7 päivää -lehden aukeama multisemioottisena tekstinä

Sensaatiolehden teksti, joka koostuu monista kuvallisista ja kielellisistä elementeistä, on tutkielman aiheena. Tutkielmassa vastataan kysymykseen, millainen tämä teksti on, kun sitä tarkastellaan multisemioottisesti. Analyysin lähtökohdaksi otetaan neljä merkityksen muodostumisen tasoa: tekstin rakentuminen (kompositio), maailman hahmottaminen (ideationaalinen merkitys), maailmaan osallistuminen (interpersoonainen merkitys) ja intertekstuaalisuus ynnä oletuslukijat (rekontekstualisointi). Teksti toimii yhtaikaa jokaisella tasolla. Aineistona on 7 päivää -lehden aukeama, jossa on Pop-palat-palsta. Aineistoa lähestytään deskriptiivisesti, eikä sitä arvoteta hyväksi tai huonoksi. Tutkielmassa käytetään viitekehyksinä systeemis-funktionaalista kieliteoriaa, kriittistä tekstianalyysiä ja sosiosemioottista visuaalista teoriaa. Tutkielma kuuluu tekstintutkimuksen alaan. Tekstiksi luetaan tässä työssä sekä visuaalisten että verbaalisten semioottisten merkkijärjestelmien tuotokset. Analyysissä osoitetaan, millaisen kokonaisuuden kuva ja kieli muodostavat, miten ne pelaavat yhteen ja millaista merkitystä yhteispeli viestii. Aikaisemman suomalaisen multisemioottisen tekstintutkimuksen kohteeksi ei ole otettu aikakauslehtiä saati sensaatiolehtiä. Elementtien muodostama kokonaisuus mahdollistaa lukijalle monta eri reittiä edetä tekstissä; teksti on multilineaarinen. Tärkeimmiksi elementeiksi erottuvat valokuvat ja otsikot. Sekä kuvassa että otsikossa, juttutekstissä ja kuvatekstissä etualaistetaan sama henkilö. Etualaistettu henkilö esitetään usein valokuvassa kahden henkilön välillä aktiivisena toimijana, hän on otsikossa tekijä sekä juttutekstissä ja kuvatekstissä teema. Osa otsikoista on puhekuplassa, ja muutenkin otsikoissa on vallalla verbaalinen prosessityyppi. Kuvan henkilöt puhuvat suoraan lukijalle. Referaattiotsikoiden totuudellisuus on otettu aukeamalla rennosti. Tätä selitetään moniäänisyyden käsitteellä: kuvan henkilön ja palstan kirjoittajan äänet kuuluvat otsikoissa samanaikaisesti. Tärkeä tutkimustulos on se, että otsikoita ei ole merkitty referoinniksi tyypillisten referointikonventioiden tapaan, vaan johtolauseen paikan ja tehtävän täyttää valokuva. Kuva kehystää referaattiotsikon. Lukijaan otetaan läheinen kontakti: häntä pyydetään vastaamaan viikkokilpailuun, kuvien henkilöt vaativat katseellaan lukijaa osallistumaan, valokuvat on rajattu sosiaalisti läheisiksi, käytetään arkikieltä. Aineistoteksti on ennen kaikkea sosiaalista. Analyysissä osoitetaan tekstin tehtäviä, joita ovat sosiaalisuuden lisäksi mm. kaupallisuus, viihteellisyys ja juoruilu. Tekstipiirteistä erityisesti kirjasinlajit ja -leikkaukset nähdään interteksteinä muihin aikakauslehtiin. Aukeaman kokonaisuus tulkitaan analogiseksi kollaasitaiteen kanssa. Räväkät kuvat ja otsikot yhdessä juttu- ja kuvatekstien ym. elementtien kanssa muodostavat multisemioottisen kokonaisuuden, jossa koodien perinteiset tehtävät sekoittuvat: visuaalinen on myös verbaalista ja verbaalinen visuaalista.

Idealähtöistä koulualgebraa : IDEAA-opetusmallin kehittäminen algebran opetukseen peruskoulun 7. luokalla

This research is based on the problems in secondary school algebra I have noticed in my own work as a teacher of mathematics. Algebra does not touch the pupil, it remains knowledge that is not used or tested. Furthermore the performance level in algebra is quite low. This study presents a model for 7th grade algebra instruction in order to make algebra more natural and useful to students. I refer to the instruction model as the Idea-based Algebra (IDEAA). The basic ideas of this IDEAA model are 1) to combine children's own informal mathematics with scientific mathematics ("math math") and 2) to structure algebra content as a "map of big ideas", not as a traditional sequence of powers, polynomials, equations, and word problems. This research project is a kind of design process or design research. As such, this project has three, intertwined goals: research, design and pedagogical practice. I also assume three roles. As a researcher, I want to learn about learning and school algebra, its problems and possibilities. As a designer, I use research in the intervention to develop a shared artefact, the instruction model. In addition, I want to improve the practice through intervention and research. A design research like this is quite challenging. Its goals and means are intertwined and change in the research process. Theory emerges from the inquiry; it is not given a priori. The aim to improve instruction is normative, as one should take into account what "good" means in school algebra. An important part of my study is to work out these paradigmatic questions. The result of the study is threefold. The main result is the instruction model designed in the study. The second result is the theory that is developed of the teaching, learning and algebra. The third result is knowledge of the design process. The instruction model (IDEAA) is connected to four main features of good algebra education: 1) the situationality of learning, 2) learning as knowledge building, in which natural language and intuitive thinking work as "intermediaries", 3) the emergence and diversity of algebra, and 4) the development of high performance skills at any stage of instruction.

