Multidisciplinary practice vs. inter-firm collaboration in professional services market

Yritysten välinen yhteistyö kasvaa asiantuntijamarkkinoilla. Suppean palvelutarjooman omaavat yritykset muodostavat laajempia palveluita yhdistämällä osaamisiaan kumppaneidensa kanssa. Näin muodostuvat yritysryhmittymät uhkaavat alaa hallitsevia monipuolisen palvelutarjooman omaavia kansainvälisiä moniosaajayrityksiä. Tämän diplomityön tavoitteena on selvittää minkälaisia hyötyjä moniosaajayritys voi saada näitä ryhmittymiä vastaan lisäämällä omaa yhteistyötään. Tavoitteeseen pääsemiseksi markkinoilla olevat yritysryhmittymät tunnistetaan ja selvitetään minkälaisia asioita asiakas pitää tärkeänä ostaessaan asiantuntijapalveluita. Toimialan trendit ja aikaisemmat tutkimukset yritysten välisestä yhteistyöstä sekä asiakkaan ostokäyttäytymisestä osoittavat, että yhteistyön avulla yrityksellä on mahdollisuus saavuttaa monia hyötyjä. Tietoa olemassa olevista yritysryhmittymistä ja asiakkaiden ostokäyttäytymisestä kerättiin haastattelemalla yhden kansainvälisen moniosaajayrityksen henkilöstöä sekä asiakkaita. Tuloksena löytyi yritysryhmittymiä, joista osa uhkaa moniosaajayrityksen kilpailuetua. Asiakkaiden ostokäyttäyminen suosi hieman enemmän asiantuntijapalveluiden hankkimista yritysryhmittymältä moniosaajayrityksen sijaan. Tekemällä yhteistyötä ja tarjoamalla tiettyjä palveluita yhdessä kumppanin kanssa, moniosaajayritys voi saavuttaa hyötyjä yritysryhmittymiä vastaan ja vaikuttaa positiivisesti asiakkaan ostokäyttäytymiseen.

Transfusion practice in early trauma management

Introduction: Blood transfusions carry risks and complications. At the University Hospital of Lausanne the need for transfusion in early trauma resuscitation is based on clinical judgment and standard laboratory tests. We aimed to assess the transfusion practice for trauma patients during their early management. Method: Based on 2008 data from the Lausanne Trauma Registry of Acute Care (TRAC), we analyzed all adult trauma patients admitted to the shock room who received blood products or pro-coagulants in shock room and/or during their emergency operation. Demographics, physiological parameters and lab tests were recorded at arrival and at the end of anesthesiologic management. Coagulopathy was defined as PT <70%, PTT >60 sec, Fibrinogen <1 g/l or Thrombocytes <100 x 109 g/l. Results: In 2008, 323 trauma-patients were included in TRAC. 55 patients (17%) received blood products or pro-coagulants. 44 (83%) had an ISS >15 (med 29, IQR 10-35.5). 43 (78.2%) needed an emergency intervention. Coagulopathy was present in 25 patients (45.5%) at arrival vs. 30 (54.5%) after resuscitation (p = 0.446).

Directives pratiques de la Société européenne d'hypertension sur la mesure de la pression artérielle à domicile [Practice guidelines of the European Society of Hypertension for home blood pressure measurement].

Self-measurement of blood pressure at home is increasingly used in the diagnostic and therapeutic approach of hypertension. This technique allows multiple measurements of blood pressure away from the clinical setting, making it possible to improve the evaluation of cardiovascular risk. Recently new guidelines on the use of self-measured blood pressure have been made available by the European Society of Hypertension, as summarized in the present paper.

