Incidence and management of pulmonary embolism following spinal surgery occurring while under chemical thromboprophylaxis.

Patients undergoing spinal surgery are at risk of developing thromboembolic complications even though lower incidences have been reported as compared to joint arthroplasty surgery. Deep vein thrombosis (DVT) has been studied extensively in the context of spinal surgery but symptomatic pulmonary embolism (PE) has engaged less attention. We prospectively followed a consecutive cohort of 270 patients undergoing spinal surgery at a single institution. From these patients, only 26 were simple discectomies, while the largest proportion (226) was fusions. All patients received both low molecular weight heparin (LMWH) initiated after surgery and compressive stockings. PE was diagnosed with spiral chest CT. Six patients developed symptomatic PE, five during their hospital stay. In three of the six patients the embolic event occurred during the first 3 postoperative days. They were managed by the temporary insertion of an inferior vena cava (IVC) filter thus allowing for a delay in full-dose anticoagulation until removal of the filter. None of the PE patients suffered any bleeding complication as a result of the introduction of full anticoagulation. Two patients suffered postoperative haematomas, without development of neurological symptoms or signs, requiring emergency evacuation. The overall incidence of PE was 2.2% rising to 2.5% after exclusion of microdiscectomy cases. The incidence of PE was highest in anterior or combined thoracolumbar/lumbar procedures (4.2%). There is a large variation in the reported incidence of PE in the spinal literature. Results from the only study found in the literature specifically monitoring PE suggest an incidence of PE as high as 2.5%. Our study shows a similar incidence despite the use of LMWH. In the absence of randomized controlled trials (RCT) it is uncertain if this type of prophylaxis lowers the incidence of PE. However, other studies show that the morbidity of LMWH is very low. Since PE can be a life-threatening complication, LMWH may be a worthwhile option to consider for prophylaxis. RCTs are necessary in assessing the efficacy of DVT and PE prophylaxis in spinal patients.

Heuristic procedures for solving the General Assembly Line Balancing Problem with Setups (GALBPS)

The General Assembly Line Balancing Problem with Setups (GALBPS) was recently defined in the literature. It adds sequence-dependent setup time considerations to the classical Simple Assembly Line Balancing Problem (SALBP) as follows: whenever a task is assigned next to another at the same workstation, a setup time must be added to compute the global workstation time, thereby providing the task sequence inside each workstation. This paper proposes over 50 priority-rule-based heuristic procedures to solve GALBPS, many of which are an improvement upon heuristic procedures published to date.

Release Process Effectiveness - Case of Operating Room Management Software

Työn päätavoitteena oli tuoda esiin tärkeimmät julkistamisprosessin tehokkuuteen vaikuttavat tekijät. Tutkimuksessa tarkasteltiin aihetta julkistamisprojektien vetäjän näkökulmasta. Kirjallinen selvitys kattaa keskeisimmät ohjelmistoprosessin, palvelun laadun sekä projektihallinnan teoriat. Kokeellisena aineistona käytettiin asiakkailta ja myynnin sekä käyttöönoton organisaatioilta tullutta palautetta ja asiantuntijahaastatteluita. Case-tuotteena tarkasteltiin suuren kansainvälisen yrityksen jälleenmyymää leikkaussalihallinnan ohjelmistoa. Tärkeimpiä julkistamisprosessin tehokkuuteen vaikuttavia tekijöitä ovat tiekartan ja julkistamispakettien sisällön hallinta, projektin aikataulujen pitäminen, rehellinen ja nopea kommunikaatio myyntikanavaan ja asiakkaille, sekä hyvin toteutettu testaus. Työssä käydään läpi esimerkkistrategioita kehittymiseen näillä alueilla.

Validation of a model to predict adverse outcomes in patients with pulmonary embolism.

AIMS: To validate a model for quantifying the prognosis of patients with pulmonary embolism (PE). The model was previously derived from 10 534 US patients. METHODS AND RESULTS: We validated the model in 367 patients prospectively diagnosed with PE at 117 European emergency departments. We used baseline data for the model's 11 prognostic variables to stratify patients into five risk classes (I-V). We compared 90-day mortality within each risk class and the area under the receiver operating characteristic curve between the validation and the original derivation samples. We also assessed the rate of recurrent venous thrombo-embolism and major bleeding within each risk class. Mortality was 0% in Risk Class I, 1.0% in Class II, 3.1% in Class III, 10.4% in Class IV, and 24.4% in Class V and did not differ between the validation and the original derivation samples. The area under the curve was larger in the validation sample (0.87 vs. 0.78, P=0.01). No patients in Classes I and II developed recurrent thrombo-embolism or major bleeding. CONCLUSION: The model accurately stratifies patients with PE into categories of increasing risk of mortality and other relevant complications. Patients in Risk Classes I and II are at low risk of adverse outcomes and are potential candidates for outpatient treatment.