Yhteinen käsityö peruskoulun 7. luokalla : Opettajien kokemuksia yhteisen käsityön opetuksesta ja organisoinnista

Finnish education politics presume that basic education should be equal to all students. While organising craft education equality can be understood as similarity or as possibility to choose. The possibility to be able to choose whether textile or technical craft despite of one´s gender has been the aim of laws and curriculums already over 30 years. In practice it´s almost impossible to students to ignore feminine and masculine roles that go deep into our culture. Choosing craft has been divided by gender, which is the reason why possibility to choose has not been good enough to educationalists of equality. The latest guidelines for the National core curriculum for bacis education were issued in 2004. According to curriculum craft education consists parts of both technical and textile craft. All students should take part in both sectors of crafts. Furthermore, one can be given a possibility to consentrate his studies in whether textile or technical craft. The curriculum does not set the rules how the education should be organised, which means that it can be organised in many ways depending on city, school or teacher. Teachers and other specialists have contradictory feelings towards shared craft education, because traditional way to see craft in Finland is to separate textile craft from technical craft. Both crafts have some common features that are introduced in curriculum. Besides there is many equal things in craft theories that bind textile and technical craft to each other. The main purpose of this research was to find out, how shared craft education has been organised at the 7.th grade in Finnish comprehensive school, and which things affect in the settlements. Second goal was to describe and compare teachers´ experiences in teaching shared craft education. Third aim of this study was how shared craft has changed craft education. I collected the research material in May 2006 by interviewing both textile and technical craft teachers who teach shared craft. The material consists of fourteen theme interviews. In the analysis of the material I used theoretic bounded document analysis. According to the research there are three different ways to organise shared craft education: 50 50-arrangement, exchanging period and project week. In the schools that carried out 50 50-arrangement teaching was realised mainly in heterogenous groups. Principals had usual a lot of authorization on how to arrange craft education, which means that their views on equality, laws and curriculum affected in the settlemets more than teachers´ opinions. Teachers´ attitudes to shared craft were mainly positive. The changing of craft education can be divided in two parts: the aims and the containings of the curriculum have changed, as well as the meaning of the craft as core subject. Teachers have been forced to decrease the containings of both textile and technical crafts. Despite of eliminations both crafts still have comprehensive containings. Teachers decided what to teach by these argumets: Students should learn some basic things or produce a certain product. Usually teachers had also a lot of experience and special intrests in crafts. According to this research there is four significant meanings for shared craft education: 1) developing readiness for doing things, 2) developing skills of thinking, 3) delight of doing things and 4) teaching attitude.

Anthropometric measures of obesity-their association with type 2 diabetes and hypertension across ethnic groups

Clinical trials have shown that weight reduction with lifestyles can delay or prevent diabetes and reduce blood pressure. An appropriate definition of obesity using anthropometric measures is useful in predicting diabetes and hypertension at the population level. However, there is debate on which of the measures of obesity is best or most strongly associated with diabetes and hypertension and on what are the optimal cut-off values for body mass index (BMI) and waist circumference (WC) in this regard. The aims of the study were 1) to compare the strength of the association for undiagnosed or newly diagnosed diabetes (or hypertension) with anthropometric measures of obesity in people of Asian origin, 2) to detect ethnic differences in the association of undiagnosed diabetes with obesity, 3) to identify ethnic- and sex-specific change point values of BMI and WC for changes in the prevalence of diabetes and 4) to evaluate the ethnic-specific WC cutoff values proposed by the International Diabetes Federation (IDF) in 2005 for central obesity. The study population comprised 28 435 men and 35 198 women, ≥ 25 years of age, from 39 cohorts participating in the DECODA and DECODE studies, including 5 Asian Indian (n = 13 537), 3 Mauritian Indian (n = 4505) and Mauritian Creole (n = 1075), 8 Chinese (n =10 801), 1 Filipino (n = 3841), 7 Japanese (n = 7934), 1 Mongolian (n = 1991), and 14 European (n = 20 979) studies. The prevalence of diabetes, hypertension and central obesity was estimated, using descriptive statistics, and the differences were determined with the χ2 test. The odds ratios (ORs) or  coefficients (from the logistic model) and hazard ratios (HRs, from the Cox model to interval censored data) for BMI, WC, waist-to-hip ratio (WHR), and waist-to-stature ratio (WSR) were estimated for diabetes and hypertension. The differences between BMI and WC, WHR or WSR were compared, applying paired homogeneity tests (Wald statistics with 1 df). Hierarchical three-level Bayesian change point analysis, adjusting for age, was applied to identify the most likely cut-off/change point values for BMI and WC in association with previously undiagnosed diabetes. The ORs for diabetes in men (women) with BMI, WC, WHR and WSR were 1.52 (1.59), 1.54 (1.70), 1.53 (1.50) and 1.62 (1.70), respectively and the corresponding ORs for hypertension were 1.68 (1.55), 1.66 (1.51), 1.45 (1.28) and 1.63 (1.50). For diabetes the OR for BMI did not differ from that for WC or WHR, but was lower than that for WSR (p = 0.001) in men while in women the ORs were higher for WC and WSR than for BMI (both p < 0.05). Hypertension was more strongly associated with BMI than with WHR in men (p < 0.001) and most strongly with BMI than with WHR (p < 0.001), WSR (p < 0.01) and WC (p < 0.05) in women. The HRs for incidence of diabetes and hypertension did not differ between BMI and the other three central obesity measures in Mauritian Indians and Mauritian Creoles during follow-ups of 5, 6 and 11 years. The prevalence of diabetes was highest in Asian Indians, lowest in Europeans and intermediate in others, given the same BMI or WC category. The  coefficients for diabetes in BMI (kg/m2) were (men/women): 0.34/0.28, 0.41/0.43, 0.42/0.61, 0.36/0.59 and 0.33/0.49 for Asian Indian, Chinese, Japanese, Mauritian Indian and European (overall homogeneity test: p > 0.05 in men and p < 0.001 in women). Similar results were obtained in WC (cm). Asian Indian women had lower  coefficients than women of other ethnicities. The change points for BMI were 29.5, 25.6, 24.0, 24.0 and 21.5 in men and 29.4, 25.2, 24.9, 25.3 and 22.5 (kg/m2) in women of European, Chinese, Mauritian Indian, Japanese, and Asian Indian descent. The change points for WC were 100, 85, 79 and 82 cm in men and 91, 82, 82 and 76 cm in women of European, Chinese, Mauritian Indian, and Asian Indian. The prevalence of central obesity using the 2005 IDF definition was higher in Japanese men but lower in Japanese women than in their Asian counterparts. The prevalence of central obesity was 52 times higher in Japanese men but 0.8 times lower in Japanese women compared to the National Cholesterol Education Programme definition. The findings suggest that both BMI and WC predicted diabetes and hypertension equally well in all ethnic groups. At the same BMI or WC level, the prevalence of diabetes was highest in Asian Indians, lowest in Europeans and intermediate in others. Ethnic- and sex-specific change points of BMI and WC should be considered in setting diagnostic criteria for obesity to detect undiagnosed or newly diagnosed diabetes.

