Suchergebnisse

Health and social services are increasingly produced in cooperation among several specialized organizations. This has increased the importance of service integration in the sector. While the literature acknowledges the need for performance measurement addressing outcomes and effectiveness of service integration, not enough is known about applying such measurement practices. This paper examines the design of a performance measurement system to support the effectiveness management of an integrated service delivery. The research identifies three aspects of effectiveness – community, client and network level. Empirical examination reveals that success factors for design of measures for integrated service delivery include consensus on the targets, coordination and fluent cooperation among actors in the network. The paper contributes to performance measurement literature by illustrating how the design of system level measurement is carried out in practice and analyzing the lessons learned.

Polvilumpion sijoiltaanmeno on tavallinen, usein nuoren aikuisen akuutti polven nivelsidevamma, joka liittyy tyypillisesti liikuntasuorituksiin. Sijoiltaanmenon yhteydessä pääasiallisin polvilumpion tukirakenne, sisempi patellofemoraaliligamentti (MPFL), vaurioituu. Polvilumpion ensimmäisen sijoiltaanmenon jälkeen monilla esiintyy toistuvia polvilumpion muljahteluja tai sijoiltaanmenoja, polven kipua, liikunnallisen aktiivisuustason heikkenemistä ja polvilumpion liukupinnan nivelkulumaa. Polvilumpion ensimmäisen sijoiltaanmenon hoitotapa on ollut epäselvä, koska laadukkaita tutkimuksia on niukasti. Perinteisesti suurin osa polvilumpion ensimmäisistä sijoiltaanmenoista on hoidettu ilman leikkausta saranalastalla tai polvilumpiotuella. Tämän väitöskirjan tarkoituksena oli selvittää polvilumpion ensimmäisen sijoiltaanmenon ilmaantuvuus, riskitekijät ja vertailla eri hoitomenetelmiä. Lisäksi tutkimus selvitti nykyaikaisen MPFL-leikkauksen pitkäaikaistuloksia ja sekä MPFL-vammakohdan kliinistä merkitystä. Tutkimus kohdistui vuosina 1994-2002 varusmiespalveluksensa suorittaneisiin nuoriin miehiin ja naisiin. Tutkimusaineistoon kuului yli 130 000 nuoren, 18-28 vuotiaan aikuisen väestö, jota analysoiden selvitettiin polvilumpion ensimmäisen sijoiltaanmenon ilmaantuvuus ja riskitekijät. Väitöskirjatutkimuksessa verrattiin MPFL-leikkauksen ja perinteisemmän polvilumpion tukileikkauksen pitkäaikaistuloksia, kun leikkaus oli tehty toistuvan polvilumpion sijoiltaanmenon vuoksi. Väitöskirjatutkimukseen kuului myös kaksi etenevää tutkimusta, joissa verrattiin tähystystekniikalla tehtävää polvilumpioleikkausta ilman leikkausta hoidettuihin sekä satunnaistetussa tutkimusasetelmassa polvilumpion avoleikkausta ilman leikkausta hoidettuihin. Hoitoryhmiä seurattiin keskimäärin seitsemän vuotta. Lisäksi väitöskirjassa analysoitiin kolmen eri MPFL-vauriokohdan pitkäaikaisennuste, kun jälkihoito oli ollut sama, ilman leikkausta, saranalastaa käyttäen. Päätemuuttujina tutkimuksissa olivat vamman jälkeinen polvilumpion tukevuus ja liikunta-aktiivisuustason säilyminen. Väitöskirjatutkimuksen perusteella polvilumpion ensimmäinen sijoiltaanmeno on aiemmin arvioitua yleisempi polvivamma, jonka vuotuinen ilmaantuvuus on 77/100 000 nuoressa aikuisväestössä. Potilaan pituus ja paino todettiin olevan polvilumpion sijoiltaanmenon riskitekijöitä. Huono fyysinen suorituskyky, ylipaino tai heikko lihaskunto ei lisännyt riskiä saada polvilumpion sijoiltaanmeno. Modernilla MPFL-leikkauksella saavutettiin perinteistä leikkaustekniikkaa vastaava polvilumpion tukevuus, mutta polvilumpionivelen kulumaa kehittyi merkitsevästi vähemmän. Alkuvaiheen tähystysleikkauksesta ei todettu merkitsevää hyötyä ilman leikkausta hoidettuihin verrattuna. Sen sijaan etenevä satunnaistettu tutkimus polvilumpion ensimmäisen sijoiltaanmenon hoidosta paljasti, että ilman leikkausta hoidetut kärsivät merkitsevästi enemmän polvilumpion löysyydestä kuin alkuvaiheessa leikatut. Leikatut eivät silti olleet oireettomampia muissa mittauksissa. Kun jälkihoito ensimmäisen sijoiltaanmenon jälkeen oli ollut samanlainen, MPFL-repeämä reisiluun kiinnityskohdasta ennusti merkitsevää fyysisen suoritustason laskua ja merkitsevästi löysempää polvilumpiota kuin MPFL-repeämä polvilumpion kiinnityskohdassa tai nivelsiteen keskiosassa. Väitöskirjatutkimuksen perusteella polvilumpion ensimmäinen sijoiltaanmeno, joka liittyy akuuttiin polven vääntövammaan, aiheuttaa MPFL-vaurion. Vauriokohta tulisi magneettikuvausta käyttämällä määrittää, koska tulkitseminen auttaa oikean hoitomuodon valinnassa. Polvilumpion ensimmäinen sijoiltaanmeno, johon liittyy MPFL-repeämä reisiluun kiinnityskohdasta, näyttää olevan hyödyllistä hoitaa alkuvaiheen leikkauksella. Väitöskirjatutkimuksen tulokset osoittavat, että polvilumpionivelen kuluma on merkittävä ilmiö polvilumpion sijoiltaanmenon sairastaneilla. Aiemmissa tutkimuksissa nivelkulumaa on esiintynyt runsaasti sekä ilman leikkausta hoidetuilla että perinteisin leikkausmenetelmin hoidetuilla. Tämän tutkimuksen mukaan anatomiseen korjaukseen pyrkivä MPFL-leikkaus vähentää nivelkuluman kehittymistä. Tämän vuoksi polvilumpion sijoiltaanmenon leikkaushoidoksi suositellaan MPFL-leikkausta, joskin polven anatomiset poikkeavuudet tulee huomioida leikkaushoitoa suunnitellessa. ; First-time (primary) traumatic patellar dislocations are considered to be a consequence of active lifestyle and defined as acute ligamentous knee injury. After first-time patellar dislocation various subsequent problems may occur such as anterior knee pain, recurrent patellar instability, decreased level of sporting activity, and development of patellofemoral osteoarthritis (OA). The management of a primary traumatic patellar dislocation has been controversial with no evidence-based consensus how a clinician should treat these injuries to achieve the best possible result. Traditionally, most primary patellar dislocations have been treated nonoperatively. Recently, however, increasing interest has been focused on investigating primary traumatic patellar dislocation and the possible benefits of initial surgical management. This phenomenon has arisen since the medial patellofemoral ligament (MPFL) has been recognized as the primary medial stabilizer of the patella and MPFL inju! ry has been associated with traumatic patellar dislocations. The purpose of this thesis was to investigate the incidence, risk factors and initial management of primary traumatic patellar dislocation, the long-term results of MPFL reconstruction and the clinical significance of the MPFL injury in primary traumatic patellar dislocation. The study population consisted of Finnish military conscripts who served during 1994-2002. Five data sets were used. The first data was obtained from a large military health care database of over 130 000 young adults 18-28 years of age. This information was combined with the Finnish National Hospital Discharge Register in order to assess the incidence and risk factors for primary traumatic patellar dislocation. The second data compared MPFL reconstructions and distal realignment procedures performed in Central Military Hospital in 1994-1997. The outcome variables in this study were long-term recurrent instability and the presence of patellofemoral OA. The third and fourth data consisted of two prospective cohorts comparing initial arthroscopic medial repair and nonoperative treatment, and stabilizing surgery and nonoperative treatment (randomly allocated), respectively. These patients were clinically followed-up and the outcome variables were subsequent patellar instability and clinical symptoms. The fifth data consisted of a cohort of conscripts with nonoperatively treated primary patellar dislocation with MPFL injury. In this cohort, the predictive value of the MPFL injury location was assessed when subsequent instability was used as the primary outcome. The follow-up review of these physically active young adults disclosed that primary traumatic patellar dislocation is a common knee injury yielding an incidence rate of 77/100 000 person-years. The risk factors for primary traumatic patellar dislocation were height and weight, not poor physical performance or muscle fitness. MPFL reconstruction compared to distal realignment procedure achieved comparable patellar stability but significantly less patellofemoral OA progression. The prospective study comparing initial arthroscopic medial repair to nonoperative management failed to show any benefit with initial arthroscopic stabilization. The prospective randomized study with or without initial stabilizing surgery revealed that patients who underwent surgery had more stable patellae at follow-up. To explore the clinical significance of the MPFL injury location, the magnetic resonance imaging (MRI) evaluation of nonoperatively treated patients proved that a femoral avulsion o! f the MPFL predicted subsequent instability and lower return to preinjury level of activity when compared to other MPFL injury locations (patellar and midsubstance). While previous studies have concluded that MPFL injury is frequently associated with primary traumatic dislocations with variation in the location of the MPFL tear, the studies in this thesis are the first to indicate a clinical aspect of using MRI findings in guiding the treatment pathway. In primary traumatic patellar dislocation, MR images should be evaluated because of the predictive value they carry. It may be concluded that patients who have high demands of patellar stability are likely to benefit from initial surgical repair or reconstruction. If we look at the long-term consequences of patellar dislocation, there are specific circumstances where initial stabilizing surgery should be considered; cases presenting substantial disruption of the MPFL at its femoral attachment, an osteochondral fracture that requires surgery, a laterally subluxated instable patella in patients with high demand of patellar stability, and in patients not improving with appropriate rehabi! litation. This thesis also indicates that PF OA is a frequent sequel of patellar dislocation. Based on the previous findings of PF OA presence after nonoperative management and traditional distal realignment surgery, there is a role for anatomic MPFL reconstruction that seems to reduce the risk of OA progression. Especially when stabilizing surgery is considered after traumatic patellar dislocation, MPFL reconstruction should be preferred. Based on the findings of this study and previous literature, a treatment algorithm for first-time traumatic patellar dislocation is proposed.

