Integration of Economics into Life Cycle Assessment in the Finnish Pulp and Paper Industry

Taloudellisen laskennan yhdistäminen elinkaariarviointiin (LCA) on alkanut kiinnostaa eri teollisuuden aloja maailmanlaajuisesti viime aikoina. Useat LCA-tietokoneohjelmat sisältävät kustannuslaskentaominaisuuksia ja yksittäiset projektit ovat yhdistäneet ympäristö- ja talouslaskentamenetelmiä. Tässä projektissa tutkitaan näiden yhdistelmien soveltuvuutta suomalaiselle sellu- ja paperiteollisuudelle, sekä kustannuslaskentaominaisuuden lisäämistä KCL:n LCA-ohjelmaan, KCL-ECO 3.0:aan. Kaikki tutkimuksen aikana löytyneet menetelmät, jotka yhdistävät LCA:n ja taloudellista laskentaa, on esitelty tässä työssä. Monet näistä käyttävät elinkaarikustannusarviointia (LCCA). Periaatteessa elinkaari määritellään eri tavalla LCCA:ssa ja LCA:ssa, mikä luo haasteita näiden menetelmien yhdistämiselle. Sopiva elinkaari tulee määritellä laskennan tavoitteiden mukaisesti. Työssä esitellään suositusmenetelmä, joka lähtee suomalaisen sellu- ja paperiteollisuuden erikoispiirteistä. Perusvaatimuksena on yhteensopivuus tavanomaisesti paperin LCA:ssa käytetyn elinkaaren kanssa. Menetelmän yhdistäminen KCL-ECO 3.0:aan on käsitelty yksityiskohtaisesti.

Participation rates for organized colorectal cancer screening programmes: an international comparison.

OBJECTIVE: Participation, an indicator of screening programme acceptance and effectiveness, varies widely in clinical trials and population-based colorectal cancer (CRC) screening programmes. We aimed to assess whether CRC screening participation rates can be compared across organized guaiac fecal occult blood test (G-FOBT)/fecal immunochemical test (FIT)-based programmes, and what factors influence these rates. METHODS: Programme representatives from countries participating in the International Cancer Screening Network were surveyed to describe their G-FOBT/FIT-based CRC screening programmes, how screening participation is defined and measured, and to provide participation data for their most recent completed screening round. RESULTS: Information was obtained from 15 programmes in 12 countries. Programmes varied in size, reach, maturity, target age groups, exclusions, type of test kit, method of providing test kits and use, and frequency of reminders. Coverage by invitation ranged from 30-100%, coverage by the screening programme from 7-67.7%, overall uptake/participation rate from 7-67.7%, and first invitation participation from 7-64.3%. Participation rates generally increased with age and were higher among women than men and for subsequent compared with first invitation participation. CONCLUSION: Comparisons among CRC screening programmes should be made cautiously, given differences in organization, target populations, and interpretation of indicators. More meaningful comparisons are possible if rates are calculated across a uniform age range, by gender, and separately for people invited for the first time vs. previously.

Dépistage du risque d'allergie et prévention en maternité : enquête des pratiques AllerNaiss [Screening for the risk of allergy and prevention in French maternity units: A survey].

Allergy has been on the rise for half a century and concerns nearly 30% of children; it has now become a real public health problem. The guidelines on prevention of allergy set up by the French Society of Paediatrics (SFP) and the European Society of Paediatric Allergology and Clinical Immunology (ESPACI) are based on screening children at risk through a systematic search of the family history and recommend, for children at risk, exclusive breastfeeding whenever possible or otherwise utilization of hypoallergenic infant formula, which has demonstrated efficacy. The AllerNaiss practice survey assessed the modes of screening and prevention of allergy in French maternity units in 2012. The SFP guidelines are known by 82% of the maternity units that took part in the survey, and the ESPACI guidelines by 55% of them. A screening strategy is in place in 59% of the participating maternity wards, based on local consensus for 36% of them, 13% of the units having a written screening procedure. Screening is based on the search for a history of allergy in first-degree relatives (99%) during pregnancy (51%), in the delivery room (50%), and after delivery (89%). A mode of prevention of the risk of allergy exists in 62% of the maternity units, most often in writing (49%). A hypoallergenic infant formula is prescribed for non-breastfed children in 90% of the units. The survey shows that there is a real need for formalization of allergy risk screening and prevention of allergy in newborns in French maternity units.

Abdominal Aortic Aneurysm: What About Screening?