From a tree to a stand in Finnish boreal forests: biomass estimation and comparison of methods

There is an increasing need to compare the results obtained with different methods of estimation of tree biomass in order to reduce the uncertainty in the assessment of forest biomass carbon. In this study, tree biomass was investigated in a 30-year-old Scots pine (Pinus sylvestris) (Young-Stand) and a 130-year-old mixed Norway spruce (Picea abies)-Scots pine stand (Mature-Stand) located in southern Finland (61º50' N, 24º22' E). In particular, a comparison of the results of different estimation methods was conducted to assess the reliability and suitability of their applications. For the trees in Mature-Stand, annual stem biomass increment fluctuated following a sigmoid equation, and the fitting curves reached a maximum level (from about 1 kg/yr for understorey spruce to 7 kg/yr for dominant pine) when the trees were 100 years old. Tree biomass was estimated to be about 70 Mg/ha in Young-Stand and about 220 Mg/ha in Mature-Stand. In the region (58.00-62.13 ºN, 14-34 ºE, ≤ 300 m a.s.l.) surrounding the study stands, the tree biomass accumulation in Norway spruce and Scots pine stands followed a sigmoid equation with stand age, with a maximum of 230 Mg/ha at the age of 140 years. In Mature-Stand, lichen biomass on the trees was 1.63 Mg/ha with more than half of the biomass occurring on dead branches, and the standing crop of litter lichen on the ground was about 0.09 Mg/ha. There were substantial differences among the results estimated by different methods in the stands. These results imply that a possible estimation error should be taken into account when calculating tree biomass in a stand with an indirect approach.

