Approaches to Supply Chain Risk Management: Identification, Analysis and Control

Supply chain risk management has emerged as an increasingly important issue in logistics as disruptions in the supply chain have become critical issues for many companies. The scientific literature on the subject is developing and in many respects the understanding of it is still in its infancy. Thus, there is a need for more information in order for scholars and practitioners to understand the causalities and interrelations that characterise the phenomenon. The aim of this dissertation is to narrow this gap by exploring key aspects of supply chain risk management through two maritime supply chains in the immediate region of the Gulf of Finland. The study contributes to the field in three different ways. Firstly, it facilitates the identification of risks on different levels of the supply chain through a systematic analysis of the processes and actors, and of the cognitive barriers that limit the actors’ visibility and their understanding of the operations and the risks involved. There is a clear need to increase collaboration and information exchange in order to improve visibility in the chain. Risk management should be a collaborative effort among the individual actors, aimed at obtaining a holistic picture. Secondly, the study contributes to the literature on risk analysis through the use of systemic frameworks that illustrate the causalities and linkages in the system, thereby making it easier to perceive the vulnerabilities. Thirdly, the study enhances current knowledge of risk control in identifying actor roles, risk visibility and risk controllability as being among the key factors determining risk-management effectiveness against supply-chain vulnerability. This dissertation is divided into two parts. The first part gives a general overview of the relevant literature, the research design and the conclusions of the study, and the second part comprises six research publications. Case-study methodology with systematic combining approach is used, where in-depth interviews, questionnaires and expert panel sessions are the main data collection methods. The study illustrates the current state of risk management in multimodal maritime supply chains, and develops frameworks for further analysis. The results imply that there are major differences between organizations in their ability to execute supply chain risk management. Further collaboration should be considered in order to facilitate the development of systematic and effective management processes.

Paradigmas e evidências da nutrição peri-operatória

Understanding perioperative pathophysiology and implementing care regimes, through a multimodal approach, to reduce the organic response to stress after surgery and the related postoperative ileus, are major challenges. Multimodal surgical strategies such as pre-operative intake of a carbohydrate drink, instead of the usually recommended 2- to 6-hour period of nothing-bymouth, together with patient's education of the postoperative care plan, plus efficacious analgesia and early postoperative nutrition, among others, have been described to significantly impact on the previous variables. Therefore, these strategies accelerate rehabilitation and, as a consequence, decrease complications and hospital length of stay and, its related costs.

Volume de fluído intravenoso e alta hospitalar precoce em colecistectomia aberta

OBJETIVO: Investigar se a adoção de um protocolo de restrição hídrica intravenosa em colecistectomia aberta diminui a permanência hospitalar. MÉTODO: Estudo prospectivo envolvendo pacientes submetidas a colecistectomia aberta após a adoção de um protocolo multimodal (projeto ACERTO). Pacientes com intercorrencias intra- ou pós-operatórias foram excluídas. Todas as pacientes receberam uma solução de carboidratos 2h antes da operação. Foram coletadas as seguintes variáveis: peso, altura, estado nutricional, volume total de fluidos intravenosos (VTFI) e volume prescrito em ml/kg de peso por dia. RESULTADOS: 64 pacientes (11 M e 53 F; idade mediana = 43 [18-65] anos) completaram o estudo. A re-alimentação pós-operatória ocorreu no mesmo dia da operação (62,5%) ou no dia seguinte (37,5%). Não foram registradas complicações infecciosas ou óbitos. O tempo mediano de internação pós-operatória foi de 1 (1-4) dia. Observou-se correlação entre o VTFI (r=0,44; p<0.001) e volume de fluídos / kg peso /dia (r=-0,29; p=0,03) e o tempo de internação pós-operatória. Alta no 1º PO foi possível em 73,3% dos casos quando a prescrição foi de até 20mL/Kg/dia e em 41,2% quando o volume prescrito foi maior (p<0.001; Odds Ratio=3,92; IC95% 1,36-11,32). CONCLUSÃO: A restrição de fluidos intravenosos em colecistectomia aberta determina alta mais precoce.

