Kulutus, tieto, hallinta : Kulutuksen tilastoinnin muutokset 1900-luvun Suomessa

The aim of the study was to find out how the consumption of the population in Finland became a target of social interest and production of statistical data in the early 20th century, and what efforts have been made to influence consumption with social policy measures at different times. Questions concerning consumption are examined through the practices employed in the compilation of statistics on it. The interpretation framework in the study is Michael Foucault s perspective of modern liberal government. This mode of government is typified by pursuit of efficiency and search of equilibrium between economic government and a government of the processes of life. It shows aspirations towards both integration and individualisation. The government is based on freedom practices. It also implies knowledge-based ways of conceptualising reality. Statistical data are of specific significance in this context. The connection between the government of consumption and the compilation of statistics on it is studied through the theoretical, socio-political and statistical conceptualisation of consumption. The research material consisted of Finnish and international documentation on the compilation of statistics on consumption, publications of social programmes, and reports of studies on consumption. The analysis of the material focused especially on the problematisations related to consumption found in these documents and on changes in them over history. There have been both clearly observable changes and as well as historical stratification and diversity in the rationalities and practices of consumption government during the 20th century. Consumption has been influenced by pluralistic government, based at different times and in varying ways on the logics of solidarity and markets. The difference between these is that in the former risks are prepared for collectively while in the latter risks are individualised. Despite the differences, the characteristic that is common to these logics is certain kind of contractuality. They are both permeated by the household logic which differs from them in that it is based on the normative and ethical demands imposed on an individual. There has been a clear interactive connection between statistical data and consumption government. Statistical practices have followed changes in the way consumption has been conceptualised in society. This has been reflected in the statistical phenomena of interest, concepts, classifications and indicators. New ways of compiling statistics have in their turn shaped perceptions of reality. Statistical data have also facilitated a variety of rational calculations with which the consequences of the population s consumption habits have been evaluated at the levels of economy at large and individuals.

Parathyroid hormone as an outcome indicator in old age

Serum parathyroid hormone (PTH) and vitamin D are the major regulators of extracellular calcium homeostasis. The inverse association between PTH and vitamin D and the common age-related elevation of the PTH concentration are well known phenomena. However, the confounding or modifying factors of this relationship and their impact on the response of PTH levels to vitamin D supplementation need further investigation. Clinical conditions such as primary hyperparathyroidism (PHPT), renal failure and vitamin D deficiency, characterized by an elevation of the PTH concentration, have been associated with impaired long-term health outcomes. Curative treatments for these conditions have also been shown to decreases PTH concentration and attenuate some of the adverse health effects. In PHPT it has also been commonly held that hypercalcaemia, the other hallmark of the disease, is the key mediator of the adverse health outcomes. In chronic kidney disease the systemic vascular disease has been proposed to have the most important impact on general health. Some evidence also indicates that vitamin D may have significant extraskeletal actions. However, the frank elevation of PTH concentration seen in advanced PHPT and in end-stage renal failure have also been suggested to be at least partly causally related to an increased risk of death as well as cognitive dysfunction. However, the exact mechanisms have remained unclear. Furthermore, the predictive value of elevated PTH in unselected older populations has been less well studied. The studies presented in this thesis investigated the impact of age and mobility on the responses of PTH levels to vitamin D deficiency and supplementation. Furthermore, the predictive value of PTH for long-term survival and cognitive decline was addressed in an unselected population of older people. The hypothesis was that age and chronic immobility are related to a persistently blunted elevation of PTH concentration, even in the presence of chronic vitamin D deficiency, and to attenuated responses of PTH to vitamin D supplementation. It was also further hypothesized that a slightly elevated or even high-normal PTH concentration is an independent indicator of an increased risk of death and cognitive decline in the general aged population. The data of this thesis are based on three samples: a meta-analysis of published vitamin D supplementation trials, a randomized placebo controlled six-month vitamin D supplementation trial, and a longitudinal prospective cohort study on a general aged population. Based on a PubMed search, a meta-analysis of 52 clinical trials with 6 290 adult participants was performed to evaluate the impact of age and immobility on the responses of PTH to 25-OHD levels and vitamin D supplementation. A total of 218 chronically immobile, very old inpatients were also enrolled into a vitamin D supplementation trial. Mortality data for these patients was also collected after a two-year follow-up. Finally, data from the Helsinki Aging Study, which followed three random age cohorts (75, 80 and 85 years) until death in almost all subjects, was used to evaluate the predictive value of PTH for long-term survival and cognitive decline. This series of studies demonstrated that in older people without overt renal failure or severe hypercalcaemia, serum 25-OHD and PTH were closely associated, but this relationship was also affected by age and immobility. Furthermore, a substantial proportion of old chronically bedridden patients did not respond to vitamin D deficiency by elevating PTH, and the effect of a high-dose (1200 IU/d) six-month cholecalciferol supplementation on the PTH concentration was minor. This study demonstrated longitudinally for the first time that the blunted PTH also persisted over time. Even a subtle elevation of PTH to high-normal levels predicted impaired long-term health outcomes. Slightly elevated PTH concentrations indicated an increased risk of clinically significant cognitive decline and death during the last years of life in a general aged population. This association was also independent of serum ionized calcium (Ca2+) and the estimated glomerular filtration rate (GFR). A slightly elevated PTH also indicated impaired two-year survival during the terminal years of frail elderly subjects independently of Ca2+, GFR, and of 25-OHD levels. The interplay between PTH and vitamin D in the regulation of calcium homeostasis is more complex than has been generally considered. In addition to muskuloskeletal health parathyroid hormone is also related to the maintenance of other important domains of health in old age. Higher PTH concentrations, even within conventional laboratory reference ranges, seem to be an independent indicator of an increased risk of all-cause and of cardiovascular mortality, independently of established cardiovascular risk factors, disturbances in mineral metabolism, and renal failure. Limited and inconsistent evidence supports the role of vitamin D deficiency-related lack of neuroprotective effects over the causal association between PTH and impaired cognitive functions. However, the causality of these associations remains unclear. The clinical implications of the observed relationships remain to be elucidated by future studies interfering with PTH concentrations, especially by long-term interventions to reduce PTH.