Evolution and detection of cyanobacterial hepatotoxin synthetase genes

Mass occurrences (blooms) of cyanobacteria are common in aquatic environments worldwide. These blooms are often toxic, due to the presence of hepatotoxins or neurotoxins. The most common cyanobacterial toxins are hepatotoxins: microcystins and nodularins. In freshwaters, the main producers of microcystins are Microcystis, Anabaena, and Planktothrix. Nodularins are produced by strains of Nodularia spumigena in brackish waters. Toxic and nontoxic strains of cyanobacteria co-occur and cannot be differentiated by conventional microscopy. Molecular biological methods based on microcystin and nodularin synthetase genes enable detection of potentially hepatotoxic cyanobacteria. In the present study, molecular detection methods for hepatotoxin-producing cyanobacteria were developed, based on microcystin synthetase gene E (mcyE) and the orthologous nodularin synthetase gene F (ndaF) sequences. General primers were designed to amplify the mcyE/ndaF gene region from microcystin-producing Anabaena, Microcystis, Planktothrix, and Nostoc, and nodularin-producing Nodularia strains. The sequences were used for phylogenetic analyses to study how cyanobacterial mcy genes have evolved. The results showed that mcy genes and microcystin are very old and were already present in the ancestor of many modern cyanobacterial genera. The results also suggested that the sporadic distribution of biosynthetic genes in modern cyanobacteria is caused by repeated gene losses in the more derived lineages of cyanobacteria and not by horizontal gene transfer. Phylogenetic analysis also proposed that nda genes evolved from mcy genes. The frequency and composition of the microcystin producers in 70 lakes in Finland were studied by conventional polymerase chain reaction (PCR). Potential microcystin producers were detected in 84% of the lakes, using general mcyE primers, and in 91% of the lakes with the three genus-specific mcyE primers. Potential microcystin-producing Microcystis were detected in 70%, Planktothrix in 63%, and Anabaena in 37% of the lakes. The presence and co-occurrence of potential microcystin producers were more frequent in eutrophic lakes, where the total phosphorus concentration was high. The PCR results could also be associated with various environmental factors by correlation and regression analyses. In these analyses, the total nitrogen concentration and pH were both associated with the presence of multiple microcystin-producing genera and partly explained the probability of occurrence of mcyE genes. In general, the results showed that higher nutrient concentrations increased the occurrence of potential microcystin producers and the risk for toxic bloom formation. Genus-specific probe pairs for microcystin-producing Anabaena, Microcystis, Planktothrix, and Nostoc, and nodularin-producing Nodularia were designed to be used in a DNA-chip assay. The DNA-chip can be used to simultaneously detect all these potential microcystin/nodularin producers in environmental water samples. The probe pairs detected the mcyE/ndaF genes specifically and sensitively when tested with cyanobacterial strains. In addition, potential microcystin/nodularin producers were identified in lake and Baltic Sea samples by the DNA-chip almost as sensitively as by quantitative real-time PCR (qPCR), which was used to validate the DNA-chip results. Further improvement of the DNA-chip assay was achieved by optimization of the PCR, the first step in the assay. Analysis of the mcy and nda gene clusters from various hepatotoxin-producing cyanobacteria was rewarding; it revealed that the genes were ancient. In addition, new methods detecting all the main producers of hepatotoxins could be developed. Interestingly, potential microcystin-producing cyanobacterial strains of Microcystis, Planktothrix, and Anabaena, co-occurred especially in eutrophic and hypertrophic lakes. Protecting waters from eutrophication and restoration of lakes may thus decrease the prevalence of toxic cyanobacteria and the frequency of toxic blooms.

Jeremia 20:7-13 psykoanalyysissa : Nimettömän valituslaulun syntyprosessi tekstin objektimielikuvien muutosten valossa

Tämän pro gradu -työn tarkoituksena on selvittää tekstin Jer 20:7-13 jumalakuvaa ja muita ”tekstin puhujan” ilmaisemia vuorovaikutussuhteita ja vaihtelevia tunteita. On kuitenkin epäselvää, missä määrin Jeremian kirja tai sen yksittäiset jaksot kuvaavat profeetan persoonaa ja historiallista taustaa. Tekstit voivat kuvata myös muita myöhempiä tilanteita ja asenteita. Tämän tutkimuksen pääasiallinen eksegeettinen metodi on syvyyspsykologinen. Se saattaa pystyä kertomaan jotakin siitä, miten tutkittava teksti peilaa menneisyyden kokemuksellisia kaavoja. Samaan tapaan kuten psykohistoriassa, tutkimus ei yritä tutkia, tulkita tai rekonstruoida tradition tai historian Jeremiaa. Syvyyspsykologinen eksegeesi on tunnistettu jo aiemmin, mutta suomalaisessa tutkimuksessa sitä ei vielä ole sovellettu yksittäisiin teksteihin. Tämän tutkimuksen tutkimusasetelma avaa tekstin sisäisiä ja vaihtelevia vuorovaikutussuhteita eli objektisuhteita. Tutkimus nimittää tätä vuorovaikutussuhteiden analyysiä objektisuhdeanalyysiksi. Se perustuu teologian tohtori, psykoanalyytikko Matti Hyrckin psykoanalyyttiseen suhteessaolon perusmielikuvien teoriaan (SPT), jonka hän esittelee väitöskirjassaan Mielen kuvat Jumalasta (1995). Tekstin Jahve-kuvat on nähtävä objektirepresentaatioina. Nämä vahvasti värittyneet representaatiot ja kuvat kertovat enemmän kokijasta itsestään kuin niistä objekteista, joiden kuviksi ne ovat syntyneet. Käsitys objektien sisäsyntyisyydestä mahdollistaa Hyrckillä objektisuhteiden systematisoinnin ja SPT:n luomisen. Siten emotionaaliset silmälasit on tämän tutkimuksen tekijän mielestä mahdollista valjastaa myös tutkijan käyttöön. Tutkimuksen laaja näkökulmia hakeva teoriaosuus varmistaa tämän. Hermeneuttinen ”kolmen maailman malli” on lukijakeskeisyyteen ja kulttuurihyppyyn arvokas työväline. Jeremian kirja sisältää useita osin runomuotoisia valituksia, joista tutkittava teksti on viimeinen. Valituslaulujen sarja päättyy tutkittavaa tekstiä seuraavaan syntymäpäivän kiroamiseen jakeissa 14-18. Valituksen edellä kontekstina on joitakin kertomuksia Jeremiasta, mutta vasta jakeessa 20:2 Jeremia nimetään profeetaksi. Muuten valittaja on nimetön. Jeremia-kertomusten kehys on tässä toimituksellinen ja valituksen jälkeen seuraa deuteronomistista saarnaa Juudaa ja Jerusalemia vastaan. Tutkimus selvittää jakeiden 7-13 rakennetta, sisältöä ja tulkintaa ensin lähinnä laji- ja kirjallisuus- kriittisesti. Tutkimus osoittaa, että Jeremian valitus noudattaa yksilön valituslaulun kaavaa, mutta ei kuitenkaan yksiselitteisesti taivu lajin usein stereotyyppisiin tarkoituksiin. Suurin syy tähän on tekstin proosa- ja runomuodon vaihtelu ja sisällön hajanaisuus. Edes valituksen ydintä ei voi varmistaa, vaikka valituslaulun nuorimpina osina on tyypillisesti helppo pitää loppupuolen kollektiivisia lisiä. Varsinainen valitus on jakeissa 7-9 ja jakeet 10-13 ovat todennäköisimmin monivaiheinen päätössarja. Tutkimuksen keskeiset objektisuhdeteoreettiset peruskäsitteet sisäinen subjekti ja sisäinen objekti ovat ihmisen tiedostamattoman tason mielikuvia. Varhaisen tilan vuorovaikutusmielikuvien sisäisinä subjekteina ovat Riippuvainen ja Itseriittoinen. Ne ovat vaihtelevissa suhteissa Houkuttajan ja Hallitsijan muotoisia sisäisiä objekteja kohtaan. Myöhäisessä tilassa objekteille on syytä antaa uudet nimet: Vetäytyjä, Vaatija ja Parantaja. Tutkimus etenee osoittamalla tekstin ja SPT:n mukaisen mallin samankaltaisuuksia. Samalla on ollut mahdollista ottaa kantaa myös tekstin saumoihin ja tekstin syntyprosessiin. Tekstin objekti osoittautuu pääosin Hallitsijaksi, sillä Houkuttajan muotoisista jumaluuksista on kollektiivisesti pyritty tekemään pesäeroa Jerusalemin temppelin hävityksestä lähtien. Silti muistoista ja Houkuttajaksikin värittyneistä kaipuun ja pelon muodoista ei päästä eroon. Valituksen alkujakeita 7-9 leimaa Riippuvaisen masennus ja Itseriittoisen häpeä. Jakeissa 11-13 Hallitsijan muotoinen Jahve Sebaot tarjoaa hierarkkista symbioosia. Myöhäistä Vaatijaa ei tutkittavassa tekstissä ole kuin vanhurskaan käsitteenä, joka deuteronomistisessa teologiassa perustuu Jahven sanan kuulemiseen ja lain noudattamiseen. Tutkimus pyrkii osoittamaan, että kaikilla kokemuksilla on jollakin tavalla sekä yhteisöä että yksilöä eheyttäviä tarkoituksia. Kun valitus päättyy sarjaan vakuutuksia ja huipentuu kollektiiviseen ylistyskehotukseen, myös niillä on tarkoitus. Yksi osa tutkimustehtävää on ollut testata psykoanalyyttisen objektisuhdeteoreettisen metodin toimivuutta eksegeettisessä tutkimuksessa. Vaikka tulokset ovat suuntaa antavia, metodi on osoittautunut toimivaksi.

