Toimintapolitiikkaprosessi kunnassa : tapausesimerkkinä Järvenpään kaupungin toimintamalliuudistus

Tutkimuksen aiheena on kunnan toimintapolitiikkaprosessi, jota jäsennetään teoreettisesti kirjallisuuskatsauksen perusteella. Toimintapolitiikka on kaikkea sitä toimintaa, jota julkinen valta tietoisesti tekee tai jättää tekemättä. Toimintapolitiikkaprosessi johtaa toimintapolitiikan syntyyn. Siinä keskeisinä toimijoina ovat poliittiset luottamushenkilöt sekä hallinnosta vastaavat viranhaltijat. Yksinkertaistettuna se koostuu neljästä vaiheesta: ongelman tunnistamisesta, toimintapolitiikan suunnittelusta, toimeenpanosta ja arvioinnista. Tutkimus on luonteeltaan kvalitatiivinen. Tutkimuksen aineistona on käytetty Järvenpään kaupungin johtavien viranhaltijoiden ja luottamushenkilöiden haastatteluja, joita on analysoitu faktapohjaisesti. Aineistona on hyödynnetty myös Järvenpään kaupungin Asiakkaan asialla -muutoshankkeen asiakirja-aineistoa sekä muita Järvenpään kaupungin asiakirjoja. Tutkimuksen empiirisen osion muodostaa Järvenpään kaupungissa 2010-luvun taitteessa toteutettu toimintamalli- ja organisaatiouudistus, jonka myötä kaupunki siirtyi asiakaslähtöiseen ja prosessimaisesti toimivaan organisaatioon. Muutoshanketta jäsennetään toimintapoliittisena valintana ja toimintapolitiikkaprosessina. Järvenpään kaupungin muutoshanke todensi teoreettisen viitekehyksen jäsennystä onnistuneen toimeenpanon edellytyksistä. Näitä ovat toimiva vuorovaikutussuhde poliittisten luottamushenkilöiden ja kunnallisten viranhaltijoiden välillä sekä riittävä liikkumavara toimeenpanossa suhteessa laadittuihin suunnitelmiin. Kunnallista toimintaa ja muutoshankkeita voi toimivasti jäsentää toimintapolitiikkaprosesseina, mikä mahdollistaa paremman ymmärryksen muodostamista niistä vaiheista ja tapahtumista, jotka ovat vaikuttaneet kunnan eri toimintapolitiikkojen muotoutumiseen

Tumor volume as a prognostic marker in p16-positive and p16-negative oropharyngeal cancer patients treated with definitive intensity-modulated radiotherapy

To investigate the impact of primary gross tumor volume (pGTV) and nodal gross tumor volume (nGTV) in oropharyngeal squamous cell carcinoma (OPSCC) and the difference in their role between human papillomavirus (HPV)-positive and HPV-negative patients. The patient cohort consists of 91 OPSCC patients treated with definitive radiochemotherapy or radiotherapy using intensity-modulated radiotherapy (IMRT). All patients had a minimum follow-up of 31 months. Volume measurements were made from computer tomography (CT) scans and HPV status was assessed by p16 immunohistochemistry. The end points were as follows: overall survival (OS), disease-free survival (DFS) and locoregional control (LRC). pGTV was a significant independent prognostic factor for overall survival (OS; p0.020) in p16-negative patients. nGTV of p16-negative tumors had significant prognostic value in all end points in multivariate analyses. High-stage (III-IVc) p16-negative tumors were only associated with significantly poorer OS (p = 0.046) but not with poorer LRC or DFS when compared with the low-stage (I-II) tumors. nGTV of p16-positive tumors was an independent prognostic factor for DFS (p= 0.005) and LRC (p= 0.007) in multivariate analyses. pGTV may serve as an independent prognostic factor in p16-negative patients and nGTV may serve as an independent prognostic factor both in p16-positive and p16-negative patients treated with radiochemotherapy or radiotherapy using IMRT. Tumor volume may have an impact on selecting patients for de-escalation protocols in the future, both in p16-positive and p16-negative patients.Peer reviewe

Investigating the association of electrically-evoked compound action potential thresholds with inner-ear dimensions in pediatric cochlear implantation

Objectives: A narrow bony cochlear nerve canal (BCNC), as well as a hypoplastic and aplastic cochlear nerve (CN) have been associated with increased electrically-evoked compound action potential (eCAP) thresholds in some studies, suggesting poorer neural excitability in cochlear implantation. Also, in large cochleae the extent of activated spiral ganglion neurons with electrical stimulation is less than in smaller ones. However, a detailed description of the relationship between eCAP thresholds for a lateral-wall electrode array and dimensions of the inner-ear structures and internal auditory canal (IAC) is missing. Design: The study subjects were 52 pediatric patients with congenital severe-to-profound hearing loss (27 females and 25 males; ages 0.7-2.0 years; 1.0 +/- 0.3 years, mean +/- SD) implanted bilaterally with Cochlear Nucleus CI422, CI522, or CI622 implants with full insertion of the Slim Straight electrode array. Diameters of the cochlea and the BCNC as well as the widths and heights of the IAC and the CN were evaluated from preoperative computed tomography and magnetic resonance images. These anatomical dimensions were compared with each other and with the patients' intraoperative eCAP thresholds. Results: The eCAP thresholds increased from the apical to basal direction (r = 0.89, p < 0.001). After sorting the cochleae into four size categories, higher eCAP thresholds were found in larger than in smaller cochleae (p < 0.001). With similar categorization, the eCAP thresholds were higher in cochleae with a larger BCNC than in cochleae with a smaller BCNC (p < 0.001). Neither IAC nor CN cross-sectional areas affected the eCAP thresholds. Correlations were found between cochlea and BCNC diameters and between IAC and CN cross-sectional areas (r = 0.39 and r = 0.48, respectively, p < 0.001 for both). Conclusions: In the basal part of the electrode array, higher stimulation levels to elicit measurable neural responses (eCAP thresholds) were required than in the apical part. Increased eCAP thresholds associated with a larger cochlear diameter, but contrary to the earlier studies, not with a small size of the BCNC or the CN. Instead, the BCNC diameter correlated significantly with the cochlea diameter.Peer reviewe