Kelan järjestämän kuntoutuksen kohdentuminen ja vaikutukset työkykyyn kunnallisilla työpaikoilla

Tutkimuksessa selvitettiin Kansaneläkelaitoksen (Kelan) järjestämän kuuden yleisimmän työssä käyvälle väestölle tarkoitetun kuntoutusmuodon kohdentumista kuntatyöntekijöille (n = 67 106 henkilöä). Lisäksi selvitettiin Kelan järjestämän tuki- ja liikuntaelinkuntoutuksen ja ASLAKkurssien vaikutuksia työkykyyn sekä verrattiin kahta fibromyalgiaa sairastaville tarkoitettua kuntoutusmuotoa. Muuttujatiedot kerättiin työnantajien omista ja kansallisista rekistereistä. Naiset olivat Kelan järjestämässä kuntoutuksessa yliedustettuina ja määräaikaisessa työsuhteessa työskentelevät aliedustettuina. Selkäkipukuntoutukseen osallistuneiden ja työnantajien palveluksessa seurannan loppuun saakka olleiden vuosittaiset hyvin pitkät sairauspoissaolot vähenivät kolmen kuntoutuksen jälkeisen vuoden ajaksi. Niskakipukuntoutukseen osallistuneilla ei todettu tätä muutosta. ASLAK-kuntoutukseen osallistuneiden sairauspoissaolopäivät ja hyvin pitkät sairauspoissaolokerrat vähenivät kuntoutusvuonna ja kolmena sen jälkeisenä vuonna samalle tasolle kuin kuntoutukseen osallistumattomilla kaltaistetuilla verrokeilla. Työkyvyttömyyseläkkeen riski oli kuntoutujilla neljän kuntoutuksen jälkeisen vuoden aikana verrokkeja pienempi. Fibromyalgiaa sairastavien kahden kuntoutusmuodon (fibromyalgiakurssi ja epäspesifinen tules-kuntoutus) vertailussa ei kuntoutuksen vaikutuksissa työkykykyyn todettu eroa. Kelan järjestämän kuntoutuksen sisällössä tarvitaan kriittistä arviointia, tutkimusta ja kehitystyötä, jotta yhteiskunnan odotus vaikuttavuudesta toteutuu.

Physical activity and diabetic complications in patients with type 1 diabetes

Type 1 diabetes is associated with the risk for late diabetic complications which are divided into microvascular (retinopathy, nephropathy, and neuropathy) and macrovascular (cardiovascular disease, CVD) diseases. The risk for diabetic complication can be reduced by effective treatment, most importantly the glycaemic control. Glycaemia in type 1 diabetes is influenced by the interplay between insulin injections and lifestyle factors such as physical activity and diet. The effect of physical activity in patients with type 1 diabetes is not well known, however. The aim of this thesis was to investigate the physical activity and the physical fitness of patients with type 1 diabetes with special emphasis on glycaemic control and the diabetic complications. The patients included in the study were all part of the nationwide, multicenter Finnish Diabetic Nephropathy (FinnDiane) Study which aims to characterise genetic, clinical, and environmental factors that predispose to diabetic complications in patients with type 1 diabetes. In addition, subjects from the IDentification of EArly mechanisms in the pathogenesis of diabetic Late complications (IDEAL) Study were studied. Physical activity was assessed in the FinnDiane Study in 1945 patients by a validated questionnaire. Physical fitness was measured in the IDEAL Study by spiroergometry (cycle test with measurement of respiratory gases) in 86 young adults with type 1 diabetes and in 27 healthy controls. All patients underwent thorough clinical characterisation of their diabetic complication status. Four substudies were cross-sectional using baseline data and one study additionally used follow-up data. Physical activity, especially the intensity of activities, was reduced in patients affected by diabetic nephropathy, retinopathy, and CVD. Low physical activity was associated with poor glycaemic control, a finding most clear in women and evident also in patients with no signs of diabetic complications. Furthermore, low physical activity was associated with a higher HbA1c variability, which in turn was associated with the progression of renal disease and CVD during follow-up. A higher level of physical activity was also associated with better insulin sensitivity. The prevalence of the metabolic syndrome in type 1 diabetes was also lower the higher the physical activity. The aerobic physical fitness level of young adults with type 1 diabetes was reduced compared with healthy peers and in men an association between higher fitness level and lower HbA1c was observed. In patients with type 1 diabetes, a higher physical activity was associated with better glycaemic control and may thus be beneficial with respect to the prevention of diabetic complications.

