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 In this thesis, previously unpublished data on the incidence of opioid overdose between 2001-2007 and comparison of the characteristics of buprenorphine and heroin overdose patients encountered in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.

Äidin hoiva, jaettu vanhemmuus – ja vapaus valita. Perhevapaiden uudistamisen argumentointi 1970-luvulta 2000-luvulle

Tutkimuksessa tarkastellaan perhevapaista Suomessa käytyä poliittista keskustelua ja sen pitkän aikavälin muutosta. Tutkimuksessa syvennytään 1970-luvun uudistusaaltoon, jolloin isät otettiin mukaan järjestelmään, sekä 2000-lukuun, jolloin isiä on eri keinoin kannustettu vapaiden käyttöön. Tässä yhteydessä selvitetään itse uudistusprosesseja, mutta keskei-nen tutkimuskohde ovat päätöksentekoon osallistuneiden toimijoiden perhevapaita koske-vien näkemysten argumentointitavat. Tutkimuksen aineisto koostuu mm. valtiopäiväasia-kirjoista, työryhmämuistioista, hallitusten ja puolueiden ohjelmista ja työmarkkinajärjestöjen kannanotoista. Aineistoa lähestytään kehysanalyysin sekä argumentaatioteorian menetel-mien avulla. Näillä kiinnitetään huomio niihin tekniikoihin, joilla poliittisessa argumentoin-nissa on pyritty saamaan esitetyille toimenpiteille mahdollisimman laaja kannatus. 1970-luvulla keskustelu vanhempainlomista oli hyvin polarisoitunutta. Isien hoivaajaroolin kas-vattaminen oli osa vasemmiston diskurssia, joka pyrki tasa-arvoon niin kodeissa kuin työ-markkinoillakin. Konservatiivien äidinhoivan diskurssi sitä vastoin piti äitiä luonnostaan pa-rempana hoitajana lapselle ja vaati pitkän äitiysloman jatkeeksi kotihoidon tukea, jota va-semmisto puolestaan vastusti. 2000-luvun pääteemoja ovat olleet vanhemmuuden kus-tannusten tasaisempi jakaminen sekä isien kannustaminen vapaiden käyttöön. Isien kan-nustamiseksi on esitetty erilaisia malleja isäkiintiöistä: perusteina ovat olleet muun muassa isä–lapsi-suhde, tasa-arvo sekä Pohjoismaiden positiiviset kokemukset kiintiöistä. Työnan-tajat ja konservatiivit ovat kuitenkin pitäneet kiintiöitä vanhempien valinnanvapauden rajoit-tamisena, vaikka ne muuten ovatkin argumentoineet tasaarvon ja isien kannustamisen puolesta. Isäkiintiöiden kannattajat taas eivät enää 2000-luvulla ole kyseenalaistaneet ko-tihoidon tukea, joka on pidentänyt naisten katkoja työelämästä ja jolla on suuri merkitys lasten hoidon epätasaiselle jakautumiselle.

Almost Stable Matchings by Truncating the Gale–Shapley Algorithm

We show that the ratio of matched individuals to blocking pairs grows linearly with the number of propose–accept rounds executed by the Gale–Shapley algorithm for the stable marriage problem. Consequently, the participants can arrive at an almost stable matching even without full information about the problem instance; for each participant, knowing only its local neighbourhood is enough. In distributed-systems parlance, this means that if each person has only a constant number of acceptable partners, an almost stable matching emerges after a constant number of synchronous communication rounds. We apply our results to give a distributed (2 + ε)-approximation algorithm for maximum-weight matching in bicoloured graphs and a centralised randomised constant-time approximation scheme for estimating the size of a stable matching.

Nomenclatural corrections in Mesoamerican Plantaginaceae and a new species of Tetranema from Honduras

Study of the Plantaginaceae for the Flora Mesoamericana project has resulted in five lectotypifications, a new combination in Rhodochiton, and the discovery of a new species of Tetranema from Honduras. This species, Tetranema michaelfayanum, is described here, a key to the species of Tetranema is provided, and the T. roseum complex is discussed.

New combinations of the fern genus Tectaria (Tectariaceae) for the Flora of China.

For studies on the fern family Tectariaceae for the Flora of China, four species previously treated as Ctenitopsis need new combinations in Tectaria. The new combinations are proposed here and information on their types is provided.

Does the age of fine root carbon indicate the age of fine roots in boreal forests?