Three-dimensional model of bubbling fluidized bed combustion

 Diplomityön tarkoituksena on kehittää kolmiulotteinen malli kerrosleijupoltolle. Työn kirjallisuusosa sisältää seuraavat perusteet kerrosleijupolton tekniikasta: yleistiedot, leijutus- ja palamisilmiöt, kiinteän aineen ja kaasun sekoittuminen, päästöt ja lämmönsiirto. Lisäksi palamissysteemin mallinnuksen perusteet ja ratkaisumenetelmät ovat esitelty. Työn mallinnusosassa kehitetty koodi on ohjelmoitu Fortran-ohjelmointikielellä. Kehitetty malli perustuu olemassa olevaan malliin kiertoleijupoltosta. Yhtälö kiintoainekonsentraatioprofiilille on vaihdettu ja kiertovirta on poistettu koodista. Mallilla on tehty herkkyystarkasteluja polttoaineen ja kaasun sekoittumisen sekä reaktiokertoimen vaikutukselle. Visualisointi on tehty ohjelmassa Tecplot 360 ja mallinnustuloksia on vertailtu mitattuihin tuloksiin. Mallin laskemattulokset vastaavat hyvin mittaustuloksia ja kokemusperäisiä tietoja; monissa tapauksissa malli pystyy kvantitatiivisesti kuvaamaan parametrien variointia ja kaikissa tapauksissa malli antaa ainakin kvalitatiivisesti oikeita tuloksia. Työhön liittyvän kehityksen ja mallinnuskokemuksen perusteella on tehty ehdotukset mallin tulevaa kehitystä ja mittauksia varten.

Optimisation of data analysis method for a fluidized bed combustion test rig

Nowadays the used fuel variety in power boilers is widening and new boiler constructions and running models have to be developed. This research and development is done in small pilot plants where more faster analyse about the boiler mass and heat balance is needed to be able to find and do the right decisions already during the test run. The barrier on determining boiler balance during test runs is the long process of chemical analyses of collected input and outputmatter samples. The present work is concentrating on finding a way to determinethe boiler balance without chemical analyses and optimise the test rig to get the best possible accuracy for heat and mass balance of the boiler. The purpose of this work was to create an automatic boiler balance calculation method for 4 MW CFB/BFB pilot boiler of Kvaerner Pulping Oy located in Messukylä in Tampere. The calculation was created in the data management computer of pilot plants automation system. The calculation is made in Microsoft Excel environment, which gives a good base and functions for handling large databases and calculations without any delicate programming. The automation system in pilot plant was reconstructed und updated by Metso Automation Oy during year 2001 and the new system MetsoDNA has good data management properties, which is necessary for big calculations as boiler balance calculation. Two possible methods for calculating boiler balance during test run were found. Either the fuel flow is determined, which is usedto calculate the boiler's mass balance, or the unburned carbon loss is estimated and the mass balance of the boiler is calculated on the basis of boiler's heat balance. Both of the methods have their own weaknesses, so they were constructed parallel in the calculation and the decision of the used method was left to user. User also needs to define the used fuels and some solid mass flowsthat aren't measured automatically by the automation system. With sensitivity analysis was found that the most essential values for accurate boiler balance determination are flue gas oxygen content, the boiler's measured heat output and lower heating value of the fuel. The theoretical part of this work concentrates in the error management of these measurements and analyses and on measurement accuracy and boiler balance calculation in theory. The empirical part of this work concentrates on the creation of the balance calculation for the boiler in issue and on describing the work environment.

Heart transplantation: current practice and outlook to the future.

QUESTIONS UNDER STUDY: The field of heart transplantation has seen substantial progress in the last 40 years. The breakthroughs in long-term survival were followed by a period of stagnation in the last decade. This review summarises current recommendations for the identification of candidates for heart transplantation and their immunological and non-immunological postoperative follow-up. RESULTS: The progress made in the treatment of patients with advanced heart failure has considerably changed the profile of candidates for heart transplantation. Patients are older, and the load of co-morbidities is more important requiring careful evaluation for candidacy. Long-standing research in the field of immunosuppression made available various drugs, which decrease the risk of acute allograft rejection and prolong survival after heart transplantation. Powerful new molecules are entering early phase clinical studies, suggesting further improvement in the near future. As a consequence, treatment of non-immunological co-morbidity after heart transplantation will gain in importance, however, the base of evidence guiding current recommendations is poor. CONCLUSIONS: The substantial progress in heart failure treatment and immunosuppression after heart transplantation has changed the profile of heart transplant recipients. The arrival of new molecules will provide additional alternatives for immunosuppressive treatment while studies have to address non-immunological treatment in order to improve long-term survival after heart transplantation.