Functional and work disability and treatment received by patients with major depressive disorder

This study is one part of a collaborative depression research project, the Vantaa Depression Study (VDS), involving the Department of Mental and Alcohol Research of the National Public Health Institute, Helsinki, and the Department of Psychiatry of the Peijas Medical Care District (PMCD), Vantaa, Finland. The VDS includes two parts, a record-based study consisting of 803 patients, and a prospective, naturalistic cohort study of 269 patients. Both studies include secondary-level care psychiatric out- and inpatients with a new episode of major depressive disorder (MDD). Data for the record-based part of the study came from a computerised patient database incorporating all outpatient visits as well as treatment periods at the inpatient unit. We included all patients aged 20 to 59 years old who had been assigned a clinical diagnosis of depressive episode or recurrent depressive disorder according to the International Classification of Diseases, 10th edition (ICD-10) criteria and who had at least one outpatient visit or day as an inpatient in the PMCD during the study period January 1, 1996, to December 31, 1996. All those with an earlier diagnosis of schizophrenia, other non-affective psychosis, or bipolar disorder were excluded. Patients treated in the somatic departments of Peijas Hospital and those who had consulted but not received treatment from the psychiatric consultation services were excluded. The study sample comprised 290 male and 513 female patients. All their psychiatric records were reviewed and each patient completed a structured form with 57 items. The treatment provided was reviewed up to the end of the depression episode or to the end of 1997. Most (84%) of the patients received antidepressants, including a minority (11%) on treatment with clearly subtherapeutic low doses. During the treatment period the depressed patients investigated averaged only a few visits to psychiatrists (median two visits), but more to other health professionals (median seven). One-fifth of both genders were inpatients, with a mean of nearly two inpatient treatment periods during the overall treatment period investigated. The median length of a hospital stay was 2 weeks. Use of antidepressants was quite conservative: The first antidepressant had been switched to another compound in only about one-fifth (22%) of patients, and only two patients had received up to five antidepressant trials. Only 7% of those prescribed any antidepressant received two antidepressants simultaneously. None of the patients was prescribed any other augmentation medication. Refusing antidepressant treatment was the most common explanation for receiving no antidepressants. During the treatment period, 19% of those not already receiving a disability pension were granted one due to psychiatric illness. These patients were nearly nine years older than those not pensioned. They were also more severely ill, made significantly more visits to professionals and received significantly more concomitant medications (hypnotics, anxiolytics, and neuroleptics) than did those receiving no pension. In the prospective part of the VDS, 806 adult patients were screened (aged 20-59 years) in the PMCD for a possible new episode of DSM-IV MDD. Of these, 542 patients were interviewed face-to-face with the WHO Schedules for Clinical Assessment in Neuropsychiatry (SCAN), Version 2.0. Exclusion criteria were the same as in the record-based part of the VDS. Of these, 542 269 patients fulfiled the criteria of DSM-IV MDE. This study investigated factors associated with patients' functional disability, social adjustment, and work disability (being on sick-leave or being granted a disability pension). In the beginning of the treatment the most important single factor associated with overall social and functional disability was found to be severity of depression, but older age and personality disorders also significantly contributed. Total duration and severity of depression, phobic disorders, alcoholism, and personality disorders all independently contributed to poor social adjustment. Of those who were employed, almost half (43%) were on sick-leave. Besides severity and number of episodes of depression, female gender and age over 50 years strongly and independently predicted being on sick-leave. Factors influencing social and occupational disability and social adjustment among patients with MDD were studied prospectively during an 18-month follow-up period. Patients' functional disability and social adjustment were alleviated during the follow-up concurrently with recovery from depression. The current level of functioning and social adjustment of a patient with depression was predicted by severity of depression, recurrence before baseline and during follow-up, lack of full remission, and time spent depressed. Comorbid psychiatric disorders, personality traits (neuroticism), and perceived social support also had a significant influence. During the 18-month follow-up period, of the 269, 13 (5%) patients switched to bipolar disorder, and 58 (20%) dropped out. Of the 198, 186 (94%) patients were at baseline not pensioned, and they were investigated. Of them, 21 were granted a disability pension during the follow-up. Those who received a pension were significantly older, more seldom had vocational education, and were more often on sick-leave than those not pensioned, but did not differ with regard to any other sociodemographic or clinical factors. Patients with MDD received mostly adequate antidepressant treatment, but problems existed in treatment intensity and monitoring. It is challenging to find those at greatest risk for disability and to provide them adequate and efficacious treatment. This includes great challenges to the whole society to provide sufficient resources.

