Kristallivalheita : Itsepetos filosofisen tulkinnan lähtökohtana eräissä draaman klassikoissa

The philosophical problem of self-deception focuses the relation between desire, advantage, evidence and harm. A self-deceptive person is irrational because he or she belives or wants to belive contrary to the available evidence. The study focuses on different forms of self-deception that come out in certain classical Western dramas. The first self-deception forms are: "S knows that ~p but still belives that p because he wants that ~p", "S wants that p and therefore belives that p.", "S belives that p against evidence t because he wants to belive that p.", "S belives that p if t but S would belive that p even if ~t because S wants to belive that p.", "S belives that p (even if there is t that ~p) because S is ignorant of it." and "S belives that p (even if there is t that ~p) because of ignorant of t due to an internal deception." The main sources on self-deception are the views of contemporary researchers of the subject, such as Robert Audi, Marcia Baron, Bas C. van Fraassen, Mark Johnston, Mike W. Martin, Brian MaLaughlin, Alfred Mele, Amélie Oksenberg Rorty, William Ruddick and Stephen L. White. In this study it is claimed that Shakespeare´s Othello presents self-deception as a tragic phenomenom from witch it follows deceptions and murders. Moliére´s Tartuffe deals with a phony hypocrite´s attempts at cheating. Ibsen´s Wild Duck defends the necessity of vital lies. Beckett´s Waiting for Godot deals with the self-deception witch is related to the waiting of the supernatural rescuer. Miller´s The Death of a Salesman tells about a man who, while pursuing the American myth of success, winds both himself and his family into the skeins of self-deception. They are studied with a Barthesian method that emphasizes the autonomy of literary work and its interpretation independently of the author´s personal history and social conditions. Self-deception has been regarded as an immoral way of thinking or way of action. However, vital lies show the necessity or necessity of the self-deception when it brings joy and optimism to the human being and supports his or her self-esteem and does not cause a suffering or damage, either to self or others. In the study, the processual character of self-deception is brought out.

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

Across the Oceans : Development of Overseas Business Information Transmission, 1815-1875

Earlier studies have shown that the speed of information transmission developed radically during the 19th century. The fast development was mainly due to the change from sailing ships and horse-driven coaches to steamers and railways, as well as the telegraph. Speed of information transmission has normally been measured by calculating the duration between writing and receiving a letter, or between an important event and the time when the news was published elsewhere. As overseas mail was generally carried by ships, the history of communications and maritime history are closely related. This study also brings a postal historical aspect to the academic discussion. Additionally, there is another new aspect included. In business enterprises, information flows generally consisted of multiple transactions. Although fast one-way information was often crucial, e.g. news of a changing market situation, at least equally important was that there was a possibility to react rapidly. To examine the development of business information transmission, the duration of mail transport has been measured by a systematic and commensurable method, using consecutive information circles per year as the principal tool for measurement. The study covers a period of six decades, several of the world's most important trade routes and different mail-carrying systems operated by merchant ships, sailing packets and several nations' steamship services. The main sources have been the sailing data of mail-carrying ships and correspondence of several merchant houses in England. As the world's main trade routes had their specific historical backgrounds with different businesses, interests and needs, the systems for information transmission did not develop similarly or simultaneously. It was a process lasting several decades, initiated by the idea of organizing sailings in a regular line system. The evolution proceeded generally as follows: originally there was a more or less irregular system, then a regular system and finally a more frequent regular system of mail services. The trend was from sail to steam, but both these means of communication improved following the same scheme. Faster sailings alone did not radically improve the number of consecutive information circles per year, if the communication was not frequent enough. Neither did improved frequency advance the information circulation if the trip was very long or if the sailings were overlapping instead of complementing each other. The speed of information transmission could be improved by speeding up the voyage itself (technological improvements, minimizing the waiting time at ports of call, etc.) but especially by organizing sailings so that the recipients had the possibility to reply to arriving mails without unnecessary delay. It took two to three decades before the mail-carrying shipping companies were able to organize their sailings in an optimal way. Strategic shortcuts over isthmuses (e.g. Panama, Suez) together with the cooperation between steamships and railways enabled the most effective improvements in global communications before the introduction of the telegraph.