Patients who attend a private practice vs a university outpatient clinic: how do they differ?

Although interpersonal continuity is commonly assumed to be essential for care, some patients prefer to attend a university outpatient clinic where physicians change regularly and interpersonal continuity of care is not ensured. The aim of this exploratory study was to evaluate the differences between patients attending a university outpatient clinic and patients frequenting a private practice, explore their patterns of care-seeking and their understanding of continued care. We conducted a cross-sectional study of patients attending the university medical outpatient clinic (OC) in Lausanne, Switzerland and ten randomly selected private general practices (PP). Eligible patients were >30 years, Swiss nationals or long term residents, with one or more chronic conditions and attending the same practice for >3 years. They were asked to complete a questionnaire on sociodemographic data, use of medical resources and reasons for choosing and remaining at the same practice. Semi-structured interviews were conducted with a randomly selected subset of 26 patients to further explore their preferences. 329 patient questionnaires were completed, 219 by PP and 110 by OC patients. OC patients tended to be of lower socioeconomic status than PP patients. The main reason for choosing a PP were personal recommendation, while a higher percentage of patients chose the OC because they could obtain a first appointment quickly. A higher percentage of PP patients accorded importance to physician communication skills and trust, whereas a higher percentage of OC patients favoured investigation facilities. Qualitative data suggested that although OC and PP patients reported different reasons for consulting, their expectations on the medical and relationship level were similar. Our study suggests that the two groups of patients belong to different social backgrounds, have different patterns of care-seeking and attach importance to different aspects of care continuity. However, patients' expectations and perceptions of the physician-patient relationship are similar.

Recommandations suisses pour la prise en charge des cancers cutanés chez les patients transplantés d'organe [Swiss clinical practice guidelines for skin cancer in organ transplant recipients]

Swiss clinical practice guidelines for skin cancer in organ transplant recipients Transplant patients have increased over the last decades. As a consequence of long-term immunosuppression, skin cancer, in particular squamous cell carcinoma (SCC), has become an important problem. Screening and education of potential organ transplant recipients (OTRs) regarding prevention of sun damage and early recognition of skin cancer are important before transplantation. Once transplanted, OTRs should be seen yearly by a dermatologist to ensure compliance with sun avoidance as well as for treatment of precancerosis and SCC. Early removal is the best treatment for SCC. Reduction of immunosuppression, switch to mTOR inhibitors and chemoprevention with acitretin may reduce the incidence of SCC. The dermatological follow-up of OTRs should be integrated into a comprehensive post-transplant management strategy.

Traitement pharmacologique de la schizophrénie : évaluation comparative de la qualité des recommandations de pratique clinique = Comparative evaluation of clinical practice guidelines for the treatment of schizophrenia

De nombreuses recommandations de pratique clinique (RPC) ont été publiées, en réponse au développement du concept de la médecine fondée sur les preuves et comme solution à la difficulté de synthétiser et trier l'abondante littérature médicale. Pour faire un choix parmi le foisonnement de nouvelles RPC, il est primordial d'évaluer leur qualité. Récemment, le premier instrument d'évaluation standardisée de la qualité des RPC, appelé " AGREE " pour appraisal of guidelines for research and evaluation, a été validé. Nous avons comparé - avec l'aide de la grille " AGREE " - les six principales RPC publiées depuis une dizaine d'années sur le traitement de la schizophrénie : (1) les Recommandations de l'Agence nationale pour le développement de l'évaluation médicale (ANDEM) ; (2) The American Psychiatric Association (APA) practice guideline for the treatment of patients with schizophrenia ; (3) The quick reference guide of APA practice guideline for the treatment of patients with schizophrenia [APA - guide rapide de référence] ; (4) The schizophrenia patient outcomes research team (PORT) treatment recommandations ; (5) The Texas medication algorithm project " T-MAP " ; (6) The expert consensus guideline for the treatment of schizophrenia. Les résultats de notre étude ont ensuite été comparés avec ceux d'une étude similaire publiée en 2005 par Gæbel et al. portant sur 24 RPC abordant le traitement de la schizophrénie, réalisée également avec l'aide de la grille " AGREE " et deux évaluateurs [Br J Psychiatry 187 (2005) 248-255]. De manière générale, les scores des deux études ne sont pas trop éloignés et les deux évaluations globales des RPC convergent : chacune des six RPC est perfectible et présente différemment des points faibles et des points forts. La rigueur d'élaboration des six RPC est dans l'ensemble très moyenne, la prise en compte de l'opinion des utilisateurs potentiels est lacunaire et un effort sur la présentation des recommandations faciliterait leur utilisation clinique. L'applicabilité des recommandations est également peu considérée par les auteurs. Globalement, deux RPC se distinguent et peuvent être fortement recommandées selon les critères de la grille " AGREE " : " l'APA - guide rapide de référence " et le " T-MAP ".

