On linear order and computation : The expressiveness of interactive computations on linear orders and computations indexed by ordinals

We solve the Dynamic Ehrenfeucht-Fra\"iss\'e Game on linear orders for both players, yielding a normal form for quantifier-rank equivalence classes of linear orders in first-order logic, infinitary logic, and generalized-infinitary logics with linearly ordered clocks. We show that Scott Sentences can be manipulated quickly, classified into local information, and consistency can be decided effectively in the length of the Scott Sentence. We describe a finite set of linked automata moving continuously on a linear order. Running them on ordinals, we compute the ordinal truth predicate and compute truth in the constructible universe of set-theory. Among the corollaries are a study of semi-models as efficient database of both model-theoretic and formulaic information, and a new proof of the atomicity of the Boolean algebra of sentences consistent with the theory of linear order -- i.e., that the finitely axiomatized theories of linear order are dense.

Current Care Guidelines for Cardiopulmonary Resuscitation : Implementation, skills and attitudes

Background: The national resuscitation guidelines were published in Finland in 2002 and are based on international guidelines published in 2000. The main goal of the national guidelines, available on the Internet free of charge, is early defibrillation by nurses in an institutional setting. Aim: To study possible changes in cardiopulmonary resuscitation (CPR) practices, especially concerning early defibrillation, nurses and students attitudes of guideline implementation and nurses and students ability to implement the guideline recommendations in clinical practices after publication of the Current Care (CC) guidelines for CPR 2002. Material and methods: CPR practices in Finnish health centres; especially concerning rapid defibrillation programmes, as well as the implementation of CC guidelines for CPR was studied in a mail survey to chief physicians of every health centre in Finland (Study I). The CPR skills using an automated external defibrillator (AED) were compared in a study including Objective stuctured clinical examination (OSCE) of resuscitation skills of nurses and nursing students in Finnish and Swedish hospital and institution (Studies II, III). Attitudes towards CPR-D and CPR guidelines among medical and nursing students and secondary hospital nurses were studied in surveys (Studies IV, V). The nurses receiving different CPR training were compared in a randomized trial including OSCE of CPR skills of nurses in Finnish Hospital (Study VI). Results: Two years after the publication, 40.7% of Finnish health centres used national resuscitation guidelines. The proportion of health centres having at least one AED (66%) and principle of nurse-performed defibrillation without the presence of a physician (42%) had increased. The CPR-D training was estimated to be insufficient regarding basic life support and advanced life support in the majority of health centres (Study I). CPR-D skills of nurses and nursing students in two specific Swedish and Finnish hospitals and institutions (Study II and III) were generally inadequate. The nurses performed better than the students and the Swedish nurses surpassed the Finnish ones. Geriatric nurses receiving traditional CPR-D training performed better than those receiving an Internet-based course but both groups failed to defibrillate within 60 s. Thus, the performance was not satisfactory even two weeks after traditional training (Study VI). Unlike the medical students, the nursing students did not feel competent to perform procedures recommended in the cardiopulmonary resuscitation guidelines including the defibrillation. However, the majority of nursing students felt confident about their ability to perform basic life support. The perceived ability to defibrillate correlated significantly with a positive attitude towards nurse-performed defibrillation and negatively with fear of damaging the patient s heart by defibrillation (Study IV). After the educational intervention, the nurses found their level of CPR-D capability more sufficient than before and felt more confident about their ability to perform defibrillation themselves. A negative attitude toward defibrillation correlated with perceived negative organisational attitudes toward cardiopulmonary resuscitation guidelines. After CPR-D education in the hospital, the majority (64%) of nurses hesitated to perform defibrillation because of anxiety and 27 % hesitated because of fear of injuring the patient. Also a negative personal attitude towards guidelines increased markedly after education (Study V). Conclusions: Although a significant change had occurred in resuscitation practices in primary health care after publication of national cardiopulmonary resuscitation guidelines the participants CPR-D skills were not adequate according to the CPR guidelines. The current way of teaching is unlikely to result in participants being able to perform adequate and rapid CPR-D. More information and more frequent training are needed to diminish anxiety concerning defibrillation. Negative beliefs and attitudes toward defibrillation affect the nursing students and nurses attitudes toward cardiopulmonary resuscitation guidelines. CPR-D education increased the participants self-confidence concerning CPR-D skills but it did not reduce their anxiety. AEDs have replaced the manual defibrillators in most institutions, but in spite of the modern devices the anxiety still exists. Basic education does not provide nursing students with adequate CPR-D skills. Thus, frequent training in the workplace has vital importance. This multi-professional program supported by the administration might provide better CPR-D skills. Distance learning alone cannot substitute for traditional small-group learning, tutored hands-on training is needed to learn practical CPR-D skills. Standardized testing would probably help controlling the quality of learning. Training of group-working skills might improve CPR performance.

