Assessment of pelvic floor by three-dimensional-ultrasound in primiparous women according to delivery mode: initial experience from a single reference service in Brazil

PURPOSE: To evaluate changes to the pelvic floor of primiparous women with different delivery modes, using three-dimensional ultrasound. METHODS: A prospective cross-sectional study on 35 primiparae divided into groups according to the delivery mode: elective cesarean delivery (n=10), vaginal delivery (n=16), and forceps delivery (n=9). Three-dimensional ultrasound on the pelvic floor was performed on the second postpartum day with the patient in a resting position. A convex volumetric transducer (RAB4-8L) was used, in contact with the large labia, with the patient in the gynecological position. Biometric measurements of the urogenital hiatus were taken in the axial plane on images in the rendering mode, in order to assess the area, anteroposterior and transverse diameters, average thickness, and avulsion of the levator ani muscle. Differences between groups were evaluated by determining the mean differences and their respective 95% confidence intervals. The proportions of levator ani muscle avulsion were compared between elective cesarean section and vaginal birth using Fisher's exact test. RESULTS: The mean areas of the urogenital hiatus in the cases of vaginal and forceps deliveries were 17.0 and 20.1 cm², respectively, versus 12.4 cm² in the Control Group (elective cesarean). Avulsion of the levator ani muscle was observed in women who underwent vaginal delivery (3/25), however there was no statistically significant difference between cesarean section and vaginal delivery groups (p=0.5). CONCLUSION: Transperineal three-dimensional ultrasound was useful for assessing the pelvic floor of primiparous women, by allowing pelvic morphological changes to be differentiated according to the delivery mode.

Reference range of uterine artery Doppler parameters between the 11th and 14th pregnancy weeks in a population sample from Northeast Brazil

PURPOSE: To establish reference values for the first trimester uterine artery resistance index (UtA-RI) and pulsatility index (UtA-PI) in healthy singleton pregnant women from Northeast Brazil. METHODS: A prospective observational cohort study including 409 consecutive singleton pregnancies undergoing routine early ultrasound screening at 11 - 14 weeks of gestation was performed. The patients responded to a questionnaire to assess maternal epidemiological characteristics. The left and right UtA-PI and UtA-RI were examined by color and pulsed Doppler by transabdominal technique and the mean UtA-PI, mean UtA-RI and the presence of bilateral protodiastolic notching were recorded. Quartile regression was used to estimate reference values. RESULTS: The mean±standard deviation UtA-RI and UtA-PI were 0.7±0.1 and 1.5±0.5, respectively. When segregated for gestation age, mean UtA-PI was 1.6±0.5 at 11 weeks, 1.5±0.6 at 12 weeks, 1.4±0.4 at 13 weeks and 1.3±0.4 at 14 weeks' gestation and mean UtA-RI was 0.7±0.1 at 11 weeks, 0.7±0.1 at 12 weeks, 0.6±0.1 at 13 weeks and 0.6±0.1 at 14 weeks' gestation. Uterine artery bilateral notch was present in 261 (63.8%) patients. We observed that the 5th and 95th percentiles of the UtA-PI and UtA-RI uterine arteries were 0.7 and 2.3 and, 0.5 and 0.8, respectively. CONCLUSION: Normal reference range of uterine artery Doppler in healthy singleton pregnancies from Northeast Brazil was established. The 95th percentile of UtA-PI and UtA-RI values may serve as a cut-off for future prediction of pregnancy complications studies (i.e., pre-eclampsia) in Northeast Brazil.

Pregnancy in women undergoing hemodialysis: case series in a Southeast Brazilian reference center

PURPOSE: To describe maternal and neonatal outcomes in pregnant women undergoing hemodialysis in a referral center in Brazilian Southeast side.METHODS: Retrospective and descriptive study, with chart review of all pregnancies undergoing hemodialysis that were followed-up at an outpatient clinic of high- risk prenatal care in Southeast Brazil.RESULTS: Among the 16 women identified, 2 were excluded due to follow-up loss. In 14 women described, hypertension was the most frequent cause of chronic renal failure (half of cases). The majority (71.4%) had performed hemodialysis treatment for more than one year and all of them underwent 5 to 6 hemodialysis sessions per week. Eleven participants had chronic hypertension, 1 of which was also diabetic, and 6 of them were smokers. Regarding pregnancy complications, 1 of the hypertensive women developed malignant hypertension (with fetal growth restriction and preterm delivery at 29 weeks), 2 had acute pulmonary edema and 2 had abruption placenta. The mode of delivery was cesarean section in 9 women (64.3%). All neonates had Apgar score at five minutes above 7.CONCLUSIONS: To improve perinatal and maternal outcomes of women undergoing hemodialysis, it is important to ensure multidisciplinary approach in referral center, strict control of serum urea, hemoglobin and maternal blood pressure, as well as close monitoring of fetal well-being and maternal morbidities. Another important strategy is suitable guidance for contraception in these women.