Prognostic significance of cyclooxygenase-2 and associated molecules in gastric cancer

Background and aims: Low stage and curative surgery are established factors for improved survival in gastric cancer. However, not all low-stage patients have a good prognosis. Cyclooxygenase-2 (COX-2) is known to associate with reduced survival in several cancers, and has been shown to play an important role in gastric carcinogenesis. Since new and better prognostic markers are needed for gastric cancer, we studied the prognostic significance of COX-2 and of markers that associate with COX-2 expression. We also studied markers reflecting proliferation and apoptosis, and evaluated their association with COX-2. Our purpose was to construct an accurate prognostic model by combining tissue markers and clinicopathogical factors. Materials and methods: Of 342 consecutive patients who underwent surgery for gastric cancer at Meilahti Hospital, Helsinki University Central Hospital, 337 were included in this study. Low stages I to II were represented by 141 (42%) patients, and high stages III to IV by 196 (58%). Curative surgery was performed on 176 (52%) patients. Survival data were obtained from the national registers. Slides from archive tissue blocks were prepared for immunohistochemistry by use of COX-2, human antigen R (HuR), cyclin A, matrix metalloproteinases 2 and 9 (MMP-2, MMP-9), and Ki-67 antibodies. Immunostainings were scored by microscopy, and scores were entered into a database. Associations of tumor markers with clinicopathological factors were calculated, as well as associations with p53, p21, and results of flow cytometry from earlier studies. Survival analysis was performed by the Kaplan-Meier method, and Cox multivariate models were reconstructed. Cell culture experiments were performed to explore the effect of small interfering (si)RNA of HuR on COX-2 expression in a TMK-1 gastric cancer cell line. Results: Overall 5-year survival was 35.1%. Study I showed that COX-2 was an independent prognostic factor, and that the prognostic impact of COX-2 was more pronounced in low-stage patients. Cytoplasmic HuR expression also associated with reduced survival in gastric cancer patients in a non-independent manner. Cell culture experiments showed that HuR can regulate COX-2 expression in TMK-1 cells in vitro, with an association also between COX-2 and HuR tissue expression in a clinical material. In Study II, cyclin A was an independent prognostic factor and was associated with HuR expression in the gastric cancer material. The results of Study III showed that epithelial MMP-2 associated with survival in univariate, but not in multivariate analysis. However, MMP-9 showed no prognostic value. MMP-2 expression was associated with COX-2 expression. In Study IV, the prognostic power of COX-2 was compared with that of all tested markers associated with survival in Studies I to III, as well as with p21, p53, and flow cytometry results. COX-2 and p53 were independent prognostic factors, and COX-2 expression was associated with that of p53 and Ki-67 and also with aneuploidy. Conclusions: COX-2 is an independent prognostic factor in gastric cancer, and its prognostic power emerges especially in low stage cancer. COX-2 is regulated by HuR, and is associated with factors reflecting invasion, proliferation, and apoptosis. In an extended multivariate model, COX-2 retained its position as an independent prognosticator. COX-2 can be considered a promising new prognostic marker in gastric cancer.

Uskonto, luonto ja talous Yhdysvaltain uudestisyntyneiden ilmastonmuutoskeskustelussa

Tutkielmani tarkastelee Yhdysvaltain uudestisyntyneitä protestantteja ja heidän suhtautumistaan ilmastonmuutokseen. Heidän käymässään keskustelussa uskonto määrittää yksilön suhtautumisen talouteen sekä luontoon. Tarkoituksenani on selvittää ja tehdä ymmärrettäväksi näiden asioiden keskinäisiä suhteita ja yhtyeenkietoutuneisuutta. Uudestisyntyneen uskon eräs keskeinen tekijä on uskonnollisen narratiivisen tradition omaksuminen, jolle uskova vapaaehtoisesti alistaa menneisyytensä, nykyisyytensä ja tulevaisuutensa. Narratiivisen tradition keskeisyyden vuoksi kehittelen tutkielmani teoreettiseksi viitekehykseksi narratiivisen rationaalisuuden näkökulmaa, joka pohjautuu Max Weberin, Jerome Brunerin, uskontososiologian uuden paradigman sekä narratiivisen tutkimuksen käsitteistöön. Narratiivisessa rationaalisuudessa uskonto näyttäytyy Robert Bellahin sanoin todellisuutena sui generis, joka muodostaa uskovan elämän fokuksen. Ninian Smartin määritelmän mukaisesti fokuksen käsite mahdollistaa uskonnon tutkimisen siten, että vain uskomisella on totuusarvoa, ei uskomisen kohteella. Tutkimusaineistoni koostin internetistä uudestisyntyneiden ylläpitämistä blogeista. Blogien käyttäminen aineistolähteinä mahdollistaa analyysin kohdentamisen uudestisyntyneiden keskenään käymään keskusteluun eikä tutkijalla ole riskiä joutua käännytyspuheen kohteeksi. Lisäksi blogit ovat aineistoa, joka on syntynyt ilman tutkijan tai tutkimusintressin vaikutusta. Tutkimusaineistoni muodostavat 15 blogilta haetut ilmastonmuutokseen liittyvät kirjoitukset. Aineistoni jäsennyksen suoritan sisällönanalyyttisin perustein käyttäen apunani akateemisia ja teologisia keskusteluja. Keskeisimpiä näistä ovat Max Weberin Protestanttinen etiikka, Colin Campbellin Romanttinen etiikka, Robert Bellahin kansalaisuskonto sekä kristillisen tilanhoitajuuden käsite. Pääasiallinen analyysimetodini on narratiivinen analyysi, jolla haen aineistostani niitä kansanomaisen ajattelun malleja, joiden valossa uudestisyntyneiden käymä ilmastonmuutoskeskustelu on sisäisesti johdonmukaista ja ulkopuolisille ymmärrettävää. Uudestisyntyneiden ilmastonmuutoskeskustelua jäsentää amerikkalaisen unelman ja sekulaarin humanismin kansanomaisen ajattelun mallit. Yhdessä nämä mallit muodostavat kokonaisuuden, joka tekee keskustelusta sisäisesti johdonmukaista ja ymmärrettävää ja jonka uudestisyntyneet ovat omaksuneet. Molemmilla malleilla on kristilliset juuret, vaikka amerikkalainen unelma on niistä jo etääntynyt. Amerikkalaisen unelman voi lisäksi nähdä Weberin Protestanttisen etiikan sekä Campbellin Romanttisen etiikan yhdysvaltalaisena synteesinä.