Drag på parnassen. Två sextiotalsstudier. : Del I: Medelklass med mänskligt ansikte. Medelklassradikalism i fyra romaner av Christer Kihlman, Jarl Sjöblom, Marianne Alopaeus och Ulla-Lena Lundberg. Del II: Modernistdebatten. Sak, person och fält i en finlandssvensk litteraturdebatt år 1965.

The objective of my dissertation Pull (or Draught, or Moves) at the Parnassus , is to provide a deeper understanding of Nordic Middle Class radicalism of the 1960 s as featured in Finland-Swedish literature. My approach is cultural materialist in a broad sense; social class is regarded a crucial aspect of the contents and contexts of the novels and literary discussions explored. In the first volume, Middle Class With A Human Face , novels by Christer Kihlman, Jarl Sjöblom, Marianne Alopaeus, and Ulla-Lena Lundberg, respectively, are read from the points of view of place, emotion, and power. The term "cryptotope" is used to designate the hidden places found to play an important role in all of these four narratives. Also, the "chronotope of the provincial small town", described by Mikhail Bakhtin in 1938, is exemplified in Kihlman s satirical novel, as is the chronotope of of war (Algeria, Vietnam) in those of Alopaeus and Lundberg s. All the four novels signal changes in the way general "scripts of emotions", e.g. jealousy, are handled and described. The power relations in the novels are also read, with reference to Michel Foucault. As the protagonists in two of them work as journalists, a critical discussion about media and Bourgeois hegemony is found; the term "repressive legitimation" is created to grasp these patterns of manipulation. The Modernist Debate , part II of the study, concerns a literary discussion between mainly Finland-Swedish authors and critics. Essayist Johannes Salminen (40) provided much of the fuel for the debate in 1963, questioning the relevance to contemporary life of the Finland-Swedish modernist tradition of the 1910 s and 1920 s. In 1965, a group of younger authors and critics, including poet Claes Andersson (28), followed up this critique in a debate taking place mainly in the newspaper Vasabladet. Poets Rabbe Enckell (62), Bo Carpelan (39) and others defended a timeless poetry. This debate is contextualized and the changing literary field is analyzed using concepts provided by sociologist Pierre Bourdieu. In the thesis, the historical moment of Middle Class radicalism with a human face is regarded a temporary luxury that new social groups could afford themselves, as long as they were knocking over the statues and symbols of the Old Bourgeoisie. This is not to say that all components of the Sixties strategy have lost their power. Some of them have survived and even grown, others remain latent in the gene bank of utopias, waiting for new moments of change.

