Työkykyarviokokous moniammatillisen työryhmän päätöksentekotilanteena : Tutkimus vuorovaikutuksesta ja potilaan osallisuudesta

Work capacity assessment meeting as a decision-making situation of a multi-professional team a study on interaction and patient participation Multi-professional working has become an increasingly popular method of work in social and health care. The introduction of the viewpoints of several professionals is seen as a way to enhance the openness and quality of decision-making. However, so far relatively few study results are available on the implementation of this method in actual operations. This study examines one work method, a work capacity assessment meeting, along with medical certificates B and their enclosures written by the doctor to the patient after a meeting. After the theoretical and methodological chapter, providing background information, the study describes the structure of the meeting and the medical certificate as a constructive factor. This is followed by a discussion on the manner of assessing the various domains of the patient s functional capacity and the decision-making based on the assessed factors. Next, the study moves on to examine the effect of patient involvements on the conclusions and decisions that professionals make at the meeting. In conclusion, the study looks into how the voices of the professionals and the customer are transferred to the medical certificate. The material of the study consists of 11 meetings recorded on video, of which eight are work capacity assessment meetings and three are rehabilitation examination meetings. The first type of meeting is attended by a patient and a number of professionals, while the latter is attended only by the professionals. All the patients, whose cases are discussed in the work capacity assessment meetings, have a musculoskeletal disorder, while the rehabilitation meetings are related to patients who all also have some additional problem. The study material also consists of seven medical certificates B, written after a work capacity assessment meeting. For the most part, the material has been collected by the conversation analysis method. Moreover, also discourse analysis and a rhetorical approach were used. By using conversation analysis, it is possible to study closely how interaction is built up at the meeting and to examine how the actors implement their institutional assessment tasks in a co-operation that takes its form turn by turn. The four main findings of the study are as follows: firstly, the meeting is structured to a great extent on the basis of the medical certificate form to various phases of the meeting and the headings of the certificate are seen as communicative affordances at the meeting, directed primarily to the professionals that have assessed the patient s work capacity with various tests. The medical certificate is the ethno-method of the doctor acting as the chairman of the meeting that functions in two directions: it constructs the meeting and constitutes the task of the professionals as they produce contents for it. Secondly, the study describes the ways that are used to assess the different domains of the patient s work capacity, how they are described at the meeting and how a decision is taken when the assessment information has been saturated in the opinion of the team. Thirdly, the study brings up ways, with which the patient can influence the conclusions and decisions made by the professionals at the meeting. The study showed that the patient can affect the preconditions of his or her own future and wellbeing. Fourthly, the study describes how the wealth of expressions at the meeting is transferred to the certificate as an argumentative micro-cosmos, where the patient is classified to be recommended for rehabilitation or disability pension. An important finding is also how objective and subjective information and the voices of actors at the meeting are transferred to the statement in a strategic and intentional manner, with an orientation to the decision that will be taken at the insurance institution. The study results can be utilized in the training of professionals and in developing the operations of organisations performing the assessment of the work capacity of people suffering from musculoskeletal disorders.

The relationships between work stressors and organizational performance in long-term care for elderly residents

This study investigates the relationships between work stressors and organizational performance in terms of the quality of care provided by the long-term care facilities. Work stressors are first examined in relation to the unit's structural factors, resident characteristics, and to the unit specialization. The study is completed by an investigation into the associations of work stressors such as job demands or time pressure, role ambiguity, resident-related stress, and procedural injustice to organizational performance. Also the moderating effect of job control in the job demands organizational performance relationship is examined. The study was carried out in the National Research and Development Centre for Welfare and Health (STAKES). Survey data were drawn from 1194 nursing employees in 107 residential-home and health-center inpatient units in 1999 and from 977 employees in 91 units in 2002. Information on the unit resident characteristics and the quality of care was provided by the Resident Assessment Instrument (RAI). The results showed that large unit size or lower staffing levels were not consistently related to work stressors, whereas the impairments in residents' physical functioning in particular initiated stressful working conditions for employees. However, unit specialization into dementia and psychiatric residents was found to buffer the effects that the resident characteristics had on employee appraisals of work stressors, in that a high proportion of behavioral problems was related to less time pressure and role conflicts for employees in specialized units. Unit specialization was also related to improved team climates and the organizational commitment of employees. Work stressors associated with problems in care quality. Time pressure explained most of the differences between units in how the employees perceived the quality of physical and psychosocial care they provide for the residents. A high level of job demands in the unit was also found to be related to some increases in all clinical quality problems. High job control buffered the effects of job demands on the quality of care in terms of the use of restraints on elderly residents. Physical restraint and especially antipsychotic drug use were less prevalent in units that combined both high job demands and high control for employees. In contrast, in high strain units where heavy job demands coincided with a lack of control for employees, quality was poor in terms of the frequent use of physical restraints. In addition, procedural injustice was related to the frequent use of antianxiety of hypnotic drugs for elderly residents. The results suggest that both job control and procedural justice may have improved employees' abilities to cope when caring for the elderly residents, resulting in better organizational performance.

