Phimose : Sind topische Kortikosteroide eine Alternative zur chirurgischen Behandlung [Phimosis : are topical corticosteroids an alternative to surgical treatment?]

Hintergrund: Die physiologische Phimose ist bereits bei der Geburt vorhanden und wächst sich in den meisten Fällen aus. Während 10% der Knaben im Alter von drei Jahren noch eine Phimose haben, nimmt diese Prävalenz auf 6-8% im Alter von sieben Jahren und 1% im Alter von 16 Jahren ab. Man spricht von einer pathologischen Phimose, wenn die Vorhaut Vernarbungen infolge von wiederholten Entzündungen oder forcierten Retraktionsversuchen aufweist. Dennoch ist die Unterscheidung zwischen pathologischer und physiologischer Phimose schwierig, und eine chirurgische Behandlung (Zirkumzision, Vorhautplastik) ist häufig. Eine topische Kortikosteroidbehandlung wird seit mehreren Jahren wegen seiner anti-inflammatorischen und immunsuppressiven Wirkung (Verminderung der Kollagenproduktion) angewendet. Es gibt aber keine Evidenz bezüglich Wirksamkeit und Sicherheit dieser Behandlung.

Survival after surgical drainage of malignant pericardial effusion.

OBJECTIVES: Management of malignant pericardial effusion (PE) is complex. Cardiac surgeons are not necessarily familiar with or are challenged by the many underlying etiologies. Analyzing risk factors for mortality may help to estimate the benefit of surgery in high-risk patients. METHODS: Patients undergoing a surgical pericardiotomy for malignant PE, between 2001 and 2011, were included. The influence of tumor type, disease extension, intra-pericardial tumor infiltration on early mortality and long-term survival as well as freedom from symptoms after drainage, and the use of sclerosing agents on PE recurrence rates was analyzed. RESULTS: PE drainage was performed on 46 patients 12 ± 30 months after tumor diagnosis. Malignant diseases were lung cancers (50 %), breast cancers (15 %), lymphoma and leukemia (13 %), cancers of the digestive tract (13 %), and others (9 %). 80 % of patients were symptomatic and symptom relief was achieved in 65 %. Nobody died during surgery. Recurrence rate was 4 %. Early in-hospital mortality was 22 %. After 1 year, 29 % of patients were alive. Eleven patients (24 %) had a complete tumor regression. Metastatic spread (p < 0.001), pericardial infiltration (p = 0.02), and intra-pericardial Bleomycin (p = 0.01) injection were associated with increased mortality. Hematological malignancies had a better prognosis for survival. CONCLUSION: Surgical pericardiotomy is safe, associated with a low recurrence rate and symptom relief in the majority of dyspneic patients. Intra-pericardial Bleomycin may reduce recurrent effusion but does not ameliorate survival. Long-term survival rate was low with an increased mortality in cases of metastatic spreading, pericardial infiltration, and as the tumor of origin: breast cancers. Leukemic and lymphatic tumors have better prognosis.

Practical Solutions for Increased Safety in Paper Mill Operations

Tämä diplomityö käsittelee työterveys- ja työturvallisuushallinnan (TTT) sekä ympäristönsuojelun ongelmia ja riskejä, joita tehdasalueen toiminnanharjoittaja kohtaa ulkoistaessaan tehdastoimintojaan ja siirtyessään käyttämään 24 h ulkoisia kunnossapitopalveluja. Teoriaosa selventää ulkoistukseen liittyviä lainmukaisia määräyksiä ja vaatimuksia koskien terveyden, turvallisuuden ja ympäristöongelmien hallintaa sellu-, paperi- ja kartonkitehtaissa Euroopassa, Yhdysvalloissa ja Suomessa. TTT-toiminnan tason sekä ympäristönsuojelun tason mittaamisen ongelmat tuodaan esille. Olemassa olevia kansainvälisiä TTT-johtamisjärjestelmien ja ympäristöjärjestelmien standardeja, riskien hallintatyökaluja ja ohjelmia esitellään lyhyesti. Käytännön osa toteutettiin tapaustutkimuksena, jonka kohteena oli Äänekosken tehdaskombinaatti ja kemianteollisuuden laitos, Noviant CMC Oy. TTT-hallintatoimien ja ympäristönsuojelun ongelmia tutkitaan tehdastoimintoja ulkoistettaessa. Integroidun johtamisjärjestelmän auditointimenettelyt, ulkoistuksen kohdealueet, pk-yrityksien riskien hallinta ja ulkoisten työntekijöiden turvallisuuskoulutus ovat erityisen tarkastelun alla. Käyttäen hyväksi kerättyä TTT- ja ympäristöaineistoa, suunniteltiin malli ja sisältöehdotus uudelle internet-selain tyyppiselle työkalulle TTT- ja ympäristöasioiden hallinnan avuksi. Työkalu on tarkoitettu palvelemaan Noviant CMC Oy:n eri sidosryhmien tarpeita. Diplomityön käytännön osa muodostaa pohjan JP MILLSAFE - pilottiprojektille, joka käynnistettiin internet-selain tyyppisen turvallisuuspalvelusovelluksen kehittämiseksi palvelemaan Äänekosken tehdaskombinaatin eri sidosryhmien tarpeita.