The prevalence of abdominal aortic aneurysm (AAA) in general population is 4-9% with a high mortality rate when ruptured. Therefore, screening programs were developed in many countries to detect small and large AAA in selected patients. Indeed, prevalence of AAA increases in patients over 65 years old with cigarette smoking history. This paper reviews recent literature related to AAA screening focusing on epidemiology, screening tests and evidence based medicine to highlight not only advantages but also disadvantages of screening programs among population.

Non-invasive prenatal testing for aneuploidy and beyond: challenges of responsible innovation in prenatal screening.

This paper contains a joint ESHG/ASHG position document with recommendations regarding responsible innovation in prenatal screening with non-invasive prenatal testing (NIPT). By virtue of its greater accuracy and safety with respect to prenatal screening for common autosomal aneuploidies, NIPT has the potential of helping the practice better achieve its aim of facilitating autonomous reproductive choices, provided that balanced pretest information and non-directive counseling are available as part of the screening offer. Depending on the health-care setting, different scenarios for NIPT-based screening for common autosomal aneuploidies are possible. The trade-offs involved in these scenarios should be assessed in light of the aim of screening, the balance of benefits and burdens for pregnant women and their partners and considerations of cost-effectiveness and justice. With improving screening technologies and decreasing costs of sequencing and analysis, it will become possible in the near future to significantly expand the scope of prenatal screening beyond common autosomal aneuploidies. Commercial providers have already begun expanding their tests to include sex-chromosomal abnormalities and microdeletions. However, multiple false positives may undermine the main achievement of NIPT in the context of prenatal screening: the significant reduction of the invasive testing rate. This document argues for a cautious expansion of the scope of prenatal screening to serious congenital and childhood disorders, only following sound validation studies and a comprehensive evaluation of all relevant aspects. A further core message of this document is that in countries where prenatal screening is offered as a public health programme, governments and public health authorities should adopt an active role to ensure the responsible innovation of prenatal screening on the basis of ethical principles. Crucial elements are the quality of the screening process as a whole (including non-laboratory aspects such as information and counseling), education of professionals, systematic evaluation of all aspects of prenatal screening, development of better evaluation tools in the light of the aim of the practice, accountability to all stakeholders including children born from screened pregnancies and persons living with the conditions targeted in prenatal screening and promotion of equity of access.

Responding to Young People's Health Risks in Primary Care: A Cluster Randomised Trial of Training Clinicians in Screening and Motivational Interviewing.

OBJECTIVE: To evaluate the effectiveness of a complex intervention implementing best practice guidelines recommending clinicians screen and counsel young people across multiple psychosocial risk factors, on clinicians' detection of health risks and patients' risk taking behaviour, compared to a didactic seminar on young people's health. DESIGN: Pragmatic cluster randomised trial where volunteer general practices were stratified by postcode advantage or disadvantage score and billing type (private, free national health, community health centre), then randomised into either intervention or comparison arms using a computer generated random sequence. Three months post-intervention, patients were recruited from all practices post-consultation for a Computer Assisted Telephone Interview and followed up three and 12 months later. Researchers recruiting, consenting and interviewing patients and patients themselves were masked to allocation status; clinicians were not. SETTING: General practices in metropolitan and rural Victoria, Australia. PARTICIPANTS: General practices with at least one interested clinician (general practitioner or nurse) and their 14-24 year old patients. INTERVENTION: This complex intervention was designed using evidence based practice in learning and change in clinician behaviour and general practice systems, and included best practice approaches to motivating change in adolescent risk taking behaviours. The intervention involved training clinicians (nine hours) in health risk screening, use of a screening tool and motivational interviewing; training all practice staff (receptionists and clinicians) in engaging youth; provision of feedback to clinicians of patients' risk data; and two practice visits to support new screening and referral resources. Comparison clinicians received one didactic educational seminar (three hours) on engaging youth and health risk screening. OUTCOME MEASURES: Primary outcomes were patient report of (1) clinician detection of at least one of six health risk behaviours (tobacco, alcohol and illicit drug use, risks for sexually transmitted infection, STI, unplanned pregnancy, and road risks); and (2) change in one or more of the six health risk behaviours, at three months or at 12 months. Secondary outcomes were likelihood of future visits, trust in the clinician after exit interview, clinician detection of emotional distress and fear and abuse in relationships, and emotional distress at three and 12 months. Patient acceptability of the screening tool was also described for the intervention arm. Analyses were adjusted for practice location and billing type, patients' sex, age, and recruitment method, and past health risks, where appropriate. An intention to treat analysis approach was used, which included multilevel multiple imputation for missing outcome data. RESULTS: 42 practices were randomly allocated to intervention or comparison arms. Two intervention practices withdrew post allocation, prior to training, leaving 19 intervention (53 clinicians, 377 patients) and 21 comparison (79 clinicians, 524 patients) practices. 69% of patients in both intervention (260) and comparison (360) arms completed the 12 month follow-up. Intervention clinicians discussed more health risks per patient (59.7%) than comparison clinicians (52.7%) and thus were more likely to detect a higher proportion of young people with at least one of the six health risk behaviours (38.4% vs 26.7%, risk difference [RD] 11.6%, Confidence Interval [CI] 2.93% to 20.3%; adjusted odds ratio [OR] 1.7, CI 1.1 to 2.5). Patients reported less illicit drug use (RD -6.0, CI -11 to -1.2; OR 0·52, CI 0·28 to 0·96), and less risk for STI (RD -5.4, CI -11 to 0.2; OR 0·66, CI 0·46 to 0·96) at three months in the intervention relative to the comparison arm, and for unplanned pregnancy at 12 months (RD -4.4; CI -8.7 to -0.1; OR 0·40, CI 0·20 to 0·80). No differences were detected between arms on other health risks. There were no differences on secondary outcomes, apart from a greater detection of abuse (OR 13.8, CI 1.71 to 111). There were no reports of harmful events and intervention arm youth had high acceptance of the screening tool. CONCLUSIONS: A complex intervention, compared to a simple educational seminar for practices, improved detection of health risk behaviours in young people. Impact on health outcomes was inconclusive. Technology enabling more efficient, systematic health-risk screening may allow providers to target counselling toward higher risk individuals. Further trials require more power to confirm health benefits. TRIAL REGISTRATION: ISRCTN.com ISRCTN16059206.

