Laboratoriohoitaja- ja sairaanhoitajakoulutuksen antamat valmiudet kliinisen mikrobiologian näytteenottoon

Tutkimuksen tavoitteena on ollut kuvata pian valmistuvien sairaanhoitaja- ja laboratoriohoitajaopiskelijoiden teoreettista työnhallintaa kliinisen mikrobiologian alaan kuuluvien potilasnäytteiden ottamisessa. Tutkimuksessa haluttiin selvittää, miten peruskoulutus ja työelämän harjoittelujaksot ovat vaikuttaneet näytteenottovalmiuksien syntymiseen sekä minkälainen käsitys valmistuvilla hoitajilla on omista mikrobiologisista näytteenottotaidoistaan. Syy tutkimuksen tekemiseen oli tarve arvioida ammatillisen koulutuksen tuloksellisuutta sekä hakea mikrobiologian opetusalueelta tutkimustietoa opetuksen kehittämiseen ja sisältöjen suuntaamiseen. Tutkimukseen osallistui 21 laboratoriohoitajaopiskelijaa ja 27 sairaanhoitajaopiskelijaa. Opiskelijat olivat viimeiseltä lukukaudelta ja valmistuivat keväällä 1998. Tiedonkeruumenetelmänä oli kyselylomake, jonka alkuosa koostui neljästä mikrobiologisesta näytteenottotilanteesta. Opiskelija vastasi toimintatapansa kertoen ja perustellen, miten hän ottaisi näytteet näissä tilanteissa. Vastaukset ryhmiteltiin käyttäen luokitteluun mukaeltua Solo-taksonomiaa. Koulutusta ja opiskelijan käsityksiä kartoittavat kysymykset olivat joko puolistrukturoituja tai avoimia. Laboratoriohoitajaopiskelijoiden tiedollinen työnhallinta sijoittuu tulosten perusteella tyydyttävän ja hyvän välimaastoon. Sairaanhoitajaopiskelijoiden tietotaso oli heikko ja osin hyvin heikko. Laboratoriohoitajaopiskelijat arvioivat koulutuksen antamia mikrobiologisen näytteenoton valmiuksia pääasiassa hyviksi tai tyydyttäviksi; sairaanhoitajaopiskelijat pitivät opetuksesta saamiaan valmiuksia heikkoina. Näytteenoton arvostusta pidettiin kaiken kaikkiaan matalana, ja tietoa laadukkaasta näytteenotosta arvioitiin puuttuvan työelämässä laajasti. Tutkimuksen perusteella näyttää siltä, ettei valmistuvilla sairaanhoitajilla ole tiedollisia ja taidollisia valmiuksia suoriutua edes perusnäytteenotosta niin, että saatu näyte edustaisi laadukkaasti potilaan tilaa näytteenottohetkellä. Näytteenotto on koko laboratoriotyön prosessin kriittisin vaihe. Jos näyte on otettu, säilytetty tai kuljetettu väärin, paraskaan analyysitekniikka ei pysty tuottamaan siitä potilaan hoitoa oikeaan suuntaan ohjaavaa tulosta. Kaikkien laboratorionäytteiden oton siirtäminen laboratoriohoitajille ja runsaan lisäkoulutuksen anto tälle ammattiryhmälle voisi tuottaa parannuksen vallitsevaan tilanteeseen. Avainsanat: ammattitaito, osaaminen, ammatillinen koulutus, kliinisen mikrobiologian näytteenotto, tiedollinen työnhallinta Keywords: occupational skills, competence, vocational education, collecting of specimen in clinical microbiology, conceptual mastery of work