Impacto do projeto acerto na morbi-mortalidade pós-operatória em um hospital universitário

OBJETIVO: Avaliar resultados pós-operatórios de pacientes do Serviço de Cirurgia Geral do Hospital Universitário Julio Muller antes e após a implantação do protocolo multimodal ACERTO. MÉTODO: Estudo retrospectivo em fichas preenchidas prospectivamente referentes a 5974 pacientes. Foram comparadas duas fases: de Janeiro de 2002 a Dezembro de 2004 (antes da implantação do protocolo ACERTO: período AA, n=1987); e de Janeiro de 2005 a Dezembro de 2008 (após a implantação do mesmo: período DA, n=3987). Comparou-se tempo de internação hospitalar, hemotransfusões realizadas, infecções de sítio cirúrgico (ISC), complicações operatórias e óbitos. RESULTADOS: Houve uma diminuição em um dia no tempo de internação entre o período AA e DA (mediana [variação]: 4 [0-137] vs. 3 [0-126] dias e moda: 3 vs. 2 dias; p<0,001). No período AA houve uma relação de 2,53 bolsas de hemoderivados transfundidas por paciente contra 0,77 no período DA (p<0,001). Notou-se tendência decrescente no número de casos de ISC ao longo dos anos estudados (A=-153,08; AA:7,51% vs. DA: 3,36% (p<0,001; RR=2,23; IC95%:1,73-2,89). Houve ainda tendência decrescente em relação a complicações operatórias (A=-51,41; AA:7,9% vs. DA: 6,14%; p=0,02; RR=1,29; IC95%:1,03-1,60), reoperações (A=-57,10; AA:/2,65% vs. DA:1,19%; p<0,001; RR=2,22; IC95% 1,43-3,44) e óbitos (A=-62,07;2,81% vs.1,73%; p<<0,01; RR=1,63; IC95%:1,15-2,31). CONCLUSÃO: A introdução do protocolo ACERTO proporcionou melhora dos resultados cirúrgicos, expressos por menor tempo de permanência hospitalar, uso de hemoderivados, e diminuição dos casos de infecção do sítio cirúrgico, complicações operatórias e óbitos.

Manejo atual das metástases hepáticas de câncer colorretal: recomendações do Clube do Fígado de São Paulo

Aproximadamente metade dos pacientes portadores de câncer colorretal apresenta metástases hepáticas durante a evolução de sua doença que afetam diretamente o prognóstico e são diretamente responsáveis por 2/3 dos óbitos relacionados à doença. Nas últimas duas décadas o tratamento das metástases hepáticas de câncer colorretal (MHCCR) proporcionou ganho expressivo na sobrevida quando todas as opções terapêuticas são colocadas à disposição do paciente. Nesse contexto, o tratamento cirúrgico persiste como a única possibilidade de cura com índices de sobrevida em cinco anos de 25 a 58%. No entanto, apenas 1/4 dos pacientes tem doença ressecável ao diagnóstico. Por essa razão, um dos pontos fundamentais no manejo atual dos pacientes com MHCCR é o desenvolvimento de estratégias que possibilitem a ressecção completa das lesões hepáticas. O advento e aperfeiçoamento dos métodos ablativos expandiram as possibilidades da terapêutica cirúrgica, além disto, o surgimento de novos esquemas quimioterápicos e a introdução das terapias-alvo proporcionou altas taxas de resposta e alteraram definitivamente o manejo destes pacientes. O tratamento multimodal e a utilização da experiência de diversas especialidades médicas permitiram que o tratamento das MHCCR se aproximasse cada vez mais do tratamento ideal, ou seja, individualizado. Baseado em uma extensa revisão da literatura e na experiência de alguns dos centros especializados mais importantes do Brasil, o Clube do Fígado de São Paulo iniciou um trabalho de discussão multi-institucional que resultou nas recomendações que se seguem. Essas recomendações, no entanto, não visam ser absolutas, mas sim ferramentas úteis no processo de decisão terapêutica desse grupo complexo de pacientes.

Simulerade skoldilemman : redskap för utveckling av reflektionsförmåga?