Sikiöaikana päihteille altistuneiden lasten kasvuympäristö ja kehitys

Life of children exposed to alcohol or drugs in utero This study focused on the growth environment, physical development and socio-emotional development of children, aged 16 and under, who had been exposed to alcohol (n=78) or drugs (n=15) in utero. The aim of the study was to obtain a comprehensive picture of the living conditions of these children and to examine the role of the growth environment in their development. The study was carried out using questionnaires, written life stories and interviews. Attachment theory was used as a background theory in the study. Over half of the children exposed to alcohol were diagnosed with foetal alcohol syndrome (FAS), one quarter was diagnosed with foetal alcohol effects (FAE), and one fifth had no diagnosis. Most of the children exposed to drugs had been exposed to either amphetamines or cannabis, and a smaller number to heroin. Some of the children exposed to alcohol were mentally handicapped or intellectually impaired. The children exposed to drugs did not exhibit any serious learning difficulties but a considerable number of them had socio-emotional development problems. Language and speech problems and attention, concentration and social interaction problems were typical among both the children exposed to alcohol and those exposed to drugs. Only one child had been placed into long-term foster care in a family immediately after leaving the maternity hospital. In biological families there had been neglect, violence, mental health problems, crime and unemployment, and many parents were already dead. Two of the children had been sexually abused and four were suspected of having been abused. From the point of view of the children's development, the three most critical issues were 1) the range of illnesses and handicaps that had impaired their functional capacity as a result of their prenatal exposure to alcohol, 2) child's age at the time of placement on a long-term basis, and 3) the number of their traumatic experiences. The relationship with their biological parents after placement also played a role. Children with symptoms were found in all diagnosis categories and types of exposure. Children with the smallest number of symptoms were found among those who had never lived with their biological parents. Almost all children were exhibiting strong symptoms at the time of placement in foster care. In most cases, they were behaving in a disorderly manner towards others, but some children were withdrawn. The most conspicuous feature among those with the most severe symptoms was their disorganized behaviour. Placement in a foster family enhanced the children's development, but did not solve the problems. The foster parents who brought these children up did not receive as much therapy for the children and support for the upbringing as they appear to have needed. In Finland, transfer to long-term custody is based on strict criteria. The rights of children prescribed in the child protection law are not fulfilled in practice. Key words: FASD, FAS, FAE, alcohol exposure, drugs exposure, illegal drugs, early interaction, child development, attachment

Retirement Transition and Well-being : A 16-year Longitudinal Study

The ageing of the labour force and falling employment rates have forced policy makers in industrialized countries to find means of increasing the well-being of older workers and of lengthening their work careers. The main objective of this thesis was to study longitudinally how health, functional capacity, subjective well-being, and lifestyle change as people grow older, and what effect retirement has on these factors and on their relationships. The present study is a follow-up questionnaire study of Finnish municipal workers, conducted in 1981 to 1997 at the Finnish Institute of Occupational Health. In 1981, a postal questionnaire was sent to 7344 municipal workers in different parts of Finland. The respondents were born between 1923 and 1937. A total of 6257 persons responded to the first questionnaire. In the end, a total of 3817 persons had responded to all four (1981, 1985, 1992, 1997) questionnaires. (The response rate was 69% of the living participants). Cross-tabulations, comparison of means, logistic regression analyses and general linear models with repeated measures were used to derive the results. The transition from work life to retirement, and the following years as a pensioner were associated with many changes. Involvement in various activities increased during the transition stage but later decreased to the previous level. Physical exercise was an exception: it became increasingly popular over the years. Perceived health improved markedly from the working stage to the retirement transition stage, even though morbidity increased steadily during the follow-up. On the other hand, functional capacity decreased over the follow-up, especially among those who were occupationally active until the retirement stage. Subjective well-being remained stable during the follow-up period. There were, however, great differences based on the type of work, favouring those whose work had been mental in nature. The impact of activity level on maintaining well-being became greater during the follow-up, whereas the effect of physical functioning diminished. Good physical functioning and an active life-style contributed to staying on at work until normal retirement age. Also work-related factors, i.e. possibilities for development and influence at work, responsibility for others, meaningful work, and satisfaction with working time arrangements were positively related to continuing working. The transition from work to retirement had a positive impact on a person s health and functional capacity. The study results support the view that it should be possible to ease one s work pace during the last years of a work career. This might lower the threshold between work and retirement and convince people that there will still be time to enjoy retirement also a few years later.