Product management in global sales operations

Työn tavoitteena oli määrittää myyntikonfiguraattorissa käytettävän tuotemallin yleinen rakenne. Ensin selvitettiin tuotemallin luomista ja konseptin suunnittelua kirjallisuuden ja asiantuntijoiden haastattelujen avulla. Asiantuntijoiden haastattelut toteutettiin vapaamuotoisesti kysymyslistaa apuna käyttäen. Tämän lisäksi työssä pohditaan sähköisen liiketoiminnan roolia sekä myyntikonfiguraattorin tulevaisuuden näkymiä. Diplomityössä käsitellään tuotemallia yleisellä tasolla. Toinen näkökulma käsittelee tuotemallia tietoteknisissä sovelluksissa käytettyjen menetelmien pohjalta. Tuotemallin muodostaminen aloitettiin asiakkaalle näkyvästä osasta eli myyntikonfiguraattorin ulkoasusta. Seuraava ongelma oli standardoida tuotetta ja tarjousta kuvaavat dokumentit globaalisti. Tähän ratkaisuun päädyttiin haastattelujen sekä asiantuntijoiden kokoontumisien pohjalta. Loppuosa diplomityöstä käsittelee myyntikonfiguraattorin asemaa kohdeyrityksen sähköisessä liiketoiminnassa sekä esittelee erään näkemyksen myyntikonfiguraattorin yhteenliittymästä asiakashallinta- ja tuotetiedonhallinta järjestelmiin. Diplomityössä saavutettiin asetetut tavoiteet: Myyntikonfigurattori yhtenäistää kohdeyrityksen hinnoittelua globaalisti, nopeuttaa tarjouksentekoprosessia, helpottaa uuden tuotteen lanseerausta ja standardoi tuotemallin globaalisti. Myyntikonfiguraattorin integrointi muihin tietojärjestelmiin tehostaa myynnin toimintoja. Haasteeksi jää loppukäyttäjien kannustaminen tehokkaaseen käyttöön sekä ylläpidon toteuttaminen. Ilman käyttäjiä ja heidän innostustaan voi projekti menettää johdon luottamuksen.

Assessing e-procurement System for Improving the Purchasing Operations

Diplomityön tavoitteena oli luoda suunnitelma elektronisen hankintatoimen aloittamiseksi, analysoimalla nykyisiä ostoprosesseja ja konsernin laajuista elektronista hankintajärjestelmää. Työ pohjautuu yritysten väliseen elektroniseen kauppaan, elektroniseen hankintatoimeen ja systeemisuunnitteluun liittyvään kirjallisuuteen. Työssä tehdyn suunnitelman tarkoituksena on auttaa Siemens Oy:tä siirtymään uuteen elektroniseen ostotoimintaan. Elektroniselle ostotoiminnalle suunniteltiin tavoitteet ja näitä vastaavat vaatimukset. Elektronisen hankintajärjestelmän analysointi perustuu kirjallisuudessa esitettyihin järjestelmän elinkaari-mallin vaiheisiin. Analysoinnin tarkoituksena oli saada selville järjestelmän soveltuvuus Siemens Oy: n liiketoimintaympäristöön, prosesseihin ja vaatimuksiin. Elektronisen hankintatoiminnan etuja ovat liiketoiminta prosessien johtamisen parantuminen, kustannusten väheneminen sekä taloudellisen suorituskyvyn lisääntyminen. Elektronisen hankintatoiminnan aloittaminen vaatii kuitenkin huolellista suunnittelua. Työssä tehdyt suunnitelmat ja analysoinnit auttavat arvioidessa järjestelmän sopivuutta Siemens Oy: n vaatimuksiin. Oikean ja toimivan järjestelmän valinta ei kuitenkaan takaa elektronisesta hankintatoiminnasta hyötymistä. Tärkeimpiä jatkotoimenpiteitä onkin suorittaa kustannus/hyöty analyysi ja arvioida toimittajien halukkuutta ja kykyjä osallistua markkinapaikkaan.