Noise sensitivity medical, psychological and genetic aspects

Noise can be defined as unwanted sound. It may adversely affect the health and well-being of individuals. Noise sensitivity is a personality trait covering attitudes towards noise in general and a predictor of noise annoyance. Noise sensitive individuals are more affected by noise than less sensitive individuals. The determinants and characteristics related to noise sensitivity are rather poorly known. The risk of health effects caused by noise can be hypothesized to be higher for noise sensitive individuals compared to those who are not noise sensitive. A cardiovascular disease may be an example of outcomes. The general aim of the present study was to investigate the association of noise sensitivity with specific somatic and psychological factors, including the genetic component of noise sensitivity, and the association of noise sensitivity with mortality. The study was based on the Finnish Twin Cohort of same-sex twin pairs born before 1958. In 1988 a questionnaire was sent to twin pairs discordant for hypertension. 1495 individuals (688 men, 807 women) aged 31 88 years replied, including 573 twin pairs. 218 of the subjects lived in the Helsinki Metropolitan Area. Self-reported noise sensitivity, lifetime noise exposure and hypertension were obtained from the questionnaire study in 1988 and other somatic and psychological factors from the questionnaire study in 1981 for the same individuals. In addition, noise map information (1988 1992) from the Helsinki Metropolitan Area and mortality follow-up 1989 2003 were used. To evaluate the stability and validity of noise sensitivity, a new questionnaire was sent in 2002 to a sample of the subjects who had replied to the 1988 questionnaire. Of all subjects who had answered the question on noise sensitivity, 38 % were noise sensitive. Noise sensitivity was independent of noise exposure levels indicated in noise maps. Subjects with high noise sensitivity reported more transportation noise exposure than subjects with low noise sensitivity. Noise sensitive subjects reported transportation noise exposure outside the environmental noise map areas almost twice as often as non-sensitive subjects. Noise sensitivity was associated with hypertension, emphysema, use of psychotropic drugs, smoking, stress and hostility, even when lifetime noise exposure was adjusted for. Monozygotic twin pairs were more similar with regards noise sensitivity than dizygotic twin pairs, and quantitative genetic modelling indicated significant familiality. The best fitting genetic model provided an estimate of heritability of 36 %. Follow-up of subjects in the case-control study showed that cardiovascular mortality was significantly increased among noise sensitive women, but not among men. For coronary heart mortality the interaction of noise sensitivity and lifetime noise exposure was statistically significant in women. In conclusion, noise sensitivity has both somatic and psychological components. It does aggregate in families and probably has a genetic component. Noise sensitivity may be a risk factor for cardiovascular mortality in women.

Characterization of Actinobacteria Degrading and Tolerating Organic Pollutants

Species of the genera Rhodococcus, Gordonia and Mycobacterium are known as degraders of recalcitrant pollutants. These bacteria are good survivors in harsh environments. Due to such properties these organisms are able to occupy a wide range of environmental niches. The members of these taxa have been suggested as tools for biotechnical applications such as bioremediation and biosynthesis. At the same time several of the species are known as opportunistic human pathogens. Therefore, the detailed characterization of any isolate that has potential for biotechnological applications is very important. This thesis deals with several corynebacterial strains originating from different polluted environments: soil, water-damaged indoor walls, and drinking water distribution systems. A polyphasic taxonomic approach was applied for characterization of the isolates. We found that the strains degrading monoaromatic compounds belonged to Rhodococcus opacus, a species that has not been associated with any health problem. The taxonomic position of strain B293, used for many years in degradation research under different names, was clarified. We assigned it to the species Gordonia polyisoprenivorans. This species is classified under European Biohazard grouping 1, meaning that it is not considered a health hazard for humans. However, there are reports of catheter-associated bacteraemia caused by G. polyisoprenivorans. Our results suggested that the ability of the organism to grow on phthalate esters, used as softeners in medical plastics, may be associated with the colonization of catheters and other devices. In this thesis Mycobacterium lentiflavum, a new emerging opportunistic human pathogen, was isolated from biofilms growing in public drinking water distribution systems. Our report on isolation of M. lentiflavum from water supplies is the second report on this species from drinking water systems, which may thus constitute a reservoir of M. lentiflavum. Automated riboprinting was evaluated for its applicability in rapidly identifying environmental mycobacteria. The technique was found useful in the characterization of several species of rapidly and slowly growing environmental mycobacteria. The second aspect of this thesis refers to characterization of the degradation and tolerance power of several R. opacus, M. murale and G. polyisoprenivorans strains. R. opacus GM-14 utilizes a wide range of aromatic substrates, including benzene, 15 different halobenzenes, 18 phenols and 7 benzoates. This study revealed the high tolerance of R. opacus strains toward toxic hydrophobic compounds. R. opacus GM-14 grew in mineral medium to which benzene or monochlorobenzene was added in amounts of 13 or 3 g l-1, respectively. R. opacus GM-29 utilized toluene and benzene for growth. Strain GM-29 grew in mineral medium with 7 g l-1 of liquid toluene or benzene as the sole carbon source, corresponding to aqueous concentrations of 470 and 650 mg l-1, respectively. Most organic solvents, such as toluene and benzene, due to their high level of hydrophobicity, pass through the bacterial membrane, causing its disintegration. In this thesis the mechanisms of adaptation of rhodococci to toxic hydrophobic compounds were investigated. The rhodococcal strains increased the level of saturation of their cellular fatty acids in response to challenge with phenol, chlorophenol, benzene, chlorobenzene or toluene. The results indicated that increase in the saturation level of cellular fatty acids, particularly that in tuberculostearic acid, is part of the adaptation mechanism of strains GM-14 and GM-29 to the presence of toxic hydrophobic compounds.