Varhaismoderni paikallisyhteisö hallinnon ja toiminnan tilana

publishedVersionPeer reviewe

Presenting symptoms and clinical findings in HPV-positive and HPV-negative oropharyngeal cancer patients

Objectives: Oropharyngeal squamous cell carcinoma (OPSCC) is divided in two different disease entities depending on HPV involvement. We investigated differences in presenting symptoms and clinical findings in patients with HPV-positive and -negative OPSCC tumors. Methods: Altogether 118 consecutive patients diagnosed with primary OPSCC between 2012 and 2014 at the Helsinki University Hospital were included. HPV-status of the tumors was assessed by PCR detection of HPV DNA and immunostaining with p16-INK4a antibody. Results: Fifty-one (47.7%) of the patients had HPV-positive and 56 (52.3%) HPV-negative tumors. Forty-nine (49/51, 96.1%) of the HPV+ tumors were also p16+ showing high concordance. The most common presenting symptom among HPV+/p16+ patients was a neck mass (53.1%), whereas any sort of pain in the head and neck area was more frequently related to the HPV-/p16- (60.0%) group. HPV+/p16+ tumors had a tendency to locate in the tonsillar complex and more likely had already spread into regional lymph nodes compared with HPV-/p16- tumors. Smoking and heavy alcohol consumption were significantly more common among HPV-/p16- patients but also rather common among HPV+/p16+ patients. Conclusions: This analysis of symptoms and signs confirm that OPSCC can be dichotomized in two distinct disease entities as defined by HPV status.Peer reviewe

Additive Manufacturing of Resected Oral and Oropharyngeal Tissue : A Pilot Study

Better visualization of tumor structure and orientation are needed in the postoperative setting. We aimed to assess the feasibility of a system in which oral and oropharyngeal tumors are resected, photographed, 3D modeled, and printed using additive manufacturing techniques. Three patients diagnosed with oral/oropharyngeal cancer were included. All patients underwent preoperative magnetic resonance imaging followed by resection. In the operating room (OR), the resected tissue block was photographed using a smartphone. Digital photos were imported into Agisoft Photoscan to produce a digital 3D model of the resected tissue. Physical models were then printed using binder jetting techniques. The aforementioned process was applied in pilot cases including carcinomas of the tongue and larynx. The number of photographs taken for each case ranged from 63 to 195. The printing time for the physical models ranged from 2 to 9 h, costs ranging from 25 to 141 EUR (28 to 161 USD). Digital photography may be used to additively manufacture models of resected oral/oropharyngeal tumors in an easy, accessible and efficient fashion. The model may be used in interdisciplinary discussion regarding postoperative care to improve understanding and collaboration, but further investigation in prospective studies is required

Prognostic Value of Apparent Diffusion Coefficient in Oropharyngeal Carcinoma

Purpose To investigate clinical and radiological factors predicting worse outcome after (chemo)radiotherapy ([C]RT) in oropharyngeal squamous cell carcinoma (OPSCC) with a focus on apparent diffusion coefficient (ADC). Methods This retrospective study included 67 OPSCC patients, treated with (C)RT with curative intent and diagnosed during 2013-2017. Human papilloma virus (HPV) association was detected with p16 immunohistochemistry. Of all 67 tumors, 55 were p16 positive, 9 were p16 negative, and in 3 the p16 status was unknown. Median follow-up time was 38 months. We analyzed pretreatment magnetic resonance imaging (MRI) for factors predicting disease-free survival (DFS) and locoregional recurrence (LRR), including primary tumor volume and the largest metastasis. Crude and p16-adjusted hazard ratios were analyzed using Cox proportional hazards model. Interobserver agreement was evaluated. Results Disease recurred in 13 (19.4%) patients. High ADC predicted poor DFS, but not when the analysis was adjusted for p16. A break in RT (hazard ratio, HR = 3.972, 95% confidence interval, CI 1.445-10.917, p = 0.007) and larger metastasis volume (HR = 1.041, 95% CI 1.007-1.077, p = 0.019) were associated with worse DFS. A primary tumor larger than 7 cm(3) was associated with increased LRR rate (HR = 4.861, 1.042-22.667, p = 0.044). Among p16-positive tumors, mean ADC was lower in grade 3 tumors compared to lower grade tumors (0.736 vs. 0.883; p = 0.003). Conclusion Low tumor ADC seems to be related to p16 positivity and therefore should not be used independently to evaluate disease prognosis or to choose patients for treatment deintensification.Peer reviewe