Performance of parental history for the targeted screening of hypertension in children.

OBJECTIVES: Several guidelines recommend universal screening for hypertension in childhood and adolescence. Targeted screening to children with parental history of hypertension could be a more efficient strategy than universal screening. Therefore, we assessed the association between parental history of hypertension and hypertension in children, and estimated the sensitivity, specificity, negative, and positive predictive values of parental history of hypertension for hypertension in children. METHODS: The present study was a school-based cross-sectional study including 5207 children aged 10-14 years from all public 6th grade classes in the Canton of Vaud, Switzerland. Children had hypertension if they had sustained elevated blood pressure over three separate visits. RESULTS: In children, the prevalence of hypertension was 2.2%. Some 8.5% of mothers and 12.9% of fathers reported to be hypertensive. Maternal history of hypertension (odds ratio 2.0, 95% confidence interval 1.2-3.3) and paternal history of hypertension (odds ratio 2.2, 95% confidence interval 1.4-3.6) were independent risk factors for hypertension in children. Nevertheless, the sensitivity of parental history of hypertension for the identification of hypertension in children was low (from 4% for both parents' positive history up to 41% for at least one parent's positive history). Positive predictive values were also low (between 4 and 5%). CONCLUSION: Children with hypertensive parents were at higher risk of hypertension. Nevertheless, parental history of hypertension helped only marginally to identify hypertension in offspring. Targeting screening only toward children with a parental history of hypertension may not be a substantially better strategy to identify hypertension in children compared with universal screening.

Potential health-care service utilization substitution effects induced by case management for emergency department frequent users

BACKGROUND: In most of the emergency departments (ED) in developed countries, a subset of patients visits the ED frequently. Despite their small numbers, these patients are the source of a disproportionally high number of all ED visits, and use a significant proportion of healthcare resources. They place a heavy economic burden on hospital and healthcare systems budgets overall. Several interventions have been carried out to improve the management of these ED frequent users. Case management has been shown in some North American studies to reduce ED utilization and costs. In these studies, cost analyses have been carried out from the hospital perspective without examining the costs induced by healthcare consumed in the community. However, case management might reduce ED visits and costs from the hospital's perspective, but induce substitution effects, and increase health service utilization outside the hospital. This study examined if an interdisciplinary case-management intervention-compared to standard ED care -reduced costs generated by frequent ED users not only from the hospital perspective, but also from the healthcare system perspective-that is, from a broader perspective taking into account the costs of healthcare services used outside the hospital. METHODS: In this randomized controlled trial, 250 adult frequent emergency department users (5 or more visits during the previous 12 months) who visited the ED of the University Hospital of Lausanne, Switzerland, between May 2012 and July 2013 were allocated to one of two groups: case management intervention (CM) or standard ED care (SC), and followed up for 12 months. Depending on the perspective of the analysis, costs were evaluated differently. For the analysis from the hospital's perspective, the true value of resources used to provide services was used as a cost estimate. These data were obtained from the hospital's analytical accounting system. For the analysis from the health-care system perspective, all health-care services consumed by users and charged were used as an estimate of costs. These data were obtained from health insurance providers for a subsample of participants. To allow comparisons in a same time period, individual monthly average costs were calculated. Multivariate linear models including a fixed effect "group" were run using socio-demographic characteristics and health-related variables as controlling variables (age, gender, educational level, citizenship, marital status, somatic and mental health problems, and risk behaviors).

Frequent users of the emergency department in a universal health coverage system : a randomized controlled trial of a case-management intervention

