Pain in juvenile idiopathic arthritis : parents and children as agents of disease management

Juvenile idiopathic arthritis (JIA) is a severe childhood disease usually characterized by long-term morbidity, unpredictable course, pain, and limitations in daily activities and social participation. The disease affects not only the child but also the whole family. The family is expected to adhere to an often very laborious regimen over a long period of time. However, the parental role is incoherently conceptualized in the research field. Pain in JIA is of somatic origin, but psychosocial factors, such as mood and self-efficacy, are critical in the perception of pain and in its impact on functioning. This study examined the factors correlating and possibly explaining pain in JIA, with a special emphasis on the mutual relations between parent- and patient-driven variables. In this patient series pain was not associated with the disease activity. The degree of pain was on average fairly low in children with JIA. When the children were clustered according to age, anxiety and depression, four distinguishable cluster groups significantly associated with pain emerged. One of the groups was described by concept vulnerability because of unfavorable variable associations. Parental depressive and anxiety symptoms accompanied by illness management had a predictive power in discriminating groups of children with varying distress levels. The parent’s and child’s perception of a child’s functional capability, distress, and somatic self-efficacy had independent explanatory power predicting the child’s pain. Of special interest in the current study was self-efficacy, which refers to the belief of an individual that he/she has the ability to engage in the behavior required for tackling the disease. In children with JIA, strong self-efficacy was related to lower levels of pain, depressive symptoms and trait anxiety. This suggests strengthening a child’s sense of self-efficacy, when helping the child to cope with his or her disease. Pain experienced by a child with JIA needs to be viewed in a multidimensional bio-psycho-social context that covers biological, environmental and cognitive behavioral mechanisms. The relations between the parent-child variables are complex and affect pain both directly and indirectly. Developing pain-treatment modalities that recognize the family as a system is also warranted.

Effect of waiting time on health outcomes and service utilization : A prospective randomized study on patients admitted to hospital for hip or knee replacement

Although the principle of equal access to medically justified treatment has been promoted by official health policies in many Western health care systems, practices do not completely meet policy targets. Waiting times for elective surgery vary between patient groups and regions, and growing problems in the availability of services threaten equal access to treatment. Waiting times have come to the attention of decision-makers, and several policy initiatives have been introduced to ensure the availability of care within a reasonable time. In Finland, for example, the treatment guarantee came into force in 2005. However, no consensus exists on optimal waiting time for different patient groups. The purpose of this multi-centre randomized controlled trial was to analyse health-related quality of life, pain and physical function in total hip or knee replacement patients during the waiting time and to evaluate whether the waiting time is associated with patients health outcomes at admission. This study also assessed whether the length of waiting time is associated with social and health services utilization in patients awaiting total hip or knee replacement. In addition, patients health-related quality of life was compared with that of the general population. Consecutive patients with a need for a primary total hip or knee replacement due to osteoarthritis were placed on the waiting list between August 2002 and November 2003. Patients were randomly assigned to a short waiting time (maximum 3 months) or a non-fixed waiting time (waiting time not fixed in advance, instead the patient followed the hospitals routine practice). Patients health-related quality of life was measured upon being placed on the waiting list and again at hospital admission using the generic 15D instrument. Pain and physical function were evaluated using the self-report Harris Hip Score for hip patients and a scale modified from the Knee Society Clinical Rating System for knee patients. Utilization measures were the use of home health care, rehabilitation and social services, physician visits and inpatient care. Health and social services use was low in both waiting time groups. The most common services used while waiting were rehabilitation services and informal care, including unpaid care provided by relatives, neighbours and volunteers. Although patients suffered from clear restrictions in usual activities and physical functioning, they seemed primarily to lean on informal care and personal networks instead of professional care. While longer waiting time did not result in poorer health-related quality of life at admission and use of services during the waiting time was similar to that at the time of placement on the list, there is likely to be higher costs of waiting by people who wait longer simply because they are using services for a longer period. In economic terms, this would represent a negative impact of waiting. Only a few reports have been published of the health-related quality of life of patients awaiting total hip or knee replacement. These findings demonstrate that, in addition to physical dimensions of health, patients suffered from restrictions in psychological well-being such as depression, distress and reduced vitality. This raises the question of how to support patients who suffer from psychological distress during the waiting time and how to develop strategies to improve patients initiatives to reduce symptoms and the burden of waiting. Key words: waiting time, total hip replacement, total knee replacement, health-related quality of life, randomized controlled trial, outcome assessment, social service, utilization of health services