Gustaf III inför sina undersåtar : Konsten att härska och politikens kulturhistoria

The dissertation analyses the political culture of Sweden during the reign of King Gustav III (1771-1792). This period commonly referred to as the Gustavian era followed the so-called Age of Liberty ending half a century of strong parliamentary rule in Sweden. The question at the heart of this study engages with the practice of monarchical rule under Gustav III, its ideological origins and power-political objectives as well as its symbolic expression. The study thereby addresses the very nature of kingship. In concrete terms, why did Gustav III, his court, and his civil service vigorously pursue projects that contemporaneous political opponents and, in particular, subsequent historiography have variously pictured as irrelevant, superficial, or as products of pure vanity? The answer, the study argues, is to be found in patterns of political practice as developed and exercised by Gustav III and his administration, which formed a significant part of the political culture of Gustavian Sweden. The dissertation is divided into three parts. The first traces the use and development of royal graces chivalric orders, medals, titles, privileges, and other gifts issued by the king. The practice of royal reward is illustrated through two case studies: the 1772 coup d état that established Gustav III s rule, and the birth and baptism of the crown prince, Gustav Adolf, in 1778. The second part deals with the establishment of the Court of Appeal in Vasa in 1776. The formation of the Appeals Court was accompanied by a host of ceremonial, rhetorical, emblematic, and architectural features solidifying its importance as one of Gustav III s most symbolic administrative reform projects and hence portraying the king as an enlightened monarch par excellence. The third and final part of the thesis engages with war as a cultural phenomenon and focuses on the Russo-Swedish War of 1788-1790. In this study, the war against Russia is primarily seen as an arena for the king and other players to stage, create and re-create as well as articulate themselves through scenes and roles adhering to a particular cultural idiom. Its codes and symbolic forms, then, were communicated by means of theatre, literature, art, history, and classical mythology. The dissertation makes use of a host of sources: protocols, speeches, letters, diaries, newspapers, poetry, art, medals, architecture, inscriptions and registers. Traditional political source material and literary and art sources are studied as totalities, not as separate entities. Also it is argued that political and non-fictional sources cannot be understood properly without acknowledging the context of genre, literary conventions, and artistic modes. The study critically views the futile, but nonetheless almost habitual juxtaposition of the reality of images, ideas, and metaphors, and the reality of supposedly factual historical events. Significantly, the thesis presumes the symbolic dimension to be a constitutive element of reality, not its cooked up misrepresentation. This presumption is reflected in a discussion of the concept of role , which should not be anachronistically understood as roles in which the king cast himself at different times and in different situations. Neither Gustav III nor other European sovereigns of this period played the roles as rulers or majesties. Rather, they were monarchs both in their own eyes and in the eyes of their contemporaries as well as in all relations and contexts. Key words: Eighteenth-Century, Gustav III, Cultural History, Monarchs, Royal Graces, the Vasa Court of Appeal, the Russo-Swedish War 1788–1790.