Characterization of genomic diversity in extraintestinal pathogenic Escherichia coli (ExPEC) and development of a diagnostic DNA microarray for the differentiation of ExPEC isolates causing urinary tract infections

Extraintestinal pathogenic Escherichia coli (ExPEC) represent a diverse group of strains of E. coli, which infect extraintestinal sites, such as the urinary tract, the bloodstream, the meninges, the peritoneal cavity, and the lungs. Urinary tract infections (UTIs) caused by uropathogenic E. coli (UPEC), the major subgroup of ExPEC, are among the most prevalent microbial diseases world wide and a substantial burden for public health care systems. UTIs are responsible for serious morbidity and mortality in the elderly, in young children, and in immune-compromised and hospitalized patients. ExPEC strains are different, both from genetic and clinical perspectives, from commensal E. coli strains belonging to the normal intestinal flora and from intestinal pathogenic E. coli strains causing diarrhea. ExPEC strains are characterized by a broad range of alternate virulence factors, such as adhesins, toxins, and iron accumulation systems. Unlike diarrheagenic E. coli, whose distinctive virulence determinants evoke characteristic diarrheagenic symptoms and signs, ExPEC strains are exceedingly heterogeneous and are known to possess no specific virulence factors or a set of factors, which are obligatory for the infection of a certain extraintestinal site (e. g. the urinary tract). The ExPEC genomes are highly diverse mosaic structures in permanent flux. These strains have obtained a significant amount of DNA (predictably up to 25% of the genomes) through acquisition of foreign DNA from diverse related or non-related donor species by lateral transfer of mobile genetic elements, including pathogenicity islands (PAIs), plasmids, phages, transposons, and insertion elements. The ability of ExPEC strains to cause disease is mainly derived from this horizontally acquired gene pool; the extragenous DNA facilitates rapid adaptation of the pathogen to changing conditions and hence the extent of the spectrum of sites that can be infected. However, neither the amount of unique DNA in different ExPEC strains (or UPEC strains) nor the mechanisms lying behind the observed genomic mobility are known. Due to this extreme heterogeneity of the UPEC and ExPEC populations in general, the routine surveillance of ExPEC is exceedingly difficult. In this project, we presented a novel virulence gene algorithm (VGA) for the estimation of the extraintestinal virulence potential (VP, pathogenicity risk) of clinically relevant ExPECs and fecal E. coli isolates. The VGA was based on a DNA microarray specific for the ExPEC phenotype (ExPEC pathoarray). This array contained 77 DNA probes homologous with known (e.g. adhesion factors, iron accumulation systems, and toxins) and putative (e.g. genes predictably involved in adhesion, iron uptake, or in metabolic functions) ExPEC virulence determinants. In total, 25 of DNA probes homologous with known virulence factors and 36 of DNA probes representing putative extraintestinal virulence determinants were found at significantly higher frequency in virulent ExPEC isolates than in commensal E. coli strains. We showed that the ExPEC pathoarray and the VGA could be readily used for the differentiation of highly virulent ExPECs both from less virulent ExPEC clones and from commensal E. coli strains as well. Implementing the VGA in a group of unknown ExPECs (n=53) and fecal E. coli isolates (n=37), 83% of strains were correctly identified as extraintestinal virulent or commensal E. coli. Conversely, 15% of clinical ExPECs and 19% of fecal E. coli strains failed to raster into their respective pathogenic and non-pathogenic groups. Clinical data and virulence gene profiles of these strains warranted the estimated VPs; UPEC strains with atypically low risk-ratios were largely isolated from patients with certain medical history, including diabetes mellitus or catheterization, or from elderly patients. In addition, fecal E. coli strains with VPs characteristic for ExPEC were shown to represent the diagnostically important fraction of resident strains of the gut flora with a high potential of causing extraintestinal infections. Interestingly, a large fraction of DNA probes associated with the ExPEC phenotype corresponded to novel DNA sequences without any known function in UTIs and thus represented new genetic markers for the extraintestinal virulence. These DNA probes included unknown DNA sequences originating from the genomic subtractions of four clinical ExPEC isolates as well as from five novel cosmid sequences identified in the UPEC strains HE300 and JS299. The characterized cosmid sequences (pJS332, pJS448, pJS666, pJS700, and pJS706) revealed complex modular DNA structures with known and unknown DNA fragments arranged in a puzzle-like manner and integrated into the common E. coli genomic backbone. Furthermore, cosmid pJS332 of the UPEC strain HE300, which carried a chromosomal virulence gene cluster (iroBCDEN) encoding the salmochelin siderophore system, was shown to be part of a transmissible plasmid of Salmonella enterica. Taken together, the results of this project pointed towards the assumptions that first, (i) homologous recombination, even within coding genes, contributes to the observed mosaicism of ExPEC genomes and secondly, (ii) besides en block transfer of large DNA regions (e.g. chromosomal PAIs) also rearrangements of small DNA modules provide a means of genomic plasticity. The data presented in this project supplemented previous whole genome sequencing projects of E. coli and indicated that each E. coli genome displays a unique assemblage of individual mosaic structures, which enable these strains to successfully colonize and infect different anatomical sites.