Syftet med avhandlingen är att studera lärarstuderandes samtal om simulerad skolverksamhet för att söka förstå möjligheter och begränsningar med simulerade dilemman som medierande redskap för reflektion över lärares arbete. Undersökningen är genomförd under seminarier i svensk och finländsk lärarutbildning. Forskningsprocessen består av tre faser; en konstruktionsfas, en prövningsfas och en undersökningsfas. Under konstruktionsfasen producerades simuleringar på basen av en narrativ analys av semistrukturerade intervjuer med nyutbildade lärare. Simuleringarna testades med lärare och lärarstuderande i prövningsfasen. I undersökningsfasen utarbetades reflektionsfrågor och studiens empiriska data samlades in genom videoobservation. Totalt femton samtal filmades vid fem seminarier och tre olika lärosäten, två i Sverige och ett i Svenskfinland. De studerande som förekommer i datamaterialet befann sig i början, mitten och i slutet av sin lärarutbildning. Analysen bygger på Schöns olika reflektionsbegrepp och ett sociokulturellt perspektiv som bygger på den ryska kulturhistoriska skolan. Resultaten visar att de studerande engagerade sig starkt i samtalen i de flesta fall och att engagemanget var relaterat till deras uppfattningar om simuleringens autenticitet. Simuleringarna och reflektionsfrågorna användes både som sekundära och tertiära artefakter. Bland simuleringarnas modaliteter framstod ljudet som den viktigaste för nyanser av förståelse och engagemang och reflektionsfrågorna fungerade som kommunikativt stöd och strukturell scaffolding. När de studerande använde simuleringen för dekontextualisering i en öppen dialog förekom en tertiär dialog, i vilken förhandling av ny mening ägde rum. Kreativ reflektion – att se dilemmat ur olika perspektiv och reciprok reflektion – öppen utmanande dialog förekom flitigt i vilka en didaktiskanalytisk praktikgemenskap skapades. Slutsatserna är att simulerade skoldilemman kan utgöra en potential för lärarstuderandes utveckling av reflektionsförmåga när de används i mindre samtalsgrupper och den didaktiska inramningen relateras till aktuellt kursinnehåll. Om simuleringens innehåll inte upplevs som autentiskt finns dock risk för att förutfattade meningar om lärares arbete förstärks om de inte utmanas av medstuderande eller lärarutbildare.

Elever syns på nätet : multimodala texter och autentiska mottagare

This study is based on the notion that all students are likely to have a computer of some kind as their primary tool at school within a few years. The overall aim is to contribute to the knowledge of what this development of computer-assisted multimodal text production and communication on and over the net may entail in a school context. The study has an abductive approach drawing on theory from Media and Communication studies and from Pedagogy - particularly on media peda-gogy, multimodality, storytelling, conversation research and deliberative democracy – and is based on a DBR project in three schools. The empirical data are retrieved from four school classes, school years 4 and 5, with good access to computers and digital cameras. The classes have used the class blogs to tell the blog visitors about their school work and Skype to communicate with other classes in Sweden and Tanzania. A variety of research methods was employed: content analysis of texts, observations with field notes and camera documentation, interviews with individual students, group interviews with teachers and students, and a small survey. The study is essentially qualitative, focusing on students’ different perceptions. A small quantitative study was conducted to determine if any factors and variables could be linked to each other and to enable comparisons of the surveyed group with other research results. The results suggest that more computers at school offer more opportunities for real-life assignments and the chance to secure an authentic audience to the students’ production; primarily the students’ parents and relatives, students in the same class and at other schools. A theoretical analysis model to determine the degree of reality and authenticity in various school assignments was developed. The results also indicate that having access to cameras for documenting various events in the classes and to an authentic audience can create new opportunities for storytelling that have not been practiced previously at school. The documentary photo invites a viewer into the present tense of the image and the location where the picture was taken, whoever took the picture. It is used by the students and here too, a model has been developed to describe this relationship. The study also focuses on the freedom of expression and democracy. One of the more unexpected findings is that the students in the study did not see that they can influence other people’s perceptions or change various power structures through communication on the web, neither in nor outside of school.