Lihaluujauhon soveltuvuus sokerijuurikkaan lannoitteeksi

Lihaluujauho muodostaa maatilojen myytävien kasvi- ja eläinperäisten tuotteiden jälkeen tärkeimmän agroekosysteemeistä poispäin suuntautuvan ravinnevirran. Se sisältää runsaasti pääkasvinravinteita typpeä, fosforia ja kalsiumia (N ~8%, P ~5%, Ca yleensä ~10-15% luuaineksen määrästä riippuen), sekä kaliumia n.1% tai alle. Lihaluujauho on todettu tehokkaaksi lannoitteeksi useilla viljelykasveilla ja sen käyttö on sallittu myös luomuviljelyssä EU-alueella. Lihaluujauhoon ja erityisesti sen rehukäyttöön liittyvistä riskeistä merkittävin on TSE-tautien riski (naudan BSE-, lampaiden ja vuohien scrapie-, sekä ihmisen vCJD-taudit). Rehukäyttöä on monissa maissa rajoitettu 1980-luvulla puhjenneen BSE-kriisin myötä. BSE-taudin leviäminen yhdistettiin tilanteeseen, jossa nautaperäistä lihaluujauhoa käytettiin nautaeläinten rehun ainesosana. Myös lihaluujauhon käytössä turkiseläinrehuna saattaa piillä BSE:n tai muun TSE-taudin riski. Oikein käsitellyn lihaluujauhon lannoitekäyttöön ei kuitenkaan näytä tarkastelemieni tutkimusten perusteella sisältyvän huomattavaa TSEriskiä, jos huolehditaan asianmukaisista varotoimista ja menettelyistä sekä tuotteen valmistusprosessissa, että käytettäessä lannoitetta. Lihaluujauhon lannoitekäytön lisääminen edistäisi ruokajärjestelmämme ravinnekierron sulkemista etenkin fosforin osalta. Lihaluujauho on uusiutuva luonnonvara, jonka lannoitekäytöllä voitaisiin korvata huomattava osa lannoiteaineena kulutettavista fosforipitoisista kiviaineista. Sokerijuurikkaan lannoituskokeissa Varsinais-Suomen Kaarinassa vuosina 2008 ja 2009 lihaluujauhokäsittelyt eivät menestyneet aivan yhtä hyvin satotasovertailussa kuin kontrollikäsittelyiden NPK-väkilannoitteet, mutta laatuominaisuuksiltaan (sokeripitoisuus, amino-N, K, ja Na-pitoisuudet) joiltakin osin kontrollikäsittelyjä paremmin. Kokeissa käytetyt lajikkeet olivat ’Jesper’ vuonna 2008 ja ’Lincoln’ vuonna 2009. Käytetty lihaluujauholannoite oli Honkajoki Oy:n Viljo Yleislannoite 8-4-3, joka sisälsi noin 10% kaliumsulfaatin ja kasviperäisten sivutuotteiden seosta. Viljo-lannoitetta käytettiin sekä yksistään, että yhdistettynä 10-25%:iin väkilannoitetta. Vuoden 2009 Viljo-koejäseniin vielä lisättiin kaliumsulfaattilannoitetta (42% K, 18% S), jotta päästiin annetun kaliumin määrässä päästiin lannoitussuosituksen (60 kg K/ha) tasolle. Pelkkä Viljo-lannoite tuotti merkitsevästi alhaisemmat sadot kuin kontrollikäsittelyt molempina vuosina. Kuitenkin kun Viljolannoitteen ohella käytettiin väkilannoitetta (10-25% kasvin typentarpeesta) päästiin varsin lähelle kontrollikäsittelyiden satotasoja. Myös pelkän LLJ-lannoitteen tuottamat satotasot olivat kuitenkin selvästi paremmat kuin Suomen keskimääräiset juurikassadot. Viljo-käsittelyillä oli selvästi positiivinen vaikutus laatutekijöihin amino-N, K ja Na vuonna 2008, mutta vuonna 2009 näiden pitoisuudet jäivät kontrollikäsittelyjen tasolle. Viljo-käsittelyiden sokeripitoisuudet olivat vuonna 2008 kontrollikäsittelyn luokkaa ja Viljo77%+NK1:n osalta kontrollia merkitsevästi paremmat. Vuoden 2009 sokeripitoisuudet olivat kaikilla koejäsenillä erinomaiset, ja käsittelyiden välillä ei ilmennyt merkitseviä eroja. Kokeiden perusteella kaliumsulfaatilla täydennetty lihaluujauho on hyvin toimiva lannoite sokerijuurikkaalla Suomen olosuhteissa, etenkin yhdistettynä väkilannoitteeseen.