Cutaneous porphyrias : Clinical and histopathological study

The prevalence of variegate porphyria (VP) (2.1:100 000, in 2006 n=108) was higher in Finland than elsewhere in European countries due to a founder effect (R152C). The incidence of VP was estimated at 0.2:1 000 000 based on the number of new symptomatic patients yearly. The prevalence of porphyria cutanea tarda (PCT) was 1.2:100 000 (in 2006 n=63), which is only one fourth of the numbers reported from other European countries. The estimated incidence of PCT was 0.5:1 000 000. Based on measurements of the uroporphyrinogen decarboxylase activity in erythrocytes, the proportion of familial PCT was 49% of the cases. The prevalence of erythropoietic protoporphyria (EPP) was at 0.8:100 000 (in 2006 n=39) including asymptomatic carriers of a mutation in the ferrochelatase (FECH) gene. The incidence of EPP was estimated at 0.1:1 000 000. After 1980 the penetrance was 37% among patients with VP. Of the mutation carriers (n=57) 30% manifested with skin symptoms. Frequency of skin symptom as only clinical sign was stable before or after 1980 (22% vs. 21%), but acute attacks became infrequent (29% vs. 7%). Of the symptomatic patients 30% had both acute attacks and skin symptoms and 80% had skin symptoms. Fragility (95%) and blistering (46%) of the skin in the backs of the hands were the most common skin symptoms. Transient correction of porphyrin metabolism using eight haem arginate infusions within five weeks had no effect on the skin symptoms in three of four patients with VP. In one case skin symptoms disappeared transiently. One patient with homozygous VP had severe photosensitivity since birth. Sensory polyneuropathy, glaucoma and renal failure developed during the 25-year follow-up without the presence of acute attacks. The I12T mutation was detected in both of his alleles in the protoporphyrinogen oxidase gene. Lack of skin symptoms and infrequency of acute attacks (1/9) in the patients with I12T mutation at the heterozygous stage indicate a mild phenotype (the penetrance 11%). Four mutations (751delGAGAA, 1122delT, C286T, C343T) in the FECH gene were characterised in four of 15 families with EPP. Burning pain (96%) and swelling (92%) of the sun-exposed skin were the major skin symptoms. Hepatopathy appeared in one of 25 symptomatic patients (4%). Clinical manifestations and associated factors of PCT were similar in the sporadic and familial types of PCT. The majority of the patients with PCT had one to three precipitating factors: alcohol intake (78%), mutations in hemochromatosis associated gene (50%), use of oestrogen (25% of women) and hepatitis B or C infections (25 %). Fatty liver disease (67%) and siderosis (67%) were commonly found in their liver biopsies. The major histopathological change of the sun-exposed skin in the patients with VP (n=20), EPP (n=8) and PCT (n=5) was thickening of the vessel walls of the upper dermis suggesting that the vessel wall is the primary site of the phototoxic reaction in each type of porphyria. The fine structure of the vessel walls was similar in VP, EPP and PCT consisting of the multilayered basement membrane and excess of finely granular substance between the layers which were surrounded by the band of homogenous material. EPP was characterised by amorphous perivascular deposits extending also to the extravascular space. In direct immunofluorescence study homogenous IgG deposits in the vessel walls of the upper dermis of the sun-exposed skin were demonstrated in each type of porphyria. In EPP the excess material around vessel walls consisted of other proteins such as serum amyloid protein, and kappa and lambda light chains in addition to the basement membrane constituents such as collagen IV and laminin. These results suggest that the alterations of the vessel walls are a consequence of the repeated damage and the repairing process in the vessel wall. The microscopic alterations could be demonstrated even in the normal looking but sun-exposed skin of the patients with EPP during the symptom-free phase suggesting that vascular change can be chronic. The stability of vascular changes in the patients with PCT after treatment indicates that circulating porphyrins are not important for the maintenance of the changes.