La traduzione della letteratura per l’infanzia dal finlandese all’italiano: l’esempio degli albi illustrati di Mauri Kunnas

Despite the increasing number of research on translating for children, no study has so far taken into consideration the translations of children’s literature from Finnish into Italian. This dissertation sets out to fill this gap with a comparative study of Finnish picturebooks and their translations into Italian. Besides being the first research in the field analysing the shifts between these two systems, the study thoroughly investigates the characteristics of the translation process of picturebooks. The works chosen as case study are the Finnish picturebooks by Mauri Kunnas and their Italian translations from the period 1979-2009 because they are characterized by a high number of linguistic and cultural complexities which challenge translators’ skills and knowledge. The dissertation establishes whether and how culture-specific elements (anthroponyms, toponyms, food and allusions) and the word-image interaction have a significant impact on the quality and the nature of the target works, and also whether these aspects are still consistent after the translation and the adaptation process to the target system. Since picturebooks are multimodal texts whose message is produced by both the verbal and the visual, it has been necessary to use a multimodal comparative analysis. Such a descriptive comparative study has allowed me to describe the textual and cultural manipulations undergone by Kunnas’s picturebooks translated into Italian. Indeed, it has helped to identify what kind of shifts occur when cultural specific elements are transferred from the source system to the target one, to determine the most frequent translation strategies used to ensure a higher degree of readability, and to establish whether particular translation choices have contributed to modify the word-image interaction. The results of the multimodal comparative analysis have shown that Italian translators have been deeply influenced by the preponderance of the illustrations and for this reason they have often verbalised the visual and added information not originally contained in the source written text. Moreover, the findings of the analysis together with the interviews to the Italian translator and publishing house have also demonstrated that the latter aimed at producing works “good for the child” – and at the same time “good for the adult” – and at minimizing Finnish cultural specificity, even to the detriment of the aesthetic nature of the original picturebooks.

Heritage through Fiction: Dracula Tourism in Romania

Heritage and tourism have become inextricably linked. This link can be seen as producing inauthentic and falsified tradition, and it can therefore be seen as a threat to cultural heritage. On the other hand the link can be seen as a positive thing, as something which helps to preserve herit-age, culture and folklore in a changing and globalising world. This dissertation investigates heritage in the context of Dracula Tourism in Romania. Dracula tourism is tourism where tourists visit places connected with either the fictional vampire Dracula or the historical Dracula, a Romanian historical ruler Vlad the Impaler. The main research question of this study is how can Romanian heritage and culture be shown and promoted through a seemingly superficial Dracula tourism which is based on Western popular cul-ture? And is it possible to find Romanian heritage through popular fiction in Dracula tourism? The main sources for this work are based on the fieldwork done by the author in 2010 and 2011 and the web pages of ten Romanian travel agencies that offer Dracula tourism. The stories and images found on the web pages and used by the tour guides form the bulk of the research material. The emphasis and perspective of this research is folkloristic. Critical discourse analysis and multimodal discourse analysis form the main theoretical approach of this dissertation. In addition the research material is approached through intertextuality, folklore process, hybridisation, authenticity and social constructionism. This dissertation aims to offer new perspectives on the research literature concerning tourism and heritage and to offer a folkloristic view of tourism research. It also aims to offer new perspectives to folkloristics in terms of the research on the use of folklore and tradition and offer new perspectives on the use and definition of the concept of authenticity. Although the research subject of this thesis is Dracula tourism in Romania, the findings can be utilised and applied in a larger context and field of research. The key research findings show that heritage can be found within Dracula Tourism in three forms: as defined from above (UNESCO World Heritage Sites), as local heritage and as a form of opposition. The Romanian travel agencies researched in this dissertation use Dracula tourism as a gateway into Romanian history, culture, tradition and heritage. Kulttuuriperintö ja turismi yhdistyvät toisiinsa erottamattomasti. Toisaalta tämän yhteyden on nähty tuottavan epäautenttista ja väärennettyä perinnettä, ja tällöin sen on koettu muodostavan uhan kulttuuriperinnölle. Toisaalta yhteys on mielletty myös positiivisena asiana, sillä sen on nähty toimivan globalisoituvassa maailmassa kulttuuriperintöä, kulttuuria ja kansanperinnettä säilyttävänä tekijänä. Väitöskirjassa tutkitaan sitä, miten kulttuuriperintö ilmenee Dracula-turismissa Romaniassa. Dracula- turismi on turismia, joka liittyy joko fiktiiviseen vampyyrikreivi Draculaan tai historiallisena Draculana tunnettuun romanialaiseen hallitsijaan Vlad Seivästäjään. Väitöskirjan päätutkimuskysymyksenä on, miten romanialaista kulttuuriperintöä ja kulttuuria voidaan tuoda esiin näennäisesti pinnallisen ja länsimaiseen populaarikulttuuriin pohjautuvan Dracula-turismin kautta. Työn päälähteet pohjautuvat tutkijan vuosina 2010 ja 2011 tekemiin kenttätöihin sekä kymmenen Dracula-turismia tarjoavan romanialaisen matkatoimiston WWW-sivustoihin. Internet-sivuilta löytyvät tarinat ja kuvat sekä matkaoppaiden käyttämät tarinat muodostavat tutkimuksen tutkimusaineiston. Tutkimuksen painotus ja näkökulma ovat folkloristisia. Tutkimuksen teoreettinen viitekehys muodostuu kriittisestä diskurssianalyysistä sekä multimodaalisesta diskurssianalyysistä. Näiden lisäksi tutkimusaineistoa analysoidaan intertekstuaalisuuden, folkloreprosessin, hybridisaation, autenttisuuden ja sosiaalisen konstruktion käsitteiden avulla. Väitöskirjatutkimus tarjoaa uusia näkökulmia turismia ja kulttuuriperintöä käsittelevään tutkimukseen sekä tarjoaa matkailun tutkimukseen folkloristisen lisänäkökulman. Folkloristisen tutkimuksen näkökulmasta työn keskiössä ovat perinteen ja folkloren hyödyntäminen sekä autenttisuuden käsitteen määrittely ja käyttö, joihin työssä otetaan kantaa. Vaikka tutkimus käsittelee Dracula-turismia Romaniassa, ovat tutkimustulokset käytettävissä ja sovellettavissa myös laajemmin. Työn keskeiset tutkimustulokset osoittavat, että kulttuuriperintö ilmenee Dracula-turismissa kolmella eri tavalla: ylätasolla kuten esimerkiksi UNESCO:n kohteissa, alatasolla paikallisten ihmisten tai ihmisryhmien määrittelemänä sekä vastustuksen muotona. Väitöskirjassa tutkitut matkatoimistot käyttävät Dracula-turismia ikään kuin porttina romanialaiseen historiaan, kulttuuriin, perinteeseen ja kulttuuriperinteeseen.

