The Effects of the Breast Cancer Mammography Screening Programme in Women aged 40 to 84 years in Turku, Finland (1987-2009)

The objective of this thesis was to evaluate whether a more extensive mammography screening programme (TurkuMSP) conducted by the city of Turku, had an effect on breast cancer (BC) incidence, survival, or mortality in years 1987 to 2009. Despite the fact that some studies have suggested a 20 percent reduction in BC mortality due to mammography screening, there are findings of harm to subjects, which are claimed to negate the benefits of screening. Thus, the aims of this study are most pertinent. A total of 176 908 screening examinations were performed in 36 000 women aged 40−74 during the years 1987−1997. In all, 685 primary BCs were found in the screened women, either screen-detected (n=531) or during screening intervals (n=154). Survival and BC recurrence rate of women with screen-detected BC was compared to 184 women with clinical BCs detected among individuals who did not take part in the screening. The invitation interval, which may influence the outcome, was studied in the age group 40 to 49 by inviting those born in even calendar years annually for mammography screening and those born in odd years, triennially. In addition, BC incidence and mortality in the total female population of Turku aged 40 to 84 years was compared with the respective figures of Helsinki and the rest of Finland, both during the pre-screening era (1976-1986) and the screening era (1987-2009). The study was designed to compare women by age groups, because women aged 50 to 59 were generally screened in all of Finland, whereas only in Turku women aged 40 to 49 and 60 to 74 were screened in addition. Data regarding cancer recurrence were derived from the Finnish Cancer Registry and data on deaths were collected from Statistics Finland. In survival analyses, screened women with invasive BC had a significantly higher survival rate than the women with clinical BC. The survival benefit started to appear already during the first follow-up years and was evident in all age groups. A marginal survival extension was also seen in screened women when BC had spread to ipsilateral axillary nodes already at diagnosis. Recurrence-free survival rate after BC treatment was significantly more favorable among the screened women compared with women with BC found clinically. The screening invitation interval did not significantly influence BC mortality in the subset of women aged 40 to 49 years. There were no consistent differences in the changes of BC incidence between Turku and the comparison areas during the screening era. In Turku, the BC mortality incidence in women aged 55−69 years was significantly lower during the screening era (from 1987 to 1997) compared with the pre-screening era, whereas no such change was found in the city of Helsinki or Tampere. When comparing the changes in incidence-based BC mortality during years 1987 to 2009 in Turku to those of Helsinki and the rest of Finland, there was a suggestion of more than 20 percent lower mortality in Turku among oldest age group (75-84 years) compared with the reference residential areas, but the differences were not consistently significant. Interpretation of the study results should be made with caution because there were no random control groups, and on the other hand, the number of cases in subgroups was fairly low to yield definite conclusions. Also due to the many statistical analyses, some of the findings may be due to chance. The results are, however, suggestive for a decrease of BC mortality in the elderly age groups due to wide mammography screening. This finding needs confirmation in further studies before recommending an expansion of mammography screening to women up to the age of 74 years

From statin efficacy to everyday effectiveness: Studying the gap in between.

Statins are indicated for preventing cardiovascular disease events. Patients with diabetes have a risk of major cardiovascular events double the risk of their peers without diabetes. Thus, clinical treatment guidelines recommend statins for the management of diabetic dyslipidemia. The evidence base for statin use in cardiovascular disease derives from the randomized controlled statin trials designed to prove statin efficacy under ideal conditions, among a homogenous study population meeting strict trial eligibility criteria. This thesis was implemented as four pharmacoepidemiological statin studies using register data on realworld statin users. The overall purpose was to evaluate the trends, patterns and effectiveness of statin use in everyday life. More specifically, nationwide secular trends in statin use in Finland were analysed, especially among patient groups which had been underrepresented in the statin trials. Furthermore, the benchmarking statin trials in diabetes, the Heart Protection Study and the Collaborative Atorvastatin Diabetes Study, were evaluated for their representativeness for real-world diabetes care with the emphasis placed on adherence to statin use. The association between good adherence and the incidence of major cardiovascular events in the real-world was further investigated in diabetes. These studies demonstrate that statin initiations increased from 1995 to 2005 in Finland. The increase was most pronounced among those aged at least 75 years and was observed already before the publication of rigorous trial data conducted in elderly subjects. Thus, statins seem to have been initiated in clinical practice also going beyond the strict trial eligibility criteria. Nonetheless, low adherence to statin use among the real-world patients with diabetes was found not only to limit the representativeness of the trials for clinical care but also to attenuate in all likelihood their benefits in the real-world. In fact, good adherence to statin use was found to associate with a decreased risk for major cardiovascular events in patients with diabetes. In conclusion, these studies highlight the importance of good adherence to statin use in clinical practice in order to obtain the full therapeutic value demonstrated in the statin trials. Simply increasing the number of statin users will not alone suffice in sharing our common resources appropriately.

