Early prediction of poor outcome in patients with acute asthma in the emergency room

Early identification of patients who need hospitalization or patients who should be discharged would be helpful for the management of acute asthma in the emergency room. The objective of the present study was to examine the clinical and pulmonary functional measures used during the first hour of assessment of acute asthma in the emergency room in order to predict the outcome. We evaluated 88 patients. The inclusion criteria were age between 12 and 55 years, forced expiratory volume in the first second below 50% of predicted value, and no history of chronic disease or pregnancy. After baseline evaluation, all patients were treated with 2.5 mg albuterol delivered by nebulization every 20 min in the first hour and 60 mg of intravenous methylprednisolone. Patients were reevaluated after 60 min of treatment. Sixty-five patients (73.9%) were successfully treated and discharged from the emergency room (good responders), and 23 (26.1%) were hospitalized or were treated and discharged with relapse within 10 days (poor responders). A predictive index was developed: peak expiratory flow rates after 1 h <=0% of predicted values and accessory muscle use after 1 h. The index ranged from 0 to 2. An index of 1 or higher presented a sensitivity of 74.0, a specificity of 69.0, a positive predictive value of 46.0, and a negative predictive value of 88.0. It was possible to predict outcome in the first hour of management of acute asthma in the emergency room when the index score was 0 or 2.

Puunjalostuskonsernin tehtaiden käyttäjäkunnossapidon nykytilanteen selvitys- ja kehitystyö

Tässä diplomityössä selvitettiin kohdeorganisaation tehtaiden käyttäjäkunnossapidon nykytilannetta ja kehityskohteita konelinjoittain. Käyttäjäkunnossapito otettiin käyttöön vain vähän aikaa sitten entisen vuorohuollon tilalle. Tutkimus toteutettiin haastattelututkimuksena ja tietoa kerättiin kyselylomakkeiden avulla. Kyselyn otanta oli 200 henkilöä, joista 89,5 % vastasi kyselyyn. Haastateltavia oli seitsemästä eri henkilöryhmästä. Haastateltavat henkilöryhmät olivat käyttäjäkunnossapidon kanssa päivittäin työskenteleviä ryhmiä. Tuloksia analysoitiin konelinjoittain, tehtastasolla ja henkilöryhmittäin. Analysoinnissa käytettiin apuna tehtaan järjestelmistä löytyviä tilastoja ja kyselyn teettämisen jälkeisiä keskusteluja. Suurin haaste käyttäjäkunnossapidon nykytilanteessa oli kunnossapito-osaamisen säilyttäminen, sillä käyttäjäkunnossapitäjien työ on suurimmaksi osaksi tuotantotyötä. Käyttäjäkunnossapitäjien osaamistasot vaihtelivat suuresti. Joidenkin konelinjojen käyttäjäkunnossapitäjillä osaamistasot eivät olleet vielä työn vaatimalla tasolla. Toimintamallin käytännön toteutuksessa oli parannettavaa useilla konelinjoilla. Käyttäjäkunnossapito ei ole pystynyt tekemään kunnossapitoa yhtä suuressa mittakaavassa kuin vuorohuolto. Jatkotoimenpiteinä ehdotettiin käyttäjäkunnossapitäjien kunnossapitotyön määrän lisäämistä tarkastuskierrosten ja ennakkohuoltojen muodossa, sekä linjakunnossapidon ja käyttäjäkunnossapidon yhteistyömallin kehittämistä.

Fuzzy expert system in the prediction of neonatal resuscitation

In view of the importance of anticipating the occurrence of critical situations in medicine, we propose the use of a fuzzy expert system to predict the need for advanced neonatal resuscitation efforts in the delivery room. This system relates the maternal medical, obstetric and neonatal characteristics to the clinical conditions of the newborn, providing a risk measurement of need of advanced neonatal resuscitation measures. It is structured as a fuzzy composition developed on the basis of the subjective perception of danger of nine neonatologists facing 61 antenatal and intrapartum clinical situations which provide a degree of association with the risk of occurrence of perinatal asphyxia. The resulting relational matrix describes the association between clinical factors and risk of perinatal asphyxia. Analyzing the inputs of the presence or absence of all 61 clinical factors, the system returns the rate of risk of perinatal asphyxia as output. A prospectively collected series of 304 cases of perinatal care was analyzed to ascertain system performance. The fuzzy expert system presented a sensitivity of 76.5% and specificity of 94.8% in the identification of the need for advanced neonatal resuscitation measures, considering a cut-off value of 5 on a scale ranging from 0 to 10. The area under the receiver operating characteristic curve was 0.93. The identification of risk situations plays an important role in the planning of health care. These preliminary results encourage us to develop further studies and to refine this model, which is intended to implement an auxiliary system able to help health care staff to make decisions in perinatal care.