ADHD-aikuisten psykologinen kuntoutus : Neljän uuden lyhytintervention tutkimus

ADHD (attention deficit hyperactivity disorder) is developmental neurobiological disability. In adults, the prevalence of ADHD has been estimated to be about 4 %. In addition to the difficulties of attention, the problems in executive functioning are typical. The psychiatric comorbidities are common. The most extensively studied treatments are pharmacological. There is also evidence about the usefulness of the cognitive-behavioural therapy (CBT) in the treatment of adults with ADHD. There are some preliminary results about the effectiveness of cognitive training and hypnosis in children, but there is no scientific proof in adults. This dissertation is based on two intervention studies. In the first study, the usefulness of the new group CBT (n = 29) and the maintenance of the symptom reduction in the follow-up of six months were studied. In the second study, the usefulness of short hypnotherapy (n = 9), short individual CBT (n = 10) and computerized cognitive training (n = 9) were examined by comparing groups with each other and to the control group (n = 10). The participation in the group CBT and the participants' satisfaction were good. There were no changes in self-reports during waiting period of three months. After the rehabilitation, the symptoms decreased. Participants having symptom reduction during rehabilitation maintained their benefit through 6-month follow-up period. In a combined ADHD symptom score based on self-reports, seven participants in the hypnotherapy, six in the CBT, two in the cognitive training and two controls improved. Using independent evaluations, improvement was found in six of the hypnotherapy, seven of the CBT, two of the cognitive training and three of the control participants. There was no treatment-related improvement in cognitive performance. Thus, in the hypnotherapy and CBT groups, some encouraging improvement was seen. In the cognitive training group, there was improvement in the trained tasks but no generalization of the improvement. The results support the earlier results from the usefulness of CBT in the treatment of adults with ADHD. Also the hypnotherapy seems a useful rehabilitation. More research is needed to evaluate the usefulness of cognitive training. These promising results warrant further studies with more participants and with longer treatment duration. Also different measures of cognitive functioning and quality of life are needed. It is important in addition to the medication to arrange psychosocial interventions for the ADHD adults.

Routine Measurement of Health-Related Quality of Life in Assessing Cost-Effectiveness in Secondary Health Care

Aims: The aims of this study were 1) to identify and describe health economic studies that have used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL); 2) to test the feasibility of routine collection of health-related quality of life (HRQoL) data as an indicator of effectiveness of secondary health care; and 3) to establish and compare the cost-utility of three large-volume surgical procedures in a real-world setting in the Helsinki University Central Hospital, a large referral hospital providing secondary and tertiary health-care services for a population of approximately 1.4 million. Patients and methods: So as to identify studies that have used QALYs as an outcome measure, a systematic search of the literature was performed using the Medline, Embase, CINAHL, SCI and Cochrane Library electronic databases. Initial screening of the identified articles involved two reviewers independently reading the abstracts; the full-text articles were also evaluated independently by two reviewers, with a third reviewer used in cases where the two reviewers could not agree a consensus on which articles should be included. The feasibility of routinely evaluating the cost-effectiveness of secondary health care was tested by setting up a system for collecting HRQoL data on approximately 4 900 patients' HRQoL before and after operative treatments performed in the hospital. The HRQoL data used as an indicator of treatment effectiveness was combined with diagnostic and financial indicators routinely collected in the hospital. To compare the cost-effectiveness of three surgical interventions, 712 patients admitted for routine operative treatment completed the 15D HRQoL questionnaire before and also 3-12 months after the operation. QALYs were calculated using the obtained utility data and expected remaining life years of the patients. Direct hospital costs were obtained from the clinical patient administration database of the hospital and a cost-utility analysis was performed from the perspective of the provider of secondary health care services. Main results: The systematic review (Study I) showed that although QALYs gained are considered an important measure of the effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited. Of the reviewed full-text articles, only 70 reported QALYs based on actual before after measurements using a valid HRQoL instrument. Collection of simple cost-effectiveness data in secondary health care is feasible and could easily be expanded and performed on a routine basis (Study II). It allows meaningful comparisons between various treatments and provides a means for allocating limited health care resources. The cost per QALY gained was 2 770 for cervical operations and 1 740 for lumbar operations. In cases where surgery was delayed the cost per QALY was doubled (Study III). The cost per QALY ranges between subgroups in cataract surgery (Study IV). The cost per QALY gained was 5 130 for patients having both eyes operated on and 8 210 for patients with only one eye operated on during the 6-month follow-up. In patients whose first eye had been operated on previous to the study period, the mean HRQoL deteriorated after surgery, thus precluding the establishment of the cost per QALY. In arthroplasty patients (Study V) the mean cost per QALY gained in a one-year period was 6 710 for primary hip replacement, 52 270 for revision hip replacement, and 14 000 for primary knee replacement. Conclusions: Although the importance of cost-utility analyses has during recent years been stressed, there are only a limited number of studies in which the evaluation is based on patients own assessment of the treatment effectiveness. Most of the cost-effectiveness and cost-utility analyses are based on modeling that employs expert opinion regarding the outcome of treatment, not on patient-derived assessments. Routine collection of effectiveness information from patients entering treatment in secondary health care turned out to be easy enough and did not, for instance, require additional personnel on the wards in which the study was executed. The mean patient response rate was more than 70 %, suggesting that patients were happy to participate and appreciated the fact that the hospital showed an interest in their well-being even after the actual treatment episode had ended. Spinal surgery leads to a statistically significant and clinically important improvement in HRQoL. The cost per QALY gained was reasonable, at less than half of that observed for instance for hip replacement surgery. However, prolonged waiting for an operation approximately doubled the cost per QALY gained from the surgical intervention. The mean utility gain following routine cataract surgery in a real world setting was relatively small and confined mostly to patients who had had both eyes operated on. The cost of cataract surgery per QALY gained was higher than previously reported and was associated with considerable degree of uncertainty. Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is two-fold compared to hip replacement. Cost-utility results from the three studied specialties showed that there is great variation in the cost-utility of surgical interventions performed in a real-world setting even when only common, widely accepted interventions are considered. However, the cost per QALY of all the studied interventions, except for revision hip arthroplasty, was well below 50 000, this figure being sometimes cited in the literature as a threshold level for the cost-effectiveness of an intervention. Based on the present study it may be concluded that routine evaluation of the cost-utility of secondary health care is feasible and produces information essential for a rational and balanced allocation of scarce health care resources.