Cardiovascular health from childhood to adulthood – with special reference to early vascular changes. The Cardiovascular Risk in Young Finns Study

Background: Recent recommendations aim to improve cardiovascular health (CVH) by encouraging the general population to meet positive and modifiable ideal CVH metrics: not smoking, being physically active, and maintaining normal weight, blood pressure, blood glucose and total cholesterol levels and a healthy diet. Aims: The aim of the present study was to report the prevalence of ideal CVH in children and young adults and study the associations of CVH metrics with markers of subclinical atherosclerosis. Participants and methods: The present thesis is part of the Cardiovascular Risk in Young Finns Study (Young Finns Study). Data on associations of CVH metrics and subclinical atherosclerosis were available from 1,898 Young Finns Study participants. In addition, joint analyses were performed combining data from the International Childhood Cardiovascular Cohort (i3C) Consortium member studies from Australia and the USA. Results: None of the participants met all 7 CVH metrics and thus had ideal CVH in childhood and only 1% had ideal CVH as young adults. The number of CVH metrics present in childhood and adulthood predicted lower carotid artery intima-media thickness, improved carotid artery distensibility and lower risk of coronary artery calcification. Those who improved their CVH status from childhood to adulthood had a comparable risk of subclinical atherosclerosis to participants who had always had a high CVH status. Conclusions: Ideal CVH proved to be rare among children and young adults. A higher number of ideal CVH metrics and improvement of CVH status between childhood and adulthood predicted a lower risk of subclinical atherosclerosis.

User Experience of Geocaching and Its Application to Tourism and Education

Advances in technology have provided new ways of using entertainment and game technology to foster human interaction. Games and playing with games have always been an important part of people’s everyday lives. Traditionally, human-computer interaction (HCI) research was seen as a psychological cognitive science focused on human factors, with engineering sciences as the computer science part of it. Although cognitive science has made significant progress over the past decade, the influence of people’s emotions on design networks is increasingly important, especially when the primary goal is to challenge and entertain users (Norman 2002). Game developers have explored the key issues in game design and identified that the driving force in the success of games is user experience. User-centered design integrates knowledge of users’ activity practices, needs, and preferences into the design process. Geocaching is a location-based treasure hunt game created by a community of players. Players use GPS (Global Position System) technology to find “treasures” and create their own geocaches; the game can be developed when the players invent caches and used more imagination to creations the caches. This doctoral dissertation explores user experience of geocaching and its applications in tourism and education. Globally, based on the Geocaching.com webpage, geocaching has been played about 180 countries and there are more than 10 million registered geocachers worldwide (Geocaching.com, 25.11.2014). This dissertation develops and presents an interaction model called the GameFlow Experience model that can be used to support the design of treasure hunt applications in tourism and education contexts. The GameFlow Model presents and clarifies various experiences; it provides such experiences in a real-life context, offers desirable design targets to be utilized in service design, and offers a perspective to consider when evaluating the success of adventure game concepts. User-centered game designs have adapted to human factor research in mainstream computing science. For many years, the user-centered design approach has been the most important research field in software development. Research has been focusing on user-centered design in software development such as office programs, but the same ideas and theories that will reflect the needs of a user-centered research are now also being applied to game design (Charles et al. 2005.) For several years, we have seen a growing interest in user experience design. Digital games are experience providers, and game developers need tools to better understand the user experience related to products and services they have created. This thesis aims to present what the user experience is in geocaching and treasure hunt games and how it can be used to develop new concepts for the treasure hunt. Engineers, designers, and researchers should have a clear understanding of what user experience is, what its parts are, and most importantly, how we can influence user satisfaction. In addition, we need to understand how users interact with electronic products and people, and how different elements synergize their experiences. This doctoral dissertation represents pioneering work on the user experience of geocaching and treasure hunt games in the context of tourism and education. The research also provides a model for game developers who are planning treasure hunt concepts.