Musiikki ahdistuksen taitona : Filosofinen tutkimus musiikin eksistentiaalis-ontologisesta merkityksestä

Music as the Art of Anxiety: A Philosophical Approach to the Existential-Ontological Meaning of Music. The present research studies music as an art of anxiety from the points of view of both Martin Heidegger s thought and phenomenological philosophy in general. In the Heideggerian perspective, anxiety is understood as a fundamental mode of being (Grundbefindlichkeit) in human existence. Taken as an existential-ontological concept, anxiety is conceived philosophically and not psychologically. The central research questions are: what is the relationship between music and existential-ontological anxiety? In what way can music be considered as an art of anxiety? In thinking of music as a channel and manifestation of anxiety, what makes it a special case? What are the possible applications of phenomenology and Heideggerian thought in musicology? The main aim of the research is to develop a theory of music as an art of existential-ontological anxiety and to apply this theory to musicologically relevant phenomena. Furthermore, the research will contribute to contemporary musicological debates and research as it aims to outline the phenomenological study of music as a field of its own; the development of a specific methodology is implicit in these aims. The main subject of the study, a theory of music as an art of anxiety, integrates Heideggerian and phenomenological philosophies with critical and cultural theories concerning violence, social sacrifice, and mimetic desire (René Girard), music, noise and society (Jacques Attali), and the affect-based charme of music (Vladimir Jankélévitch). Thus, in addition to the subjective mood (Stimmung) of emptiness and meaninglessness, the philosophical concept of anxiety also refers to a state of disorder and chaos in general; for instance, to noise in the realm of sound and total (social) violence at the level of society. In this study, music is approached as conveying the existentially crucial human compulsion for signifying i.e., organizing chaos. In music, this happens primarily at the immediate level of experience, i.e. in affectivity, and also in relation to all of the aforementioned dimensions (sound, society, consciousness, and so on). Thus, music s existential-ontological meaning in human existence, Dasein, is in its ability to reveal different orders of existence as such. Indeed, this makes music the art of anxiety: more precisely, music can be existentially significant at the level of moods. The study proceeds from outlining the relevance of phenomenology and Heidegger s philosophy in musicology to the philosophical development of a theory of music as the art of anxiety. The theory is developed further through the study of three selected specific musical phenomena: the concept of a musical work, guitar smashing in the performance tradition of rock music, and Erik Bergman s orchestral work Colori ed improvvisazioni. The first example illustrates the level of individual human-subject in music as the art of anxiety, as a means of signifying chaos, while the second example focuses on the collective need to socio-culturally channel violence. The third example, being music-analytical, studies contemporary music s ability to mirror the structures of anxiety at the level of a specific musical text. The selected examples illustrate that, in addition to the philosophical orientation, the research also contributes to music analysis, popular music studies, and the cultural-critical study of music. Key words: music, anxiety, phenomenology, Martin Heidegger, ontology, guitar smashing, Erik Bergman, musical work, affectivity, Stimmung, René Girard

Sopimusohjaus ohjausmenettelynä sairaanhoitopiirin ja terveyskeskusten yksiköissä ja niiden lääkärien työssä

This study concerns the implementation of steering by contracting in health care units and in the work of the doctors employed by them. The study analyses how contracting as a process is being implemented in hospital district units, health centres and in the work of their doctors, as well as how these units carry out their operations and patient care within the restrictions set by the contracts. Based on interviews with doctors, the study analyses the realisation of operations within the units from the doctors perspective and through their work. The key result of the study is that the steering impact of contracting was not felt at the level of practical work. The contracting was implemented by assigning the related tasks to management only. The management implemented the contract by managing their resources rather than by intervening in doctors activities or the content of their tasks. The steering did not extend to improving practical care processes. This allowed the unchanged continuation of core operations in an autonomous manner and in part, protected from the impacts of contracting. In health centres, the contract concluded was viewed as merely steering the operations of the hospital district and its implementation did not receive the support of the centres. The fact that primary health care and specialised health care constitute separate contracting parties had adverse effects on the contract s implementation and the integration of care. A theoretical review unveiled several reasons for the failure of steering by contracting to alter operations within units. These included the perception steering by contracting as a weak change incentive. The doctors shunned the introduction of an economic logic and ideology into health care and viewed steering by contracting as a hindrance to delivering care to patients and a disturbance to their work and patient relationships. Contracting caused tensions between representatives of the financial administration and health care professionals. It also caused internal tensions, while it had varying impacts on different specialities, including the introduction of varying potential to influence contracts. Most factors preventing the realisation of the steering objective could have been ameliorated through positive leadership. There is a need to bridge the gap between financial steering and patient work. Key measures include encouraging the commitment of middle management, supporting leadership expertise and identifying the right methods of contributing to a mutual understanding between the cultures of financing, administration and health care. Criticism of the purchasers expertise and the view that undersized orders are due to the purchaser s financial difficulties underlines the importance of the purchaser s size. Overly detailed, product-based contracts seemed to place the focus on the quantities and costs of services rather than health impacts and efficiency of operations. Bundling contracts into larger service packages would encourage the enhancement of operations. Steering by contracting represents unexploited potential: it could function as a forum for integrated regional planning of services, and the prioritisation and integration of care, and offer an opportunity and an incentive for developing core operations.