Sitoutunut yritysyhteistyö onnistuneen muutosprosessin mahdollistajana

Tutkimuksen tavoitteena oli selvittää, millä tekijöillä yritysyhteistyön osapuolet kokevat olevan merkitystä muutoksen toteuttamiseen sitoutumisessa ja miten muutoksen onnistumiseen voidaan vaikuttaa. Esioletuksena oli, että sitoutuminen on mahdollista vain luottamuksellisissa yhteistyösuhteissa, joten teoriaosiossa perehdyttiin ensin yritysten väliseen luottamukseen vaikuttaviin tekijöihin. Lisäksi teoriaosassa käsitellään sitoutumista liiketoimintasuhteissa, liiketoimintaprosessien kehittämistä ja muutosjohtamista. Näiden teorioiden pohjalta luotiin tutkimukselle viitekehys. Tutkimuksen empiirinen osa koostuu kuudesta haastattelusta, joihin osallistui vastuuhenkilö kolmen eri tavoin toimintaansa kehittäneen liiketoimintasuhteen molemmilta osapuolilta. Teemahaastattelut tehtiin syksyn 2010 aikana. Haastatteluista saatu aineisto analysoitiin teemoittelun ja sitä kautta sisällönanalyysin avulla. Tulosten perusteella alussa esitettyä teoreettista viitekehystä muokattiin vastaamaan paremmin saatuja tuloksia. Tutkimuksen mukaan erityisesti kommunikointi, opportunismi ja valta vaikuttavat luottamukseen yritysyhteistyössä. Kommunikointi tuli tutkimuksessa esiin niin tekijänä kuin välineenä muiden tekijöiden parantamiseen. Taustalla merkittävänä asiana on nähtävissä myös riski ja se, mikä eri osapuolten riskinsietokyky on. Muutosprosessin johtaminen on jaettavissa kahteen osaan: ensin on luotava muutosinto ja saatava aikaan päätös muutokseen osallistumisesta, sen jälkeen siirrytään itse muutoksen suunnitteluun ja toteutukseen. Näiden osioiden hallinnassa jokaisella luottamukseen vaikuttavalla tekijällä on oma merkityksensä. Tehty tutkimus vahvisti ennakkokäsitystä siitä, että organisaatioiden sisäisen muutoksen johtamiseen kehitetyt mallit sopivat myös organisaatioiden välisessä muutostyössä käytettäväksi. Mallien käytön edellytyksenä on sitoutumisen aikaansaaminen suhteessa. Tutkimuksen perusteella voidaan todeta, että pelkkä yleinen ja järjestelmään perustuva luottamus eivät muutostilanteessa riitä, vaan erittäin tärkeää muutoksen onnistumiselle on myös halu luottaa toiseen osapuoleen. Tämä affektiivinen luottamus yhdessä kognitiivisen luottamuksen kanssa heijastuu osapuolten käyttäytymiseen ja saa aikaan sitoutumista suhteeseen ja muutokseen.

Consequences of Vertebral Fractures

Vertebral fractures occur due to forces applied to spinal structures. When the bone tissue is weakened, vertebral fractures can result from a minor trauma. Adult vertebral fractures are commonly considered to be an indication for osteoporosis. In children osteoporosis is a rare condition, and pediatric vertebral fractures are usually clearly trauma-related. The aims of this dissertation are to produce knowledge of the epidemiology of osteoporotic vertebral fractures and to analyse their association with total and cause-specific mortality, to find indicators with which to identify individuals who are at great risk of subsequent fractures, to study the incidence of pediatric vertebral fractures and need for their operative treatment and hospital care. The Mobile-Clinic and Mini-Finland Health surveys of the adult population were used as materials in this research. Record linkages to the Finnish Hospital Discharge Register and the Official Cause of Death register were used to study mortality and hospitalization in the same population group. These registers were also used to evaluate epidemiology, mortality, hospitalization and the need for operative management of pediatric vertebral fracture patients. The main findings and conclusions of the present dissertation are: 1. The presence of a thoracic vertebral fracture in adults is a significant predictor of cancer and respiratory mortality. In women, but not in men, vertebral fractures strongly predict mortality due to injuries. Most of these deaths in the study group were hip fracture related. 2. Severe thoracic vertebral fracture in adults was a strong predictor of a subsequent hip fracture, whereas mild or moderate fractures and the number of compressed vertebrae were much weaker predictors, 3. Pediatric spinal fractures were rare: The incidence was 66 per one million children per year. In younger children cervical spine was most often affected, whereas in older children fractures of the thoracic and lumbar spine were more common. Maturation of spinal structures seems to play a major role in the typical injury patterns in children. Thirty per cent of pediatric spinal fractures required surgical treatment. The current study focuses on consequences of vertebral fractures in general, without evaluating further the causation of the studied phenomena. Further studies are needed to clarify the mechanisms of association between vertebral fractures and specific causes of mortality. A severe vertebral fracture appears to indicate a substantial risk of a subsequent hip fracture. If such a fracture is identified from a chest radiograph, urgent clinical evaluation, treatment of osteoporosis and protective measures against falls are recommended.

Psychosocial processes of health behaviour change in a lifestyle intervention : Influences of gender, socioeconomic status and personality