Ultrastructure of Biofilms Formed by Bacteria from Industrial Processes

Microorganisms exist predominantly as sessile multispecies communities in natural habitats. Most bacterial species can form these matrix-enclosed microbial communities called biofilms. Biofilms occur in a wide range of environments, on every surface with sufficient moisture and nutrients, also on surfaces in industrial settings and engineered water systems. This unwanted biofilm formation on equipment surfaces is called biofouling. Biofouling can significantly decrease equipment performance and lifetime and cause contamination and impaired quality of the industrial product. In this thesis we studied bacterial adherence to abiotic surfaces by using coupons of stainless steel coated or not coated with fluoropolymer or diamond like carbon (DLC). As model organisms we used bacterial isolates from paper machines (Meiothermus silvanus, Pseudoxanthomonas taiwanensis and Deinococcus geothermalis) and also well characterised species isolated from medical implants (Staphylococcus epidermidis). We found that coating of steel surface with these materials reduced its tendency towards biofouling: Fluoropolymer and DLC coatings repelled all four biofilm formers on steel. We found great differences between bacterial species in their preference of surfaces to adhere as well as their ultrastructural details, like number and thickness of adhesion organelles they expressed. These details responded differently towards the different surfaces they adhered to. We further found that biofilms of D. geothermalis formed on titanium dioxide coated coupons of glass, steel and titanium, were effectively removed by photocatalytic action in response to irradiation at 360 nm. However, on non-coated glass or steel surfaces irradiation had no detectable effect on the amount of bacterial biomass. We showed that the adhesion organelles of bacteria on illuminated TiO2 coated coupons were complety destroyed whereas on non-coated coupons they looked intact when observed by microscope. Stainless steel is the most widely used material for industrial process equipments and surfaces. The results in this thesis showed that stainless steel is prone to biofouling by phylogenetically distant bacterial species and that coating of the steel may offer a tool for reduced biofouling of industrial equipment. Photocatalysis, on the other hand, is a potential technique for biofilm removal from surfaces in locations where high level of hygiene is required. Our study of natural biofilms on barley kernel surfaces showed that also there the microbes possessed adhesion organelles visible with electronmicroscope both before and after steeping. The microbial community of dry barley kernels turned into a dense biofilm covered with slimy extracellular polymeric substance (EPS) in the kernels after steeping in water. Steeping is the first step in malting. We also presented evidence showing that certain strains of Lactobacillus plantarum and Wickerhamomyces anomalus, when used as starter cultures in the steeping water, could enter the barley kernel and colonise the tissues of the barley kernel. By use of a starter culture it was possible to reduce the extensive production of EPS, which resulted in a faster filtration of the mash.