Type 1 and type 2 diabetes among young adults in Finland : Incidence and perinatal exposures

This study aimed to examine the incidence of young adult-onset T1DM and T2DM among Finns, and to explore the possible risk factors for young adult-onset T1DM and T2DM that occur during the perinatal period and childhood. In the studies I-II, the incidence of diabetes was examined among 15-39-year-old Finns during the years 1992-2001. Information on the new diagnoses of diabetes was collected from four sources: standardized national reports filled in by diabetes nurses, the Hospital Discharge Register, the Drug Reimbursement Register, and the Drug Prescription Register. The type of diabetes was assigned using information obtained from these four data sources. The incidence of T1DM was 18 per 100,000/year, and there was a clear male predominance in the incidence of T1DM. The incidence of T1DM increased on average 3.9% per year during 1992-2001. The incidence of T2DM was 13 per 100,000/year, and it displayed an increase of 4.3% per year. In the studies III-V, the effects of perinatal exposures and childhood growth on the risk for young adult-onset T1DM and T2DM were explored in a case-control setting. Individuals diagnosed with T1DM (n=1,388) and T2DM (n=1,121) during the period 1992-1996 were chosen as the diabetes cases for the study, and two controls were chosen for each case from the National Population Register. Data on the study subjects parents and siblings was obtained from the National Population Register. The study subjects original birth records and child welfare clinic records were traced nationwide. The risk for young adult-onset T2DM was the lowest among the offspring of mothers aged about 30 years, whereas the risk for T2DM increased towards younger and older maternal ages. Birth orders second to fourth were found protective of T2DM. In addition, the risk for T2DM was observed to decrease with increasing birth weight until 4.2 kg, after which the risk began to increase. A high body mass index (BMI) at the BMI rebound between ages 3-11 years substantially increased the risk for T2DM, and the excess weight gain in individuals diagnosed with T2DM began in early childhood. Maternal age, birth order, or body size at birth had no effect on the risk for young adult-onset T1DM. Instead, individuals with T1DM were observed to have a higher maximum BMI before the age of 3 than their control subjects. In conclusion, the increasing trend in the development of both T1DM and T2DM among young Finnish adults is alarming. The high risk for T1DM among the Finnish population extends to at least 40 years of age, and at least 200-300 young Finnish adults are diagnosed with T2DM every year. Growth during the fetal period and childhood notably affects the risk for T2DM. T2DM prevention should also target childhood obesity. Rapid growth during the first years of life may be a risk factor for late-onset T1DM.

Landscape-scale soil erosion modelling and ecological restoration for a mountainous watershed in Sichuan, China