Occurrence and photochemical fate of selected pharmaceutical active ingredients in the aquatic environment

Läkemedel konsumeras årligen i enorma mängder världen över. Efter intag kommer en del av läkemedlets aktiva förening(ar) att utsöndras från kroppen med urin och fekalier för att sedan transporteras till avloppsreningsverk. Till följd av att reningsverken inte fullständigt förmår rena avloppsvattnet från dessa föreningar kommer de att kontinuerligt tillföras vattenmiljön. Således är det viktigt att utveckla analytiska metoder för att kunna studera halterna av de aktiva föreningarna i reningsverkens utloppsvatten och den närliggande vattenmiljön. Ute i naturen kommer föreningarna att utsättas för olika fysikaliska, kemiska och biologiska processer, vilka kan orsaka förändringar i deras kemiska struktur och därigenom deras identitet och biologiska aktivitet. En stor del av de befintliga aktiva föreningarna genomgår kemisk förändring då de i vattenmiljön utsätts för solljus (fototransformation). Genom fototransformation kan nya föreningar (transformationsprodukter) med andra kemiska och biologiska egenskaper bildas. Denna avhandling inriktar sig på de aktiva föreningarnas förekomst och fotokemiska öde i miljön. I avhandlingen presenteras framtagna analytiska metoder för kvantifiering av läkemedelsföreningar i avloppsvatten och ytvatten samt för studier av vissa utvalda föreningars fotokemiska transformationsvägar. Därtill beskrivs några syntetiska metoder för att få tillgång till transformationsprodukter av det antiinflammatoriska ämnet diklofenak.

Projektien markkinoinnin ja myynnin kehittäminen rakennusalan pk-yrityksessä Venäjän markkinoilla

Tämä diplomityö keskittyy kehittämään työssä käsiteltävän Venäjällä toimivan rakennusalan urakoitsijan projektien markkinointia ja myyntiä. Työssä paneudutaan projektimarkkinoinnin kautta yrityksen markkinointiin ja myyntiin. Käsittelyn aiheena ovat myös proaktiivinen markkinointi ja Venäjän rakennusmarkkinoiden aiheuttamat erityispiirteet. Tutkimuksesta selvisi, että yrityksellä on erityisesti ollut vaikeuksia saada ison luokan projekteja. Usein tähän on ollut syynä kilpailijoiden parempi taloudellinen kilpailukyky. Muutama projekti on myös keskeytynyt tai peruuntunut. Onnistuneiden tarjouskilpailuiden taustalla taas ovat olleet referenssikäynnit, hyvät suhteet asiakkaaseen ja laadukas suorittaminen. Projektimarkkinoinnin kirjallisuuden ja yrityksessä suoritettujen teemahaastattelujen pohjalta yritykselle kehitettiin ennakoivaa markkinointia painottava kokonaisvaltainen markkinointi- ja myyntiprosessi. Tärkeimpiä kohtia prosessissa ovat proaktiivinen projektien etsintä ja projektin valmistelu. Projekteja etsitään osallistumalla teollisuuden alan konferensseihin sekä ottamalla itse yhteyttä asiakkaaseen ja eri toimijoihin. Potentiaaliset projektit seulotaan suuremmasta joukosta ennalta määrättyjen kriteereiden avulla. Projekteihin pyritään aktiivisesti vaikuttamaan ennen tarjouskilpailua, jolloin myös järjestetään referenssikäyntejä. Neuvotteluissa sovelletaan kilpailutilanteen mukaan joustavaa kustannusperusteista hinnoittelua. Suoritetun urakan jälkeen asiakasyrityksen investointisuunnitelmia tutkitaan ja tarpeen vaatiessa pyritään säilyttämään yhteys nukkuvan suhteen aikana. Tällöin järjestetään asiakkaan kanssa seminaareja sekä epävirallisia ta-pahtumia. Yrityksen markkinointia ja myyntiä hankaloittavat Venäjän rakennusmarkkinoiden erityispiirteet. Epävarmuudesta aiheutuvat riskit pitää huomioida katteessa, mutta usein Venäjän erityisolosuhteet tulee vain hyväksyä, koska niihin on vaikea vaikuttaa.

