinojen merkityksen tuotantolähtöisen tuotelanseerauksen taloudellisten riskien minimoimiseksi. Uuden teollisen tuotteen asiakastarpeita on selvitetty kyselymuotoisen markkinointitutkimuksen menetelmiä hyväksikäyttäen. Tuotteen tärkeimpien ominaisuuksien, kuten turvallisuuden, kestävyyden ja hinnan merkitystä voidaan hyödyntää ennen tuotteen kaupallista esittelyä potentiaalisten asiakassegmenttien kartoitukseen ja menestyksellisen lanseerauksen edesauttamiseksi.

Endometrial cancer and oral contraceptives : an individual participant meta-analysis of 27 276 women with endometrial cancer from 36 epidemiological studies.

BACKGROUND: Oral contraceptives are known to reduce the incidence rate of endometrial cancer, but it is uncertain how long this effect lasts after use ceases, or whether it is modified by other factors. METHODS: Individual participant datasets were sought from principal investigators and provided centrally for 27 276 women with endometrial cancer (cases) and 115 743 without endometrial cancer (controls) from 36 epidemiological studies. The relative risks (RRs) of endometrial cancer associated with oral contraceptive use were estimated using logistic regression, stratified by study, age, parity, body-mass index, smoking, and use of menopausal hormone therapy. FINDINGS: The median age of cases was 63 years (IQR 57-68) and the median year of cancer diagnosis was 2001 (IQR 1994-2005). 9459 (35%) of 27 276 cases and 45 625 (39%) of 115 743 controls had ever used oral contraceptives, for median durations of 3·0 years (IQR 1-7) and 4·4 years (IQR 2-9), respectively. The longer that women had used oral contraceptives, the greater the reduction in risk of endometrial cancer; every 5 years of use was associated with a risk ratio of 0·76 (95% CI 0·73-0·78; p<0·0001). This reduction in risk persisted for more than 30 years after oral contraceptive use had ceased, with no apparent decrease between the RRs for use during the 1960s, 1970s, and 1980s, despite higher oestrogen doses in pills used in the early years. However, the reduction in risk associated with ever having used oral contraceptives differed by tumour type, being stronger for carcinomas (RR 0·69, 95% CI 0·66-0·71) than sarcomas (0·83, 0·67-1·04; case-case comparison: p=0·02). In high-income countries, 10 years use of oral contraceptives was estimated to reduce the absolute risk of endometrial cancer arising before age 75 years from 2·3 to 1·3 per 100 women. INTERPRETATION: Use of oral contraceptives confers long-term protection against endometrial cancer. These results suggest that, in developed countries, about 400 000 cases of endometrial cancer before the age of 75 years have been prevented over the past 50 years (1965-2014) by oral contraceptives, including 200 000 in the past decade (2005-14). FUNDING: Medical Research Council, Cancer Research UK.

Responding to Young People's Health Risks in Primary Care: A Cluster Randomised Trial of Training Clinicians in Screening and Motivational Interviewing.

OBJECTIVE: To evaluate the effectiveness of a complex intervention implementing best practice guidelines recommending clinicians screen and counsel young people across multiple psychosocial risk factors, on clinicians' detection of health risks and patients' risk taking behaviour, compared to a didactic seminar on young people's health. DESIGN: Pragmatic cluster randomised trial where volunteer general practices were stratified by postcode advantage or disadvantage score and billing type (private, free national health, community health centre), then randomised into either intervention or comparison arms using a computer generated random sequence. Three months post-intervention, patients were recruited from all practices post-consultation for a Computer Assisted Telephone Interview and followed up three and 12 months later. Researchers recruiting, consenting and interviewing patients and patients themselves were masked to allocation status; clinicians were not. SETTING: General practices in metropolitan and rural Victoria, Australia. PARTICIPANTS: General practices with at least one interested clinician (general practitioner or nurse) and their 14-24 year old patients. INTERVENTION: This complex intervention was designed using evidence based practice in learning and change in clinician behaviour and general practice systems, and included best practice approaches to motivating change in adolescent risk taking behaviours. The intervention involved training clinicians (nine hours) in health risk screening, use of a screening tool and motivational interviewing; training all practice staff (receptionists and clinicians) in engaging youth; provision of feedback to clinicians of patients' risk data; and two practice visits to support new screening and referral resources. Comparison clinicians received one didactic educational seminar (three hours) on engaging youth and health risk screening. OUTCOME MEASURES: Primary outcomes were patient report of (1) clinician detection of at least one of six health risk behaviours (tobacco, alcohol and illicit drug use, risks for sexually transmitted infection, STI, unplanned pregnancy, and road risks); and (2) change in one or more of the six health risk behaviours, at three months or at 12 months. Secondary outcomes were likelihood of future visits, trust in the clinician after exit interview, clinician detection of emotional distress and fear and abuse in relationships, and emotional distress at three and 12 months. Patient acceptability of the screening tool was also described for the intervention arm. Analyses were adjusted for practice location and billing type, patients' sex, age, and recruitment method, and past health risks, where appropriate. An intention to treat analysis approach was used, which included multilevel multiple imputation for missing outcome data. RESULTS: 42 practices were randomly allocated to intervention or comparison arms. Two intervention practices withdrew post allocation, prior to training, leaving 19 intervention (53 clinicians, 377 patients) and 21 comparison (79 clinicians, 524 patients) practices. 69% of patients in both intervention (260) and comparison (360) arms completed the 12 month follow-up. Intervention clinicians discussed more health risks per patient (59.7%) than comparison clinicians (52.7%) and thus were more likely to detect a higher proportion of young people with at least one of the six health risk behaviours (38.4% vs 26.7%, risk difference [RD] 11.6%, Confidence Interval [CI] 2.93% to 20.3%; adjusted odds ratio [OR] 1.7, CI 1.1 to 2.5). Patients reported less illicit drug use (RD -6.0, CI -11 to -1.2; OR 0·52, CI 0·28 to 0·96), and less risk for STI (RD -5.4, CI -11 to 0.2; OR 0·66, CI 0·46 to 0·96) at three months in the intervention relative to the comparison arm, and for unplanned pregnancy at 12 months (RD -4.4; CI -8.7 to -0.1; OR 0·40, CI 0·20 to 0·80). No differences were detected between arms on other health risks. There were no differences on secondary outcomes, apart from a greater detection of abuse (OR 13.8, CI 1.71 to 111). There were no reports of harmful events and intervention arm youth had high acceptance of the screening tool. CONCLUSIONS: A complex intervention, compared to a simple educational seminar for practices, improved detection of health risk behaviours in young people. Impact on health outcomes was inconclusive. Technology enabling more efficient, systematic health-risk screening may allow providers to target counselling toward higher risk individuals. Further trials require more power to confirm health benefits. TRIAL REGISTRATION: ISRCTN.com ISRCTN16059206.