Adhesion,Presence and Antifouling of Deinococcus geothermalis in Paper Machine Environment

This thesis has two items: biofouling and antifouling in paper industry. Biofouling means unwanted microbial accumulation on surfaces causing e.g. disturbances in industrial processes, contamination of medical devices or of water distribution networks. Antifouling focuses on preventing accumulation of the biofilms in undesired places. Deinococcus geothermalis is a pink-pigmented, thermophilic bacterium, and extremely resistant towards radiation, UV-light and desiccation and known as a biofouler of paper machines forming firm and biocide resistant biofilms on the stainless steel surfaces. The compact structure of biofilm microcolonies of D. geothermalis E50051 and the adhesion into abiotic surfaces were investigated by confocal laser scanning microscope combined with carbohydrate specific fluorescently labelled lectins. The extracellular polymeric substance in D. geothermalis microcolonies was found to be a composite of at least five different glycoconjugates contributing to adhesion, functioning as structural elements, putative storages for water, gliding motility and likely also to protection. The adhesion threads that D. geothermalis seems to use to adhere on an abiotic surface and to anchor itself to the neighbouring cells were shown to be protein. Four protein components of type IV pilin were identified. In addition, the lectin staining showed that the adhesion threads were covered with galactose containing glycoconjugates. The threads were not exposed on planktic cells indicating their primary role in adhesion and in biofilm formation. I investigated by quantitative real-time PCR the presence of D. geothermalis in biofilms, deposits, process waters and paper end products from 24 paper and board mills. The primers designed for doing this were targeted to the 16S rRNA gene of D. geothermalis. We found D. geothermalis DNA from 9 machines, in total 16 samples of the 120 mill samples searched for. The total bacterial content varied in those samples between 107 to 3 ×1010 16S rRNA gene copies g-1. The proportion of D. geothermalis in those same samples was minor, 0.03 1.3 % of the total bacterial content. Nevertheless D. geothermalis may endanger paper quality as its DNA was shown in an end product. As an antifouling method towards biofilms we studied the electrochemical polarization. Two novel instruments were designed for this work. The double biofilm analyzer was designed for search for a polarization program that would eradicate D. geothermalis biofilm or from stainless steel under conditions simulating paper mill environment. The Radbox instrument was designed to study the generation of reactive oxygen species during the polarization that was effective in antifouling of D. geothermalis. We found that cathodic character and a pulsed mode of polarization were required to achieve detaching D. geothermalis biofilm from stainless steel. We also found that the efficiency of polarization was good on submerged, and poor on splash area biofilms. By adding oxidative biocides, bromochloro-5,5-dimethylhydantoin, 2,2-dibromo-2-cyanodiacetamide or peracetic acid gave additive value with polarization, being active on splash area biofilms. We showed that the cathodically weighted pulsed polarization that was active in removing D. geothermalis was also effective in generation of reactive oxygen species. It is possible that the antifouling effect relied on the generation of ROS on the polarized steel surfaces. Antifouling method successful towards D. geothermalis that is a tenacious biofouler and possesses a high tolerance to oxidative stressors could be functional also towards other biofoulers and applicable in wet industrial processes elsewhere.

Dimensions of University Student Learning in Medicine and Pharmacy

Study orientations in higher education consist of various dimensions, such as approaches to learning, conceptions of learning and knowledge (i.e. epistemologies), self-regulation, and motivation. They have also been measured in different ways. The main orientations typically reported are reproducing and meaning orientations. The present study explored dimensions of study orientations, focusing in particular on pharmacy and medicine. New versions of self-report instruments were developed and tested in various contexts and in two countries. Furthermore, the linkages between study orientations and students epistemological development were explored. The context of problem-based (PBL) small groups was investigated in order to better understand how collaboration contributes to the quality of learning. The participants of Study I (n=66) were pharmacy students, who were followed during a three-year professionally oriented program in terms of their study orientations and epistemologies. A reproducing orientation to studying diminished during studying, whereas only a few students maintained their original level of meaning orientation. Dualism was found to be associated with a reproducing orientation. In Study II practices associated with deep and surface approaches to learning were measured in two differing ways, in order to better distinguish between what students believed to be useful in studying, and the extent to which they applied their beliefs to practice when preparing for examinations. Differences between domains were investigated by including a sample of Finnish and Swedish medical students (n=956) and a Finnish non-medical sample of university students (n=865). Memorizing and rote learning appeared as differing components of a surface approach to learning, while understanding, relating, and critical evaluation of knowledge emerged as aspects of a deep approach to learning. A structural model confirmed these results in both student samples. Study III explored a wide variety of dimensions of learning in medical education. Swedish medical students (n=280) answered the questionnaire. The deep approach to learning was strongly related to collaboration and reflective learning, whereas the surface approach was associated with novice-like views of knowledge and the valuing of certain and directly applicable knowledge. PBL students aimed at understanding, but also valued the role of memorization. Study IV investigated 12 PBL tutorial groups of students (n=116) studying microbiology and pharmacology in a medical school. The educational application was expected to support a deep approach to learning: Group members course grades in a final examination were related to the perceived functioning of the PBL tutorial groups. Further, the quality of cases that had been used as triggers for learning, was associated with the quality of small group functioning. New dimensions of study orientations were discovered. In particular, novel, finer distinctions were found within the deep approach component. In medicine, critical evaluation of knowledge appeared to be less valued than understanding and relating. Further, collaboration appeared to be closely related to the deep approach, and it was also important in terms of successful PBL studying. The results of the studies confirmed the previously found associations between approaches to learning and study success, but showed interesting context- and subgroup-related differences in this respect. Students ideas about the nature of knowledge and their approaches to learning were shown to be closely related. The present study expanded our understanding of the dimensions of study orientations, of their development, and their contextual variability in pharmacy and medicine.