Konsumerismi, potilaiden ja kuluttajien aktiivinen toiminta sekä erityisesti lääkäreiden kokemukset ja näkemykset potilaista kuluttajina

Consumerism emphasises the patient s position and freedom of choice. Consumerism is being promoted by a range of phenomena occurring in society and health care. Different actors hold different views on the patient as a consumer and on his or her participation. Consumer demand is created outside the patient physician relationship and the commercialisation of services generates new expectations with respect to physician s work. More and more patients may be interested in adopting a more equal position in the care relationship, and trying to negotiate with the physician or to even dictate how he or she should be cared for. In Finland, very little research has been conducted on patients and consumers organising themselves at national system level, patients as choosers, and physicians attitudes to various consumerist phenomena or the choice made by the patient. In the empirical data for this study, the term consumer-patient refers to active consumers and patients making choices related to their clinical care prior to a physician s diagnosis. Consumer-patients are also represented by consumer and patient organisations and movements. The main research question is: How do physicians regard the care choice made by the patient? This question is addressed from a perspective encompassing patients and consumers organised activities and individuals active behaviour in health care as well as physicians experiences and their views on patients as consumers making choices related to their care. The first part (Study I), examines the patient organisation field, information sources used including the websites of such organisations, files from Finland s Slot Machine Association, RAY, a survey conducted by a Finnish television news department and interviews of patient organisations. Based on observation and a physician survey, Study II examines physicians attitudes to the idea that patients could obtain information through consumer movements about physicians care practices before seeking medical care. Studies III−IV use a physician survey to examine physicians attitudes to direct-to-consumer-advertising of prescription drugs (DTCA) and their experiences and views of patient requests related to treatments and examinations. Study V uses comparative surveys to examine the attitudes of health care professionals and the population to the introduction of new technologies in health care, using genetic screenings and tests as an example. The number of patient organisations increased, with a particular escalation as of the 1990s. The characteristics and operating methods of the organisations varied greatly. Physicians organisations adopted a negative or neutral attitude towards the consumer movements idea of distributing information on care practices, whereas individual physicians attitudes were slightly more positive. Physicians regarded direct-to-consumer-advertising of prescription drugs as negative, but took a more permissive attitude towards indirect advertising. More than every third physician considered drug advertisements in general to be harmful or useless in the distribution of drug information to patients or consumers. More than half of physicians conducting patient work reported that they (very) often encountered patients who stated upon arrival for a consultation that they wanted specific treatments or examinations, and that the number of such situations had increased. Such situations were viewed as positive with regard to the care relationship by every fifth physician and as negative by two fifths. Physicians justified a reserved attitude to the patients consumer role by referring to their medical expertise and position as care decision-makers, the patient physician relationship and the public health care system. Reasons for a positive attitude included the patient s participation and co-operation, the patient physician relationship and the patient s knowledge. Professionals were more reserved than lay people about the introduction and extension of genetic technologies in health care. A significant minority of the physicians did not take a clear pro or con attitude to the patients consumer role or to the use of new technologies in health care. The physicians age, gender, place of work and specialisation influenced their attitudes to the patient s consumer role, and private physicians viewed it in a more positive light than those working in public health care. Active consumer-patients challenge the society to hold a discussion of the patient s choice, participation in care decision-making and participation in health care policy in general. Their transformation into customers and consumers implies not only a new division of individuals roles and powers, but also contributes to changing relationships between system level roles: between citizens and the state and between public and private health care. This phenomenon raises various issues related to health care policy. In conclusion, topics are presented for discussion, practical measures and further research. Keywords: health care, consumerism, distribution of technologies, commercialisation, physicians, patients, consumers, patient s choice, patient s role.

"Towards 'a real reunion'?" : Archbishop Aleksi Lehtonen's efforts for closer relations with the Church of England 1945–1951