Structure, function and intracellular dynamics of alphavirus replication complexes

Intracellular membrane alterations are hallmarks of positive-sense RNA (+RNA) virus replication. Strong evidence indicates that within these exotic compartments, viral replicase proteins engage in RNA genome replication and transcription. To date, fundamental questions such as the origin of altered membranes, mechanisms of membrane deformation and topological distribution and function of viral components, are still waiting for comprehensive answers. This study addressed some of the above mentioned questions for the membrane alterations induced during Semliki Forest virus (SFV) infection of mammalian cells. With the aid of electron and fluorescence microscopy coupled with radioactive labelling and immuno-cytochemistry techniques, our group and others showed that few hours after infection the four non structural proteins (nsP1-4) and newly synthesized RNAs of SFV colocalized in close proximity of small membrane invaginations, designated as spherules . These 50-70 nm structures were mainly detected in the perinuclear area, at the limiting membrane of modified endosomes and lysosomes, named CPV-I (cytopathic vacuoles type I). More rarely, spherules were also found at the plasma membrane (PM). In the first part of this study I present the first three-dimensional reconstruction of the CPV-I and the spherules, obtained by electron tomography after chemical or cryo-fixation. Different approaches for imaging these macromolecular assemblies to obtain better structure preservation and higher resolution are presented as unpublished data. This study provides insights into spherule organization and distribution of viral components. The results of this and other experiments presented in this thesis will challenge currently accepted models for virus replication complex formation and function. In a revisitation of our previous models, the second part of this work provides the first complete description of the biogenesis of the CPV-I. The results demonstrate that these virus-induced vacuoles, where hundreds of spherules accumulate at late stages during infection, represent the final phase of a journey initiated at the PM, which apparently serves as a platform for spherule formation. From the PM spherules were internalized by an endocytic event that required the activity of the class I PI3K, caveolin-1, cellular cholesterol and functional actin-myosin network. The resulting neutral endocytic carrier vesicle delivered the spherules to the membrane of pre-existing acidic endosomes via multiple fusion events. Microtubule based transport supported the vectorial transfer of these intermediates to the pericentriolar area where further fusions generated the CPV-I. A signal for spherule internalization was identified in one of the replicase proteins, nsP3. Infections of cells with viruses harbouring a deletion in a highly phosphorylated region of nsP3 did not result in the formation of CPV-Is. Instead, thousands of spherules remained at the PM throughout the infection cycle. Finally, the role of the replicase protein nsP2 during viral RNA replication and transcription was investigated. Three enzymatic activities, protease, NTPase and RNA-triphosphatase were studied with the aid of temperature sensitive mutants in vitro and, when possible, in vivo. The results highlighted the interplay of the different nsP2 functions during different steps of RNA replication and sub-genomic promoter regulation, and suggest that the protein could have different activities when participating in the replication complex or as a free enzyme.