Anaesthesia and Pain Management for Use in Orthopaedic Day Surgery

Day surgery has gained a large popularity during the last decades. In Finland, 57% of the elective procedures, and 50% at Turku University Hospital, were already conducted on day basis during 2012. The steady growth of day surgery is mostly due to an increased safety in perioperative care and cost-effectiveness. The development of surgical techniques and anaesthetic methods has advanced the modern day surgery and extended the repertory of the procedures for use in day surgery operations. Day surgery also offers certain benefits like reduced risk for hospital-related infections, stress and confusion. Patient satisfaction, regarding several issues, is high. Most concerns and complaints are related to postoperative pain, nausea and vomiting pain and nausea. Pain can hamper recovery and pain management is a crucial factor for hospital discharge. Appropriate pain treatment is effective, safe, easy and economical. A procedure-specific approach and an individually planned, multimodal analgesia should be the basis of modern pain management. The main aim of this thesis was to evaluate the effectiveness and safety of anaesthetic technique and methods in pain treatment of orthopaedic day case surgery, and following conclusions were made. Unilateral spinal block was achieved using hyperbaric bupivacaine with a small dose of clonidine but clonidine prolonged the block. Continuous subacromial bupivacaine was found to be safe but conferring only moderate efficacy in pain care after shoulder arthroscopy. Transdermal fentanyl, 12 g/h, as part of multimodal analgesia, offered a safe and easy option to pain management in this patient group. However, after forefoot surgery, it did not reduce pain any further. In general, pain scores in all patient groups were low and the need for rescue opioid moderate.