BACKGROUND: Frequent emergency department users represent a small number of patients but account for a large number of emergency department visits. They should be a focus because they are often vulnerable patients with many risk factors affecting their quality of life (QoL). Case management interventions have resulted in a significant decrease in emergency department visits, but association with QoL has not been assessed. One aim of our study was to examine to what extent an interdisciplinary case management intervention, compared to standard emergency care, improved frequent emergency department users' QoL. METHODS: Data are part of a randomized, controlled trial designed to improve frequent emergency department users' QoL and use of health-care resources at the Lausanne University Hospital, Switzerland. In total, 250 frequent emergency department users (≥5 attendances during the previous 12 months; ≥ 18 years of age) were interviewed between May 2012 and July 2013. Following an assessment focused on social characteristics; social, mental, and somatic determinants of health; risk behaviors; health care use; and QoL, participants were randomly assigned to the control or the intervention group (n=125 in each group). The final sample included 194 participants (20 deaths, 36 dropouts, n=96 in the intervention group, n=99 in the control group). Participants in the intervention group received a case management intervention by an interdisciplinary, mobile team in addition to standard emergency care. The case management intervention involved four nurses and a physician who provided counseling and assistance concerning social determinants of health, substance-use disorders, and access to the health-care system. The participants' QoL was evaluated by a study nurse using the WHOQOL-BREF five times during the study (at baseline, and at 2, 5.5, 9, and 12 months). Four of the six WHOQOL dimensions of QoL were retained here: physical health, psychological health, social relationship, and environment, with scores ranging from 0 (low QoL) to 100 (high QoL). A linear, mixed-effects model with participants as a random effect was run to analyze the change in QoL over time. The effects of time, participants' group, and the interaction between time and group were tested. These effects were controlled for sociodemographic characteristics and health-related variables (i.e., age, gender, education, citizenship, marital status, type of financial resources, proficiency in French, somatic and mental health problems, and behaviors at risk).

Impact of case management on frequent users quality of life : a randomized controlled trial

BACKGROUND: Frequent emergency department users represent a small number of patients but account for a large number of emergency department visits. They should be a focus because they are often vulnerable patients with many risk factors affecting their quality of life (QoL). Case management interventions have resulted in a significant decrease in emergency department visits, but association with QoL has not been assessed. One aim of our study was to examine to what extent an interdisciplinary case management intervention, compared to standard emergency care, improved frequent emergency department users' QoL. METHODS: Data are part of a randomized, controlled trial designed to improve frequent emergency department users' QoL and use of health-care resources at the Lausanne University Hospital, Switzerland. In total, 250 frequent emergency department users (≥5 attendances during the previous 12 months; ≥ 18 years of age) were interviewed between May 2012 and July 2013. Following an assessment focused on social characteristics; social, mental, and somatic determinants of health; risk behaviors; health care use; and QoL, participants were randomly assigned to the control or the intervention group (n=125 in each group). The final sample included 194 participants (20 deaths, 36 dropouts, n=96 in the intervention group, n=99 in the control group). Participants in the intervention group received a case management intervention by an interdisciplinary, mobile team in addition to standard emergency care. The case management intervention involved four nurses and a physician who provided counseling and assistance concerning social determinants of health, substance-use disorders, and access to the health-care system.

Kotimaan tuotekuljetusten kehittäminen

Työn tavoitteena oli selvittää kotimaan tuotekuljetusten nykytila ja löytää mahdollisia kehityskohteita kuljetustoiminnan kehittämiselle. Kotimaan tuotekuljetuksiin kuuluivat kotimaan asiakaskuljetukset sekä viennin esikuljetukset satamiin. Tarkoituksena oli saada aikaan hallittu kokonaisuus kotimaan kuljetusten osalta. Kuljetusten kehittäminen aloitettiin selvittämällä Finnforestin kotimaan kuljetusten nykytila. Kotimaan tuotekuljetuksia tutkittiin haastattelujen, vierailuiden, voimassa olevien sopimusten ja yrityksen oman tietojärjestelmän avulla. Selvityksessä havaittuihin ongelmiin pyrittiin löytämään mahdollisia ratkaisuja. Kuljetusten kehittämiskohteita löytyi paljon. Kuljetuksia tulisi hoitaa tulevaisuudessa konsernitasolta, jotta kotimaan kuljetuksia saadaan yhdenmukaistettua ja kuljetuskumppanien määrää karsittua. Ristiin kuljetuksen vähentäminen pienentäisi vuosittaisia kuljetuskustannuksia. Kuljetusten suunnittelu ja kehittely helpottuisi tulevaisuudessa, jos yrityksessä otettaisiin käyttöön EDI –yhteydet sekä kuljetuksia seurattaisiin jatkuvasti ongelmien havaitsemiseksi ajoissa.