Reduced visual function and its association with physical functioning in the Finnish adult population : Prevalence, causes, and need for eye care services

The purpose of this study was to estimate the prevalence and distribution of reduced visual acuity, major chronic eye diseases, and subsequent need for eye care services in the Finnish adult population comprising persons aged 30 years and older. In addition, we analyzed the effect of decreased vision on functioning and need for assistance using the World Health Organization’s (WHO) International Classification of Functioning, Disability, and Health (ICF) as a framework. The study was based on the Health 2000 health examination survey, a nationally representative population-based comprehensive survey of health and functional capacity carried out in 2000 to 2001 in Finland. The study sample representing the Finnish population aged 30 years and older was drawn by a two-stage stratified cluster sampling. The Health 2000 survey included a home interview and a comprehensive health examination conducted at a nearby screening center. If the invited participants did not attend, an abridged examination was conducted at home or in an institution. Based on our finding in participants, the great majority (96%) of Finnish adults had at least moderate visual acuity (VA ≥ 0.5) with current refraction correction, if any. However, in the age group 75–84 years the prevalence decreased to 81%, and after 85 years to 46%. In the population aged 30 years and older, the prevalence of habitual visual impairment (VA ≤ 0.25) was 1.6%, and 0.5% were blind (VA < 0.1). The prevalence of visual impairment increased significantly with age (p < 0.001), and after the age of 65 years the increase was sharp. Visual impairment was equally common for both sexes (OR 1.20, 95% CI 0.82 – 1.74). Based on self-reported and/or register-based data, the estimated total prevalences of cataract, glaucoma, age-related maculopathy (ARM), and diabetic retinopathy (DR) in the study population were 10%, 5%, 4%, and 1%, respectively. The prevalence of all of these chronic eye diseases increased with age (p < 0.001). Cataract and glaucoma were more common in women than in men (OR 1.55, 95% CI 1.26 – 1.91 and OR 1.57, 95% CI 1.24 – 1.98, respectively). The most prevalent eye diseases in people with visual impairment (VA ≤ 0.25) were ARM (37%), unoperated cataract (27%), glaucoma (22%), and DR (7%). One-half (58%) of visually impaired people had had a vision examination during the past five years, and 79% had received some vision rehabilitation services, mainly in the form of spectacles (70%). Only one-third (31%) had received formal low vision rehabilitation (i.e., fitting of low vision aids, receiving patient education, training for orientation and mobility, training for activities of daily living (ADL), or consultation with a social worker). People with low vision (VA 0.1 – 0.25) were less likely to have received formal low vision rehabilitation, magnifying glasses, or other low vision aids than blind people (VA < 0.1). Furthermore, low cognitive capacity and living in an institution were associated with limited use of vision rehabilitation services. Of the visually impaired living in the community, 71% reported a need for assistance and 24% had an unmet need for assistance in everyday activities. Prevalence of ADL, instrumental activities of daily living (IADL), and mobility increased with decreasing VA (p < 0.001). Visually impaired persons (VA ≤ 0.25) were four times more likely to have ADL disabilities than those with good VA (VA ≥ 0.8) after adjustment for sociodemographic and behavioral factors and chronic conditions (OR 4.36, 95% CI 2.44 – 7.78). Limitations in IADL and measured mobility were five times as likely (OR 4.82, 95% CI 2.38 – 9.76 and OR 5.37, 95% CI 2.44 – 7.78, respectively) and self-reported mobility limitations were three times as likely (OR 3.07, 95% CI 1.67 – 9.63) as in persons with good VA. The high prevalence of age-related eye diseases and subsequent visual impairment in the fastest growing segment of the population will result in a substantial increase in the demand for eye care services in the future. Many of the visually impaired, especially older persons with decreased cognitive capacity or living in an institution, have not had a recent vision examination and lack adequate low vision rehabilitation. This highlights the need for regular evaluation of visual function in the elderly and an active dissemination of information about rehabilitation services. Decreased VA is strongly associated with functional limitations, and even a slight decrease in VA was found to be associated with limited functioning. Thus, continuous efforts are needed to identify and treat eye diseases to maintain patients’ quality of life and to alleviate the social and economic burden of serious eye diseases.