Effect of air pollution on pediatric respiratory emergency room visits and hospital admissions

In order to assess the effect of air pollution on pediatric respiratory morbidity, we carried out a time series study using daily levels of PM10, SO2, NO2, ozone, and CO and daily numbers of pediatric respiratory emergency room visits and hospital admissions at the Children's Institute of the University of São Paulo Medical School, from August 1996 to August 1997. In this period there were 43,635 hospital emergency room visits, 4534 of which were due to lower respiratory tract disease. The total number of hospital admissions was 6785, 1021 of which were due to lower respiratory tract infectious and/or obstructive diseases. The three health end-points under investigation were the daily number of emergency room visits due to lower respiratory tract diseases, hospital admissions due to pneumonia, and hospital admissions due to asthma or bronchiolitis. Generalized additive Poisson regression models were fitted, controlling for smooth functions of time, temperature and humidity, and an indicator of weekdays. NO2 was positively associated with all outcomes. Interquartile range increases (65.04 µg/m³) in NO2 moving averages were associated with an 18.4% increase (95% confidence interval, 95% CI = 12.5-24.3) in emergency room visits due to lower respiratory tract diseases (4-day moving average), a 17.6% increase (95% CI = 3.3-32.7) in hospital admissions due to pneumonia or bronchopneumonia (3-day moving average), and a 31.4% increase (95% CI = 7.2-55.7) in hospital admissions due to asthma or bronchiolitis (2-day moving average). The study showed that air pollution considerably affects children's respiratory morbidity, deserving attention from the health authorities.

Nasal CPAP in the delivery room for newborns with extremely low birth weight in a hospital in a developing country

The objective of this study was to determine the feasibility of the use of continuous positive airway pressure installed prophylactically in the delivery room (DR-CPAP), for infants with a birth weight between 500 and 1000 g in settings with limited resources. During 23 months, infants with a birth weight between 500 and 1000 g consecutively received DR-CPAP. A total of 33 infants with low birth weight were enrolled, 16 (48.5%) were females. Only 14 (42.4%) received antenatal corticosteroids and only 2 of those 14 (14.3%) infants weighing 500-750 g were not intubated in the delivery room, and apnea was given as the reason for intubation of these patients. Of the 19 infants in the 751-1000 g weight range, 9 (47.4%) were intubated in the delivery room, 6 due to apnea and 3 due to respiratory discomfort. For DR-CPAP to be successful, it is probably necessary for preterm babies to be more prepared at birth to withstand the respiratory effort without the need for intubation. Antenatal corticosteroids and better prenatal monitoring are fundamental for success of DR-CPAP.

Application of continuous positive airway pressure in the delivery room: a multicenter randomized clinical trial

This study evaluated whether the use of continuous positive airway pressure (CPAP) in the delivery room alters the need for mechanical ventilation and surfactant during the first 5 days of life and modifies the incidence of respiratory morbidity and mortality during the hospital stay. The study was a multicenter randomized clinical trial conducted in five public university hospitals in Brazil, from June 2008 to December 2009. Participants were 197 infants with birth weight of 1000-1500 g and without major birth defects. They were treated according to the guidelines of the American Academy of Pediatrics (APP). Infants not intubated or extubated less than 15 min after birth were randomized for two treatments, routine or CPAP, and were followed until hospital discharge. The routine (n=99) and CPAP (n=98) infants studied presented no statistically significant differences regarding birth characteristics, complications during the prenatal period, the need for mechanical ventilation during the first 5 days of life (19.2 vs 23.4%, P=0.50), use of surfactant (18.2 vs 17.3% P=0.92), or respiratory morbidity and mortality until discharge. The CPAP group required a greater number of doses of surfactant (1.5 vs 1.0, P=0.02). When CPAP was applied to the routine group, it was installed within a median time of 30 min. We found that CPAP applied less than 15 min after birth was not able to reduce the need for ventilator support and was associated with a higher number of doses of surfactant when compared to CPAP applied as clinically indicated within a median time of 30 min.

The transforming network of a foreign company operating in Mongolia. Case: A Finnish firm in Mongolia

In the globalising business environment ever fewer market areas remain unknown. Mongolia is yet only considered as an isolated strip between two power states. The purpose of this study is to put Mongolia on the map of academic business research. This is done by describing the transforming network of a foreign company operating in Mongolia. The objective of the study is approached through a case study, which presents the transformation of a Finnish company operating in Mongolia. This study aims at providing understanding on how the foreign case company observes the transformations of its network. The transformation within the case company is reflected to the transformations that occur in the Mongolian business environment. This study was conducted through a qualitative, intrinsic case study approach. The empirical data was gathered by using the method of network pictures. The network pictures were completed with the assistance of themed interviews. In order to be able to analyse the transformation within a network, three different time periods were observed: the past period around 2000, the present around 2014, and the estimated future around 2020. The data was collected from four executives positioned either in Finland, Russia or Mongolia. The respondents have a long experience within the case company, they hold managerial position, and therefore were able to offer valuable data for this study. The analytical framework used to analyse the collected data was built on the industrial network model, the ARA (actors-resources-activities)-model. The study shows that the changing business environment of Mongolia was utilised by the case company. In order to better meet the transforming customer wishes, the case company transformed from being a retailer to being a manufacturer. The case company was able to become a pioneer in the market. Thus, the case company has undergone similar kind of rapid transformation as the economy of Mongolia in entirety. This study shows that the general nature of the ARA-model makes it usable for new research contexts. The initial ARA-model offers a way to identify the dimensions of a network and a mean to understand these dimensions. The ARA-model can be applied to different contexts and to all time dimensions, past, present and future. The managerial recommendations offered in this study are directed towards the managers that plan to start operations in Mongolia. While this study is the first of its kind, it offers a good starting point for the future research on the change of Mongolian business networks. Valuable information could, for example, be obtained from a comparative study between the case company of this study and a multinational mining company operating in Mongolia.