Preoperative visual acuity of cataract patients. Repeatability of visual acuity and refractive error measurements in clinical settings

Visual acuities at the time of referral and on the day before surgery were compared in 124 patients operated on for cataract in Vaasa Central Hospital, Finland. Preoperative visual acuity and the occurrence of ocular and general disease were compared in samples of consecutive cataract extractions performed in 1982, 1985, 1990, 1995 and 2000 in two hospitals in the Vaasa region in Finland. The repeatability and standard deviation of random measurement error in visual acuity and refractive error determination in a clinical environment in cataractous, pseudophakic and healthy eyes were estimated by re-examining visual acuity and refractive error of patients referred to cataract surgery or consultation by ophthalmic professionals. Altogether 99 eyes of 99 persons (41 cataractous, 36 pseudophakic and 22 healthy eyes) with a visual acuity range of Snellen 0.3 to 1.3 (0.52 to -0.11 logMAR) were examined. During an average waiting time of 13 months, visual acuity in the study eye decreased from 0.68 logMAR to 0.96 logMAR (from 0.2 to 0.1 in Snellen decimal values). The average decrease in vision was 0.27 logMAR per year. In the fastest quartile, visual acuity change per year was 0.75 logMAR, and in the second fastest 0.29 logMAR, the third and fourth quartiles were virtually unaffected. From 1982 to 2000, the incidence of cataract surgery increased from 1.0 to 7.2 operations per 1000 inhabitants per year in the Vaasa region. The average preoperative visual acuity in the operated eye increased by 0.85 logMAR (in decimal values from 0.03to 0.2) and in the better eye 0.27 logMAR (in decimal values from 0.23 to 0.43) over this period. The proportion of patients profoundly visually handicapped (VA in the better eye <0.1) before the operation fell from 15% to 4%, and that of patients less profoundly visually handicapped (VA in the better eye 0.1 to <0.3) from 47% to 15%. The repeatability visual acuity measurement estimated as a coefficient of repeatability for all 99 eyes was ±0.18 logMAR, and the standard deviation of measurement error was 0.06 logMAR. Eyes with the lowest visual acuity (0.3-0.45) had the largest variability, the coefficient of repeatability values being ±0.24 logMAR and eyes with a visual acuity of 0.7 or better had the smallest, ±0.12 logMAR. The repeatability of refractive error measurement was studied in the same patient material as the repeatability of visual acuity. Differences between measurements 1 and 2 were calculated as three-dimensional vector values and spherical equivalents and expressed by coefficients of repeatability. Coefficients of repeatability for all eyes for vertical, torsional and horisontal vectors were ±0.74D, ±0.34D and ±0.93D, respectively, and for spherical equivalent for all eyes ±0.74D. Eyes with lower visual acuity (0.3-0.45) had larger variability in vector and spherical equivalent values (±1.14), but the difference between visual acuity groups was not statistically significant. The difference in the mean defocus equivalent between measurements 1 and 2 was, however, significantly greater in the lower visual acuity group. If a change of ±0.5D (measured in defocus equivalents) is accepted as a basis for change of spectacles for eyes with good vision, the basis for eyes in the visual acuity range of 0.3 - 0.65 would be ±1D. Differences in repeated visual acuity measurements are partly explained by errors in refractive error measurements.