Factors predicting mortality in type 2 diabetes. With special reference to physical exercise, blood pressure, proteinuria, inflammation and P wave duration

Background: Type 2 diabetes patients have a 2-4 fold risk of cardiovascular disease (CVD) compared to the general population. In type 2 diabetes, several CVD risk factors have been identified, including obesity, hypertension, hyperglycemia, proteinuria, sedentary lifestyle and dyslipidemia. Although much of the excess CVD risk can be attributed to these risk factors, a significant proportion is still unknown. Aims: To assess in middle-aged type 2 diabetic subjects the joint relations of several conventional and non-conventional CVD risk factors with respect to cardiovascular and total mortality. Subjects and methods: This thesis is part of a large prospective, population based East-West type 2 diabetes study that was launched in 1982-1984. It includes 1,059 middle-aged (45-64 years old) participants. At baseline, a thorough clinical examination and laboratory measurements were performed and an ECG was recorded. The latest follow-up study was performed 18 years later in January 2001 (when the subjects were 63-81 years old). The study endpoints were total mortality and mortality due to CVD, coronary heart disease (CHD) and stroke. Results: Physically more active patients had significantly reduced total, CVD and CHD mortality independent of high-sensitivity C-reactive protein (hs-CRP) levels unless proteinuria was present. Among physically active patients with a hs-CRP level >3 mg/L, the prognosis of CVD mortality was similar to patients with hs-CRP levels ≤3 mg/L. The worst prognosis was among physically inactive patients with hs-CRP levels >3 mg/L. Physically active patients with proteinuria had significantly increased total and CVD mortality by multivariate analyses. After adjustment for confounding factors, patients with proteinuria and a systolic BP <130 mmHg had a significant increase in total and CVD mortality compared to those with a systolic BP between 130 and 160 mmHg. The prognosis was similar in patients with a systolic BP <130 mmHg and ≥160 mmHg. Among patients without proteinuria, a systolic BP <130 mmHg was associated with a non-significant reduction in mortality. A P wave duration ≥114 ms was associated with a 2.5-fold increase in stroke mortality among patients with prevalent CHD or claudication. This finding persisted in multivariable analyses. Among patients with no comorbidities, there was no relationship between P wave duration and stroke mortality. Conclusions: Physical activity reduces total and CVD mortality in patients with type 2 diabetes without proteinuria or with elevated levels of hs-CRP, suggesting that the anti-inflammatory effect of physical activity can counteract increased CVD morbidity and mortality associated with a high CRP level. In patients with proteinuria the protective effect was not, however, present. Among patients with proteinuria, systolic BP <130 mmHg may increase mortality due to CVD. These results demonstrate the importance of early intervention to prevent CVD and to control all-cause mortality among patients with type 2 diabetes. The presence of proteinuria should be taken into account when defining the target systolic BP level for prevention of CVD deaths. A prolongation of the duration of the P wave was associated with increased stroke mortality among high-risk patients with type 2 diabetes. P wave duration is easy to measure and merits further examination to evaluate its importance for estimation of the risk of stroke among patients with type 2 diabetes.

Characterisation of waste for combustion : with special reference to the role of zinc