The historic claim of the Sami to lands that they have traditionally used and occupied – an issue that has long been dormant – is emerging as a significant public issue in Finland, Sweden and Norway. This article develops a control‐consociationalism typology to analyze bow each of the three states responds to Sami claims to their historic rights. Under a control situation, the cultural identity of a minority is almost exclusively determined by the laws, regulations and administrative procedures of the state. Under a consociationalism model, there would be a continuing dialogue between a stale and a minority within an administrative framework that the minority has had a major role in developing. The typology traces more than two centuries of administrative control by the three states and examines how existing institutions deal with the Sami minority. Interviews indicate that most authorities see collective minority rights as a component of human rights and, furthermore, that the Sami constitute an indigenous minority. However, the concept of aboriginal land title divides politicians and administrators; many oppose it or maintain that it is not really necessary. Many Sami rights activists, on the other hand, see it as a fundamental issue – even one of moral justice – that ultimately must be addressed by each state.

The light curve of quasar OJ287 extends from 1891 up today without major gaps. This is partly due to extensive studies of historical plate archives by Rene Hudec and associates, and partly due to several observing campaigns in recent times. Here we summarize the results of the 2005–2010 observing campaign, in which several hundred scientists and amateur astronomers took part. The main results are the following: (1) The 2005 October optical outburst came at the expected time, thus confirming the General Relativistic precession in the binary black hole system, as was originally proposed bySillanp¨a¨a et al. (1988). At the same time, this result disproved the model of a single black hole system with accretion disk oscillations, as well as several toy models of binaries without relativistic precession. In the latter models the main outburst would have been a year later. No particular activity was seen in OJ287 in 2006 October. (2) The nature of the radiation of the 2005 October outburst was expected to be bremsstrahlung from hot gas at a temperature of 3 × 105 K. The reason for the outburst is a collision of the secondary on the accretion disk of the primary, which heats the gas to this temperature. This was confirmed by combined ground based and ultraviolet observations using the XMM-Newton X-ray telescope. (3) A secondary outburst of the same nature was expected at 2007 September 13. Within the accuracy of the observations (about 6 hours), it started at the correct time. Thus the prediction was accurate at the same level as the prediction of the return of Halley's comet in 1986. Due to the bremsstrahlung nature of the outburst, the radiation was unpolarised, as expected. (4) Further synchrotron outbursts were expected following the two bremsstrahlung outbursts.They came as scheduled between 2007 October and 2009 December. (5) Due to the effect of the secondary on the overall direction of the jet, the parsec scale jet was expected to rotate in the sky by a large angle around 2009. This rotation has been seen in high frequency radio observations. The OJ287 binary black hole system is currently our best laboratory for testing theories of gravitation. Using OJ287, the correctness of General Relativity has now been demonstrated up to second Post-Newtonian order, higher than has been possible using binary pulsars.