A Critical Evaluation of the MARS Treatment in Finland

The Molecular Adsorbent Recirculating System (MARS) is an extracorporeal albumin dialysis device which is used in the treatment of liver failure patients. This treatment was first utilized in Finland in 2001, and since then, over 200 patients have been treated. The aim of this thesis was to evaluate the impact of the MARS treatment on patient outcome, the clinical and biochemical variables, as well as on the psychological and economic aspects of the treatment in Finland. This thesis encompasses 195 MARS-treated patients (including patients with acute liver failure (ALF), acute-on-chronic liver failure (AOCLF) and graft failure), and a historical control group of 46 ALF patients who did not undergo MARS. All patients received a similar standard medical therapy at the same intensive care unit. The baseline data (demographics, laboratory and clinical variables) and MARS treatment-related and health-related quality-of-life data were recorded before and after treatment. The direct medical costs were determined for a period of 3.5 years.Additionally, the outcome of patients (survival, native liver recovery and need for liver transplantation) and survival predicting factors were investigated. In the outcome analysis, for the MARS-treated ALF patients, their 6-month survival (75% vs. 61%, P=0.07) and their native liver recovery rate (49% vs. 17%, P<0.001) were higher, and their need for transplantations was lower (29% vs. 57%, P= 0.001) than for the historical controls. However, the etiological distribution of the ALF patients referred to our unit has changed considerably over the past decade and the percentage of patients with a more favorable prognosis has increased. The etiology of liver failure was the most important predictor of the outcome. Other survival predicting factors in ALF included hepatic encephalopathy, the coagulation factors and the liver enzyme levels prior to MARS treatment. In terms of prognosis, the MARS treatment of the cirrhotic AOCLF patient seems meaningful only when the patient is eligible for transplantation. The MARS treatment appears to halt the progression of encephalopathy and reduce the blood concentration of neuroactive amino acids, albumin-bound and water-soluble toxins. In general, the effects of the MARS treatment seem to stabilize the patients, thus allowing additional time either for the native liver to recover, or for the patients to endure the prolonged waiting for transplantation. Furthermore, for the ALF patients, the MARS treatment appeared to be less costly and more cost-efficient than the standard medical therapy alone. In conclusion, the MARS treatment appears to have a beneficial effect on the patient outcome in ALF and in those AOCLF patients who can be bridged to transplantation.

Optimal Risk Adoption: A Real Options Approach

This study develops a real options approach for analyzing the optimal risk adoption policy in an environment where the adoption means a switch from one stochastic flow representation into another. We establish that increased volatility needs not decelerate investment, as predicted by the standard literature on real options, once the underlying volatility of the state is made endogenous. We prove that for a decision maker with a convex (concave) objective function, increased post-adoption volatility increases (decreases) the expected cumulative present value of the post-adoption profit flow, which consequently decreases (increases) the option value of waiting and, therefore, accelerates (decelerates) current investment.