The role of brand identification in alumni support to their alma mater

Universities around the world are facing global competition and challenges to finance their main functions - research and education. This study focused on the role of graduates, alumni, in the success of a university. The purpose of this study was to examine the role of brand identification in alumni willingness to support their alma mater. The research concentrated on finding out what is the relationship between brand identification and it’s antecedents (prestige, satisfaction, interpretation of brand) to alumni willingness to promote university, participate in university activities and support financially by donating money to university’s research. The research method was quantitative and the data was collected via online survey from 569 alumni of a Finnish university. The findings suggest that there is a strong relationship between brand identification and alumni support. The stronger brand identification is, the more willing alumni were to promote university, participate in university activities and support financially. Based on the research, it is beneficial for universities to invest in brand development in order to get alumni to act as ambassadors of the university after their graduation.

Comparative analysis of vitamin A and iron content in food according to different food composition tables and nutritional evaluation software programs

The objective of this study was to analyze retinol equivalent and iron content in different food composition tables and nutritional evaluation software programs. A literature search was conduct to identify tables and software available in Brazil containing information about retinol equivalent and iron content that are currently used by nutritionists. Ten tables and five software programs were selected for this study. The methodology used to present the retinol equivalent and iron content was evaluated and no pattern to obtain such content was found in the tables and software programs analyzed. Only one of the tables had enough information for the calculation of retinol equivalents; this table is recommended to all Latin America As for the iron content, three of the tables analyzed stand out and therefore should be used; two of them are based on national foods and the other is recommended for use in all Latin America countries. None of the software programs evaluated use the conversion factors suggested by IVACG to assess the vitamin A content in foods. Special attention should be given to the content of iron provided in the software programs since they use tables as international sources and fortified foods.

Steps towards more effective antitrust system in EU – The Damages Directive’s effect on victim’s right to compensation for antitrust harm