Ultrastructure of Biofilms Formed by Bacteria from Industrial Processes

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

Opaskoirien pentutestin perinnölliset tunnusluvut

Tutkimuksen tarkoituksena oli selvittää Opaskoirakoulun pentutestissä mitattavien ominaisuuksien perinnölliset tunnusluvut sekä niihin vaikuttavat tekijät. Aineisto koostui Opaskoirakoululla vuosina 1988–2008 pentutestin suorittaneista koirista (900 kpl). Suomen Kennelliito ry:stä saatiin sukulaisuusaineisto, johon täydennettiin rekisteriin kuulumattomat koirat. Tutkittavia ominaisuuksia oli 11 kappaletta: käyttäytyminen sylissä, luoksetulo, kontakti, taistelu, alistus, palautuminen, ääniherkkyys, käyttäytyminen pöydällä, seuraaminen, toimintakyky ja hermorakenne. Kaikki ominaisuudet arvostellaan pentutestissä valmiiden käyttäytymismallien mukaisesti. Aineiston esikäsittelyyn ja alustaviin analyyseihin käytettiin Microsoft Office Excel 2003-ohjelmaa sekä WSYS-L ja XWSYS-ohjelmistoja. Kiinteiden tekijöiden luokitteluun ja merkitsevyyden testaamiseen käytettiin WSYS-L ja XWSYS-ohjelmistoa. Varianssikomponentit sekä periytymisasteet laskettiin Restricted Maximum Likelihood (REML)-menetelmällä käyttäen VCE6-ohjelmistoa Tutkittujen ominaisuuksien periytymisasteiden arviot olivat alhaisia tai keskinkertaisia (h2= 0,07-0,39). Korkeimmat periytymisasteiden arviot olivat ominaisuuksilla alistus (0,39), toimintakyky (0,32) ja kontakti (0,31). Ominaisuuksien väliset geneettiset korrelaatiot olivat pääosin positiivisia. Poikkeuksen muodosti ominaisuus alistus, joka oli negatiivisesti korreloitunut palautumisen (-0,47) ja seuraamisen (-0,64) kanssa. Osa ominaisuuksista oli erittäin voimakkaasti korreloituneita (r > 0,8). Fenotyyppiset korrelaatiot vaihtelivat välillä 0,11–0,73 ja olivat geneettisiä korrelaatioita matalampia. Tämän tutkimuksen perusteella ominaisuuksissa käyttäytyminen sylissä, luoksetulo, kontakti, taistelu, alistus, ääniherkkyys, käyttäytyminen pöydällä ja toimintakyky on geneettistä vaihtelua ja sen perusteella niitä on mahdollista muuttaa haluttuun suuntaan jalostuksen avulla.