The Effects of Reduction Mammaplasty

Symptomatic hypertrophic breasts cause a health burden with physical and psychosocial morbidity. The value of reduction mammaplasty in the treatment of symptomatic breast hypertrophy has been consistently reported by patients and has been well recognised by plastic surgeons for a long time. However, the scientific evidence of the effects of reduction mammaplasty has been weak or lacking. During the design of this study most of the previous studies were retrospective and the few prospective studies had methodological limitations. Therefore, an obvious need for prospective randomised studies was present. Nevertheless, practical and ethical considerations seemed to make this study design impossible, because the waiting time for the operation was several years. The legislation and subsequent introduction of the uniform criteria for access to non-emergency treatment in Finland removed these obstacles, as all patients received their treatment within a reasonable time. As a result, a randomised controlled trial with a six-month follow-up time was designed and conducted. In addition, a follow-up study with two to five years follow-up was also carried out later. The effects of reduction mammaplasty on the patients breast-related symptoms, psychological symptoms, pain and quality of life was assessed. In addition, factors affecting the outcome were investigated. This study was carried out in the Hospital District of Helsinki and Uusimaa, Finland. Eighty-two out of the approximately 300 patients on the waiting list in 2004 agreed to participate in the study. Patients were randomised either to be operated (40 patients) on or to be followed up (42 patients). The follow-up time for both groups was six months. The patients were operated on by plastic surgeons or trainees at the Department of Plastic Surgery at Helsinki University Central Hospital or at the Department of Surgery at Hyvinkää Hospital. The patients completed five questionnaires: the SF-36 and the 15D quality of life questionnaires, the Finnish Breast-Associated Symptoms questionnaire (FBAS), a mood questionnaire (Raitasalo s modification of the short form of the Beck Depression Inventory, RBDI), and a pain questionnaire (The Finnish Pain Questionnaire, FPQ). Sixty-two out of the original 82 patients agreed to participate in the prospective follow-up study. In this study, patients completed the 15D quality of life questionnaire, the Finnish Breast-Associated Symptoms questionnaire, and the RBDI mood questionnaire. After six months follow-up, patients who had undergone reduction mammaplasty had a significantly better quality of life, fewer breast-associated symptoms and less pain, and they were less depressed or anxious when compared to patients who had not undergone surgery. The change in quality of life was more than two times the minimal clinically important difference. The patients preoperative quality of life was significantly inferior when compared to the age-standardised general population. This health burden was removed with reduction mammaplasty. The health loss related to symptomatic breast hypertrophy was comparable to that of patients with major joint arthrosis. In terms of change in quality of life, the intervention effect of reduction mammaplasty was comparable to that of hip joint replacement and more pronounced than that of knee joint replacement surgery. The outcome of reduction mammaplasty was affected more by preoperative psychosocial factors than by changes in breast dimensions. The effects of reduction mammaplasty remained stable at two to five years follow-up. In terms of quality of life, symptomatic breast hypertrophy causes a considerable health loss comparable to that of major joint arthrosis. Patients who undergo surgery have fewer breast-associated symptoms and less pain, and they are less depressed or anxious and have an improved quality of life. The intervention effect is comparable to that of major joint replacement surgery, and it remains stable at two to five years follow-up. The outcome of reduction mammaplasty is affected by preoperative psychosocial factors.

Liminal Belonging: West African male asylum seekers’ narratives of the asylum experience whilst in Finland

The dominant discourses on the issue of asylum have placed it on a uniquely higher level of scrutiny as a politically very sensitive area for social research. Today, member states within the EU have implemented stricter policies to control new arrivals, whilst instituting statutory procedures to manage the existing asylum claims. In 2010, the number of applicants for asylum in Finland totalled 5988, out of which 1784 were given positive decisions. This thesis endeavour to highlight asylum seekers in the discourses about them by adding their voices to the discussions of them in contemporary Finland. Studies, which has concentrated on asylum seekers in Finland, uses the living conditions within asylum reception centres to assess the impacts of structural barriers on asylum seekers’ efforts to deal with the asylum process. By highlighting the impacts of the entire asylum process, which I believe starts from the country of origin; I focus on examining narratives of dealing with the experience of liminality whilst waiting for asylum, and then explore areas of possible participation within informal social networks for West African asylum seekers in Finland. The overall aim is to place the current research within the broader sociological discussion of ‘belonging’ for asylum seekers who are yet to be recognized as refugees, and who exist in a state of limbo. Methodologically, oral interviews, self-written autobiographical narratives, and ethnographic field work are qualitatively combined as data in this thesis for an empirical study of West African male asylum seekers in Finland. Narrative analysis is employed to analyze the data for this thesis. The ethnographic research data for the study began in May 2009 and ended in August of 2010. Altogether, ten interviews and four self-written narratives were collected as data. In total seven hours of audio recording were made, along eleven pages of hand-written autobiographical narratives. Field observation notes are employed in the study to provide contexts to the active interactional processes of interpretation throughout the analysis. Findings from the study suggest that within the experience of liminality, which surrounds the entire asylum process, participations within informal social networks are found to be important to the process of re-making place and the sense of belonging. My study shows that this is necessary to countering the experience of boredom, stress and social isolation, which permeate all aspects of life for West African asylum seekers, whilst they wait for asylum decisions in Finland.