Mika KT Pajusen väitös "Towards 'a real reunion'?" – Archbishop Aleksi Lehtonen's efforts for closer relations with the Church of England 1945–1951 on yleiseen kirkkohistoriaan lukeutuva tutkimus Englannin kirkon ja Suomen evankelis-luterilaisen kirkon välisistä suhteista Aleksi Lehtosen arkkipiispakaudella 1945–1951. Suhteita on tutkittu kolmesta näkökulmasta: ekumeenisesta, poliittisesta ja kirkkopoliittisesta. Tutkimuskausi alkaa pastori H.M. Waddamsin joulukuussa 1944 Suomeen tekemän vierailun jälkimainingeista ja päättyy arkkipiispa Lehtosen kuolemaan pääsiäisenä 1951. Kirkollisten suhteiden kehitystä rytmittivät lukuisat vierailut, jotka osoittivat Englannin kirkon asenteen muuttumisen sodan aikaisesta neuvostomyönteisyydestä kylmän sodan aikaiseen täysin vastakkaiseen kantaan. Englantilaiset vieraat kohtasivat Suomessa sekä kirkon että yhteiskunnan ylimmän johdon. Molemmat maat olivat valmiita tukemaan hyviä kirkollisia suhteita tilanteen niin salliessa, joskaan eivät kovin suunnitelmallisesti. Suomen evankelis-luterilainen kirkko käytti hyviä suhteita Englannin kirkkoon saadakseen tukea ja ymmärrystä omalle kirkolleen ja yhteiskunnalleen kokemaansa Neuvostoliiton uhkaa vastaan erityisesti vaaran vuosina 1944–1948. Englannin kirkko halusi tukea suomalaista sisarkirkkoaan, mutta varoi, ettei tuottaisi tuellaan enemmän haittaa kuin hyötyä suhteessa Neuvostoliittoon. Sodan jälkeinen ekumeeninen jälleenrakentaminen lähensi kirkkoja toisiinsa. Lehtonen pyrki jatkamaan 1930-luvun kirkkojen välisiä, ehtoollisvieraanvaraisuuden saavuttaneita neuvotteluita kohti täyttä kirkollista yhteyttä. Häntä motivoi sekä evankelis-katolinen teologia että pyrkimys tukea oman maan ja kirkon läntisiä yhteyksiä. Tämä haastoi Englannin kirkon ekumeenisen linjan, joka Suomen kirkon sijasta pyrki jatkamaan neuvotteluja Tanskan, Norjan ja Islannin luterilaisten kirkkojen kanssa, joilla ei vielä ollut virallista ekumeenista sopimusta Englannin kirkon kanssa. Lehtosen pyrkimyksistä huolimatta Englannin kirkko päätyi jättämään Suomen tilanteen hautumaan. Sillä se tarkoitti suhteiden koetinkivenä olleen historiallisen piispuuden leviämistä läpi Suomen kirkon ennen kuin katsoi olevansa valmis jatkamaan kohti täyttä kirkollista yhteyttä. Molemmissa kirkoissa vaikutti pieni, innokkaiden, lähempiä suhteita toivoneiden kirkollisten vaikuttajien ydinjoukko. Englantilaisia Suomen-ystäviä motivoi tarve auttaa Suomea hankalassa poliittisessa tilanteessa. Suomessa arkkipiispa Lehtonen tuki korkeakirkollista liturgista liikettä, jolla oli läheinen yhteys anglikaanisuuteen, mutta joka sai vastaansa vanhoilliset pietistit. Suomen kirkon yleinen mielipide asettui etupäässä pietistiselle kannalle, jolle anglikaanisuus näyttäytyi teologisesti sekä liian katolisena että liian reformoituna. Kirkolliset suhteet tasaantuivat vuoden 1948 Lambeth-konferenssin jälkeen, joka rohkaisi anglikaanisia kirkkoja hyväksymään 1930-luvun neuvottelujen lähempiin kirkollisiin suhteisiin tähtäävät suositukset. Lehtonen näytti tyytyvän tähän. Samaan aikaan lähempää kirkollista kanssakäymistä tukenut ekumeeninen jälleenrakennus tuli tiensä päähän. Lehtonen jatkoi läheisempien suhteiden edistämistä, mutta hänen intonsa hiipui yhdessä heikkenevän terveydentilan kanssa. Osoituksena Lehtosen linjan kapeudesta Suomen evankelis-luterilaisen kirkon piispoista ei löytynyt hänen kuoltuaan ketään, joka olisi jatkanut hänen aktiivista anglikaanimyönteistä linjaansa.

Elite Bargaining and the Evolution of Centre-Periphery Relations in Post-Soviet Russia : A Comparative Analysis