Observations on Software Testing Practice

This thesis investigates factors that affect software testing practice. The thesis consists of empirical studies, in which the affecting factors were analyzed and interpreted using quantitative and qualitative methods. First, the Delphi method was used to specify the scope of the thesis. Secondly, for the quantitative analysis 40industry experts from 30 organizational units (OUs) were interviewed. The survey method was used to explore factors that affect software testing practice. Conclusions were derived using correlation and regression analysis. Thirdly, from these 30 OUs, five were further selected for an in-depth case study. The data was collected through 41 semi-structured interviews. The affecting factors and their relationships were interpreted with qualitative analysis using grounded theory as the research method. The practice of software testing was analyzed from the process improvement and knowledge management viewpoints. The qualitative and quantitativeresults were triangulated to increase the validity of the thesis. Results suggested that testing ought to be adjusted according to the business orientation of the OU; the business orientation affects the testing organization and knowledge management strategy, and the business orientation andthe knowledge management strategy affect outsourcing. As a special case, the complex relationship between testing schedules and knowledge transfer is discussed. The results of this thesis can be used in improvingtesting processes and knowledge management in software testing.

Formation and Control of Trace Metal Emissions in Co-Firing of Biomass, Peat, and Wastes in Fluidised Bed Combustors

Environmentally harmful consequences of fossil fuel utilisation andthe landfilling of wastes have increased the interest among the energy producers to consider the use of alternative fuels like wood fuels and Refuse-Derived Fuels, RDFs. The fluidised bed technology that allows the flexible use of a variety of different fuels is commonly used at small- and medium-sized power plants ofmunicipalities and industry in Finland. Since there is only one mass-burn plantcurrently in operation in the country and no intention to build new ones, the co-firing of pre-processed wastes in fluidised bed boilers has become the most generally applied waste-to-energy concept in Finland. The recently validated EU Directive on Incineration of Wastes aims to mitigate environmentally harmful pollutants of waste incineration and co-incineration of wastes with conventional fuels. Apart from gaseous flue gas pollutants and dust, the emissions of toxic tracemetals are limited. The implementation of the Directive's restrictions in the Finnish legislation is assumed to limit the co-firing of waste fuels, due to the insufficient reduction of the regulated air pollutants in the existing flue gas cleaning devices. Trace metals emission formation and reduction in the ESP, the condensing wet scrubber, the fabric filter, and the humidification reactor were studied, experimentally, in full- and pilot-scale combustors utilising the bubbling fluidised bed technology, and, theoretically, by means of reactor model calculations. The core of the model is a thermodynamic equilibrium analysis. The experiments were carried out with wood chips, sawdust, and peat, and their refuse-derived fuel, RDF, blends. In all, ten different fuels or fuel blends were tested. Relatively high concentrations of trace metals in RDFs compared to the concentrations of these metals in wood fuels increased the trace metal concentrations in the flue gas after the boiler ten- to hundred-folds, when RDF was co-fired with sawdust in a full-scale BFB boiler. In the case of peat, lesser increase in trace metal concentrations was observed, due to the higher initial trace metal concentrations of peat compared to sawdust. Despite the high removal rate of most of the trace metals in the ESP, the Directive emission limits for trace metals were exceeded in each of the RDF co-firing tests. The dominat trace metals in fluegas after the ESP were Cu, Pb and Mn. In the condensing wet scrubber, the flue gas trace metal emissions were reduced below the Directive emission limits, whenRDF pellet was used as a co-firing fuel together with sawdust and peat. High chlorine content of the RDFs enhanced the mercuric chloride formation and hence the mercury removal in the ESP and scrubber. Mercury emissions were lower than theDirective emission limit for total Hg, 0.05 mg/Nm3, in all full-scale co-firingtests already in the flue gas after the ESP. The pilot-scale experiments with aBFB combustor equipped with a fabric filter revealed that the fabric filter alone is able to reduce the trace metal concentrations, including mercury, in the flue gas during the RDF co-firing approximately to the same level as they are during the wood chip firing. Lower trace metal emissions than the Directive limits were easily reached even with a 40% thermal share of RDF co-firing with sawdust.Enrichment of trace metals in the submicron fly ash particle fraction because of RDF co-firing was not observed in the test runs where sawdust was used as the main fuel. The combustion of RDF pellets with peat caused an enrichment of As, Cd, Co, Pb, Sb, and V in the submicron particle mode. Accumulation and release oftrace metals in the bed material was examined by means of a bed material analysis, mass balance calculations and a reactor model. Lead, zinc and copper were found to have a tendency to be accumulated in the bed material but also to have a tendency to be released from the bed material into the combustion gases, if the combustion conditions were changed. The concentration of the trace metal in the combustion gases of the bubbling fluidised bed boiler was found to be a summary of trace metal fluxes from three main sources. They were (1) the trace metal flux from the burning fuel particle (2) the trace metal flux from the ash in the bed, and (3) the trace metal flux from the active alkali metal layer on the sand (and ash) particles in the bed. The amount of chlorine in the system, the combustion temperature, the fuel ash composition and the saturation state of the bed material in regard to trace metals were discovered to be key factors affecting therelease process. During the co-firing of waste fuels with variable amounts of e.g. ash and chlorine, it is extremely important to consider the possible ongoingaccumulation and/or release of the trace metals in the bed, when determining the flue gas trace metal emissions. If the state of the combustion process in regard to trace metals accumulation and/or release in the bed material is not known,it may happen that emissions from the bed material rather than the combustion of the fuel in question are measured and reported.