Kaikkien kansalaisten ja yritysten, jotka kärsivät vahinkoa Euroopan Unionin kilpailusääntöjen (SEUT 101 ja 102 artiklan) rikkomisen vuoksi, on voitava vaatia korvauksia vahingon aiheuttaneelta osapuolelta. Euroopan unionin tuomioistuin on ratkaisuillaan Courage ja Manfredi vahvistanut vahinkoa kärsineen oikeuden saada korvausta kärsimästään vahingosta. Suomessa kilpailuoikeudellista vahingonkorvausta koskeva oikeuskäytäntö on ollut vähäistä, vaikkakin viime aikoina on annettu muutama merkittävä vahingonkorvausratkaisu, näistä kenties tunnetuimpana asvalttikartelliratkaisu. Kilpailuoikeuden rikkomisesta vahinkoa kärsineet saavat kuitenkin vain harvoin korvausta kärsimästään vahingosta, mikä on ollut seurausta erilaisista lainsäädännöllisistä ja menettelyistä johtuvista esteistä jäsenvaltioiden säännöissä. Komission pitkään kestänyt lainsäädäntöhanke EU:n kilpailuoikeuden täytäntöönpanojärjestelmän selkeyttämiseksi päättyi marraskuussa 2014, kun Euroopan parlamentin ja neuvoston direktiivi tietyistä säännöistä, joita sovelletaan jäsenvaltioiden ja Euroopan unionin kilpailuoikeuden rikkomisen johdosta kansallisen lainsäädännön nojalla nostettuihin vahingonkorvauskanteisiin (2014/104/ EU) hyväksyttiin. Direktiivi julkaistiin Euroopan unionin virallisessa lehdessä 5. joulukuuta 2014, ja jäsenvaltioilla on 27.12.2016 asti aikaa implementoida direktiivi osaksi kansallista lainsäädäntöä. Direktiivin tavoitteena on EU:n kilpailusääntöjen tehokas täytäntöönpano sekä kilpailuoikeuden julkisoikeudellisen ja yksityisoikeudellisen täytäntöönpanon selkeyttäminen. Lisäksi direktiivi pyrkii varmistamaan, että vahingonkärsijät voivat saada täyden korvauksen kärsimästään vahingosta, sekä poistamaan esteitä ja pienentämään kustannuksia vahingon todistamisessa, samalla harmonisoiden eri jäsenmaissa toimivien yritysten oikeussuojan tasoa. Tarkastelen pro gradu –tutkielmassani kilpailuoikeudellisen vahingonkorvauksen kehitystä sekä uuden EU:n vahingonkorvausdirektiivin vaikutuksia erityisesti vahingonkärsijän näkökulmasta, eli sitä kuinka direktiivi vaikuttaa vahingonkärsijän mahdollisuuteen saada korvausta kärsimästään vahingosta, joka johtuu EU:n kilpailusääntöjen rikkomisesta. Lisäksi tarkastelen lyhyesti direktiivin tuomia muutoksia Suomen lainsäädäntöön. Tutkielmani loppupäätelmä on, että vaikka vahingonkorvausdirektiivi ei täydellisesti paranna vahingonkärsijän asemaa, se selkeyttää monella tavalla kilpailuoikeudellisten vahingonkorvauskanteiden nykyistä tilaa, ja saattaa tietyssä määrin rohkaista vahingonkärsijiä hakemaan korvausta kärsimästään vahingosta.

Storage of 'Swingle' citrumelo seeds in different maturation stages subjected to fungicide treatment

The establishment of citrus orchards with rootstocks from seed with a low physiological quality has been a recurring problem. Low quality seeds directly affect both the final stand and the time required for seedling production. The irregular maturation of fruits, seed recalcitrance, and the high incidence of fungi, make long term storage difficult, even at low temperatures. This study evaluated the storage potential and the use of fungicide treatments on 'Swingle' citrumelo seeds extracted from fruits collected at two maturation stages, green or ripe. The seeds were subjected to a thermal treatment, treated with Derosal, Thiram or Tecto+Captan fungicides, packaged in impermeable polyethylene bags and stored in a cold chamber for nine months. Every three months, the physiological and sanitary qualities of the seeds were evaluated from germination and sanitary tests and also from enzyme profiles. Seeds from green fruits deteriorated less than those from mature fruits; deterioration increased up to nine months of storage; treatment with the Tecto+Captan mixture gave effective pathogen control and maintained seed quality during storage. The germination of the green and ripe seeds is satisfactory (70%) after three months storage.

Datenherrschaft – an Ethically Justified Solution to the Problem of Ownership of Patient Information