The long run impact of mergers and acquisitions on performance – empirical study in the pulp and paper industry

Mergers and acquisitions (M&A) have played very important role in restructuring the pulp and paper industry (PPI). The poor performance and fragmented nature of the industry, overcapacity problems, and globalisation have driven companies to consolidate. The objective of this thesis was to examine how PPI acquirers’ have performed subsequent M&As and whether the deal characteristics have had any impact on performance. Based on the results it seems that PPI companies have not been able to enhance their performance in the long run after M&As although the per-formance of acquiring firms has remained above the industry median, and deal characteristics or the amount of premiums paid do not seem to have had any effect. The statistical significance of the results was tested with change model and regression analysis. Performance was assessed with accrual, cash flow, and market based indicators. Results are congruent with behavioural theory: managers and investors seem to be overoptimistic in determining the synergies from M&As.

Why and how would we implement a lung cancer screening program?

For decades, lung cancer has been the most common cancer in terms of both incidence and mortality. There has been very little improvement in the prognosis of lung cancer. Early treatment following early diagnosis is considered to have potential for development. The National Lung Screening Trial (NLST), a large, well-designed randomized controlled trial, evaluated low-dose computed tomography (LDCT) as a screening tool for lung cancer. Compared with chest X-ray, annual LDCT screening reduced death from lung cancer and overall mortality by 20 and 6.7 %, respectively, in high-risk people aged 55-74 years. Several smaller trials of LDCT screening are under way, but none are sufficiently powered to detect a 20 % reduction in lung cancer death. Thus, it is very unlikely that the NLST results will be replicated. In addition, the NLST raises several issues related to screening, such as the high false-positive rate, overdiagnosis and cost. Healthcare providers and systems are now left with the question of whether the available findings should be translated into practice. We present the main reasons for implementing lung cancer screening in high-risk adults and discuss the main issues related to lung cancer screening. We stress the importance of eligibility criteria, smoking cessation programs, primary care physicians, and informed-decision making should lung cancer screening be implemented. Seven years ago, we were waiting for the results of trials. Such evidence is now available. Similar to almost all other cancer screens, uncertainties exist and persist even after recent scientific efforts and data. We believe that by staying within the characteristics of the original trial and appropriately sharing the evidence as well as the uncertainties, it is reasonable to implement a LDCT lung cancer screening program for smokers and former smokers.