Sellulinjojen rejektinkäsittelyn tehokkuuden arviointi

Työssä kartoitettiin sellulinjojen rejektinkäsittelyn toimintaa ja arvioitiin rejektinkäsittelyssä liikkuvan rejektin laatua. Tavoitteena oli arvioida rejektinkäsittelyn toiminnan hyvyyttä ja löytää mahdollisia ongelmakohtia. Toiminnan hyvyyttä arvioitiin rejektinkäsittelyn ajettavuuden, hallinnan ja käytettävyyden sekä rejektin laadun perusteella. Työn kirjallisuusosassa käsitellään yleisesti sellulinjoilla esiintyviä epäpuhtauksia ja kemiallisen massan lajittelua. Kirjallisuusosan pääpaino on sellulinjan ruskean massan lajittelun ja erityisesti lajittamon rejektinkäsittelyn esittelyssä. Rejektinkäsittelyosuus käsittelee nykyaikaiseen rejektinkäsittelyyn kuuluvia laitteita ja toimintoja sekä esittelee erilaisia rejektinkäsittelyjärjestelmiä ja –vaihtoehtoja. Työn kokeellisessa osassa arvioitiin kolmen sellutehtaan kuitulinjan rejektinkäsittelyn toiminnan hyvyyttä. Arvioitavat tehdaskohteet olivat Stora Enson Kaukopään sellutehdas, Botnian Joutsenon sellutehdas sekä UPM-Kymmenen Kaukaan sellutehdas. Tavoitteena oli selvittää ruskean massan lajittelun rejektinkäsittelyssä liikkuvan rejektin laatua, jonka perusteella toiminnan hyvyyttä voitiin arvioida. Tutkimus tehtiin siten, että tehdaskäyntien aikana otettiin arviointiin tarvittavat tehdasnäytteet sekä kerättin muu arviointiin tarvittava tieto. Tehdyn tutkimuksen perusteella saatiin kokonaiskuva kolmen nykyaikaisen sellutehtaan rejektinkäsittelyn toiminnasta. Työssä saatiin runsaasti tietoa rejektinkäsittelyyn ajettavan rejektin laadusta ja määristä sekä rejektinkäsittelylaitteiden toimivuudesta. Prosessista poistettavan rejektin määrän ja laadun selvittäminen oli tehtaille erityisen tärkeä asia selvittää. Kuitutappioiden muodossa prosessista poistettavan rejektin laadulla on myös jonkinlainen taloudellinen merkitys. Arvokasta tietoa saatiin myös prosessissa liikkuvista ja poistettavista hiekkamääristä. Yleisenä havaintona oli, että työhön kuuluneilla sellutehtailla rejektinkäsittely oli hyvin hallinnassa eikä suuria ongelmakohtia löytynyt.

Sähköisen hankintatoiminnan arviointi benchmarkingin avulla - tapaus IBM

Työn tavoitteena on ollut arvioida Oy International Business Machines Ab:n sähköistä hankintatoimintaa benchmarkingin avulla. Tutkimuksessa on selvitetty, miten IBM:n sähköinen hankintatoiminta on toteutettu kolmen muun yrityksen sähköisiin hankintatoimintoihin verrattuna. Lisäksi tarkoituksena on ollut löytää uusia mahdollisuuksia IBM:n sähköisten hankintatoimintojen kehittämiseksi. Työn teoriaosassa on käsitelty ensin hankintatoimintaa ja sen roolia toimitusketjussa, jonka jälkeen on tarkasteltu Internetin käyttöä hankintatoiminnoissa. Lisäksi on esitelty IBM:n sähköistä hankintatoimintaa sekä benchmarkingia toiminnan arvioinnin välineenä. Soveltavassa osassa on rakennettu benchmarking-prosessi, jonka avulla benchmarking-tutkimus suoritettiin. Tutkimusaineisto on kerätty benchmarking-vierailujen ja kirjallisuuslähteiden avulla. Benchmarking-tutkimuksen tulokset osoittivat, että kaikilla yrityksillä on kokemuksia sähköisien menetelmien käytöstä yritysten hankintatoiminnoissa ja ne on koettu hyödyllisiksi. Yritysten hankintatoiminnot perustuivat kuitenkin edelleen sekä perinteisiin toimintatapoihin että sähköisiin menetelmiin, mutta niiden kehittäminen täysin sähköisiksi oli yrityksille lähivuosien tärkeä tavoite. IBM:n hankintatoimintojen kehittämiseksi on esitetty useiden eri tekniikoiden käyttämistä sähköisen hankintatoiminnan toteuttamisessa. Kehitysmahdollisuutena on myös ehdotettu toimittajien verkkosivujen käyttämistä joidenkin tuotteiden hankkimisessa.