Sichuanissa Tiibetin ylängön metsäkato on pysähtynyt mutta eroosio-ongelmat jatkuvat Viikin tropiikki-instituutin tutkija Ping ZHOU kartoitti trooppisen metsänhoidon alaan kuuluvassa väitöskirjatyössään maaperän eroosioalttiutta ja sen riippuvuutta metsäkasvillisuudesta Jangtsen tärkeää sivuhaaraa Min-jokea ympäröivällä n. 7400 neliökilometrin suuruisella valuma-alueella Sichuanin Aba-piirikunnassa. Aineistonaan hän käytti muun muassa satelliittikartoitustietoja ja mittaustuloksia yli 600 maastokoealalta. Tutkimuksen nimi suomeksi on "Maaperän eroosion mallinnus ja vuoristoisen valuma-alueen ekologinen ennallistaminen Sichuanissa Kiinassa". Aikaisempien tutkimusten perusteella oli tiedossa että metsien häviäminen tällä alueella pysähtyi jo 1980-luvun alussa. Sen jälkeen on metsien pinta-ala hitaasti kasvanut etupäässä sen vuoksi, että teollinen puunhakkuu luonnonmetsissä kiellettiin kokonaan v. 1998 ja 25 astetta jyrkemmillä rinteillä myös maatalouden harjoittaminen on saatu lopetetuksi viljelijöille tarjottujen taloudellisten houkuttimien avulla. Täten myös pelto- ja laidunmaata on voitu ennallistaa metsäksi. Ping Zhou pystyi jakamaan 5700 metrin korkeuteen saakka kohoavan vuoristoalueen eroosioalttiudeltaan erilaisiin vyöhykkeisiin rinteen kaltevuuden, sademäärän, kasvipeitteen ja maalajin perusteella. Noin 15 prosentilla tutkitun valuma-alueen pinta-alasta, lähinnä Min-joen pääuomaa ympäröivillä jyrkillä rinteillä, eroosioriski oli suuri tai erittäin suuri. Eri tyyppisellä kasvillisuudella oli hyvin erilainen vaikutus eroosioalttiuteen, ja myös alueen sijainti vuoriston eri korkeuksilla vaikutti eroosioon. Säästyneet lähes luonnontilaiset havumetsät, joita on etupäässä vuoriston ylimmissä osissa 2600-4000 metrin korkeudella, edistävät tehokkaasti metsän luontaista uudistumista ja levittäytymistä vaurioituneille alueille. Säilyneiden metsien puulajikoostumus antoi tutkimuksessa mahdollisuuden ennustaa metsien tulevaa kehitystä koko tutkitulla valuma-alueella sen eri korkeusvyöhykkeissä ja eri maaperätyypeillä. Ennallistamisen kannalta ongelmallisimpia olivat alueet joilta metsäpeite oli lähinnä puiden teollisen hakkuun vuoksi kokonaan hävinnyt ja joilla maaperä yleisesti oli eroosion pahoin kuluttama. Näillä alueilla ei ole tehty juuri mitään uudistamis- tai ennallistamistoimenpiteitä. Niillä metsien ennallistaminen vaatii myös puiden tai pensaiden istuttamista. Tähän sopivia ovat erityisesti ilmakehän typpeä sitovat lajit, joista alueella kasvaa luontaisena mm. sama tyrnilaji joka esiintyy myös Suomessa. Työssä tutkittiin yli kahdeksankymmenen paikallisen luontaisen puulajin (joista peräti noin kolmannes on havupuulajeja) ekologisia ominaisuuksia ja soveltuvuutta metsien ennallistamiseen. Avainasemassa työn onnistumisen kannalta ovat nyt paikalliset asukkaat, joiden maankäytön muutokset ovat jo selvästi edistänet luonnonmetsän ennalleen palautumista. Suomen Akatemia rahoitti vuosina 2004-2006 VITRI:n tutkimushanketta, josta Ping Zhou'n väitöskirjatyö muodosti keskeisen osan. Kenttätyö Sichuanissa avasi mahdollisuuden hedelmälliseen monitieteiseen yhteistyöhön ja tutkijavaihtoon Kiinan tiedeakatemian alaisen Chengdun biologiainstituutin (CIB) kanssa; tämä tieteellinen kanssakäyminen jatkuu edelleen.

From Francovich to Köbler and beyond : The evolution of a State liability regime for the EC