Background: The onset of many chronic diseases such as type 2 diabetes can be delayed or prevented by changes in diet, physical activity and obesity. Known predictors of successful behaviour change include psychosocial factors such as selfefficacy, action and coping planning, and social support. However, gender and socioeconomic differences in these psychosocial mechanisms underlying health behaviour change have not been examined, despite well-documented sociodemographic differences in lifestyle-related mortality and morbidity. Additionally, although stable personality traits (such as dispositional optimism or pessimism and gender-role orientation: agency and communion) are related to health and health behaviour, to date they have rarely been studied in the context of health behaviour interventions. These personality traits might contribute to health behaviour change independently of the more modifiable domain-specific psychosocial factors, or indirectly through them, or moderated by them. The aims were to examine in an intervention setting: (1) whether changes (during the three-month intervention) in psychological determinants (self-efficacy beliefs, action planning and coping planning) predict changes in exercise and diet behaviours over three months and 12 months, (2) the universality assumption of behaviour change theories, i.e. whether preintervention levels and changes in psychosocial determinants are similar among genders and socioeconomic groups, and whether they predict changes in behaviour in a similar way in these groups, (3) whether the personality traits optimism, pessimism, agency and communion predict changes in abdominal obesity, and the nature of their interplay with modifiable and domain-specific psychosocial factors (self-efficacy and social support). Methods: Finnish men and women (N = 385) aged 50 65 years who were at an increased risk for type 2 diabetes were recruited from health care centres to participate in the GOod Ageing in Lahti Region (GOAL) Lifestyle Implementation Trial. The programme aimed to improve participants lifestyle (physical activity, eating) and decrease their overweight. The measurements of self-efficacy, planning, social support and dispositional optimism/pessimism were conducted pre-intervention at baseline (T1) and after the intensive phase of the intervention at three months (T2), and the measurements of exercise at T1, T2 and 12 months (T3) and healthy eating at T1 and T3. Waist circumference, an indicator of abdominal obesity, was measured at T1 and at oneyear (T3) and three-year (T4) follow-ups. Agency and communion were measured at T4 with the Personal Attributes Questionnaire (PAQ). Results: (1) Increases in self-efficacy and planning were associated with three-month increases in exercise (Study I). Moreover, both the post-intervention level and three-month increases (during the intervention) in self-efficacy in dealing with barriers predicted the 12-month increase in exercise, and a high postintervention level of coping plans predicted the 12-month decrease in dietary fat (Study II). One- and three-year waist circumference reductions were predicted by the initial three-month increase in self-efficacy (Studies III, IV). (2) Post-intervention at three months, women had formed more action plans for changing their exercise routines and received less social support for behaviour change than men had. The effects of adoption self-efficacy were similar but change in planning played a less significant role among men (Study I). Examining the effects of socioeconomic status (SES), psychosocial determinants at baseline and their changes during the intervention yielded largely similar results. Exercise barriers self-efficacy was enhanced slightly less among those with low SES. Psychosocial determinants predicted behaviour similarly across all SES groups (Study II). (3) Dispositional optimism and pessimism were unrelated to waist circumference change, directly or indirectly, and they did not influence changes in self-efficacy (Study III). Agency predicted 12-month waist circumference reduction among women. High communion coupled with high social support was associated with waist circumference reduction. However, the only significant predictor of three-year waist circumference reduction was an increase in health-related self-efficacy during the intervention (Study IV). Conclusions: Interventions should focus on improving participants self-efficacy early on in the intervention as well as prompting action and coping planning for health behaviour change. Such changes are likely to be similarly effective among intervention participants regardless of gender and educational level. Agentic orientation may operate via helping women to be less affected by the demands of the self-sacrificing female role and enabling them to assertively focus on their own goals. The earlier mixed results regarding the role of social support in behaviour change may be in part explained by personality traits such as communion.

Health-related quality of life, symptoms and comorbidity in inflammatory bowel disease

Health-related quality of life (HRQoL) measurement has become an important outcome in treatment trials and in health policy decisions. HRQoL can be measured by using generic or disease-specific tools. Generic instruments can be used for comparing health status among patients in different health states and conditions but they do not focus specifically on the issues relevant in a particular disease. Disease-specific tools may be more responsive to changes within a specific condition. In earlier studies, impairment of HRQoL has been evident in patients with inflammatory bowel disease (IBD), especially when the disease is active. Data about the impact of comorbidity or demographic characteristics of the patients on HRQoL are partly controversial. This study, which comprised 2913 adult IBD patients, examined HRQoL using the disease-specific IBDQ and the general 15D instruments. The 15D scores of IBD patients were compared with scores of a gender and age matched general population sample. Frequency of IBD symptoms and arrangement of therapy were studied and compared with those of IBD patients in an earlier European study. Furthermore, data of other chronic diseases of the patients were obtained from the Social Insurance Institution s reimbursement register and comorbidity of IBD patients was compared with that of age and gender matched controls. --- Of the respondents, 37% reported that they suffered from disturbing IBD symptoms weekly. In 17% of the patients, the symptoms greatly affected the ability to enjoy leisure activities, and 14% stated that these symptoms greatly affected their capacity to work. Despite that, the great majority (93%) of patients expressed satisfaction with their current treatment, which exceeded the rate observed in the other European patients. The mean IBDQ score was 163, as the possible range is 32-224, and disease activity was strongly correlated with HRQoL. Older age, comorbid diseases, and female gender were also related to impairment of HRQoL. Lower HRQoL scores were seen also in newly-diagnosed patients and in those with a history of surgery, especially after stoma or ileal pouch-anal anastomosis (IPAA) operation. The range of 15D scores was 0.30-1.00, with mean of 0.87. As with the IBDQ, disease activity, older age and history of surgery were correlated with the score. Both the newly-diagnosed patients and patients with a long-lasting disease had lower scores than average even after adjusting for age. The 15D scores of IBD patients were significantly lower than those of the control group. A strong correlation was seen between the 15D and the IBDQ scores. Comorbidity with other chronic diseases was observed in 29% of IBD patients. Connective tissue diseases, chronic obstructive pulmonary diseases, pernicious anaemia, and coronary heart disease (CHD) were significantly increased in patients with IBD. Especially female IBD patients appeared to be at increased risk for CHD, and patients who reported weekly IBD symptoms had a higher risk for having other chronic diseases in addition to IBD. Comorbidity impaired HRQoL, as measured with both generic and disease-specific tools. In conclusion, HRQoL is impaired in IBD patients. An understanding of predictors of HRQoL will help to recognise patients who will need special support.