Automated User Interface testing in Symbian Operating System

Tässä diplomityössä tutkitaan automatisoitua testausta ja käyttöliittymätestauksen tekemistä helpommaksi Symbian-käyttöjärjestelmässä. Työssä esitellään Symbian ja Symbian-sovelluskehityksessä kohdattavia haasteita. Lisäksi kerrotaan testausstrategioista ja -tavoista sekä automatisoidusta testaamisesta. Lopuksi esitetään työkalu, jolla testitapausten luominen toiminnalisuus- ja järjestelmätestaukseen tehdään helpommaksi. Graafiset käyttöliittymättuovat ainutlaatuisia haasteita ohjelmiston testaamiseen. Ne tehdään usein monimutkaisista komponenteista ja niitä suunnitellaan jatkuvasti uusiksi ohjelmistokehityksen aikana. Graafisten käyttöliittymien testaukseen käytetään usein kaappaus- ja toistotyökaluja. Käyttöliittymätestauksen testitapausten suunnittelu ja toteutus vaatii paljon panostusta. Koska graafiset käyttöliittymät muodostavat suuren osan koodista, voitaisiin säästää paljon resursseja tekemällä testitapausten luomisesta helpompaa. Käytännön osuudessa toteutettu projekti pyrkii tähän tekemällä testiskriptien luomisesta visuaalista. Näin ollen itse testien skriptikieltä ei tarvitse ymmärtää ja testien hahmottaminen on myös helpompaa.

Monitoring System Resources During Automated Testing in Symbian Operating System

Tässä diplomityössä esitellään ohjelmistotestauksen ja verifioinnin yleisiä periaatteita sekä käsitellään tarkemmin älypuhelinohjelmistojen verifiointia. Työssä esitellään myös älypuhelimissa käytettävä Symbian-käyttöjärjestelmä. Työn käytännön osuudessa suunniteltiin ja toteutettiin Symbian-käyttöjärjestelmässä toimiva palvelin, joka tarkkailee ja tallentaa järjestelmäresurssien käyttöä. Verifiointi on tärkeä ja kuluja aiheuttava tehtävä älypuhelinohjelmistojen kehityssyklissä. Kuluja voidaan vähentää automatisoimalla osa verifiointiprosessista. Toteutettu palvelin automatisoijärjestelmäresurssien tarkkailun tallentamalla tietoja niistä tiedostoon testien ajon aikana. Kun testit ajetaan uudestaan, uusia tuloksia vertaillaan lähdetallenteeseen. Jos tulokset eivät ole käyttäjän asettamien virherajojen sisällä, siitä ilmoitetaan käyttäjälle. Virherajojen ja lähdetallenteen määrittäminen saattaa osoittautua vaikeaksi. Kuitenkin, jos ne määritetään sopivasti, palvelin tuottaa hyödyllistä tietoa poikkeamista järjestelmäresurssien kulutuksessa testaajille.

Procedures for evaluating the tolerance of cassava genotypes to postharvest physiological deterioration

Abstract: The objective of this work was to define procedures to assess the tolerance of cassava genotypes to postharvest physiological deterioration (PPD) and to microbial deterioration (MD). Roots of six cassava genotypes were evaluated in two experiments, during storage under different environmental conditions: high temperature and low soil moisture; or low temperature and high soil moisture. Roots were treated or not with fungicide (carbendazim) before storage. Genotype reactions to MD and PPD were evaluated at 0, 2, 5, 10, 15, 20, and 30 days after harvest (DAH), in the proximal, medial, and distal parts of the roots. A diagrammatic scale was proposed to evaluate nonperipheral symptoms of PPD. Fungicide treatment and root position did not influence PPD expression; however, all factors had significant effect on MD severity. Genotypes differed as to their tolerance to PPD and MD. Both deterioration types were more pronounced during periods of higher humidity and lower temperatures. The fungicide treatment increased root shelf life by reducing MD severity up to 10 DAH. Whole roots showed low MD severity and high PPD expression up to 10 DAH, which enabled the assessment of PPD without significant interference of MD symptoms during this period.

Urgences vitales au cabinet médical: implications pour la formation et l'equipement du médecin de premier recours [Life-threatening emergencies at the office: implications for medical education and equipment of the primary care physician].