Waste combustion has gone from being a volume reducing discarding-method to an energy recovery process for unwanted material that cannot be reused or recycled. Different fractions of waste are used as fuel today, such as; municipal solid waste, refuse derived fuel, and solid recovered fuel. Furthermore, industrial waste, normally a mixture between commercial waste and building and demolition waste, is common, either as separate fuels or mixed with, for example, municipal solid waste. Compared to fossil or biomass fuels, waste mixtures are extremely heterogeneous, making it a complicated fuel. Differences in calorific values, ash content, moisture content, and changing levels of elements, such as Cl and alkali metals, are common in waste fuel. Moreover, waste contains much higher levels of troublesome trace elements, such as Zn, which is thought to accelerate a corrosion process. Varying fuel quality can be strenuous on the boiler system and may cause fouling and corrosion of heat exchanger surfaces. This thesis examines waste fuels and waste combustion from different angles, with the objective of giving a better understanding of waste as an important fuel in today’s fuel economy. Several chemical characterisation campaigns of waste fuels over longer time periods (10-12 months) was used to determine the fossil content of Swedish waste fuels, to investigate possible seasonal variations, and to study the presence of Zn in waste. Data from the characterisation campaigns were used for thermodynamic equilibrium calculations to follow trends and determine the effect of changing concentrations of various elements. The thesis also includes a study of the thermal behaviour of Zn and a full—scale study of how the bed temperature affects the volatilisation of alkali metals and Zn from the fuel. As mixed waste fuel contains considerable amounts of fresh biomass, such as wood, food waste, paper etc. it would be wrong to classify it as a fossil fuel. When Sweden introduced waste combustion as a part of the European Union emission trading system in the beginning of 2013 there was a need for combustion plants to find a usable and reliable method to determine the fossil content. Four different methods were studied in full-scale of seven combustion plants; 14Canalysis of solid waste, 14C-analysis of flue gas, sorting analysis followed by calculations, and a patented balance method that is using a software program to calculate the fossil content based on parameters from the plant. The study showed that approximately one third of the coal in Swedish waste mixtures has fossil origins and presented the plants with information about the four different methods and their advantages and disadvantages. Characterisation campaigns also showed that industrial waste contain higher levels of trace elements, such as Zn. The content of Zn in Swedish waste fuels was determined to be approximately 800 mg kg-1 on average, based on 42 samples of solid waste from seven different plants with varying mixtures between municipal solid waste and industrial waste. A review study of the occurrence of Zn in fuels confirmed that the highest amounts of Zn are present in waste fuels rather than in fossil or biomass fuels. In tires, Zn is used as a vulcanizing agent and can reach concentration values of 9600-16800 mg kg-1. Waste Electrical and Electronic Equipment is the second Zn-richest fuel and even though on average Zn content is around 4000 mg kg-1, the values of over 19000 mg kg-1 were also reported. The increased amounts of Zn, 3000-4000 mg kg-1, are also found in municipal solid waste, sludge with over 2000 mg kg-1 on average (some exceptions up to 49000 mg kg-1), and other waste derived fuels (over 1000 mg kg-1). Zn is also found in fossil fuels. In coal, the average level of Zn is 100 mg kg-1, the higher amount of Zn was only reported for oil shale with values between 20-2680 mg kg-1. The content of Zn in biomass is basically determined by its natural occurrence and it is typically 10-100 mg kg-1. The thermal behaviour of Zn is of importance to understand the possible reactions taking place in the boiler. By using thermal analysis three common Zn-compounds were studied (ZnCl2, ZnSO4, and ZnO) and compared to phase diagrams produced with thermodynamic equilibrium calculations. The results of the study suggest that ZnCl2(s/l) cannot exist readily in the boiler due to its volatility at high temperatures and its conversion to ZnO in oxidising conditions. Also, ZnSO4 decomposes around 680°C, while ZnO is relatively stable in the temperature range prevailing in the boiler. Furthermore, by exposing ZnO to HCl in a hot environment (240-330°C) it was shown that chlorination of ZnO with HCl gas is possible. Waste fuel containing high levels of elements known to be corrosive, for example, Na and K in combination with Cl, and also significant amounts of trace elements, such as Zn, are demanding on the whole boiler system. A full-scale study of how the volatilisation of Na, K, and Zn is affected by the bed temperature in a fluidised bed boiler was performed parallel with a lab-scale study with the same conditions. The study showed that the fouling rate on deposit probes were decreased by 20 % when the bed temperature was decreased from 870°C to below 720°C. In addition, the lab-scale experiments clearly indicated that the amount of alkali metals and Zn volatilised depends on the reactor temperature.

Risk Assessment of a Supplier in the Pharmaceutical Industry

The topic of this Master’s Thesis is risk assessment in the supply chain, and the work was done for a company operating in the pharmaceutical industry. The unique features of the industry bring additional challenges to risk management, due to high regulatory, docu-mentation and traceability requirements. The objective of the thesis was to generate a template for assessing the risks in the supply chain of current and potential suppliers of the case company. Risks pertaining to the case setting were sought mainly from in-house expertise of this specific product and supply chain as well as academic research papers and theory on risk management. A questionnaire was set up to assess the found risks on impact, occurrence and possibility of detection. Through this classification of the severity of the risks, the supplier assessment template was formed. A questionnaire template, comprised of the top 10 risks affecting the flow of information and materials in this setting, was formulated to serve as a generic tool for assessing risks in the supply chain of a pharmaceutical company. The template was tested on another supplier for usability and accuracy of found risks, and it demonstrated functioning in a differing supply chain and product setting.

The pricing of industrial services

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Transfer pricing documentation differences in Finland and China - Case company study

This Master’s Thesis deals with the topic of transfer pricing documentation in Finland and China. The goal of the research is to find what kind of differences exist in a single case company’s transfer pricing documentation when following Chinese or Finnish transfer pricing regulations. The study is carried out as a case study research. The theoretical framework consists of information from different transfer pricing topics and transfer pricing documentation regulations in China and Finland. The main research material was the case company’s transfer pricing documents with the support of open discus-sion with one of the case company’s employees. The study compared the 2009 and 2010 documents. The 2009 document was done based on the Finnish method while the 2010 document was based on the Chinese documentation principles. The conclusion made is that the content of the documents was heavily similar, while the main differences come in the way the content is presented and the level of detail used in the documents.