Sosiaaliturvan ulkopuolella - kokemuksia kansalaisuuden reunalta

Muuttaessaan maasta toiseen ihminen kohtaa useita rajoja. Ylittäessään kohdemaan valtion rajan hän kulkee läpi ensimmäisestä maahanmuuton portista. Toinen raja erottaa tilapäiset asukkaat pysyvistä: tämän maahanmuuton toisen portin läpikulkemisen myötä yksilö pääsee osalliseksi sosiaalisista oikeuksista. Maahanmuuton viimeisestä portista kuljettuaan yksilö saavuttaa kyseisen valtion kansalaisuuden. (Hammar 1990, 21.) Tässä pro gradu -tutkielmassa tarkastelen toisen maahanmuuton portin aukeamista ja sosiaaliturvan piiriin pääsyä odottavien maahan-muuttajien kokemuksia. Käytän tarkastelussa sosiaalisen kansalaisuuden ja marginaalisuuden käsitteitä. Tutkielmassa selvitän, miten sosiaali- ja terveyspalveluiden sekä toimeentuloturvan ulkopuolelle jääminen vaikuttaa maahanmuuttajien arkeen ja miten he kokevat osallisuutensa ja jäsenyytensä yhteiskunnassa. Tutkimus on lähtökohdiltaan fenomenologis-hermeneuttinen ja sovellan lähestymistapana ko-kemuksiin keskittyvän narratiivista tutkimusta. Tutkimusaineisto on koottu kevään 2011 aikana ja se koostuu 10 teemahaastattelusta. Haastateltavien maahanmuuton keinot ja syyt vaihtelivat: he olivat saapuneet Suomeen perhesyistä, työn vuoksi tai hakeakseen turvaa. Haastateltavat tavoitettiin Helsingin Diakoniaopiston, Pro-tukipisteen, Kansainvälisen seurakunnan ja tuttava-verkostojen kautta. Aineiston analyysi toteutettiin sisällönanalyysillä Atlas-ohjelman avulla syksyn 2011 aikana. Toisen maahanmuuton portin aukeamisen odottaminen oli raskaaksi: tuota aikaa leimasi epä-varmuus, tyhjyys ja yksinäisyys. Sosiaaliturvan ulkopuolella jääminen aiheutti osalle haastatel-tavista taloudellisia vaikeuksia sekä ongelmia terveydenhuollon palveluiden piiriin pääsemisessä. Toisaalta apua hakeneet haastateltavat olivat sitä lopulta saaneet. Auttamistyön ammattilaiset ja maistraatti saivat haastateltavien kertomuksissa portinvartijan aseman. Kaikille sosiaaliturvan ulkopuolelle jääminen ei ollut ongelma vaan he kokivat sosiaaliturvan puutetta suuremmaksi ongelmaksi työnteko-oikeuden puuttumisen. Kuulumisen ja ulkopuolisuuden kokemus voivat olla läsnä samanaikaisesti, ja kuulumisesta neuvotellaan jatkuvasti esimerkiksi sosiaalisessa kanssakäymisessä tai palveluita hakiessa. Insti-tutionaaliset käytännöt ja poiskäännyttämisen kokemukset tuottavat marginaalisia identiteettejä. Tasavertainen oikeus sosiaaliturvaan vahvistaa kokemusta kuulumisesta ja kodista. Sosiaaliturva ei kuitenkaan yksin määritä kuulumisen ja kodin kokemusta vaan siihen vaikuttavat myös muut tekijät. Näistä tärkeimmät ovat kehon fyysinen sijoittuminen Suomeen, perhe- ja ystä-vyyssuhteet, työ, asunto ja rasismin kokemukset.