Treatment of illicit opioid and γ-hydroxybutyrate overdose by Helsinki emergency medical services

Aims: To examine the characteristics, incidence, treatment and outcome of presumed opioid, γ-hydroxybutyrate (GHB) and γ-butyrolactone (GBL) overdoses involving users of illicit drugs in Helsinki. GHB/GBL were included in this study, despite not being opioids, due to the relative ease with which they can cause potentially fatal respiratory depression. The incidence and time interval of recurrent opioid toxicity after prehospital administration of naloxone, an opioid antagonist, was studied in presumed heroin overdose patients. Naloxone has been reported to have many adverse effects and the effects of naloxone administered during an opioid overdose on the cardiovascular system and catecholamine levels in piglets were studied. Materials and methods: Patients included in these published retrospective studies were from the following time periods: Study I: 1995-2002, II: 1997-2000, III: 1995-2000, V: 2006-2007. Presumed opioid overdose patients were examined in studies I, II and III. GHB/GBL overdoses among injecting drug users was examined in study V. Recurrent opioid toxicity after prehospital naloxone administration in heroin overdose patients was examined in study III. The effects of naloxone (80 μg/kg i.v.) on the cardiovascular system and catecholamine levels administered during morphine overdose (8mg/kg i.v.) and under propofol anesthesia with spontaneous breathing were studied in eight piglets (IV). In this thesis, previously unpublished data on the incidence of opioid overdose between 2001-2007 and comparison of the characteristics of buprenorphine and heroin overdose patients encountered in 1995-2005 are also included. Results: Helsinki Emergency Medical Service (EMS) ambulances were dispatched annually to 34,153- 45,118 calls from 1995 to 2007. Of them, 7-8% were coded as intoxications or overdoses. During this time, 436 patients were treated by the EMS for presumed opioid overdose. The peak incidence of opioid overdoses was in the year 2000 (113 cases), after which they declined to 6-26 cases annually. The annual incidence of buprenorphine related overdoses increased from 4 (4% of opioid overdoses) in the year 2000 to 8 (30% of opioid overdoses) in 2007. The annual number of GHB related overdose patients treated by Helsinki EMS increased from 21 to 73 between 2004-2007. There appeared to be a peak in the incidence of both GHB/GBL and opioid related overdoses on Saturdays. Characteristics of opioid overdose patients The median age of opioid overdose patients was 28 years (22;33, 25- and 75-percentiles), and 84% were male. Buprenorphine overdose patients had more polydrug, such as alcohol and/or benzodiazepines, use in comparison with heroin overdose patients, 70% versus 33%, respectively. Severe respiratory depression was reported less often with buprenorphine overdoses compared to heroin overdoses, in 67.0% versus 85.4%, respectively. Outcome of heroin overdose patients with cardiac arrest Ninety four patients suffered cardiac arrest due to acute drug poisoning/overdose and were thus considered for resuscitation. Resuscitation was attempted in 72 cases. Cardiac arrest was caused by heroin overdose for 19 patients of which three (16%) were discharged alive. Other agents also induced cardiac arrest in 53 patients, of which six (11%) were discharged alive. The arrest was either EMS witnessed or occurring after the emergency call for all survivors of heroin induced cardiac arrest. Characteristics of GHB/GBL overdose patients The records of 100 GHB/GBL related overdose patients from 2006-2007 were retrieved. The median age of GHB/GBL overdose patients encountered on weekend nights was 24 years (22;27, 25- and 75-percentiles) and 49% were male. Polydrug use was reported in 62-80% of the cases. Thirty nine patients were encountered on Friday-Saturday or Saturday-Sunday night between 11 pm-6 am. The remaining sixty one patients were outside this time frame. There was a statistically significant difference between these two groups in history of chronic injecting drug use (33% vs. 59%, respectively, p=0.012). Recurrent heroin toxicity after prehospital naloxone administration Study III included 145 presumed heroin overdose patients. After prehospital care, 84 patients refused further care and were not transported to an Emergency Department (ED). Seventy one (85%) of them were administered naloxone by the EMS. During a 12-h follow up period, none of these patients developed severe recurrent opioid toxicity. The remaining 61 patients were transported to an ED. Prior to transportation, 52 (85%) patients were administered naloxone by the EMS. Fifteen of them were administered naloxone also in the ED and recurrent opioid toxicity was evident either on arrival at the ED or shortly thereafter. Prehospital naloxone was administered either intravenously, intramuscularly (i.m.) or subcutaneously (s.c.). There was a tendency for more frequent recurrent heroin toxicity among the patients with only intravenous administration of prehospital naloxone (13/36) compared with the patients with intramuscular or subcutaneous prehospital naloxone (2/16), p=0.106. The effects of naloxone on the cardiovascular system and catecholamine levels in piglets The administration of morphine to piglets resulted in an obvious respiratory depression, which was reversed by naloxone. Two severely hypoxemic piglets developed cardiac arrest after naloxone administration. In the other six animals, the administration of naloxone did not provoke arrhythmias, cardiac ischemia or visible evidence of pulmonary edema. There was a statistically significant (p=0.012) increase in norepinephrine levels after morphine administration and before naloxone administration: from 1.9 (1.3-2.3) ng/ml at baseline, to 31.7 (8.3-83.0) ng/ml (median, 25 and 75 percentiles parentheses) after morphine administration. After the administration of naloxone, the catecholamine levels continued to increase in only one of the animals. Conclusions: The incidence of buprenorphine related overdoses increased during the study period, but was still lower in comparison to those involving heroin. Injecting drug users have also started to use GHB/GBL. While recreational drug users use GHB/GBL during weekend nights, a GHB/GBL overdose patient encounter during weekdays has a more probable history of injecting drug use. Patients with cardiac arrest after heroin overdose have a poor prognosis. It appears to be safe to leave heroin overdose patients on scene after prehospital treatment with naloxone. Although no statistically significant difference was observed, it seems prudent to administer part of the total naloxone dose s.c. or i.m. to reduce the risk of recurrent respiratory depression. If transported to an ED, an observation period of one to two hours after the last naloxone dose seems adequate. The treating physician must be vigilant, however, due to the high prevalence of polydrug use and high morbidity after non fatal heroin overdose. Furthermore, care should be taken regarding possible chronic disorders and drug rehabilitation should be addressed. In the experimental animal study, two animals developed cardiac arrest after receiving naloxone while in hypoxemia and bradycardia. Further studies are required to assess the effect of naloxone during opioid-induced hypercapnia and hypoxemia in animals addicted to opioids.