Front Cover -- NATURAL ORGANIC MATTER IN WATER -- NATURAL ORGANIC MATTER IN WATER: CHARACTERIZATION, TREATMENT METHODS, AND CLIMATE CHANGE IMPACT -- Copyright -- Contents -- 1 - General introduction -- References -- 2 - Impact of climate and atmospheric pressures on natural organic matter concentration and surface water treatment ... -- 2.1 Introduction -- 2.2 Drivers of increasing DOC -- 2.2.1 Reductions in atmospheric acid deposition -- 2.2.2 Climate change pressures -- 2.2.2.1 Precipitation -- 2.2.2.2 Temperature -- 2.3 Predicting future DOC concentration under climate scenarios -- 2.4 Impact on water treatment -- 2.5 Conclusions -- References -- 3 - Characterization of natural organic matter -- 3.1 Introduction -- 3.2 General parameters -- 3.2.1 Total organic carbon/dissolved organic carbon -- 3.2.2 Specific UV-absorbance -- 3.2.3 Polarity -- 3.3 Biological tests -- 3.4 Isolation and concentration -- 3.5 Fractionation -- 3.5.1 Resin and membrane fractionation -- 3.5.1.1 Resin fractionation -- 3.5.1.2 Membrane filtration -- 3.6 Spectroscopic methods -- 3.6.1 Ultraviolet and visible -- 3.6.2 Differential absorption -- 3.6.3 Fluorescence -- 3.6.4 Fourier transform infrared spectroscopy and Raman spectroscopy -- 3.6.5 Nuclear magnetic resonance -- 3.6.6 1H NMR -- 3.6.7 13C NMR -- 3.7 Chromatographic methods -- 3.7.1 Size exclusion chromatography -- 3.7.1.1 Fractionation of NOM by size exclusion chromatography -- 3.7.1.2 Eluents and columns used for HPSEC measurements -- 3.7.1.3 Detectors used for HPSEC measurements -- 3.7.1.4 Determination of MW by HPSEC -- 3.7.1.5 HPSEC determinations in water treatment monitoring -- 3.7.2 Flow field-flow fractionation -- 3.7.3 Reverse-phase high-performance liquid chromatography -- 3.7.3.1 Liquid chromatography-mass spectrometry -- 3.7.3.2 Fourier transform ion cyclotron resonance mass spectrometry.

The Circular Economy: Case Studies about the Transition from the Linear Economy explores examples of the circular economy in action. Unlike other books that provide narrow perceptions of wide-ranging and highly interconnected paradigms, such as supply chains, recycling, businesses models and waste management, this book provides a comprehensive overview of the circular economy from various perspectives. Its unique insights into the approaches, methods and tools that enable people to make the transformation to a circular economy show how recent research, trends and attitudes have moved beyond the "call to arms" approach to a level of maturity that requires sound scientific thinking

An authoritative and comprehensive volume of knowledge and green technologies wholly focused on the future of the bioeconomy. The authors present data, show opportunities, discuss R&D findings, analyze strategies, assess the wider economic impact, showcase achievements, criticize policies and propose solutions for the green revolution in biofuels, biochemicals and biomaterials' production and power generation. A fascinating range of case studies from the US, China and many European countries are used to inform readers about the impact of this field on society and how various technologies are currently being implemented. Additionally, the role of industry on this green industrial revolution is outlined with contributions from several major companies such as DuPont (US), UPM-Kymmene Oy (Finland), Anhui BBCA Biochemical Co (China)