Room temperature aging to guarantee microbiological safety of Brazilian artisan Canastra cheese

Canastra cheese is one of the oldest and most traditional cheeses made from raw milk in Brazil. However, this type of practice may have severe consequences for human health. According to the current legislation, any cheese made from raw milk must be aged for at least 60 days. Traditionally, Canastra cheese is consumed after different ripening periods, but consumers usually prefer those that are aged less than eight days. This study aimed to evaluate the effects of physicochemical and microbiological parameters, with emphasis on the pathogenic microbiota regulated by law, on cheese aged at room temperature and under refrigeration. Cheese samples were collected from eight different cheese producers located in the Serra da Canastra region twice a year (rainy and dry seasons) and analyzed with 8, 15, 22, 29, 36, and 64 days of ripening. Room temperature aging effectively reduced pathogens, reaching the total count established by law in 22 days, regardless of the season. However, ripening under refrigeration, it was ineffective in reducing the Staphylococcus aureus counts to the legislation limits, even after 64 days. Therefore, Canastra cheese should be ripened for at least 22 days at room temperature in order to fulfill the safety regulatory limits.

Influence of spray drying operating conditions on microencapsulated rosemary essential oil properties

Spray drying is an important method used by the food industry in the production of microencapsulated flavors to improve handling and dispersion properties. The objective of this study was to evaluate the influence of the process conditions on the properties of rosemary essential oil microencapsulated by spray drying using gum Arabic as encapsulant. The effects of the wall material concentration (10-30%), inlet air temperature (135-195 ºC), and feed flow rate (0.5-1.0 L.h-1) on the moisture content, hygroscopicity, wettability, solubility, bulk and tapped densities, particle density, flowability, and cohesiveness were evaluated using a 2³ central composite rotational experimental design. Moisture content, hygroscopicity and wettability were significantly affected by the three factors analyzed. Bulk density was positively influenced by the wall material concentration and negatively by the inlet air temperature. Particle density was influenced by the wall material concentration and the inlet air temperature variables, both in a negative manner. As for the solubility, tapped density, flowability, and cohesiveness, the models did not fit the data well. The results indicated that moderate wall material concentration (24%), low inlet air temperature (135 ºC), and moderate feed flow rate (0.7 L.h-1) are the best spray drying conditions.

Foreign exchange exposure management in a fuel procurement company operating in the commodity markets

Fluctuating commodity prices, foreign exchange rates and interest rates are causing changes in cash flows, market value and the companies’ profit. Most of the commodities are quoted in US dollar. Companies with non-dollar accounting face a double risk in the form of the commodity price risk and foreign exchange risk. The objective of this Master’s thesis is to find out how companies under commodity should manage foreign exchange exposure. The theoretical literature is based on foreign exchange risk, commodity risk and foreign exchange exposure management. The empirical research is done by using constructive modelling of a case company in the oil industry. The exposure is model with foreign exchange net cash flow and net working capital. First, the factors affecting foreign exchange exposure in case company are analyzed, then a model of foreign exchange exposure is created. Finally, the models are compared and the most suitable method is defined. According to the literature, foreign exchange exposure is the foreign exchange net cash flow. However, the results of the study show that foreign exchange risk can be managed also with net working capital. When the purchases, sales and storage are under foreign exchange risk, the best way to manage foreign exchange exposure is with combined net cash flow and net working capital method. The foreign exchange risk policy of the company defines the appropriate way to manage foreign exchange risk.

Internal Changes in International New Ventures During Initial Internationalization: Finnish SMEs Operating in Dynamic High-tech Industries

The purpose of this qualitative research is to study how international new ventures change internally during initial internationalization. Based on the analysis of seven INV firms, a framework illustrating this change process, will be developed. This research will also develop earlier theories, and create a solid combination of existing theories to explain the phenomenon. INV firms internationalize more rapidly and aggressively than traditional MNEs. At the same, external and internal drivers cause changes in INVs culture, resources, capabilities, strategic management, and output decisions inside the company. Organizational learning and resource acquisition through international business networks explain how INVs are able to cope with the dynamic high-technology industry and be able to adapt. Internationalization of INVs proceeds through several phases, which may be gone through rapidly due to the network effects and INVs’ special characteristics. The results of this research revealed that INVs internal change process proceeds through four phases; pre-incorporation phase, product development phase, internationalization and growth phase, and maturation phase. INVs culture, resources, capabilities, strategic management, and outputs change significantly during initial internationalization, and INVs develop from small start-ups into fully established companies.