Aesthetic Breast Augmentation Mastopexy Followed by Post-surgical Pyoderma Gangrenosum (PSPG): Clinic, Treatment, and Review of the Literature.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare autoinflammatory neutrophilic ulcerative skin disease, often developing after a trauma or surgical wounds. In the literature there are several reports of post-surgical PG (PSPG) of the breast. The authors of this article experienced an impressive case of PSPG after an aesthetic breast augmentation mastopexy. PSPG is a rare but severe complication in this elective aesthetic surgical procedure. METHOD: A systematic review of the literature was performed, focusing on PSPG after aesthetic breast surgery (augmentation mammoplasty/mastopexy). The online databases Pubmed, Medline, and Cochrane were used and additionally a Google© search was conducted. We compared the data obtained from a systematic literature review to an index case of PSPG after esthetic augmentation mammoplasty. RESULTS: The literature search identified seven articles describing eight cases of PSPG after aesthetic breast surgery. In four of these cases augmentation mammoplasty had been carried out, in two cases mastopexy and in two cases augmentation mammoplasty and mastopexy (augmentation mastopexy). The patient we treated and describe in this paper underwent an augmentation mastopexy outside our clinic. Eight patients suffered from local disease, at the site of surgical wounds, one patient had disseminated disease. Leukocytosis was present in five cases (out of nine). Eight patients had received corticosteroid treatment, one patient refused such treatment. The duration of corticosteroid treatment was on average for 41 days (range 21-60 days). In all cases, the areola had been spared. Complete healing of PSPG was observed on average after 5 months (range 1.5 months-1 year). DISCUSSION: PSPG of the breast after aesthetic breast surgery is rare, but every plastic surgeon should consider this possibility, especially if skin disease develops post-surgery, mimicking wound infection that does not respond to broad-spectrum antibiotic treatment. CONCLUSION: Although the literature does not recommend this step, implant removal is recommended by the authors because bacterial wound infection normally cannot be ruled out definitely in the early stages of disease. Additional surgical intervention should be limited to the absolute necessary and performed only under adequate systemic immunosuppressive therapy. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Successful Surgical Pulmonary Embolectomy for Massive Perinatal Embolism after Emergency Cesarean Section.

Pregnant women are exposed to an increased risk for developing pulmonary embolism (PE), a main cause for maternal mortality. Surgical pulmonary embolectomy is one important therapeutic and potential life-saving armamentarium, considering pregnancy as a relative contraindication for thrombolysis. We present a case of a 36-year-old woman with massive bilateral PE after emergent caesarean delivery, requiring reanimation by external heart massage. The onset of massive intrauterine bleeding contraindicated thrombolysis and emergency surgical pulmonary embolectomy, followed by a hysterectomy, were preformed successfully. Acute surgical pulmonary embolectomy may be an option in critically diseased high-risk patients, requiring a multiteam approach, and should be part of the therapeutic armamentarium of the attending cardiac surgeon.

State of Logistics and Operations Management in Finnish and Swedish Companies – Survey Research Findings