Functional limitations and quality of life in schizophrenia and other psychotic disorders

There is substantial evidence of the decreased functional capacity, especially everyday functioning, of people with psychotic disorder in clinical settings, but little research about it in the general population. The aim of the present study was to provide information on the magnitude of functional capacity problems in persons with psychotic disorder compared with the general population. It estimated the prevalence and severity of limitations in vision, mobility, everyday functioning and quality of life of persons with psychotic disorder in the Finnish population and determined the factors affecting them. This study is based on the Health 2000 Survey, which is a nationally representative survey of 8028 Finns aged 30 and older. The psychotic diagnoses of the participants were assessed in the Psychoses of Finland survey, a substudy of Health 2000. The everyday functioning of people with schizophrenia is studied widely, but one important factor, mobility has been neglected. Persons with schizophrenia and other non-affective psychotic disorders, but not affective psychoses had a significantly increased risk of having both self-reported and test-based mobility limitations as well as weak handgrip strength. Schizophrenia was associated independently with mobility limitations even after controlling for lifestyle-related factors and chronic medical conditions. Another significant factor associated with problems in everyday functioning in participants with schizophrenia was reduced visual acuity. Their vision was examined significantly less often during the five years before the visual acuity measurement than the general population. In general, persons with schizophrenia and other non-affective psychotic disorder had significantly more limitations in everyday functioning, deficits in verbal fluency and in memory than the general population. More severe negative symptoms, depression, older age, verbal memory deficits, worse expressive speech and reduced distance vision were associated with limitations in everyday functioning. Of all the psychotic disorders, schizoaffective disorder was associated with the largest losses of quality of life, and bipolar I disorder with equal or smaller losses than schizophrenia. However, the subjective loss of qualify of life associated with psychotic disorders may be smaller than objective disability, which warrants attention. Depressive symptoms were the most important determinant of poor quality of life in all psychotic disorders. In conclusion, subjects with psychotic disorders need regular somatic health monitoring. Also, health care workers should evaluate the overall quality of life and depression of subjects with psychotic disorders in order to provide them with the basic necessities of life.

Micropillar Array Based Microchips for Electrospray Ionization Mass Spectrometry, Microreactors, and Liquid Chromatographic Separation

This dissertation deals with the design, fabrication, and applications of microscale electrospray ionization chips for mass spectrometry. The microchip consists of microchannel, which leads to a sharp electrospray tip. Microchannel contain micropillars that facilitate a powerful capillary action in the channels. The capillary action delivers the liquid sample to the electrospray tip, which sprays the liquid sample to gas phase ions that can be analyzed with mass spectrometry. The microchip uses a high voltage, which can be utilized as a valve between the microchip and mass spectrometry. The microchips can be used in various applications, such as for analyses of drugs, proteins, peptides, or metabolites. The microchip works without pumps for liquid transfer, is usable for rapid analyses, and is sensitive. The characteristics of performance of the single microchips are studied and a rotating multitip version of the microchips are designed and fabricated. It is possible to use the microchip also as a microreactor and reaction products can be detected online with mass spectrometry. This property can be utilized for protein identification for example. Proteins can be digested enzymatically on-chip and reaction products, which are in this case peptides, can be detected with mass spectrometry. Because reactions occur faster in a microscale due to shorter diffusion lengths, the amount of protein can be very low, which is a benefit of the method. The microchip is well suited to surface activated reactions because of a high surface-to-volume ratio due to a dense micropillar array. For example, titanium dioxide nanolayer on the micropillar array combined with UV radiation produces photocatalytic reactions which can be used for mimicking drug metabolism biotransformation reactions. Rapid mimicking with the microchip eases the detection of possibly toxic compounds in preclinical research and therefore could speed up the research of new drugs. A micropillar array chip can also be utilized in the fabrication of liquid chromatographic columns. Precisely ordered micropillar arrays offer a very homogenous column, where separation of compounds has been demonstrated by using both laser induced fluorescence and mass spectrometry. Because of small dimensions on the microchip, the integrated microchip based liquid chromatography electrospray microchip is especially well suited to low sample concentrations. Overall, this work demonstrates that the designed and fabricated silicon/glass three dimensionally sharp electrospray tip is unique and facilitates stable ion spray for mass spectrometry.