To test the reliability of the radiocarbon method for determining root age, we analyzed fine roots (originating from the years 1985 to 1993) from ingrowth cores with known maximum root age (1 to 6 years old). For this purpose, three Scots pine (Pinus sylvestris L.) stands were selected from boreal forests in Finland. We analyzed root 14C age by the radiocarbon method and compared it with the above-mentioned known maximum fine root age. In general, ages determined by the two methods (root 14C age and ingrowth core root maximum age) were in agreement with each other for roots of small diameter (<0.5mm). By contrast, in most of the samples of fine roots of larger diameter (1.5-2mm), the 14C age of root samples of 1987-89 exceeded the ingrowth core root maximum age by 1-10 years. This shows that these roots had received a large amount of older stored carbon from unknown sources in addition to atmospheric CO2 directly from photosynthesis. We conclude that the 14C signature of fine roots, especially those of larger diameter, may not always be indicative of root age, and that further studies are needed concerning the extent of possible root uptake of older carbon and its residence time in roots. Keywords: fine root age, Pinus sylvestris, radiocarbon, root carbon, ingrowth cores, tree ring

Arabidopsis GRI is involved in the regulation of cell death induced by extracellular ROS

Reactive oxygen species (ROS) have important functions in plant stress responses and development. In plants, ozone and pathogen infection induce an extracellular oxidative burst that is involved in the regulation of cell death. However, very little is known about how plants can perceive ROS and regulate the initiation and the containment of cell death. We have identified an Arabidopsis thaliana protein, GRIM REAPER (GRI), that is involved in the regulation of cell death induced by extracellular ROS. Plants with an insertion in GRI display an ozone-sensitive phenotype. GRI is an Arabidopsis ortholog of the tobacco flower-specific Stig1 gene. The GRI protein appears to be processed in leaves with a release of an N-terminal fragment of the protein. Infiltration of the N-terminal fragment of the GRI protein into leaves caused cell death in a superoxide-and salicylic acid-dependent manner. Analysis of the extracellular GRI protein yields information on how plants can initiate ROS-induced cell death during stress response and development.

Kansan raittiudeksi ja kotien onneksi : Naisten kieltolakimielipiteet ja toiminta kieltolain puolesta ja sitä vastaan 1919 - 1932

It is often maintained that the Prohibition Act (in force from 1 June 1919 to 5 April 1932) still influences both the Finnish alcohol policy and notions about alcohol. This study focuses on the development of women s opinions concerning Prohibition in Finland. What role did the formulation and expression of women s opinions and women's actions play in the final outcome of the Prohibition Act? What do the debate on Prohibition and women s activities for and against the legislation tell us about the status and possibilities of women to exert influence in the Finnish society of the Prohibition era? Women s opinions are particularly interesting since they deviated radically from what has generally been assumed. It was expected that the referendum of 1931 would result in a resounding vote of 100% in favour of Prohibition, but the outcome was a majority vote against it. Over 65% of the women who cast their vote in the referendum wanted a full repeal of Prohibition. The study approaches the history of Prohibition by combining methods and theories of the history of mentalities and social history with gender history. Women are examined as a heterogeneous group with dissimilar objectives and differing ways of acting and thinking. The research material consists of press materials, archival materials from organisations, personal materials and statistics from the Prohibition period. Both discourses and practices are examined; the object of the research is best described by Michel Foucault's concept of dispositif. When participating in the public debate on Prohibition, women based their right to express their opinions and take part in action on an ideological continuum spanning a hundred years, according to which home and family were central areas of women s interest. This idea was linked to questions of morality and social policy. On the other hand, women presented themselves as working taxpayers, voters and equal citizens. The most crucial issue in women's discussions was whether Prohibition improved or worsened the temperance of fathers, husbands and sons. The dichotomies town dweller - countryside dweller, Swedish-speaking Finnish-speaking, and middle class - working class were highly significant backgrounds both as factors dividing women and in public discussions regarding Prohibition. The 1931 referendum showed that the lines of demarcation drawn during the preceding debate did not materialise in political action in line with these dichotomies: the dispositif did not correspond to the discourse. Contrary to what was expressed in public, a great number of women among the labour and rural classes, among inland inhabitants and among Finnish-speakers were also against Prohibition. The media and organisations defended temperance and Prohibition almost until the end of the Prohibition era. This discourse was in conflict with the discourse of everyday conversations and practices in which alcohol was present.

Seasonal and short-term variation in denitrification and anammox at a coastal station on the Gulf of Finland, Baltic Sea

Benthic processes were measured at a coastal deposition area in the northern Baltic Sea, covering all seasons. The N-2 production rates, 90-400 mu mol N m(-2) d(-1), were highest in autumn-early winter and lowest in spring. Heterotrophic bacterial production peaked unexpectedly late in the year, indicating that in addition to the temperature, the availability of carbon compounds suitable for the heterotrophic bacteria also plays a major role in regulating the denitrification rate. Anaerobic ammonium oxidation (anammox) was measured in spring and autumn and contributed 10% and 15%, respectively, to the total N-2 production. The low percentage did, however, result in a significant error in the total N-2 production rate estimate, calculated using the isotope pairing technique. Anammox must be taken into account in the Gulf of Finland in future sediment nitrogen cycling research.