Optimizing the Anti-VEGF Treatment Strategy for Neovascular Age-Related Macular Degeneration: From Clinical Trials to Real-Life Requirements.

NlmCategory="UNASSIGNED">This Perspective discusses the pertinence of variable dosing regimens with anti-vascular endothelial growth factor (VEGF) for neovascular age-related macular degeneration (nAMD) with regard to real-life requirements. After the initial pivotal trials of anti-VEGF therapy, the variable dosing regimens pro re nata (PRN), Treat-and-Extend, and Observe-and-Plan, a recently introduced regimen, aimed to optimize the anti-VEGF treatment strategy for nAMD. The PRN regimen showed good visual results but requires monthly monitoring visits and can therefore be difficult to implement. Moreover, application of the PRN regimen revealed inferior results in real-life circumstances due to problems with resource allocation. The Treat-and-Extend regimen uses an interval based approach and has become widely accepted for its ease of preplanning and the reduced number of office visits required. The parallel development of the Observe-and-Plan regimen demonstrated that the future need for retreatment (interval) could be reliably predicted. Studies investigating the observe-and-plan regimen also showed that this could be used in individualized fixed treatment plans, allowing for dramatically reduced clinical burden and good outcomes, thus meeting the real life requirements. This progressive development of variable dosing regimens is a response to the real-life circumstances of limited human, technical, and financial resources. This includes an individualized treatment approach, optimization of the number of retreatments, a minimal number of monitoring visits, and ease of planning ahead. The Observe-and-Plan regimen achieves this goal with good functional results. Translational Relevance: This perspective reviews the process from the pivotal clinical trials to the development of treatment regimens which are adjusted to real life requirements. The article discusses this translational process which- although not the classical interpretation of translation from fundamental to clinical research, but a subsequent process after the pivotal clinical trials - represents an important translational step from the clinical proof of efficacy to optimization in terms of patients' and clinics' needs. The related scientific procedure includes the exploration of the concept, evaluation of security, and finally proof of efficacy.

Health care usage among immigrants and native-born elderly populations in eleven European countries: results from SHARE

Differences in health care utilization of immigrants 50 years of age and older relative to the native-born populations in eleven European countries are investigated. Negative binomial and zero-inflated Poisson regression are used to examine differences between immigrants and native-borns in number of doctor visits, visits to general practitioners, and hospital stays using the 2004 Survey of Health, Ageing, and Retirement in Europe database. In the pooled European sample and in some individual countries, older immigrants use from 13 to 20% more health services than native-borns after demographic characteristics are controlled. After controlling for the need for health care, differences between immigrants and native-borns in the use of physicians, but not hospitals, are reduced by about half. These are not changed much with the incorporation of indicators of socioeconomic status and extra insurance coverage. Higher country-level relative expenditures on health, paying physicians a fee-for-service, and physician density are associated with higher usage of physician services among immigrants.

