Tomi Seppälä

FINHYST, a prospective study of 5279 hysterectomies: complications and their risk factors

BACKGROUND Hysterectomy guidelines highlight an increase in urinary tract injuries with laparoscopic hysterectomy (LH). This national survey analyses complications of LH, abdominal hysterectomy (AH) and vaginal hysterectomy (VH). METHODS A prospective cohort undergoing hysterectomy for benign indications during 2006 was drawn from 53 hospitals in Finland; all communal hospitals participated. Detailed questionnaires covered surgical data and intra- and post-operative major and minor complications, for which risk factors were analysed by a multivariate logistic regression model adjusted for surgical data and patient characteristics. RESULTS Major complications rates in AH (n= 1255, 24%), LH (1679, 32%) and VH (2345, 44%) were 4.0, 4.3 and 2.6%, and total complications rates were 19.2, 15.4 and 11.7%, respectively. Logistic regression showed no statistically significant differences between approaches for any organ injuries or other major complications. Most bladder and bowel injuries (88 and 83%), but not ureter injuries (10%), were recognized intra-operatively. The ureter injury rate was low after LH (0.3%), as it was after other types of hysterectomy. Compared with LH, AH increased the odds of wound infection, and was an independent risk factor for urinary infections and febrile events. Compared with AH, LH and VH both presented a higher risk for pelvic infection; surgically treated equally often regardless of the type of hysterectomy. No differences in complications emerged between LH and VH. Obesity was a risk factor for many infections. Surgical adhesiolysis [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.38-4.21] was the strongest single risk factor for major complications as a whole. Bladder injury was associated with a history of caesarean section (OR 4.01, 95% CI 2.06-7.83) and with a large uterus ≥500 g (OR 2.88, 95% CI 1.05-7.90), while bowel injury was associated with adhesiolysis (OR 29.07, 95% CI 7.17-117.88). CONCLUSIONS FINHYST is a large prospective hysterectomy study illustrating actual complications. Whenever possible, hysterectomy should be minimally invasive.

National learning curve for laparoscopic hysterectomy and trends in hysterectomy in Finland 2000–2005

BACKGROUND Complications of laparoscopic hysterectomy (LH) have been evaluated with particular focus on quantities of urinary tract injuries. An earlier survey in the 1990s on LH in Finland indicated a decreasing trend in complications; our aim was to evaluate the current complications and hysterectomy trends. METHODS All hysterectomies in Finland performed for benign indication from 2000 to 2005 (n = 56 130) were included, data were obtained from the Finnish hospital care register. All major complications reported on LH were analysed; the data were collected retrospectively from the Patient Insurance Centre. RESULTS In 2000, the proportion of abdominal hysterectomy (AH) was 38%, vaginal hysterectomy (VH) 37% and LH 25%, whereas in 2005, the proportions were 26%, 45% and 29%, respectively. The overall incidence of major complications in LHs from 1992 to 1999 (LH n = 13 885) was 1.8% and from 2000 to 2005 (LH n = 13 942) it decreased to 1.0%. During the same time, urinary tract injuries decreased from 1.4% to 0.7%; in detail ureteral injuries decreased from 0.9% to 0.3%. CONCLUSIONS Laparoscopic and VHs have become more common in Finland than AH. Continuous instruction and training of the Finnish gynaecological surgeons has helped to diminish major complication rates and it seems that in LH, a plateau on the learning curve has been reached.

Marketing strategies for foreign expansion of companies originating in small and open economies: The consequences of strategic fit and performance

This study examines the marketing strategies of companies originating in small and open economies as they expand into foreign markets. It distinguishes two major globalization paths (that of born globals and that of globalizing internationals), contrasts them with traditional internationalizers, and describes their characteristics. It then outlines a framework and hypotheses regarding the marketing strategies used in foreign expansion and examines them empirically in the information and communication technology field. The authors examine two important strategic marketing issues: the breadth of product offering and the standardization of marketing strategies across countries. The empirical results show that foreign expansion path, foreign business experience, and external globalization pressure have an impact on the selection of marketing strategies. The study also finds that the fit between these contextual factors and the standardization of marketing strategy has a positive effect on performance. The novel results regarding the importance of foreign expansion paths in the selection of marketing strategies have important implications for both academicians and practitioners in the field of international marketing.

Executive views concerning decision support tools

Abstract Support tools for strategic-level decision-making have become increasingly popular. This study investigates the role of OR/MS tools in today’s strategic-level decision support tool market. Executives working in Finland’s 500 largest companies were asked about the decision support tools they use when making major decisions. The responses received indicated that executives actively use a variety of tools, and an average of five different strategic-level tools. Approximately 10% of the tools used could be identified as OR/MS type, these often suit the needs of larger companies with strategic logistical or production functions and compared to other tools, have a specific profile. Executives see advantages in using tools that provide cognitive, collaboration and communication possibilities, and also in using tools that make processes more efficient. OR methodologies have influenced some of the other tools on the market, but ‘soft OR’ tool usage could not be identified. Tools which support creativity are needed.

The EKC Hypothesis Does Not Hold for Direct Material Flows: Environmental Kuznets Curve Hypothesis Tests for Direct Material Flows in Five Industrial Countries

This study analyses the Environmental Kuznets Curve Hypothesis (EKC) with direct material flow data from the USA, Germany, Japan, the Netherlands and Finland in the years 1975 to 1994. Recently, there has been a discussion concerning the relevance of the EKC hypothesis suggesting that also the intensity of material use should decline with income growth. The EKC hypothesis has not been widely tested with direct material flow data, and this paper presents one of the first attempts to do such tests. The results of the empirical hypothesis tests indicate that the EKC hypothesis does not hold in the case of aggregated direct material flows among industrialised countries like Germany, Japan, the USA, the Netherlands and Finland.