Texts "Con and Pro" : The Early Modern Medical Controversy over Tobacco

The habit of "drinking smoke" , meaning tobacco smoking, caused a true controversy in early modern England. The new substance was used both for its alleged therapeutic properties as well as its narcotic effects. The dispute over tobacco continues the line of written controversies which were an important means of communication in the sixteenth and seventeenth century Europe. The tobacco controversy is special among medical controversies because the recreational use of tobacco soon spread and outweighed its medicinal use, ultimately causing a social and cultural crisis in England. This study examines how language is used in polemic discourse and argumentation. The material consists of medical texts arguing for and against tobacco in early modern England. The texts were compiled into an electronic corpus of tobacco texts (1577 1670) representing different genres and styles of writing. With the help of the corpus, the tobacco controversy is described and analyzed in the context of early modern medicine. A variety of methods suitable for the study of conflict discourse were used to assess internal and external text variation. The linguistic features examined include personal pronouns, intertextuality, structural components, and statistically derived keywords. A common thread in the work is persuasive language use manifested, for example, in the form of emotive adjectives and the generic use of pronouns; the latter is especially pronounced in the dichotomy between us and them. Controversies have not been studied in this manner before but the methods applied have supplemented each other and proven their suitability in the study of conflictive discourse. These methods can also be applied to present-day materials.