On the rationale of population screening for chronic kidney disease : a public health perspective

Chronic kidney disease (CKD) and its complications represent an enormous and increasing public health burden worldwide [1]. More than one in ten adults suffers from CKD in the general population [2], with a majority of people being in its early stages (i.e. 1 to 3) [2]. In the general population, the prevalence of CKD sharply increases with age [3]. CKD can be considered as a condition associated with premature ageing with accelerated vascular disease [4]. The large number of people with CKD, or at high risk of CKD (i.e. patients with hypertension, diabetes and/or CVD), implies that primary care providers and specialists other than nephrologists frequently encounter patients with CKD [5], a situation in which most CKD cases are diagnosed via opportunistic kidney function screening or automated eGFR reporting. The aim of this review is to discuss the rationale and currently available evidence for, or against, population-based screening for CKD. The focus will be on the situation of screening asymptomatic individuals at early stages of CKD regardless of the presence or absence of CKD risk factors.

Lajittumisen dynamiikka epäpuhtauksien ja kuitujen painelajittelussa

Viimevuosina kuvantamistekniikat ovat kehittyneet huomattavasti. Näiden uusien tekniikoiden avulla voidaan tarkastella erilaisia prosesseja aiempaa tarkemmin. Painelajittelun teoriat perustuvat pääasiassa makrotason mittauksien pohjalta tehtyihin matemaattisiin malleihin, ja itse lajittumistapahtumaa ei ole aiemmin päästy kovinkaan tarkasti havainnoimaan. Tämän työn tavoitteena olikin selvittää lajittumistapahtumaa uuden kuvantamistekniikan avulla. Työn kirjallisuusosassa esiteltiin lyhyesti painelajitin ja sen toiminta. Myös painelajittelun perusteoriat käytiin lyhyesti läpi. Teoriaosan pääpaino oli lajittumistapahtumassa ja siihen vaikuttavissa tekijöissä. Lisäksi teoriaosassa esiteltiin teollisen painelajittelun nykytilannetta, työtä varten tehdyn esiselvityksen pohjalta. Lajitinsimulaattorikoeajoissa selvitettiin kuitujen ja roskapartikkelien käyttäyty-mistä painelajittimessa kuvantamisen avulla. Kuvauksissa keskityttiin rakosihdin raon tapahtumiin, sekä sihtipinnan tapahtumiin. Kuvamateriaalista laskettiin kuitujen ja roskien liikenopeuksia lankasihtiprofiilin raossa, sekä sihdin pinnalla. Lisäksi tutkittiin kehänopeuden, tuotannon ja sakeuden vaikutusta liike-nopeuksiin. Kuvamateriaalista pyrittiin myös havainnoimaan mahdollista kuitujen takaisinvirtausta. Kuvantamisella saatiin uutta tietoa kuitujen ja roskapartikkelien liikkeestä painelajittimessa. Tuloksista kävi muun muassa ilmi, että roottorin elementin pienimmän välyksen kohdalla akseptoituu huomattava määrä massaa. Tämä selittyy sillä, että pienimmän välyksen kohta tuottaa huomattavan positiivisen painepulssin. Kuitujen ja roskapartikkelien nopeudet raossa noudattelivat muutenkin hyvin selkeästi elementin tuottamaa painepulssia. Lisäksi kuvamateriaalista havaittiin, että sihdin raon suulle kertyy profiilin korkuinen kuituflokki. Koko sihdin peittävää kuitumattoa ei havaittu.

Screening and overdiagnosis : public health implications

Overdiagnosis is the diagnosis of an abnormality that bears no substantial health hazard and no benefit for patients to be aware of. Resulting mainly from the use of increasingly sensitive screening and diagnostic tests, as well as broadened definitions of conditions requiring an intervention, overdiagnosis is a growing but still largely misunderstood public health issue. Fear of missing a diagnosis or of litigation, financial incentives or patient's need of reassurance are further causes of overdiagnosis. The main consequence of overdiagnosis is overtreatment. Treating an overdiagnosed condition bears no benefit but can cause harms and generates costs. Overtreatment also diverts health professionals from caring for those most severely ill. Recognition of overdiagnosis due to screening is challenging since it is rarely identifiable at the individual level and difficult to quantify precisely at the population level. Overdiagnosis exists even for screening of proven efficacy and efficiency. Measures to reduce overdiagnosis due to screening include heightened sensitization of health professionals and patients, active surveillance and deferred treatment until early signs of disease progression and prognosis estimation through biomarkers (including molecular) profiling. Targeted screening and balanced information on its risk and benefits would also help limit overdiagnosis. Research is needed to assess the the public health burden and implications of overdiagnosis due to screening activity.