Dementiakuolleisuuden sosiaaliset determinantit - rekisteriaineistoon pohjautuva tutkimus dementiakuolleisuuteen vaikuttavista sosiodemografisista tekijöistä

Tutkimuksessa tarkastellaan dementiakuolleisuutta sekä siihen vaikuttavia sosiaalisia tekijöitä. Dementia on oireyhtymä, jota pääasiassa sairastavat yli 65 -vuotiaat henkilöt. Väestön ikääntyessä sekä elinajanodotteen kasvaessa on odotettavissa, että dementiaa sairastavien määrä tulee kasvamaan merkittävästi lähivuosina. On viitteitä siitä, että dementiaan sairastumisen riskiin vaikuttavat erilaiset sosiaaliset tekijät kuten koulutus, mutta varsinkin dementiakuolleisuudesta tiedetään vähän. Tutkielman aineistona käytettiin Tilastokeskuksen muodostamaa Elinolot ja kuolinsyyt -rekisteriaineistoa, joka koostuu väestölaskentatiedoista sekä työssäkäyntitilaston pitkittäisaineistosta, johon on liitetty kuolinsyytietoja. Peruskuolinsyyn lisäksi aineistossa oli tieto korkeintaan kolmesta myötävaikuttavasta syystä. Dementiakuolleisuuden on esitetty aliarvioituvan peruskuolinsyynä, joten dementiakuolleisuuden määrittelyssä käytettiin myös tietoa myötävaikuttavista syistä. Rajausten jälkeen aineistossa on 317 944 henkilöä, joista 128 562 on miehiä ja 189 382 naisia. Pääanalyysimenetelmänä on käytetty elinaikamalleihin kuuluvaa Coxin regressiota. Dementiakuolleisuudessa oli vaihtelua kaikkien tutkimuksessa käytettyjen muuttujien, eli koulutuksen, sosiaaliluokan, tulojen, siviilisäädyn sekä perhemuodon mukaan. Koulutuksen vaikutus välittyi osin ammattiasemaan perustuvan sosiaaliluokan kautta. Suurimpia ryhmien väliset suhteelliset erot olivat nuoremmissa ikäryhmissä sekä sosiaaliluokan ja siviilisäädyn kohdalla. Eronneilla ja naimattomilla oli selvästi kohonnut riski suhteessa naimisissa oleviin. Myös työntekijöillä havaittiin kohonnut riski suhteessa ylempiin toimihenkilöihin. Siviilisääty vaikutti olevan merkittävä tekijä siinä mielessä, että koulutuksen, sosiaaliluokan ja tulojen tuominen malliin ei juuri vaikuttanut siviilisäätyryhmien välillä havaittuun vaihteluun. Dementiakuolleisuudessa havaitut ryhmien väliset suhteelliset erot olivat hieman pienempiä kuin muissa syissä, mutta kuitenkin hyvin samaa suuruusluokkaa. Tulosten perusteella on identifioitavissa tekijöitä, jotka suojaavat dementialta. Erityisesti avioliitto, korkea koulutus sekä ylemmät toimihenkilöammatit vaikuttavat olevan dementialta suojaavia tekijöitä. Avioliiton suojaavan vaikutuksen voidaan tulkita liittyvän sosiaaliseen kanssakäymiseen sekä puolison tukeen ja läsnäoloon. Korkea koulutus sekä toimihenkilöammatit indikoivat virikkeellisempää työympäristöä, mutta niiden vaikutus voi myös kulkea ylipäänsä aktiivisemman ja kognitiivisesti virikkeellisemmän elämäntavan kautta. Aktiivisen ja kognitiivisesti haastavan elämäntavan on esitetty suojaavan dementiaan sairastumiselta. Tuloksia voidaan tulkita elämänkaarinäkökulman kautta. Jo nuoruudessa vaikuttavilla tekijöillä, kuten koulutuksella, on vaikutusta. Tämän lisäksi elämänkaaren aikana myöhemmin vaikuttavat tekijät ovat merkityksellisiä. Näiden tekijöiden on esitetty vaikuttavan aivojen hermoverkostoon ja -yhteyksiin ja luovan kognitiivista reserviä, minkä on esitetty ehkäisevän tai lykkäävän dementiaan sairastumista.