The aim of this paper is to present the evolution of the Francovich doctrine within the European legal order. The first part deals with the gradual development of the ECJ's case law on State liability in damages for breach of EC law. Starting from the seminal Francovich and Brasserie du Pêcheur, the clarification of the criteria set by the Court is attempted with reference to subsequent case law, whereas issues concerning the extent and form of the compensation owned are also mentioned. The second part concerns one of the more recent developments in the field, namely State liability for breaches of Community law attributed to national judiciary. The Court's ruling in Köbler is examined in connection with two other recent judgments, namely Commission v. Italy of 2003 and Kühne & Heitz, as an attempt of the ECJ to reframe its relationships with national supreme courts and appropriate for itself the position of the Supreme Court in the European legal order. The implications on State liability claims by the ruling in Commission v. France of 1997 constitute the theme of the third part, where it is submitted that Member States can also be held liable for disregard of Community law by private individuals within their respected territories. To this extent, Schmidberger is viewed as a manifestation of this opinion, with fundamental rights acquiring a new dimension, being invoked by the States, contra the individuals as a shield to liability claims. Finally, the third part examines the relationship between the Francovich doctrine and the principle of legal certainty and concludes that the solutions employed by the ECJ have been both predictable and acceptable by the national legal orders. Keywords: State liability, damages, Francovich, Köbler, Schmidberger

Nitrous oxide emissions from selected natural and managed northern ecosystems

Microbial activity in soils is the main source of nitrous oxide (N2O) to the atmosphere. Nitrous oxide is a strong greenhouse gas in the troposphere and participates in ozone destructive reactions in the stratosphere. The constant increase in the atmospheric concentration, as well as uncertainties in the known sources and sinks of N2O underline the need to better understand the processes and pathways of N2O in terrestrial ecosystems. This study aimed at quantifying N2O emissions from soils in northern Europe and at investigating the processes and pathways of N2O from agricultural and forest ecosystems. Emissions were measured in forest ecosystems, agricultural soils and a landfill, using the soil gradient, chamber and eddy covariance methods. Processes responsible for N2O production, and the pathways of N2O from the soil to the atmosphere, were studied in the laboratory and in the field. These ecosystems were chosen for their potential importance to the national and global budget of N2O. Laboratory experiments with boreal agricultural soils revealed that N2O production increases drastically with soil moisture content, and that the contribution of the nitrification and denitrification processes to N2O emissions depends on soil type. Laboratory study with beech (Fagus sylvatica) seedlings demonstrated that trees can serve as conduits for N2O from the soil to the atmosphere. If this mechanism is important in forest ecosystems, the current emission estimates from forest soils may underestimate the total N2O emissions from forest ecosystems. Further field and laboratory studies are needed to evaluate the importance of this mechanism in forest ecosystems. The emissions of N2O from northern forest ecosystems and a municipal landfill were highly variable in time and space. The emissions of N2O from boreal upland forest soil were among the smallest reported in the world. Despite the low emission rates, the soil gradient method revealed a clear seasonal variation in N2O production. The organic topsoil was responsible for most of the N2O production and consumption in this forest soil. Emissions from the municipal landfill were one to two orders of magnitude higher than those from agricultural soils, which are the most important source of N2O to the atmosphere. Due to their small areal coverage, landfills only contribute minimally to national N2O emissions in Finland. The eddy covariance technique was demonstrated to be useful for measuring ecosystem-scale emissions of N2O in forest and landfill ecosystems. Overall, more measurements and integration between different measurement techniques are needed to capture the large variability in N2O emissions from natural and managed northern ecosystems.