Every medical practitioner is confronted on a daily basis with emergencies. Among these, life-threatening emergencies can have disastrous consequences in term of morbidity and mortality; 22 cardiac arrests and 10 deaths were reported among the 1,650 Swiss practices during a 5 year period. The occurrence of life-threatening emergencies at the office necessitates, according to the type and place of the practice, the skills of the practitioner and the organization of his practice, the implementation of procedures, equipments (for example room equipped with a defibrillator, respiratory nebulizer, splints, emergency drugs) and specific continuous education programs that should be encouraged and made available to the whole medical corporation.

Kauppakeskuksen laadunhallintajärjestelmän laatiminen ISO 9001:2000-standardin avulla

Työn tavoitteena on laatia laadunhallintajärjestelmä ja laatukäsikirja kauppakeskus H-taloon ISO 9001:2000 standardia hyväksi käyttäen. Käsikirjassa kuvataan mahdollisimman yksinkertaisesti toimintaa ohjaavat periaatteet eli yrityksen laatupolitiikka, yrityksen eri prosessit, menettelyohjeet ja laadun toteamiseksi tarvittavat mittarit. Perimmäisenä tarkoituksena on käynnistää jatkuvan parantamisen prosessi ja näin parantaa kauppakeskuksen pitkän tähtäimen suorituskykyä. Työn teoreettisessa osassa tutustutaan laadun merkitykseen ja palveluliiketoiminnan logiikkaan. Keskeisenä teoriana käytetään odotetun ja koetun laadun muodostamaa koettua kokonaislaatua, jota sovelletaan kauppakeskusympäristöön. Lopuksi tutustutaan ISO 9000 standardisarjaan. Seuraavassa osassa H-talon tarjoamien toimitilapalveluiden nykytilaa kartoitetaan kauppakeskuksen yrittäjille tehdyssä kyselyssä. Kysely toteutettiin kauppakeskusympäristöön muokatulla odotetun ja koetun palvelun laadun eroa mittaavalla SERVQUAL-mentelmällä. Lisäksi apuna käytettiin kriittisten tapahtumien menetelmää. Lopuksi laaditaan runko kauppakeskuksen laadunhallintajärjestelmään ja pohditaan toimenpiteitä järjestelmän käyttöön ottamiseksi ja kehittämiseksi. Kauppakeskuksen laatukäsikirja esitetään liitteenä.

Awareness of human immunodeficiency virus screening guidelines is low in emergency departments of western Switzerland.

Background: Human immunodeficiency virus (HIV) prevalence in Switzerland is 0.4% and 30% of HIV patients are diagnosed with CD4 counts <200 cells/microliter. In 2010, the Swiss Federal Office of Public Health (SFOP) published updated guidelines regarding Physician- Initiated Counseling and Testing (PICT) for HIV. In the new guidelines, when acute HIV infection is suspected or HIV is among the differential diagnoses, an HIV test is performed without risk assessment nor prior counseling, unless the patient specifically refuses it. Counseling and verbal consent are still required when the patient asks for an HIV test or belongs to a high risk group. Whist HIV testing in the emergency departments (ED) is recommended, only 1% of patients are currently screened. Lack of awareness among physicians has been cited in the literature as the first barrier to guideline implementation. Objectives: To test if physicians working in EDs of 5 large teaching hospitals in western Switzerland, admitting 175,000 patients / year, were aware of the updated SFOP guidelines. Methods: A survey was delivered to 167 ED physicians in the summer of 2011. The survey consisted of 26 vignettes designed to test whether physicians would request an HIV test according to the new guidelines and if they knew when the PICT strategy was allowed or counseling required. Finally, physicians were asked the number of HIV tests they had requested in the previous 4 weeks, and if they were aware of the new HIV guidelines. Results are presented as mean and standard deviation, median and interquartile range (IQR), or as proportions; Student's t test was used to compare continuous variables; Results: 143 physicians returned the survey (86%); mean age was 32 ± 8 years, and median postgraduate experience of 6 years (IQR 3-12); 52% were male and 17% were attendings. The percentage of correct responses was 60 ± 13% with no difference between attendings and residents (p = 0.31); 2 of the 3 questions with the lowest scores were failure to recognize situations in which HIV testing was indicated, and the third one a failure to recognize acute HIV infection. 82% of physicians were not aware of the new guidelines. The median number of test requests was 1 (IQR 0-2, range 1-10). Conclusion: ED physicians are not aware of current HIV screening guidelines published by the SFOP, and rarely perform HIV tests. An information campaign is required if ED physicians are expected to play a significant role in the reduction of undiagnosed HIV patients.