Pharmaceutical thrombosis prophylaxis, bleeding complications and thromboembolism in a national cohort of hysterectomy for benign disease

BACKGROUND Pharmaceutical thrombosis prophylaxis (PTP) with low-molecular-weight heparin (LMWH) is highly effective in preventing venous thromboembolic events (VTEs) and fatal pulmonary embolism. Important risk factors for VTEs are surgery and immobilization, along with malignancy. Many studies involving gynaecological malignancies show no increased risk for bleeding complications with PTP. Little is known about the PTP-associated risk for bleeding complications with hysterectomy for benign disease, or about current VTE incidence in the less-invasive hysterectomy methods. METHODS Our observational prospective national 1-year cohort from 1 January to 31 December 2006 in 53 hospitals represented 79.4% (5297 of 6645) of hysterectomies performed for benign cause in Finland in 2006. We evaluated PTP use and VTE incidence. Operative and post-operative bleeding complications were analysed with logistic regression adjusted for confounders: age, BMI, experience of the gynaecological surgeon, hospital type, indication for hysterectomy, uterine weight, operative haemorrhage, concomitant surgery, adhesiolysis and antibiotic prophylaxis. RESULTS Hysterectomies were performed by three main approaches: 2345 vaginal hysterectomies (VHs, 44%), of which 1433 were for uterine prolapse and 912 for other indications, 1679 laparoscopic hysterectomies (LHs, 32%) and 1255 abdominal hysterectomies (AHs, 24%). PTP was given to 64.8% of patients (3420 of 5279) and was identified as LMWH in 3313 patients (97%); 107 left unidentified. By type of hysterectomy, PTP was given in VH for uterine prolapse to 73.2% of patients, VH for other indication to 51.6%, in LH to 59.4% and in AH to 71.9%. For all hysterectomies analysed together, PTP doubled the odds for post-operative haemorrhage or haematoma. By type of hysterectomy, PTP associated with post-operative haemorrhage or haematoma in VH for prolapse [2.7% of PTP given, versus 0.8% of no PTP; odds ratio (OR): 4.82, 95% confidence interval (CI): 1.38-16.83]; and in AH (3.1% versus 1.4%; OR: 2.87, 95% CI: 1.03-7.98), and in AH also with post-operative transfusion (3.1% versus 1.4%; OR: 3.34, 95% CI: 1.41-7.88). For LH and VH for indications other than prolapse, the effect of PTP on post-operative haemorrhage was non-significant. For VH, the risk for post-operative haemorrhage fell with age. Operative mean haemorrhage with all hysterectomy types, and operative bleeding complications in AH and VH also fell with age. Obesity increased haemorrhage and operative bleeding complications for LH and VH, whereas post-operative bleeding complications were less for the obese in AH. VTEs were 6 of 5279 (0.1%): two PEs each occurred after AH and VH, and two deep venous thromboses after LH. CONCLUSIONS With a relatively wide PTP coverage (64.8%), VTEs were rare (0.1%). All affected had received PTP. Analysis of efficacy, meaning interpretation of how many VTEs or deaths were prevented, cannot be done from our observational study but related to safety in hysterectomy for benign disease, PTP associated with post-operative bleeding complications with AH and with VH for prolapse. TRIAL REGISTRATION NUMBER ClinicalTrials.gov protocol (NCT00744172).

Antibiotic prophylaxis for hysterectomy, a prospective cohort study: cefuroxime, metronidazole, or both?

To evaluate cefuroxime and metronidazole antibiotic prophylaxis.

Multiple Sales Channel Strategy and Performance: The Moderating Role of International Experience and Globalization Potential

Globalization and technological advancement have led to an increase in the numbers of channels available for firms expanding to foreign markets. Although research has started to address strategic choice, the implications for performance have not been adequately investigated. This study examines multiple sales channel structure selection and standardization across foreign markets and the role of foreign knowledge and industry globalization potential in determining the most profitable alternative.

Hybrid Competitive Strategies for Achieving Superior Performance During Global Expansion: Small and Medium-Sized Enterprises Originating in SMOPECs

The ongoing almost three decade’s lasting debate around whether a firm should rely on a`single’ (or pure) generic competitive strategy of either differentiation or cost leadership, or whether a combined ‘hybrid’ (or dual) competitive strategy should be used is far from being resolved. Porter (1980, 1985) originally postulated that a firm must make a choice between the two or it will become stuck in the middle (Porter, 1985, p. 16). With stuck in the middle he refers to a firm that attempts to achieve both cost leadership and differentiation advantage and as an end result fails in achieving any competitive advantage leading to below-average performance. Researchers have been heavily divided with respect to this issue (Campbell-Hunt, 2000). Researchers that support Porter’s view have in fact found empirical evidence of firms applying a hybrid strategy to underperform their rivals that follow either a cost leadership or a differentiation strategy (Kim and Lim, 1988; Aulakh and Teegen, 2000). In contrast, the opposing researchers claim that a combination of differentiation and low-cost position may lead to superior performance (Hill, 1988; Murray, 1988; Miller and Dess, 1993; Spanos et al. 2004). The interest in the SMOPECs can be understood from the view point that tentative qualitative research from leading Finnish and Greek firms indicate that use of hybrid strategy can be highly profitable (Salonen et al. 2007; Spanos et al. 2004). The study, however, suggest that the results of this chapter are particularly relevant for SMEs originating in Finland, Sweden, Denmark, Norway, Greece, New Zealand, Israel and 14, other SMOPEC countries.