Social factors at work and the health of employees

Masennus, ahdistuneisuus, alkoholiriippuvuus ja alkoholin väärinkäyttö sekä unihäiriöt ovat yleisiä ongelmia työssä käyvän väestön keskuudessa. Nämä sairaudet ja oireet aiheuttavat huomattavia kuluja myös yhteiskunnalle. Sosiaalisen tuen ja työilmapiirin yhteyttä työssä käyvien (n = 3 347–3 430) terveyteen tutkittiin Terveyden ja hyvinvoinnin laitoksen Terveys 2000 -aineistossa. Sosiaalista tukea työssä mitattiin JCQ-kyselyllä (Job Content Questionnaire) ja yksityiselämän sosiaalista tukea SSQ-kyselyllä (Social Support Questionnaire). Työilmapiiriä mitattiin kyselyllä, joka on osa Terve työyhteisö -kyselyä. Mielenterveyshäiriöiden diagnoosit perustuivat CIDI-haastatteluun (Composite International Diagnostic Interview). Tiedot lääkärin määräämistä masennus- ja unilääkkeistä poimittiin Kelan lääkerekisteristä ja tiedot työkyvyttömyyseläkkeistä Eläketurvakeskuksen ja Kelan rekistereistä. Ilmapiirin kokemisessa ei ollut merkitsevää eroa sukupuolten välillä. Sen sijaan naiset kokivat saavansa sosiaalista tukea enemmän sekä työssä että yksityiselämässä. Vähäinen sosiaalinen tuki sekä työssä että yksityiselämässä oli yhteydessä masennukseen, ahdistuneisuushäiriöihin ja moniin uniongelmiin. Huono työilmapiiri oli yhteydessä sekä masennukseen että ahdistuneisuushäiriöihin. Vähäinen tuki sekä esimiehiltä että työtovereilta oli yhteydessä myöhempään masennuslääkkeiden käyttöön. Huono työilmapiiri ennusti myös masennuslääkkeiden käyttöä. Vähäinen sosiaalinen tuki esimieheltä näytti lisäävän työkyvyttömyyseläkkeen todennäköisyyttä. Työhyvinvointiin täytyy kiinnittää huomiota, koska vähäinen sosiaalinen tuki ja huono työilmapiiri ovat yhteydessä mielenterveysongelmiin ja lisäävät työkyvyn menettämisen riskiä. – Englanninkielinen julkaisu. Suomenkielinen yhteenveto s. 89–90.

Human parvovirus infections during pregnancy : Special reference to the child-care employees

Human parvovirus B19 (B19V) is known to cause anemia, hydrops fetalis, and fetal death especially during the first half of pregnancy. Women who are in occupational contact with young children are at increased risk of B19V infection. The role of the recently discovered human parvovirus, human bocavirus (HBoV), in reproduction is unknown. The aim of this research project was to establish a scientific basis for assessing the work safety of pregnant women and for issuing special maternity leave regulations during B19V epidemics in Finland. The impact of HBoV infection on the pregnant woman and her fetus was also defined. B19V DNA was found in 0.8% of the miscarriages and in 2.4% of the intrauterine fetal death (IUFD; fetal death after completed 22 gestational weeks). All control fetuses (from induced abortions) were B19V-DNA negative. The findings on hydropic B19V DNA-positive IUFDs with evidence of acute or recent maternal B19V infection are in line with those of previous Swedish studies. However, the high prevalence of B19V-related nonhydropic IUFDs noted in the Swedish studies was mostly without evidence of maternal B19V infection and was not found during the third trimester. HBoV was not associated with miscarriages or IUFDs. Almost all of the studied pregnant women were HboV-IgG positive, and thus most probably immune to HBoV. All preterm births, perinatal deaths, smallness for gestational age (SGA) and congenital anomaly were recorded among the infants of child-care employees in a nationwide register-based cohort study over a period of 14 years. Little or no differences in the results were found between the infants of the child-care employees and those of the comparison group. The annual B19V seroconversion rate was over two-fold among the child-care employees, compared to the women in the comparison group. The seropositivity of the child-care employees increased with age, and years from qualification/joining the trade union. In general, the child-care employees are not at increased risk for adverse pregnancy outcome. However, at the population level, the risk of rare events, such as adverse pregnancy outcomes attributed to infections, could not be determined. According to previous studies, seronegative women had a 5 10% excess risk of losing the fetus during the first half of their pregnancy, but thereafter the risk was very low. Therefore, an over two-fold increased risk of B19V infection among child-care employees is considerable, and should be taken into account in the assessment of the occupational safety of pregnant women, especially during the first half of their pregnancy.

Bacteria colonizing paper machines

Bacteria growing in paper machines can cause several problems. Biofilms detaching from paper machine surfaces may lead to holes and spots in the end product or even break the paper web leading to expensive delays in production. Heat stable endospores will remain viable through the drying section of paper machine, increasing the microbial contamination of paper and board. Of the bacterial species regularly found in the end products, Bacillus cereus is the only one classified as a pathogen. Certain B. cereus strains produce cereulide, the toxin that causes vomiting disease in food poisonings connected to B. cereus. The first aim of this thesis was to identify harmful bacterial species colonizing paper machines and to assess the role of bacteria in the formation of end product defects. We developed quantitative PCR methods for detecting Meiothermus spp. and Pseudoxanthomonas taiwanensis. Using these methods I showed that Meiothermus spp. and Psx. taiwanensis are major biofoulers in paper machines. I was the first to be able to show the connection between end product defects and biofilms in the wet-end of paper machines. I isolated 48 strains of primary-biofilm forming bacteria from paper machines. Based on one of them, strain K4.1T, I described a novel bacterial genus Deinobacterium with Deinobacterium chartae as the type species. I measured the transfer of Bacillus cereus spores from packaging paper into food. To do this, we constructed a green fluorescent protein (GFP) labelled derivative of Bacillus thuringiensis and prepared paper containing spores of this strain. Chocolate and rice were the recipient foods when transfer of the labelled spores from the packaging paper to food was examined. I showed that only minority of the Bacillus cereus spores transferred into food from packaging paper and that this amount is very low compared to the amount of B. cereus naturally occurring in foods. Thus the microbiological risk caused by packaging papers is very low. Until now, the biological function of cereulide for the producer cell has remained unknown. I showed that B. cereus can use cereulide to take up K+ from environment where K+ is scarce: cereulide binds K+ ions outside the cell with high affinity and transports these ions across cell membrane into the cytoplasm. Externally added cereulide increased the growth rate of cereulide producing strains in medium where potassium was growth limiting. In addition, cereulide producing strains outcompeted cereulide non-producing B. cereus in potassium deficient environment, but not when the potassium concentration was high. I also showed that cereulide enhances biofilm formation of B. cereus.