Patient information systems are crucial components for the modern healthcare and medicine. It is obvious that without them the healthcare cannot function properly – one can try to imagine how brain surgery could be done without using information systems to gather and show information needed for an operation. Thus, it can be stated that digital information is irremovable part of modern healthcare. However, the legal ownership of patient information lacks a coherent and justified basis. The whole issue itself is actually bypassed by controlling pa- tient information with different laws and regulations how patient information can be used and by whom. Nonetheless, the issue itself – who owns the patient in- formation – is commonly missed or bypassed. This dissertation show the problems if the legislation of patient information ownership is not clear. Without clear legislation, the outcome can be unexpected like it seems to be in Finland, Sweden and United Kingdom: the lack of clear regulation has come up with unwanted consequences because of problematic Eu- ropean Union database directive implementation in those countries. The legal ownership is actually granted to the creators of databases which contains the pa- tient information, and this is not a desirable situation. In healthcare and medicine, we are dealing with issues such as life, health and information which are very sensitive and in many cases very personal. Thus, this dissertation leans on four philosophical theories form Locke, Kant, Heidegger and Rawls to have an ethically justified basis for regulating the patient infor- mation in a proper way. Because of the problems of property and ownership in the context of information, a new concept is needed and presented to replace the concept of owning, that concept being Datenherrschaft (eng. mastery over in- formation). Datenherrschaft seems to be suitable for regulating patient infor- mation because its core is the protection of one’s right over information and this aligns with the work of the philosophers whose theories are used in the work. The philosophical argumentation of this study shows that Datenherrschaft granted to the patients is ethically acceptable. It supports the view that patient should be controlling the patient information about themselves unless there are such specific circumstance that justifies the authorities to use patient information to protect other people’s basic rights. Thus, if the patients would be legally grant- ed Datenherrschaft over patient information we would endorse patients as indi- viduals who have their own and personal experience of their own life and have a strong stance against any unjustified paternalism in healthcare. Keywords: patient information, ownership, Datenherrschaft, ethics, Locke, Kant, Heidegger, Rawls

Prediction of neurodevelopment and neuromotor trajectories in very preterm born children up to 11 years of age: PIPARI Study

Very preterm birth is a risk for brain injury and abnormal neurodevelopment. While the incidence of cerebral palsy has decreased due to advances in perinatal and neonatal care, the rate of less severe neuromotor problems continues to be high in very prematurely born children. Neonatal brain imaging can aid in identifying children for closer follow-up and in providing parents information on developmental risks. This thesis aimed to study the predictive value of structural brain magnetic resonance imaging (MRI) at term age, serial neonatal cranial ultrasound (cUS), and structured neurological examinations during the longitudinal follow-up for the neurodevelopment of very preterm born children up to 11 years of age as a part of the PIPARI Study (The Development and Functioning of Very Low Birth Weight Infants from Infancy to School Age). A further aim was to describe the associations between regional brain volumes and long-term neuromotor profile. The prospective follow-up comprised of the assessment of neurosensory development at 2 years of corrected age, cognitive development at 5 years of chronological age, and neuromotor development at 11 years of age. Neonatal brain imaging and structured neurological examinations predicted neurodevelopment at all age-points. The combination of neurological examination and brain MRI or cUS improved the predictive value of neonatal brain imaging alone. Decreased brain volumes associated with neuromotor performance. At the age of 11 years, the majority of the very preterm born children had age-appropriate neuromotor development and after-school sporting activities. Long-term clinical follow-up is recommended at least for all very preterm infants with major brain pathologies.

Adherence to Treatment in Psychotic Disorders - Development of user-centered mobile health intervention

The aim of this study was to explore adherence to treatment among people with psychotic disorders through the development of user-centered mobile technology (mHealth) intervention. More specifically, this study investigates treatment adherence as well as mHealth intervention and the factors related to its possible usability. The data were collected from 2010 to 2013. First, patients’ and professionals’ perceptions of adherence management and restrictive factors of adherence were described (n = 61). Second, objectives and methods of the intervention were defined based on focus group interviews and previously used methods. Third, views of patients and professionals about barriers and requirements of the intervention were described (n = 61). Fourth, mHealth intervention was evaluated based on a literature review (n = 2) and patients preferences regarding the intervention (n = 562). Adherence management required support in everyday activities, social networks and maintaining a positive outlook. The factors restricting adherence were related to illness, behavior and the environment. The objective of the intervention was to support the intention to follow the treatment guidelines and recommendations with mHealth technology. The barriers and requirements for the use of the mHealth were related to technology, organizational issues and the users themselves. During the course of the intervention, 33 (6%) out of 562 participants wanted to edit the content, timing or amount of the mHealth tool, and 23 (4%) quit the intervention or study before its conclusion. According to the review, mHealth interventions were ineffective in promoting adherence. Prior to the intervention, participants perceived that adherence could be supported, and the use of mHealth as a part of treatment was seen as an acceptable and efficient method for doing so. In conclusion, the use of mHealth may be feasible among people with psychotic disorders. However, clear evidence for its effectiveness in regards to adherence is still currently inconclusive.