Comorbidity and nutritional indices as predictors of morbidity after transurethral procedures: A prospective cohort study.

INTRODUCTION: Preoperative scores are widely used predictors of complications after major surgery. These scores, however, are not widely used in transurethral procedures. The aim of this study was to assess the value of the Charlson Comorbidity Index (CCI), the age-adjusted CCI, the American Society of Anesthesiologist score (ASA) and the Nutritional Risk Score (NRS) in predicting early morbidity after transurethral urological procedures. METHODS: Consecutive patients undergoing transurethral resection of the bladder or the prostate were prospectively enrolled. The scores were calculated preoperatively; 30-day complications were prospectively recorded according to the Dindo-Clavien classification. Univariate logistic regression was performed to investigate the value of each score and of other factors (i.e., age, sex, body mass index, anemia, smoking habit, type of operation and anaesthesia) as predictors of complications. A multivariate model was then calculated using these predictors. RESULTS: Overall, 197 patients were included. The mean age was 72 (standard deviation ± 10). In total, 26.9% patients had at least 1 complication. Using univariate analysis, we found that each score significantly predicted complications. In multivariate analysis, only the ASA (odds ration [OR] 2.11; 95% confidence interval [CI] 1.01-4.43) and the NRS (OR 2.42; 95% CI 1.56-3.74) remained independent predictors. The best model incorporated ASA, NRS and gender, and predicted morbidity with an area under the curve of 76%. Our study's main limitations are population heterogeneity and limited sample size. CONCLUSION: The ASA and the NRS are important and independent determinants of early morbidity after transurethral procedures. The use of these indices may assist clinicians in the decision-making process to balance the possible benefits of transurethral procedures with the potential risks.

Business competence and training needs in Finnish companies operating in the Leningrad Region

Tässä pro gradu -työssä tutkitaan Leningradin alueella, Venäjällä, toimivien suomalaisyritysten liiketoimintaosaamisen koulutustarpeita. Tavoitteena on ollut tutkia, millaisia yritysten koulutustarpeet ovat, sekä lisäksi selvittää yleisemmällä tasolla, miten liiketoimintaosaaminen määritellään. Useat tutkimusta varten haastatellut johtajat pitävät liiketoimintaosaamista erityisesti markkinoilla toimimiseen liittyvänä osaamisena. Myös johtaminen, sekä tuotteet ja teknologia nähdään liiketoimintaosaamisen tärkeinä osina. Yrityksillä on koulutustarpeita seuraavilla alueilla: johtaminen; myynti, markkinat ja asiakkaat; yrityksen sisäinen yhteistyö; kielet, sekä juridiikka ja laskentatoimi. Haastateltavien mukaan markkinoiden nopea kehitys sekä yrityksen kasvu luovat yrityksille koulutustarpeita. Yllättäen myös Venäjän koulutusjärjestelmää itsessään pidetään koulutustarpeiden syynä. Tutkimuksessa mukana olleiden yritysten koulutuskäytännöt ovat keskenään melko erilaisia: koulutusbudjetti, koulutuspäivien määrä ja koulutusorganisaation valintakriteerit vaihtelevatyrityksestä riippuen. Joka tapauksessa yleisin koulutusmuoto näyttää olevan yrityksen sisäinen koulutus. Monet haastateltavat painottavat suuresti uusien työntekijöiden kouluttamista. Selvästikin rekrytointi ja uusien työntekijöiden koulutus vievät suuren osan tutkimusta varten haastateltujen johtajien ajasta. Tärkeä huomio koulutusmarkkinoihin liittyen on se, että lyhyiden, kaikille avoimien koulutusten kohdalla markkinat ovat Pietarissa täynnä. Suurimpana uhkana nähdään alalla vallitseva kouluttajapula.

Primary fluid bolus therapy for infection-associated hypotension in the emergency department.