La perception du paysage dans les images viatiques des Alpes

Etudiant les images viatiques des Alpes présentes dans la base de données VIATIMAGES, au tournant des XVIIIe-XIXe siècles, l'article montre que la prépondérance du sens de la vue dans la perception des paysages est une construction historique et anthropologique. En analysant plus précisément ces images, on peut y repérer des personnages identifiés aux habitants des lieux visités par les voyageurs. Au-delà des stéréotypes du "berger des Alpes", ces images nous disent quelque chose sur la perception pluri-sensorielle et sur l'immédiateté de la présence au monde des paysans alpins. Cependant, une équivoque demeure, que les sources viatiques ne permettent pas de lever, car les qualités attribuées aux paysans des Alpes sont celles mêmes dont les élites urbaines voyageantes sont privées. Dans les zones de contact que sont les sites touristiques au début du XIXe siècle, le regardant et le regardé mettent en miroir leurs qualités sans les partager.

Vitamin D time profile based on the contribution of non-genetic and genetic factors in HIV-infected individuals of European ancestry.

BACKGROUND: Vitamin D deficiency is prevalent in HIV-infected individuals and vitamin D supplementation is proposed according to standard care. This study aimed at characterizing the kinetics of 25(OH)D in a cohort of HIV-infected individuals of European ancestry to better define the influence of genetic and non-genetic factors on 25(OH)D levels. These data were used for the optimization of vitamin D supplementation in order to reach therapeutic targets. METHODS: 1,397 25(OH)D plasma levels and relevant clinical information were collected in 664 participants during medical routine follow-up visits. They were genotyped for 7 SNPs in 4 genes known to be associated with 25(OH)D levels. 25(OH)D concentrations were analysed using a population pharmacokinetic approach. The percentage of individuals with 25(OH)D concentrations within the recommended range of 20-40 ng/ml during 12 months of follow-up and several dosage regimens were evaluated by simulation. RESULTS: A one-compartment model with linear absorption and elimination was used to describe 25(OH)D pharmacokinetics, while integrating endogenous baseline plasma concentrations. Covariate analyses confirmed the effect of seasonality, body mass index, smoking habits, the analytical method, darunavir/ritonavir and the genetic variant in GC (rs2282679) on 25(OH)D concentrations. 11% of the inter-individual variability in 25(OH)D levels was explained by seasonality and other non-genetic covariates, and 1% by genetics. The optimal supplementation for severe vitamin D deficient patients was 300,000 IU two times per year. CONCLUSIONS: This analysis allowed identifying factors associated with 25(OH)D plasma levels in HIV-infected individuals. Improvement of dosage regimen and timing of vitamin D supplementation is proposed based on those results.

Puutuoteteollisuusyrityksen tilaus-toimitusketjun liiketoimintamallien kehittäminen

Tämä diplomityö on osa Puutavaralogistiikan läpinäkyvyyden kehittäminen – hanketta (PuLK-hanke), joka tähtää puutuoteteollisuudessa toimivan yrityksen tilaus-toimitusketjun läpinäkyvyyden lisäämiseen. Hanke on aloitettu kohdeyrityksen tarpeesta parantaa tilaus-toimitusketjun toimintaa uusien toimintaympäristön haasteiden edessä. Tämän työn tavoitteena oli selvittää kohdeyrityksen tilaus-toimitusketjun nykytila sekä tuottaa hankkeessa myöhemmässä vaiheessa toteutettavan systeemiteoreettisen mallinnuksen alkutiedoksi sopiva ylätason liiketoimintamalli. Nämä tehtiin kolmella eri lähestymistavalla, joiden avulla saatiin muodostettua kattava kuva nykytilasta sekä selvitettyä tarvittavalla tarkkuudella liiketoiminnan ylätason malliin vaaditut tiedot. Tärkeimmät käytetyt menetelmät olivat liiketoiminnan mallinnus, swot-analyysi kyselytutkimuksen tuloksista ja kirjallisuustutkimus tuettuna haastatteluilla, tutustumiskäynneillä ja yhteistyöosapuolien resurssien käytöllä. Liiketoiminnan mallinnus osoittautui hyödylliseksi työkaluksi paljastaen toiminnan epäkohdat koko ketjun tasolla niin, että korjaavien toimenpiteiden toteutus helpottui. Systeemiteoreettisen simulointimallin muodostaminen aloitettiin liiketoiminnan mallinnuksen tuottaman informaation pohjalta.