IPA-kyselylomake valinnoista ja osallistumisesta jokapäiväisessä elämässä. Toimintakyvyn itsearviointimenetelmä aikuisille, joilla on fyysisiä toimintarajoitteita

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Leisure-time physical activity, health related functioning and retirement : a prospective cohort study among middle-aged employees

Physical inactivity has become a major threat to public health worldwide. The Finnish health and welfare policies emphasize that the working population should maintain good health and functioning until their normal retirement age and remain in good health and independence later in life. Health behaviours like physical activity potentially play an important role in reaching this target as physical activity contributes to better physical fitness and to reduced risk of major chronic diseases. The aim of this study was to examine first whether the volume and intensity of leisure-time physical activity impacts on subsequent physical health functioning, sickness absence and disability retirement. The second aim was to examine changes in leisure-time physical activity of moderate and vigorous intensity after transition to retirement. This study is part of the ongoing Helsinki Health Study. The baseline data were collected by questionnaires in 2000 - 02 among the employees of the City of Helsinki aged 40 to 60. The follow-up survey data were collected in 2007. Data on sickness absence were obtained from the employer s (City of Helsinki) sickness absence registers and pension data were obtained from the Finnish Centre for Pensions. Leisure-time physical activity was measured in four grades of intensity and classified according to physical activity recommendations considering both the volume and intensity of physical activity. Statistical techniques including analysis of covariance, logistic regression, Cox proportional hazards models and Poisson regression were used. Employees who were vigorously active during leisure time especially had better physical health functioning than those physically inactive. High physical activity in particular contributed to the maintenance of good physical health functioning. High physical activity also reduced the risk of subsequent sickness absences as well as the risk of all-cause disability retirement and retirement due to musculoskeletal and mental causes. Among those transferred to old-age retirement moderate-intensity leisure-time physical activity increased on average by more than half an hour per week and in addition the occurrence of physical inactivity reduced. Such changes were not observed among those remained employed and those transferred to disability retirement. This prospective cohort study provided novel results on the effects of leisure-time physical activity on health related functioning and changes in leisure-time physical activity after retirement. Although the benefits of moderate-intensity physical activity for health are well known these results suggest the importance of vigorous physical activity for subsequent health related functioning. Thus vigorous physical activity to enhance fitness should be given more emphasis from a public health perspective. In addition, physical activity should be encouraged among those who are about to retire.

Field intercomparison of four methane gas analysers suitable for eddy covariance flux measurements

Eddy covariance (EC)-flux measurement technique is based on measurement of turbulent motions of air with accurate and fast measurement devices. For instance, in order to measure methane flux a fast methane gas analyser is needed which measures methane concentration at least ten times in a second in addition to a sonic anemometer, which measures the three wind components with the same sampling interval. Previously measurement of methane flux was almost impossible to carry out with EC-technique due to lack of fast enough gas analysers. However during the last decade new instruments have been developed and thus methane EC-flux measurements have become more common. Performance of four methane gas analysers suitable for eddy covariance measurements are assessed in this thesis. The assessment and comparison was performed by analysing EC-data obtained during summer 2010 (1.4.-26.10.) at Siikaneva fen. The four participating methane gas analysers are TGA-100A (Campbell Scientific Inc., USA), RMT-200 (Los Gatos Research, USA), G1301-f (Picarro Inc., USA) and Prototype-7700 (LI-COR Biosciences, USA). RMT-200 functioned most reliably throughout the measurement campaign and the corresponding methane flux data had the smallest random error. In addition, methane fluxes calculated from data obtained from G1301-f and RMT-200 agree remarkably well throughout the measurement campaign. The calculated cospectra and power spectra agree well with corresponding temperature spectra. Prototype-7700 functioned only slightly over one month in the beginning of the measurement campaign and thus its accuracy and long-term performance is difficult to assess.

Functional outcome and health-related quality of life after traumatic brain injury in the framework of the International Classification of Functioning, Disability and Health (ICF)