Proton translocation coupled to electron transfer reactions in terminal oxidases

Terminal oxidases are the final proteins of the respiratory chain in eukaryotes and some bacteria. They catalyze most of the biological oxygen consumption on Earth done by aerobic organisms. During the catalytic reaction terminal oxidases reduce dioxygen to water and use the energy released in this process to maintain the electrochemical proton gradient by functioning as a redox-driven proton pump. This membrane gradient of protons is extremely important for cells as it is used for many cellular processes, such as transportation of substrates and ATP synthesis. Even though the structures of several terminal oxidases are known, they are not sufficient in themselves to explain the molecular mechanism of proton pumping. In this work we have applied a complex approach using a variety of different techniques to address the properties and the mechanism of proton translocation by the terminal oxidases. The combination of direct measurements of pH changes during catalytic turnover, time-resolved potentiometric electrometry and optical spectroscopy, made it possible to obtain valuable information about various aspects of oxidase functioning. We compared oxygen binding properties of terminal oxidases from the distinct heme-copper (CcO) and cytochrome bd families and found that cytochrome bd has a high affinity for oxygen, which is 3 orders of magnitude higher than that of CcO. Interestingly, the difference between CcO and cytochrome bd is not only in higher affinity of the latter to oxygen, but also in the way that each of these enzymes traps oxygen during catalysis. CcO traps oxygen kinetically - the molecule of bound dioxygen is rapidly reduced before it can dissociate. Alternatively, cytochrome bd employs an alternative mechanism of oxygen trapping - part of the redox energy is invested into tight oxygen binding, and the price paid for this is the lack of proton pumping. A single cycle of oxygen reduction to water is characterized by translocation of four protons across the membrane. Our results make it possible to assign the pumping steps to discrete transitions of the catalytic cycle and indicate that during in vivo turnover of the oxidase these four protons are transferred, one at a time, during the P→F, F→OH, Oh→Eh, and Eh→R transitions. At the same time, each individual proton translocation step in the catalytic cycle is not just a single reaction catalyzed by CcO, but rather a complicated sequence of interdependent electron and proton transfers. We assume that each single proton translocation cycle of CcO is assured by internal proton transfer from the conserved Glu-278 to an as yet unidentified pump site above the hemes. Delivery of a proton to the pump site serves as a driving reaction that forces the proton translocation cycle to continue.

Hemodynamics and outcome of septic shock

Septic shock is a common killer in intensive care units (ICU). The most crucial issue concerning the outcome is the early and aggressive start of treatment aimed at normalization of hemodynamics and the early start of antibiotics during the very first hours. The optimal targets of hemodynamic treatment, or impact of hemodynamic treatment on survival after first resuscitation period are less known. The objective of this study was to evaluate different aspects of the hemodynamic pattern in septic shock with special attention to prediction of outcome. In particular components of early treatment and monitoring in the ICU were assessed. A total of 401 patients, 218 with septic shock and 192 with severe sepsis or septic shock were included in the study. The patients were treated in 24 Finnish ICUs during 1999-2005. 295 of the patients were included in the Finnish national epidemiologic Finnsepsis study. We found that the most important hemodynamic variables concerning the outcome were the mean arterial pressures (MAP) and lactate during the first six hours in ICU and the MAP and mixed venous oxygen saturation (SvO2) under 70% during first 48 hours. The MAP levels under 65 mmHg and SvO2 below 70% were the best predictive thresholds. Also the high central venous pressure (CVP) correlated to adverse outcome. We assessed the correlation and agreement of SvO2 and mean central venous oxygen saturation (ScvO2) in septic shock during first day in ICU. The mean SvO2 was below ScvO2 during early sepsis. Bias of difference was 4.2% (95% limits of agreement 8.1% to 16.5%) by Bland-Altman analysis. The difference between saturation values correlated significantly to cardiac index and oxygen delivery. Thus, the ScvO2 can not be used as a substitute of SvO2 in hemodynamic monitoring in ICU. Several biomarkers have been investigated for their ability to help in diagnosis or outcome prediction in sepsis. We assessed the predictive value of N-terminal pro brain natriuretic peptide (NT-proBNP) on mortality in severe sepsis or septic shock. The NT-proBNP levels were significantly higher in hospital nonsurvivors. The NT-proBNP 72 hrs after inclusion was independent predictor of hospital mortality. The acute cardiac load contributed to NTproBNP values at admission, but renal failure was the main confounding factor later. The accuracy of NT-proBNP, however, was not sufficient for clinical decision-making concerning the outcome prediction. The delays in start of treatment are associated to poorer prognosis in sepsis. We assessed how the early treatment guidelines were adopted, and what was the impact of early treatment on mortality in septic shock in Finland. We found that the early treatment was not optimal in Finnish hospitals and this reflected to mortality. A delayed initiation of antimicrobial agents was especially associated with unfavorable outcome.