The relationship between stem-form, stand-closure and site -conditions : the influence of environmental conditions on tree allometry and forest structure in west-central Alberta

Changes in the configuration of a tree stern result insignificant differences in its total volume and in the proportion of that volume that is merchantable timber. Tree allometry, as represented by stem-fo~, is the result of the vertical force of gravity and the horizontal force of wind. The effect of wind force is demonstrated in the relationship between stem-form, standclosure and site-conditions. An increase in wind force on the individual tree due to a decrease in stand density should produce a more tapered tree. The density of the stand is determined by the conditions that the trees are growing under. The ability of the tree to respond to increased wind force may also be a function of these conditions . This stem-form/stand-closure/site-conditions relationship was examined using a pre-existing database from westcentral Alberta. This database consisted of environmental, vegetation, soils and timber data covering a wide range of sites. There were 653 sample trees with 82 variables that formed the basis of the analysis. There were eight tree species consisting of Pinus contorta, Picea mariana, Picea engelmannii x glauca, Abies lasiocarpa, Larix laricina, Populus tremuloides, Betula papyrifera and Populus balsamifera plus a comprehensive all-species data set. As the actual conformation of the stern is very individual, stem-fo~was represented by the diameter at breast height to total height r~tio. The four stand-closure variables, crown closure, total basal area, total volume and total number of stems were reduced to total basal area and total number of stems utilizing a bivariate correlation matrix by species. Site-conditions were subdivided into macro, meso and micro variables and reduced in number 3 using cross-tabulations, bivariate correlation and principal components analysis as screening tools. The stem-fo~/stand-closure relationship was examined using bivariate correlation coefficients for stem-fo~ with total number of stems and stem-fo~ with total basal area. The stem-fo~/site-conditions and the stand-closure/site- conditions relationships were examined using multiple correlation coefficients. The stem-form/stand-closure/site-conditions relationship was examined using multiple correlation coefficients in separate analyses for both total number of stems and total basal area. An increase in stand-closure produced a decrease in stem-form for both total number of stems and total basal area for most species. There was a significant relationship between stem-form and site-conditions and between stand-closure and site-conditions for both total number of stems and total basal area for most species. There was a significant relationship between the stemform and site-conditions, including the stand-closure, for most species; total number of stems was involved independently of the site-conditions in the prediction of stem-form and total basal area was not. Larix laricina and Betula papyrifera were the exceptions to the trends observed with most species. The influence of both stand-closure (total number of stems in particular) and site-conditions (elevation in particular) suggest that forest management practices should include these- ecological parameters in determining appropriate restocking levels.

Stan and Carol Chapman stand behind Edy and Ernie Chapman

Chapman College trustees, left to right [above] Stan and Carol Chapman; [seated] Edy and Ernie Chapman at a dinner event.

Letter to S.D. Woodruff from John Whistle

Letter (1 double sided, handwritten) to S.D. Woodruff from John Whistle saying that he has heard that Mr. Woodruff offered $2,500.00 to anyone who would cut the timber for him. He claims that he knows where there is plenty of timber which will stand culling. Postmarks Toronto, July 25, 1880 and St. Catharines, July 27, 1880 are on the accompanying envelope, July 24, 1880.

Evolution of Various Library Instruction Strategies: Using Student Feedback to Create and Enhance Online Active Learning Assignments

This case study traces the evolution of library assignments for biological science students from paper-based workbooks in a blended (hands-on) workshop to blended learning workshops using online assignments to online active learning modules which are stand-alone without any face-to-face instruction. As the assignments evolved to adapt to online learning supporting materials in the form of PDFs (portable document format), screen captures and screencasting were embedded into the questions as teaching moments to replace face-to-face instruction. Many aspects of the evolution of the assignment were based on student feedback from evaluations, input from senior lab demonstrators and teaching assistants, and statistical analysis of the students’ performance on the assignment. Advantages and disadvantages of paper-based and online assignments are discussed. An important factor for successful online learning may be the ability to get assistance.