Traumatic brain injury (TBI) affects people of all ages and is a cause of long-term disability. In recent years, the epidemiological patterns of TBI have been changing. TBI is a heterogeneous disorder with different forms of presentation and highly individual outcome regarding functioning and health-related quality of life (HRQoL). The meaning of disability differs from person to person based on the individual s personality, value system, past experience, and the purpose he or she sees in life. Understanding of all these viewpoints is needed in comprehensive rehabilitation. This study examines the epidemiology of TBI in Finland as well as functioning and HRQoL after TBI, and compares the subjective and objective assessments of outcome. The frame of reference is the International Classification of Functioning, Disability and Health (ICF). The subjects of Study I represent the population of Finnish TBI patients who experienced their first TBI between 1991 and 2005. The 55 Finnish subjects of Studies II and IV participated in the first wave of the international Quality of life after brain injury (QOLIBRI) validation study. The 795 subjects from six language areas of Study III formed the second wave of the QOLIBRI validation study. The average annual incidence of Finnish hospitalised TBI patients during the years 1991-2005 was 101:100 000 in patients who had TBI as the primary diagnosis and did not have a previous TBI in their medical history. Males (59.2%) were at considerably higher risk of getting a TBI than females. The most common external cause of the injury was falls in all age groups. The number of TBI patients ≥ 70 years of age increased by 59.4% while the number of inhabitants older than 70 years increased by 30.3% in the population of Finland during the same time period. The functioning of a sample of 55 persons with TBI was assessed by extracting information from the patients medical documents using the ICF checklist. The most common problems were found in the ICF components of Body Functions (b) and Activities and Participation (d). HRQoL was assessed with the QOLIBRI which showed the highest level of satisfaction on the Emotions, Physical Problems and Daily Life and Autonomy scales. The highest scores were obtained by the youngest participants and participants living independently without the help of other people, and by people who were working. The relationship between the functional outcome and HRQoL was not straightforward. The procedure of linking the QOLIBRI and the GOSE to the ICF showed that these two outcome measures cover the relevant domains of TBI patients functioning. The QOLIBRI provides the patients subjective view, while the GOSE summarises the objective elements of functioning. Our study indicates that there are certain domains of functioning that are not traditionally sufficiently documented but are important for the HRQoL of persons with TBI. This was the finding especially in the domains of interpersonal relationships, social and leisure activities, self, and the environment. Rehabilitation aims to optimize functioning and to minimize the experience of disability among people with health conditions, and it needs to be based on a comprehensive understanding of human functioning. As an integrative model, the ICF may serve as a frame of reference in achieving such an understanding.

Pain measurement and management in elderly patients : Clinical studies in long term hospital care and after cardiac surgery

The proportion of patients over 75 years of age, receiving all different types of healthcare, is constantly increasing. The elderly undergo surgery and anaesthetic procedures more often than middle-aged patients. Poor pain management in the elderly is still an issue. Although the elderly consumes the greatest proportion of prescribed medicines in Western Europe, most clinical pharmacological studies have been performed in healthy volunteers or middle-aged patients. The aim of this study was to investigate pain measurement and management in cognitively impaired patients in long term hospital care and in cognitively normal elderly patients after cardiac surgery. This thesis incorporated 366 patients, including 86 home-dwelling or hospitalized elderly with chronic pain and 280 patients undergoing cardiac surgery with acute pain. The mean age of patients was 77 (SD ± 8) years and approximately 8400 pain measurements were performed with four pain scales: Verbal Rating Scale (VRS), the Visual Analogue Scale (VAS), the Red Wedge Scale (RWS), and the Facial Pain Scale (FPS). Cognitive function, depression, functional ability in daily life, postoperative sedation and postoperative confusion were assessed with MMSE, GDS, Barthel Index, RASS, and CAM-ICU, respectively. The effects and plasma concentrations of fentanyl and oxycodone were measured in elderly (≥ 75 years) and middle-aged patients (≤ 60 years) and the opioid-sparing effect of pregabalin was studied after cardiac surgery. The VRS pain scores after movement correlated with the Barthel Index. The VRS was most successful in the groups of demented patients (MMSE 17-23, 11-16 and ≤ 10) and in elderly patients on the first day after cardiac surgery. The elderly had a higher plasma concentration of fentanyl at the end of surgery than younger patients. The plasma concentrations of oxycodone were comparable between the groups. Pain intensity on the VRS was lower and the sedation scores were higher in the elderly. Total oxycodone consumption during five postoperative days was reduced by 48% and the CAM-ICU scores were higher on the first postoperative day in the pregabalin group. The incidence of postoperative pain during movement was lower in the pregabalin group three months after surgery. This investigation demonstrates that chronic pain did not seem to impair daily activities in home-dwelling Finnish elderly. The VRS appeared to be applicable for elderly patients with clear cognitive dysfunction (MMSE ≤17) and it was the most feasible pain scale for the early postoperative period after cardiac surgery. After cardiac surgery, plasma concentrations of fentanyl in elderly were elevated, although oxycodone concentrations were at similar level compared to middle-aged patients. The elderly had less pain and were more sedated after doses of oxycodone. Therefore, particular attention must be given to individual dosing of the opioids in elderly surgical patients, who often need a smaller amount for adequate analgesia than middle-aged patients. The administration of pregabalin reduced postoperative oxycodone consumption after cardiac surgery. Pregabalin-treated patients had less confusion, and additionally to less postoperative pain on the first postoperative day and during movement at three months post-surgery. Pregabalin might be a new alternative as analgesic for acute postoperative and chronic pain management in the elderly. Its clinical role and safety remains to be verified in large-scale randomized and controlled studies. In the future, many clinical trials in the older category of patients will be needed to facilitate improvements in health care methods.