Maallikon suorittama defibrillaatio sydänpysähdyspotilaan hoitoketjussa

Sudden cardiac arrest (CA) is one of the leading causes of death in Europe. It has been estimated that about 40 % of CA victims have ventricular fibrillation (VF) at the time of the first heart rhythm analysis. The treatment for VF is immediate cardiopulmonary resuscitation (CPR) and rapid defibrillation. The automated external defibrillator (AED) and the concept of public access defibrillation (PAD) may be a key to shortening defibrillation delays. Recent studies have shown that PAD programs are associated with high survival rates from VF when devices have been placed in certain risk sites and used by trained laypersons. Today many public places are equipped with AEDs. The purpose of this study was to find new ways of utilizing layperson defibrillation and promote the concept of public access defibrillation (PAD). The study explored the use of AEDs by non-medical first responders in Finland and cabin crew on board a commercial aircraft. A simulated study was performed to explore the role of dispatcher assistance in layperson CPR and defibrillation. A 15-year follow-up study of 59 one-year survivors after successful out-of-hospital resuscitation was performed to evaluate the long-term quality of life of the CA patients. Although there are many AEDs in use by non-medical first responders in Finland, the results of the study showed that there are large variations between individual first response units. This is considered to be caused by the lack of national standards and regulations that would define a full integration of first-responder programmes into the Emergency Medical Services system. The goal of rapid defibrillation in five minutes after the onset of CA is difficult to achieve in Finland due to sparse population and long distances. Local PAD programs may shorten the defibrillation delays. Dispatcher assistance in defibrillation by a layperson not trained to use an AED seems feasible and does not compromise the performance of CPR. In a simulated study, the quality of mouth-to-mouth ventilation performed by laypersons was found to be better after CPR training compared with performance with dispatcher assistance before training. Training was not found to have an influence on the quality of compressions or defibrillation compared with dispatcher assistance of untrained laypersons. The target groups for CPR and defibrillation training need further evaluation. The placements of the AEDs in public areas should be known by the emergency response center and the location should be marked with an international sign. The finding that once a good neurological outcome after CA is achieved, it can be maintained for more than 10 years, encourages further efforts to improve the survival of CA patients.

Electromagnetic signatures of lightning near the HF frequency band

The dissertation deals with remote narrowband measurements of the electromagnetic radiation emitted by lightning flashes. A lightning flash consists of a number of sub-processes. The return stroke, which transfers electrical charge from the thundercloud to to the ground, is electromagnetically an impulsive wideband process; that is, it emits radiation at most frequencies in the electromagnetic spectrum, but its duration is only some tens of microseconds. Before and after the return stroke, multiple sub-processes redistribute electrical charges within the thundercloud. These sub-processes can last for tens to hundreds of milliseconds, many orders of magnitude longer than the return stroke. Each sub-process causes radiation with specific time-domain characteristics, having maxima at different frequencies. Thus, if the radiation is measured at a single narrow frequency band, it is difficult to identify the sub-processes, and some sub-processes can be missed altogether. However, narrowband detectors are simple to design and miniaturize. In particular, near the High Frequency band (High Frequency, 3 MHz to 30 MHz), ordinary shortwave radios can, in principle, be used as detectors. This dissertation utilizes a prototype detector which is essentially a handheld AM radio receiver. Measurements were made in Scandinavia, and several independent data sources were used to identify lightning sub-processes, as well as the distance to each individual flash. It is shown that multiple sub-processes radiate strongly near the HF band. The return stroke usually radiates intensely, but it cannot be reliably identified from the time-domain signal alone. This means that a narrowband measurement is best used to characterize the energy of the radiation integrated over the whole flash, without attempting to identify individual processes. The dissertation analyzes the conditions under which this integrated energy can be used to estimate the distance to the flash. It is shown that flash-by-flash variations are large, but the integrated energy is very sensitive to changes in the distance, dropping as approximately the inverse cube root of the distance. Flashes can, in principle, be detected at distances of more than 100 km, but since the ground conductivity can vary, ranging accuracy drops dramatically at distances larger than 20 km. These limitations mean that individual flashes cannot be ranged accurately using a single narrowband detector, and the useful range is limited to 30 kilometers at the most. Nevertheless, simple statistical corrections are developed, which enable an accurate estimate of the distance to the closest edge of an active storm cell, as well as the approach speed. The results of the dissertation could therefore have practical applications in real-time short-range lightning detection and warning systems.