3B.01: Performance of targeted screening for the identification of hypertension in children

OBJECTIVE: As universal screening of hypertension performs poorly in childhood, targeted screening to children at higher risk of hypertension has been proposed. Our goal was to assess the performance of combined parental history of hypertension and overweight/obesity to identify children with hypertension. We estimated the sensitivity, specificity, negative and positive predictive values of overweight/obesity and parental history of hypertension for the identification of hypertension in children. DESIGN AND METHOD: We analyzed data from a school-based cross-sectional study including 5207 children aged 10 to 14 years from all public 6th grade classes in the canton of Vaud, Switzerland. Blood pressure was measured with a clinically validated oscillometric automated device over up to three visits separated by one week. Children had hypertension if they had sustained elevated blood pressure over the three visits. Parents were interviewed about their history of hypertension. RESULTS: The prevalence of hypertension was 2.2%. 14% of children were overweight or obese and 20% had a positive history of hypertension in either or both parents. 30% of children had either or both conditions. After accounting for several potential confounding factors, parental history of hypertension (odds ratio (OR): 2.6; 95% confidence interval (CI): 1.8-4.0), overweight excluding obesity (OR: 2.5; 95% CI: 1.5-4.2) and obesity (OR: 10.1; 95% CI: 6.0-17.0) were associated with hypertension in children. Considered in isolation, the sensitivity and positive predictive values of parental history of hypertension (respectively 41% and 5%) or overweight/obesity (respectively 43% and 7%) were relatively low. Nevertheless, considered together, the sensitivity of targeted screening in children with either overweight/obesity or paternal history of hypertension was higher (65%) but the positive predictive value remained low (5%). The negative predictive value was systematically high. CONCLUSIONS: Restricting screening of hypertension to children with either overweight/obesity or with hypertensive parents would substantially limit the proportion of children to screen (30%) and allow the identification of a relatively large proportion (65%) of hypertensive cases. That could be a valuable alternative to universal screening.

The biological family from the perspective of kinship fostered adolescents

Background: Previous studies emphasise the importance of the biological family to the welfare of fostered adolescents. However, the majority of these studies only take into consideration the viewpoints of the professionals, foster parents and biological parents not those of the adolescents themselves. For this reason little is known about the perceptions the adolescents have and the needs they express. Method: This study has gathered data from 57 adolescents in kinship family fostering in Spain (AFE). The study applied qualitative reseach, using focus groups to gather data and the Atlas.ti programme to analyse the data. The qualitative data give us a more profound understanding of how the fostered adolescents relate to their biological families. Results: The results highlight the specific needs of these adolescents a) an understanding of their family history b) the impact of visits from and relationship with their biological family and c) the relationship between the biological family and the foster family. Conclusions: These findings reveal implications to consider when creating support programmes aimed at this group.

Case management for emergency department frequent users : a randomized controlled trial

Background: Emergency department frequent users (EDFUs) account for a disproportionally high number of emergency department (ED) visits, contributing to overcrowding and high health-care costs. At the Lausanne University Hospital, EDFUs account for only 4.4% of ED patients, but 12.1% of all ED visits. Our study tested the hypothesis that an interdisciplinary case management intervention red. Methods: In this randomized controlled trial, we allocated adult EDFUs (5 or more visits in the previous 12 months) who visited the ED of the University Hospital of Lausanne, Switzerland between May 2012 and July 2013 either to an intervention (N=125) or a standard emergency care (N=125) group and monitored them for 12 months. Randomization was computer generated and concealed, and patients and research staff were blinded to the allocation. Participants in the intervention group, in addition to standard emergency care, received case management from an interdisciplinary team at baseline, and at 1, 3, and 5 months, in the hospital, in the ambulatory care setting, or at their homes. A generalized, linear, mixed-effects model for count data (Poisson distribution) was applied to compare participants' numbers of visits to the ED during the 12 months (Period 1, P1) preceding recruitment to the numbers of visits during the 12 months monitored (Period 2, P2).