Artificially Intelligent and Adaptive Methods for Prediction and Analysis of Superheater Fireside Corrosion in Fluidized Bed Boilers

Superheater corrosion causes vast annual losses for the power companies. With a reliable corrosion prediction method, the plants can be designed accordingly, and knowledge of fuel selection and determination of process conditions may be utilized to minimize superheater corrosion. Growing interest to use recycled fuels creates additional demands for the prediction of corrosion potential. Models depending on corrosion theories will fail, if relations between the inputs and the output are poorly known. A prediction model based on fuzzy logic and an artificial neural network is able to improve its performance as the amount of data increases. The corrosion rate of a superheater material can most reliably be detected with a test done in a test combustor or in a commercial boiler. The steel samples can be located in a special, temperature-controlled probe, and exposed to the corrosive environment for a desired time. These tests give information about the average corrosion potential in that environment. Samples may also be cut from superheaters during shutdowns. The analysis ofsamples taken from probes or superheaters after exposure to corrosive environment is a demanding task: if the corrosive contaminants can be reliably analyzed, the corrosion chemistry can be determined, and an estimate of the material lifetime can be given. In cases where the reason for corrosion is not clear, the determination of the corrosion chemistry and the lifetime estimation is more demanding. In order to provide a laboratory tool for the analysis and prediction, a newapproach was chosen. During this study, the following tools were generated: · Amodel for the prediction of superheater fireside corrosion, based on fuzzy logic and an artificial neural network, build upon a corrosion database developed offuel and bed material analyses, and measured corrosion data. The developed model predicts superheater corrosion with high accuracy at the early stages of a project. · An adaptive corrosion analysis tool based on image analysis, constructedas an expert system. This system utilizes implementation of user-defined algorithms, which allows the development of an artificially intelligent system for thetask. According to the results of the analyses, several new rules were developed for the determination of the degree and type of corrosion. By combining these two tools, a user-friendly expert system for the prediction and analyses of superheater fireside corrosion was developed. This tool may also be used for the minimization of corrosion risks by the design of fluidized bed boilers.