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

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 In this thesis, previously unpublished data on the incidence of opioid overdose between 2001-2007 and comparison of the characteristics of buprenorphine and heroin overdose patients encountered in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

Costs and Benefits of a Shared Digital Long-Term Preservation System

This paper describes the cost-benefit analysis of digital long-term preservation (LTP) that was carried out in the context of the Finnish National Digital Library Project (NDL) in 2010. The analysis was based on the assumption that as many as 200 archives, libraries, and museums will share an LTP system. The term ‘system’ shall be understood as encompassing not only information technology, but also human resources, organizational structures, policies and funding mechanisms. The cost analysis shows that an LTP system will incur, over the first 12 years, cumulative costs of €42 million, i.e. an average of €3.5 million per annum. Human resources and investments in information technology are the major cost factors. After the initial stages, the analysis predicts annual costs of circa €4 million. The analysis compared scenarios with and without a shared LTP system. The results indicate that a shared system will have remarkable benefits. At the development and implementation stages, a shared system shows an advantage of €30 million against the alternative scenario consisting of five independent LTP solutions. During the later stages, the advantage is estimated at €10 million per annum. The cumulative cost benefit over the first 12 years would amount to circa €100 million.

Promoting the European Union : Attitudinal stance adjectives in three genres of EU communication to the public

Målet för Pro Gradu-avhandlingen är att undersöka hur Europeiska unionen (EU) marknadsförs genom användningen av värderande adjektiv i tre genrer av skriftlig kommunikation från EU till medlemsstaternas medborgare. Undersökningen är inriktad på tre forskningsfrågor: hur marknadsföringen av EU syns i användningen av värderande adjektiv i de tre genrerna, vilka de centrala skillnaderna mellan de tre genrerna är gällande användningen av värderande adjektiv, samt på vilket sätt texterna uppfyller sitt kommunikativa syfte, nämligen att informera allmänheten om EU:s verksamhet och marknadsföra EU som en giltig och handlingskraftig union. Den teoretiska ramen för undersökningen grundar sig på genreanalys, kommunikationsteori och teorier om hur författarens värdering (stance) syns i texter. Skillnaden mellan genre, texttyp och register diskuteras, och teoridelen redogör även för begreppet diskurssamfund, dvs. den grupp personer som i ett yrkesmässigt eller institutionellt sammanhang producerar och använder sig av en genre enligt dess kommunikativa konventioner. Materialet behandlas även utgående från Egon Werlichs indelning av texttyper i deskriptiva, narrativa, expositära, argumentativa och instruktiva texter. Materialet består av tre delar som representerar var sin genre: informationsbroschyrer, pressmeddelanden och den Allmänna rapporten om Europeiska unionens verksamhet, som utges av EU varje år. Storleken på varje del av materialet varierar mellan 20 000 - 30 000 ord. Materialet har valts på basis av de teman texterna behandlar, och kriterierna för urvalet är bl.a. att texterna behandlar ämnen som har anknytning till medborgarnas vardag, att de är riktade till allmänheten, och att de finns tillgängliga på Internet. Undersökningen är genomförd som en kvalitativ genreanalys. Materialet analyseras först utgående från kontexten och det samhälleliga sammanhanget enligt Vijay K. Bhatias metodik för analys av obekanta genrer. Det kommunikativa syftet, författaren och den tilltänkta läsarkretsen, dvs. målgruppen för kommunikationen, fastställs. Värderande adjektiv som uttrycker författarens hållning har plockats ur texten manuellt och med hjälp av konkordansprogrammet AntConc, och placerats i 16 kategorier enligt de värden de uttrycker. Varje genre analyseras sedan språkligt med utgångspunkt i adjektivlistorna, varefter resultaten jämförs med varandra. Undersökningen visar att pressmeddelandena innehåller det största antalet värderande adjektiv, medan informationsbroschyrerna innehåller det minsta antalet värderande adjektiv. Den Allmänna rapporten om Europeiska unionens verksamhet innehåller delar med tätt förekommande värderande adjektiv, i synnerhet i stycken som behandlar mer kontroversiella ämnen. I alla tre genrer sammanfaller ett högt antal värderande adjektiv med argumentativ text, och argumentativ text förekommer främst då ämnet som diskuteras rör sig på en mer abstrakt nivå, t.ex. om EU:s värderingar och grundläggande principer, eller då texten behandlar sådan politik som delar allmänhetens uppfattning. För EU utgör alla tre genrer viktiga kanaler för kommunikationen till medlemsstaternas medborgare, och EU kan genom sitt informationsmaterial och sina officiella publikationer informera om, förklara och marknadsföra sin verksamhet på ett sätt som avser att upprätthålla och förbättra EU:s image. Utarbetandet av lämpliga texter är ändå krävande på grund av den heterogena målgruppen, och det är en utmaning i sig att få fram rätt budskap bland det stora utbudet information som finns tillgängligt på Internet.