In this research we are examining what is the status of logistics and operations management in Finnish and Swedish companies. Empirical data is based on the web based questionnaire, which was completed in the end of 2007 and early 2008. Our examination consists of roughly 30 answers from largest manufacturing (highest representation in our sample), trade and logistics/distribution companies. Generally it could be argued that these companies operate in complex environment, where number of products, raw materials/components and suppliers is high. However, usually companies rely on small amount of suppliers per raw material/component (highest frequency is 2), and this was especially the case among Swedish companies, and among those companies, which favoured overseas sourcing. Sample consisted of companies which mostly are operating in an international environment, and are quite often multinationals. Our survey findings reveal that companies in general have taken logistics and information technology as part of their strategy process; utilization of performance measures as well as system implementations have followed the strategy decisions. In the transportation mode side we identify that road transports dominate all transport flow classes (inbound, internal and outbound), followed by sea and air. Surprisingly small amount of companies use railways, but in general we could argue that Swedish companies prefer this mode over Finnish counterparts. With respect of operations outsourcing, we found that more traditional areas of logistics outsourcing are driving factors in company's performance measurement priority. In contrary to previous research, our results indicate that the scope of outsourcing is not that wide in logistics/operations management area, and companies are not planning to outsource more in the near future. Some support is found for more international operations and increased outsourcing activity. From the increased time pressure of companies, we find evidence that local as well as overseas customers expect deliveries within days or weeks, but suppliers usually supply within weeks or months. So, basically this leads into considerable inventory holding. Interestingly local and overseas sourcing strategy does not have that great influence on lead time performance of these particular sourcing areas - local strategy is anyway considerably better in responding on market changes due to shorter supply lead times. In the end of our research work we have completed correlation analysis concerning items asked with Likert scale. Our analysis shows that seeing logistics more like a process rather than function, applying time based management, favouring partnerships and measuring logistics within different performance dimensions results on preferred features and performance found in logistics literature.

Surgical complications due to postnatal cytomegalovirus infection in a preterm infant with malrotation.

We report a case of an extremely preterm infant with intestinal malrotation who contracted postnatal systemic cytomegalovirus (CMV) infection with a complicated intestinal evolution requiring repeated surgical interventions and antiviral treatment. This report is to emphasize that prolonged gastrointestinal symptoms in extremely preterm infants fed with non-pasteurized breast milk should lead to suspicion of CMV infection. The importance of preventive measures when feeding very preterm infants with breast milk needs to be considered. Furthermore, the indications for antiviral treatment, in particular in preterm infants, need to be clarified.

Means and challenges in international operations for a Finnish mobile application provider

Master’s Thesis concentrates to means and challenges in international operations for a Finnish mobile application provider Small Planet Oy during its various company stages from founding till maturing and during macro economical phases between year 1998 and 2008. Small Planet has just celebrated its 10 year anniversary and is therefore quite an extraordinary company which has survived all the highs and lows during past ten years and which has operated in the market as long as the whole mobile application industry has existed. Master’s Thesis describes possibilities for a company’s internationalization with different entry modes like exporting, licensing, investment entry and co-operative operations which are suitable for a mobile application provider. Unsuitable entry modes like franchising or contract manufacturing are not explained. The goal has been to analyze Small Planet’s international operations and to make conclusions from the practical experiences. Analysis and conclusions shall help Small Planet in its international operations in the future and should give insight to other mobile application companies and their managers who are in the situation of planning their own international operations. Results show that the best ways for Small Planet to internationalize its operations has been the co-operation with a big domestic client and the co-operation with Finnish operator infrastructure providers which have complementary products with Small Planet. Through these co-operations Small Planet has got lot of new international clients. Same time financial risks and investment need for international operations have been low. Co-operative international sales can be the most efficient international entry mode for a mobile application provider.

Traitements chirurgicaux des maladies fonctionnelles oesogastriques [Surgical treatment of gastroesophageal diseases].

Les pathologies fonctionnelles oesogastriques regroupent plusieurs maladies touchant la fonction digestive haute : la maladie de reflux, les hernies hiatales, l'oesophage court et l'achalasie. Leur mode de présentation est parfois similaire, mais leur traitement diffère sur de nombreux points. L'approche initiale passe souvent par une modification de l'hygiène de vie et une prise en charge médicale. Mais une prise en charge chirurgicale est parfois nécessaire. Une sélection très stricte des patients permet de garantir un bon résultat à long terme, tout en limitant le risque de complications. Elle repose sur un bilan fonctionnel précis et une prise en charge dans le cadre de discussions multidisciplinaires. Cette revue fait un point actuel sur la prise en charge générale, les bilans nécessaires et les traitements chirurgicaux disponibles. Gastroesophageal functional diseases comprise several pathologies impending upper gastrointestinal function: reflux disease, hiatal hernias, short esophagus and achalasia. Their presentation may be similar, but their treatment differs on many points. The initial approach consists of lifestyle changes and medical management. However, surgical treatment is sometimes necessary. Strict patient selection ensures good long-term results, while limiting the risk of complications. This selection is based on precise functional assessment and management in the context of multidisciplinary discussions. This article aims to discuss current aspects on general management, functional investigations and surgical treatments available.