Screening for cardiovascular disease risk factors beginning in childhood

Cardiovascular diseases (CVD) are the leading cause of death worldwide. Individual detection and intervention on CVD risk factors and behaviors throughout childhood and adolescence has been advocated as a strategy to reduce CVD risk in adulthood. The U.S. National Heart, Lung, and Blood Institute (NHLBI) has recently recommended universal screening of several risk factors in children and adolescents, at odds with several recommendations of the U.S. Services Task Force and of the U.K. National Screening committee. In the current review, we discuss the goals of screening for CVD risk factors (elevated blood pressure, abnormal blood lipids, diabetes) and behaviors (smoking) in children and appraise critically various screening recommendations. Our review suggests that there is no compelling evidence to recommend universal screening for elevated blood pressure, abnormal blood lipids, abnormal blood glucose, or smoking in children and adolescents. Targeted screening of these risk factors could be useful but specific screening strategies have to be evaluated. Research is needed to identify target populations, screening frequency, intervention, and follow-up. Meanwhile, efforts should rather focus on the primordial prevention of CVD risk factors and at maintaining a lifelong ideal cardiovascular health through environmental, policy, and educational approaches.

Diversification and its reflections on profitability - strategic change in pulp and paper industry in the years 1996 and 2006

The purpose of the thesis was to analyze diversification in pulp and paper industry (PPI), which is an industry facing enormous strategic challenges as many of the basic parameters of its operational environment are rapidly changing. The objective was to explore, how PPI companies have reacted to these changes by adjusting their strategies in terms of diversification and how the adjustments have affected their profitability. The study was statistical in nature. The results indicate that PPI companies in deed had reduced the degree of unrelated and related diversification , but the positive performance implications of the changes were debatable. In light of the data used in the study lower level of diversification did not lead to better profitability, in fact, the companies with the highest level of diversification had the best profitability. By contrast, reducing the level of unrelated diversification improved the profitability development; whereas reducing the level of related diversification deteriorated the profitability of the company. The results were not statistically significant and they cannot be generalized outside the data of the study.

Impact of Investment Strategies on Performance in Pulp and Paper Industry

The main objective of this study was to examine, what kind of investment strategies the leading European and North American pulp and paper industry companies (PPI) used in 1991-2003, and how the selected strategies affected their performance. The investment strategies were categorised in three classes including mergers and acquisitions, investments in new capacity and investments in existing capacity. The results showed that mergers and acquisitions represented the largest share of total investments in 1991-2003 followed by investments in existing capacity. PPI companies changed investment strategies over time by increasing the share of mergers and acquisitions, which decreased investments in new capacity especially among North American companies. According to the results, good asset quality and investments in new and existing capacity provided better profitability than often expensive acquisitions. Also the capacity decreases had a positive impact on profitability. Average asset quality and profitability were higher among European companies. The study concluded that in the long term the available value creating investment opportunities should limit capital expenditure levels, not the relation of capital expenditure to depreciation.

Screening for cardiovascular disease risk and subsequent management in low and middle income countries : challenges and opportunities

Background: Cardiovascular disease (CVD), mainly heart attack and stroke, is the leading cause of premature mortality in low and middle income countries (LMICs). Identifying and managing individuals at high risk of CVD is an important strategy to prevent and control CVD, in addition to multisectoral population-based interventions to reduce CVD risk factors in the entire population. Methods: We describe key public health considerations in identifying and managing individuals at high risk of CVD in LMICs. Results: A main objective of any strategy to identify individuals at high CVD risk is to maximize the number of CVD events averted while minimizing the numbers of individuals needing treatment. Scores estimating the total risk of CVD (e.g. ten-year risk of fatal and non-fatal CVD) are available for LMICs, and are based on the main CVD risk factors (history of CVD, age, sex, tobacco use, blood pressure, blood cholesterol and diabetes status). Opportunistic screening of CVD risk factors enables identification of persons with high CVD risk, but this strategy can be widely applied in low resource settings only if cost effective interventions are used (e.g. the WHO Package of Essential NCD interventions for primary health care in low resource settings package) and if treatment (generally for years) can be sustained, including continued availability of affordable medications and funding mechanisms that allow people to purchase medications without impoverishing them (e.g. universal access to health care). This also emphasises the need to re-orient health systems in LMICs towards chronic diseases management.