This work is concerned with presenting a modified theoretical approach to the study of centre-periphery relations in the Russian Federation. In the widely accepted scientific discourse, the Russian federal system under the Yeltsin Administration (1991-2000) was asymmetrical; largely owing to the varying amount of structural autonomy distributed among the federation s 89 constituent units. While providing an improved understanding as to which political and socio-economic structures contributed to federal asymmetry, it is felt that associated large N-studies have underemphasised the role played by actor agency in re-shaping Russian federal institutions. It is the main task of this thesis to reintroduce /re-emphasise the importance of actor agency as a major contributing element of institutional change in the Russian federal system. By focusing on the strategic agency of regional elites simultaneously within regional and federal contexts, the thesis adopts the position that political, ethnic and socio-economic structural factors alone cannot fully determine the extent to which regional leaders were successful in their pursuit of economic and political pay-offs from the institutionally weakened federal centre. Furthermore, this work hypothesises that under conditions of federal institutional uncertainty, it is the ability of regional leaders to simultaneously interpret various mutable structural conditions then translate them into plausible strategies which accounts for the regions ability to extract variable amounts of economic and political pay-offs from the Russian federal system. The thesis finds that while the hypothesis is accurate in its theoretical assumptions, several key conclusions provide paths for further inquiry posed by the initial research question. First, without reliable information or stable institutions to guide their actions, both regional and federal elites were forced into ad-hoc decision-making in order to maintain their core strategic focus: political survival. Second, instead of attributing asymmetry to either actor agency or structural factors exclusively, the empirical data shows that both agency and structures interact symbiotically in the strategic formulation process, thus accounting for the sub-optimal nature of several of the actions taken in the adopted cases. Third, as actor agency and structural factors mutate over time, so, too do the perceived payoffs from elite competition. In the case of the Russian federal system, the stronger the federal centre became, the less likely it was that regional leaders could extract the high degree of economic and political pay-offs that they clamoured for earlier in the Yeltsin period. Finally, traditional approaches to the study of federal systems which focus on institutions as measures of federalism are not fully applicable in the Russian case precisely because the institutions themselves were a secondary point of contention between competing elites. Institutional equilibriums between the regions and Moscow were struck only when highly personalised elite preferences were satisfied. Therefore the Russian federal system is the product of short-term, institutional solutions suited to elite survival strategies developed under conditions of economic, political and social uncertainty.

Vertigo in children

Vertigo in children is more common than previously thought. However, only a small fraction of affected children meet a physician. The reason for this may be the benign course of vertigo in children. Most childhood vertigo is self-limiting, and the provoking factor can often be identified. The differential diagnostic process in children with vertigo is extensive and quite challenging even for otologists and child neurologists, who are the key persons involved in treating vertiginous children. The cause of vertigo can vary from orthostatic hypotension to a brain tumor, and thus, a structured approach is essential in avoiding unnecessary examinations and achieving a diagnosis. Common forms of vertigo in children are otitis media-related dizziness, benign paroxysmal vertigo of childhood, migraine-associated dizziness, and vestibular neuronitis. Orthostatic hypotension, which is not a true vertigo, is the predominant type of dizziness in children. Vertigo is often divided according to origin into peripheral and central types. An otologist is familiar with peripheral causes, while a neurologist treats central causes. Close cooperation between different specialists is essential. Sometimes consultation with a psy-chiatrist or an ophthalmologist can lead to the correct diagnosis. The purpose of this study was to evaluate the prevalence and clinical characteristics of vertigo in children. We prospectively collected general population-based data from three schools and one child wel-fare clinic located close to Helsinki University Central Hospital (HUCH). A simple questionnaire with mostly closed questions was given to 300 consecutive children visiting the welfare clinic. At the schools, entire classes that fit the desired age groups received the questionnaire. Of the 1050 children who received the questionnaire, 938 (473 girls, 465 boys) returned it, the response rate thus being 89% (I). In Study II, we evaluated the 24 vertiginous children (15 girls, 9 boys) with true vertigo and 12 healthy age- and gender-matched controls. A detailed medical history was obtained using a structured approach, and an otoneurologic examination, including audiogram, electronystagmography, and tympanometry, was performed at the HUCH ear, nose, and throat clinic for cooperative subjects. In Study III, we reviewed and evaluated the medical records of 119 children (63 girls, 56 boys) aged 0-17 years who had visited the ear, nose, and throat clinic with a primary complaint of vertigo in 2000-2004. We also wanted information about indications for imaging of the head in vertiginous children. To this end, we reviewed the medical records of 978 children who had undergone imaging of the head for various indications. Of these, 87 children aged 0-16 years were imaged because of vertigo. Subjects of interest were the 23 vertiginous children with an acute deviant finding in magnetic resonance images or com-puterized tomography (IV). Our results indicate that vertigo and other balance problems in children are quite common. Of the HUCH area population, 8% of the children had sometimes experienced vertigo, dizziness, or balance problems. Of these 23% had vertigo sufficiently severe to stop their activity (I). The structured data collection approach eased the evaluation of vertiginous children. More headaches and head traumas were observed in vertiginous children than in healthy controls (II). The most common diagnoses of ear, nose, and throat clinic patients within the five-year period were benign paroxysmal vertigo of child-hood, migraine-associated dizziness, vestibular neuronitis, and otitis media-related vertigo. Valuable diagnostic tools in the diagnostic process were patient history and otoneurologic examinations, includ-ing audiogram, electronystagmography, and tympanometry (III). If the vertiginous child had neurologi-cal deficits, persistent headache, or preceding head trauma, imaging of the head was indicated (IV).