OBJECTIVES: The physiological changes associated with fluid bolus therapy (FBT) for patients with infection-associated hypotension in the emergency department (ED) are poorly understood. We describe the physiological outcomes of FBT in the first 6 hours (primary FBT) for patients presenting to the ED with infection-associated hypotension. METHODS: We studied 101 consecutive ED patients with infection and a systolic blood pressure (SBP)<100 mmHg who underwent FBT in the first 6 hours. RESULTS: We screened 1123 patients with infection and identified 101 eligible patients. The median primary FBT volume given was 1570 mL (interquartile range, 1000- 2490 mL). The average mean arterial pressure (MAP) did not change from admission to 6 hours in the whole cohort, or in patients who were hypotensive on arrival at the ED. However, the average MAP increased from its lowest value during the first 6 hours (66 mmHg [SD, 10 mmHg]) to its value at 6 hours (73 mmHg [SD, 12 mmHg]; P<0.001). The mean heart rate, body temperature, respiratory rate and plasma creatinine level decreased (P<0.05). In patients who were severely hypotensive (SBP<90 mmHg) on arrival at the ED, the MAP increased from 54 mmHg (SD, 8 mmHg) to 70 mmHg (SD, 14 mmHg) (P<0.001). At 6 hours, however, SBP was still <100 mmHg in 44 patients and <90 mmHg in 17 patients. When noradrenaline was used, in 10 patients, hypotension was corrected in all 10 and the MAP increased from 58 mmHg (SD, 9 mmHg) to 75 mmHg (SD, 13 mmHg). CONCLUSION: Among ED patients admitted to an Australian teaching hospital with infection, hypotension was uncommon. FBT for hypotension was limited in volumes given and failed to achieve a sustained SBP of >100 mmHg in 40% of cases. In contrast, noradrenaline therapy corrected hypotension in all patients who received it.

HMG CoA reductase inhibitors (statins) for preventing acute kidney injury after surgical procedures requiring cardiac bypass.

BACKGROUND: Acute kidney injury (AKI) is common in patients undergoing cardiac surgery among whom it is associated with poor outcomes, prolonged hospital stays and increased mortality. Statin drugs can produce more than one effect independent of their lipid lowering effect, and may improve kidney injury through inhibition of postoperative inflammatory responses. OBJECTIVES: This review aimed to look at the evidence supporting the benefits of perioperative statins for AKI prevention in hospitalised adults after surgery who require cardiac bypass. The main objectives were to 1) determine whether use of statins was associated with preventing AKI development; 2) determine whether use of statins was associated with reductions in in-hospital mortality; 3) determine whether use of statins was associated with reduced need for RRT; and 4) determine any adverse effects associated with the use of statins. SEARCH METHODS: We searched the Cochrane Renal Group's Specialised Register to 13 January 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared administration of statin therapy with placebo or standard clinical care in adult patients undergoing surgery requiring cardiopulmonary bypass and reporting AKI, serum creatinine (SCr) or need for renal replacement therapy (RRT) as an outcome were eligible for inclusion. All forms and dosages of statins in conjunction with any duration of pre-operative therapy were considered for inclusion in this review. DATA COLLECTION AND ANALYSIS: All authors extracted data independently and assessments were cross-checked by a second author. Likewise, assessment of study risk of bias was initially conducted by one author and then by a second author to ensure accuracy. Disagreements were arbitrated among authors until consensus was reached. Authors from two of the included studies provided additional data surrounding post-operative SCr as well as need for RRT. Meta-analyses were used to assess the outcomes of AKI, SCr and mortality rate. Data for the outcomes of RRT and adverse effects were not pooled. Adverse effects taken into account were those reported by the authors of included studies. MAIN RESULTS: We included seven studies (662 participants) in this review. All except one study was assessed as being at high risk of bias. Three studies assessed atorvastatin, three assessed simvastatin and one investigated rosuvastatin. All studies collected data during the immediate perioperative period only; data collection to hospital discharge and postoperative biochemical data collection ranged from 24 hours to 7 days. Overall, pre-operative statin treatment was not associated with a reduction in postoperative AKI, need for RRT, or mortality. Only two studies (195 participants) reported postoperative SCr level. In those studies, patients allocated to receive statins had lower postoperative SCr concentrations compared with those allocated to no drug treatment/placebo (MD 21.2 µmol/L, 95% CI -31.1 to -11.1). Adverse effects were adequately reported in only one study; no difference was found between the statin group compared to placebo. AUTHORS' CONCLUSIONS: Analysis of currently available data did not suggest that preoperative statin use is associated with decreased incidence of AKI in adults after surgery who required cardiac bypass. Although a significant reduction in SCr was seen postoperatively in people treated with statins, this result was driven by results from a single study, where SCr was considered as a secondary outcome. The results of the meta-analysis should be interpreted with caution; few studies were included in subgroup analyses, and significant differences in methodology exist among the included studies. Large high quality RCTs are required to establish the safety and efficacy of statins to prevent AKI after cardiac surgery.