Clinical Phenotype and Genetic Epidemiology of Schizophrenia in a Finnish Isolate

This study is part of the joint project "The Genetic Epidemiology and Molecular Genetics of schizophrenia in Finland" between the Departments of Mental Health and Alcohol Research, and Molecular Medicine at the National Public Health Institute. In the study, we utilized three nationwide health care registers: 1) the Hospital Discharge Register, 2) the Free Medication Register, and 3) the Disability Pension Register, plus the National Population Register, in order to identify all patients with schizophrenia born from 1940 to 1976 (N=33,731) in Finland, and their first degree-relatives. 658 patients with at least one parent born in a homogeneous isolate in northeastern Finland were identified, as well as 4904 familial schizophrenia patients with at least two affected siblings from the whole country. The comparison group was derived from the Health 2000 Study. We collected case records and reassessed the register diagnosis. Were contacted the isolate patients and a random sample of patients from the whole country to make diagnostic clinical interviews and to assess the negative and positive symptoms and signs of schizophrenia. In addition to these patients, we interviewed siblings who were initially healthy according to the Hospital Discharge Register. Of those with a register diagnosis of schizophrenia, schizoaffective or schizophreniform disorder, 69% received a record-based consensus diagnosis and 63% an interview-based diagnosis of schizophrenia. Patients with schizophrenia having first-degree relatives with psychotic disorder had more severe affective flattening and alogia than those who were the only affected individuals in their family. The novel findings were: 1) The prevalence of schizophrenia in the isolate was relatively high based on register (1.5%), case record (0.9-1.3%), and interview (0.7-1.2%) data. 2) Isolate patients, regardless of their familial loading for schizophrenia, had less delusions and hallucinations than the whole country familial patients, which may be related to the genetic homogeneity in the isolate. This phenotype encourages the use of endophenotypes in genetic analyses instead of diagnoses alone. 3) The absence of register diagnosis does not confirm that siblings are healthy, because 7.7% of siblings had psychotic symptoms already before the register diagnoses were identified in 1991. For genetic research, the register diagnosis should therefore be reassessed using either a structured interview or a best- estimate case note consensus diagnosis. Structured clinical interview methods need be considered also in clinical practice.

Primary Dislocation of the Patella : A Clinical Study

A total of 177 patients with primary dislocation of the patella (PDP) were admitted to two trauma centers in Helsinki, Finland during 1991 to 1992. The inclusion criteria were: 1. Acute (≤14 days old) first-time lateral dislocation of the patella. 2. No previous knee operations or major knee injuries. 3. No ligament injuries to be repaired. 4. No osteochondral fractures requiring fixation. 50 patients were excluded. 30 of these excluded patients would have met the inclusion criteria, 19 patients received treatment by consultants not involved in the study, 7 refused to participate and 4 had an erroneous randomization. 127 patients including, 82 females, were then randomized to have either tailor-made operative procedure (group O) or conservative treatment (group C). The aftercare was similar for both groups. The mean age of the patients was 20 (9-47) years. All patients were subjected to analysis of trauma history (starting position and knee movement during the dislocation), examination under anesthesia (EUA) and arthroscopy. 70 patients (52 females) were randomized by their odd year of birth to operative group O and 57 patients (30 females) by their even year of birth to conservative group C. The diagnosis of PDP was based on locked dislocation in 68 patients, on dislocatability in EUA in 47 patients, and on subluxation in EUA combined with typical intra-articular lesions in 12 patients. In group O, 63 patients had exploration of the injuries on the medial side of the knee and tailor made reconstruction added with lateral release in 54 cases. The medial injury was operated by suturing in 39 patients, by duplication in 18 patients and by additional augmentation of the medial patellofemoral ligament (MPFL) with adductor magnus tenodesis in 6 patients. 7 patients, without locking in trauma history and only subluxation in EUA had only lateral release for realignment. In adductor magnus tenodesis the proximal end of the distal tendinous part was rerouted to the upper medial border of the patella. In the conservative group C, the treatment was adjusted to the extent of patellar displacement in EUA. Patients with dislocation in EUA had 3 weeks’ immobilization with the knee in slight flexion. Mobilization was started with a soft patellar stabilizing orthosis (PSO) used for additional three weeks. The patients with subluxation in EUA wore an orthosis for six weeks. The aftercare was similar in group O. The outcome was similar in both groups. After an average of 25 (20-45) months´ follow-up, the subjective result was better in group C in respect of the mean Hughston VAS knee score (87 for group O and 90 for group C, p=0.04, visual analog scale), but similar in terms of the patient’s own overall opinion and the mean Lysholm II knee score. Recurrent instability episodes occurred in 18 patients in group O and in 20 patients in group C. After an average of 7 (6-9) years´ follow-up, the groups did not show statistical difference either in respect of the patient’s own overall opinion, or the mean Hughston VAS and Kujala knee scores. The proportions of stable patellae was 25/70 (36%) in group O and 17/57 (30%) in group O (p=0.5). In a multivariate risk analysis, there was a correlation between low Kujala score (<90) as dependent parameter and female gender (OR: 3.5; 95% CI: 1.4-9.0), and loose body on primary radiographs (OR: 4.1; 95% CI: 1.2-15). Recurrent instability correlated with young age at the time of PDP (OR: 0.9; 95% CI: 0.8-1.0/year). Girls with open tibial apophysis had the worst prognosis for instability (88%; 95% CI: 77-98). The most common mechanisms in trauma history of the patients were movement to flexion from a straight start (78%) and movement to extension from a well-bent start (8%). Spontaneous relocation of the patella had taken place in 13/39 of girls, in 11/21 of boys, in 26/42 of women and in 17/24 of men with skeletal maturity of the tibia. The dislocation in EUA was non-rotating in 96/126 patients followed by outward rotating dislocation in 14/126 patients. Operative treatment policy in PDP is not recommended. Locking tendency of the patella in PDP depended on the skeletal maturation. Recurrence rate after PDP was higher than expected.