Patient exposure monitoring and radiation qualities in two-dimensional digital x-ray imaging

The methods for estimating patient exposure in x-ray imaging are based on the measurement of radiation incident on the patient. In digital imaging, the useful dose range of the detector is large and excessive doses may remain undetected. Therefore, real-time monitoring of radiation exposure is important. According to international recommendations, the measurement uncertainty should be lower than 7% (confidence level 95%). The kerma-area product (KAP) is a measurement quantity used for monitoring patient exposure to radiation. A field KAP meter is typically attached to an x-ray device, and it is important to recognize the effect of this measurement geometry on the response of the meter. In a tandem calibration method, introduced in this study, a field KAP meter is used in its clinical position and calibration is performed with a reference KAP meter. This method provides a practical way to calibrate field KAP meters. However, the reference KAP meters require comprehensive calibration. In the calibration laboratory it is recommended to use standard radiation qualities. These qualities do not entirely correspond to the large range of clinical radiation qualities. In this work, the energy dependence of the response of different KAP meter types was examined. According to our findings, the recommended accuracy in KAP measurements is difficult to achieve with conventional KAP meters because of their strong energy dependence. The energy dependence of the response of a novel large KAP meter was found out to be much lower than with a conventional KAP meter. The accuracy of the tandem method can be improved by using this meter type as a reference meter. A KAP meter cannot be used to determine the radiation exposure of patients in mammography, in which part of the radiation beam is always aimed directly at the detector without attenuation produced by the tissue. This work assessed whether pixel values from this detector area could be used to monitor the radiation beam incident on the patient. The results were congruent with the tube output calculation, which is the method generally used for this purpose. The recommended accuracy can be achieved with the studied method. New optimization of radiation qualities and dose level is needed when other detector types are introduced. In this work, the optimal selections were examined with one direct digital detector type. For this device, the use of radiation qualities with higher energies was recommended and appropriate image quality was achieved by increasing the low dose level of the system.

Patient doses in ct, dental cone beam ct and projection radiography in Finland, with emphasis on paediatric patients

Diagnostic radiology represents the largest man-made contribution to population radiation doses in Europe. To be able to keep the diagnostic benefit versus radiation risk ratio as high as possible, it is important to understand the quantitative relationship between the patient radiation dose and the various factors which affect the dose, such as the scan parameters, scan mode, and patient size. Paediatric patients have a higher probability for late radiation effects, since longer life expectancy is combined with the higher radiation sensitivity of the developing organs. The experience with particular paediatric examinations may be very limited and paediatric acquisition protocols may not be optimised. The purpose of this thesis was to enhance and compare different dosimetric protocols, to promote the establishment of the paediatric diagnostic reference levels (DRLs), and to provide new data on patient doses for optimisation purposes in computed tomography (with new applications for dental imaging) and in paediatric radiography. Large variations in radiation exposure in paediatric skull, sinus, chest, pelvic and abdominal radiography examinations were discovered in patient dose surveys. There were variations between different hospitals and examination rooms, between different sized patients, and between imaging techniques; emphasising the need for harmonisation of the examination protocols. For computed tomography, a correction coefficient, which takes individual patient size into account in patient dosimetry, was created. The presented patient size correction method can be used for both adult and paediatric purposes. Dental cone beam CT scanners provided adequate image quality for dentomaxillofacial examinations while delivering considerably smaller effective doses to patient compared to the multi slice CT. However, large dose differences between cone beam CT scanners were not explained by differences in image quality, which indicated the lack of optimisation. For paediatric radiography, a graphical method was created for setting the diagnostic reference levels in chest examinations, and the DRLs were given as a function of patient projection thickness. Paediatric DRLs were also given for sinus radiography. The detailed information about the patient data, exposure parameters and procedures provided tools for reducing the patient doses in paediatric radiography. The mean tissue doses presented for paediatric radiography enabled future risk assessments to be done. The calculated effective doses can be used for comparing different diagnostic procedures, as well as for comparing the use of similar technologies and procedures in different hospitals and countries.