Jakojuuriviljelyn vaikutus kasvihuonekurkun (Cucumis sativus L.) kasvuun ja kehitykseen

Kasvit ottavat vettä parhaiten kasteluravinneliuoksesta, jonka ravinnepitoisuus on pieni. Intensiivisessä kasvihuonetuotannossa käytetään silti kastelulannoituksessa usein korkeita ravinnepitoisuuksia ravinnepuutosten ja satotappioiden välttämiseksi. Jakojuuriviljelyssä kasvin juuriston annetaan kasvaa kahteen erilliseen kasvualustaosioon. Tällöin toiselle puolelle annetaan johtokyvyltään väkevää ja toiselle puolelle laimeaa ravinneliuosta. Erityisesti kasvihuonekurkun, joka on herkkä kasvualustan suolaisuuden aiheuttamille vedensaantiongelmille, on todettu hyötyvän tästä tekniikasta, mikä näkyy kasvaneina satoina. Tämän MTT Piikkiössä toteutetun kasvihuonekurkun jakojuuriviljelytutkimuksen tavoitteena oli tarkentaa tekniikkaa erityisesti kasteluliuosten johtokyvyn osalta. Yhtenäisjuuriviljelyn ja perinteisen jakojuuriviljelyn lisäksi kokeessa oli kaksi jakojuuriviljelykäsittelyä, joissa ravinneliuosväkevyyksiä vaihdettiin väliajoin juuriston toimintakyvyn parantamiseksi. Erillisessä osakokeessa tutkittiin erilaisten johtokyky-yhdistelmien vaikutusta kasvihuonekurkun vegetatiiviseen kasvuun maanpäällisten ja -alaisten kasvinosien välillä sekä juurten morfologiaan ja anatomiaan. Tulokset osoittivat, että jakojuuriviljely lisäsi kasvihuonekurkun sadontuottoa jopa 16 %, mutta ei vaikuttanut koko viljelykauden veden tai ravinteiden ottoon. Yhtenäisjuuriviljelyssä muodostui eniten piikkikärkisiä hedelmiä, mikä viittaa vedensaantiongelmiin haihdutustarpeen ollessa suurin. Viljelytekniikalla ei ollut vaikutusta kasvien vegetatiiviseen kasvuun tai kasvuston rakenteeseen. Lehtiruodeista tehdyt nitraatti- ja kaliummittaukset osoittivat, ettei kasteluliuosten ravinnepitoisuuksilla ollut vaikutusta juurten ravinteiden ottoon. Erilaisilla johtokyky-yhdistelmillä oli huomattavampi vaikutus kasvihuonekurkun juurten painoon kuin verson painoon tai varren pituuskasvuun. Lehtiruotianalyysit viittasivat ravinteiden erilaiseen allokointiin eri johtokyky-yhdistelmissä. Korkeiden johtokykyjen aiheuttama osmoottinen stressi johti muutoksiin juurten morfologiassa ja anatomiassa. Tulosten perusteella jakojuuriviljely paransi kehittyvien hedelmien kohdevahvuutta suhteessa muihin kohteisiin vaikuttamatta vegetatiiviseen kasvuun. Kun laimean ja väkevän ravinneliuoksen puolia vaihdettiin, juuristo otti joustavasti vettä ja ravinteita olosuhteiden määräämästä edullisemmasta johtokyvystä, jolloin kasvihuonekurkun viljelyssä saavutettiin merkittävä satoetu. Juuriston jakaminen vaikuttanee kasvien hormoniaineenvaihduntaan ja voi heikentää juuriston kasvua heikentämättä sen toimintakykyä, jolloin yhteyttämistuotteita kohdennetaan tehokkaammin maanpäällisten osien kasvuun.