Dendritic thickness: a morphometric parameter to classify mouse retinal ganglion cells

To study the dendritic morphology of retinal ganglion cells in wild-type mice we intracellularly injected these cells with Lucifer yellow in an in vitro preparation of the retina. Subsequently, quantified values of dendritic thickness, number of branching points and level of stratification of 73 Lucifer yellow-filled ganglion cells were analyzed by statistical methods, resulting in a classification into 9 groups. The variables dendritic thickness, number of branching points per cell and level of stratification were independent of each other. Number of branching points and level of stratification were independent of eccentricity, whereas dendritic thickness was positively dependent (r = 0.37) on it. The frequency distribution of dendritic thickness tended to be multimodal, indicating the presence of at least two cell populations composed of neurons with dendritic diameters either smaller or larger than 1.8 µm ("thin" or "thick" dendrites, respectively). Three cells (4.5%) were bistratified, having thick dendrites, and the others (95.5%) were monostratified. Using k-means cluster analysis, monostratified cells with either thin or thick dendrites were further subdivided according to level of stratification and number of branching points: cells with thin dendrites were divided into 2 groups with outer stratification (0-40%) and 2 groups with inner (50-100%) stratification, whereas cells with thick dendrites were divided into one group with outer and 3 groups with inner stratification. We postulate, that one group of cells with thin dendrites resembles cat ß-cells, whereas one group of cells with thick dendrites includes cells that resemble cat a-cells.

Classification of brain tumor extracts by high resolution ¹H MRS using partial least squares discriminant analysis

High resolution proton nuclear magnetic resonance spectroscopy (¹H MRS) can be used to detect biochemical changes in vitro caused by distinct pathologies. It can reveal distinct metabolic profiles of brain tumors although the accurate analysis and classification of different spectra remains a challenge. In this study, the pattern recognition method partial least squares discriminant analysis (PLS-DA) was used to classify 11.7 T ¹H MRS spectra of brain tissue extracts from patients with brain tumors into four classes (high-grade neuroglial, low-grade neuroglial, non-neuroglial, and metastasis) and a group of control brain tissue. PLS-DA revealed 9 metabolites as the most important in group differentiation: γ-aminobutyric acid, acetoacetate, alanine, creatine, glutamate/glutamine, glycine, myo-inositol, N-acetylaspartate, and choline compounds. Leave-one-out cross-validation showed that PLS-DA was efficient in group characterization. The metabolic patterns detected can be explained on the basis of previous multimodal studies of tumor metabolism and are consistent with neoplastic cell abnormalities possibly related to high turnover, resistance to apoptosis, osmotic stress and tumor tendency to use alternative energetic pathways such as glycolysis and ketogenesis.

A spheroid-based 3-D culture model for pancreatic cancer drug testing, using the acid phosphatase assay

Current therapy for pancreatic cancer is multimodal, involving surgery and chemotherapy. However, development of pancreatic cancer therapies requires a thorough evaluation of drug efficacy in vitro before animal testing and subsequent clinical trials. Compared to two-dimensional culture of cell monolayer, three-dimensional (3-D) models more closely mimic native tissues, since the tumor microenvironment established in 3-D models often plays a significant role in cancer progression and cellular responses to the drugs. Accumulating evidence has highlighted the benefits of 3-D in vitro models of various cancers. In the present study, we have developed a spheroid-based, 3-D culture of pancreatic cancer cell lines MIAPaCa-2 and PANC-1 for pancreatic drug testing, using the acid phosphatase assay. Drug efficacy testing showed that spheroids had much higher drug resistance than monolayers. This model, which is characteristically reproducible and easy and offers rapid handling, is the preferred choice for filling the gap between monolayer cell cultures and in vivo models in the process of drug development and testing for pancreatic cancer.

Paisagens de ausência e de vazio

Este estudo procura evidenciar a natureza lacunar e intersticial da espacialidade própria à experiência sensível, segundo o último Merleau-Ponty, aquele da notas de trabalho de Le visible et l'invisible. Para tanto, são discutidos os momentos em que, no trato tanto com a perceptibilidade quanto com a intersubjetividade, Merleau-Ponty evoca a vida intencional a partir da analogia com a experiência estética em sua selvagem polissemia. O estudo especula que, apesar da evidência de que a plasticidade multimodal da arte moderna fornece renovado suporte para a interpretação da experiência sensorial, tarefa impossível para a racionalidade, a teoria do último Merleau-Ponty parece incapaz de propor uma noção consistente de negatividade.