Social-class inequalities in ill health - the contribution of physical workload

Tutkimuksen aiheita olivat yhteiskuntaluokkien väliset erot sairastavuudessa ja alentuneessa toimintakyvyssä, sekä fyysisen työkuormituksen ja joidenkin muiden työolojen vaikutus sairastavuuteen. Empiirisestä työstä on raportoitu myös neljässä kansainvälisissä tieteellisissä aikakauskirjoissa julkaistussa artikkelissa. Tässä julkaistu yhteenveto sisältää tulosten yhteenvedon lisäksi myös tutkimusta koskevien käsitteellisten ja teoreettisten kysymysten sekä tutkimustradition kriittisen katsauksen. Työn päätavoitteita olivat 1) tutkia fyysisesti kuormittavan työn, ja jossain määrin muiden työolojen osuutta yhteiskuntaluokkien välisiin eroihin sairaudessa ja toimintakyvyn alentuneisuudessa; 2) tutkia työn fyysisen kuormittavuuden, työhön liittyvien vaikutusmahdollisuuksien ja hallinnan (decision latitude), luokka-aseman, iän ja sukupuolen yhteisvaikutuksia heikentyneeseen terveydentilaan; sekä 3) tutkia missä määrin mekaanisten työaltisteiden ja tuki- ja liikuntaelinsairastavuuden välinen yhteys voi selittää yhteiskuntaluokkien välisiä eroja heikentyneessä yleisessä terveydentilassa. Tutkittavat olivat keski-ikäisiä Helsingin kaupungin työntekijöitä. Analyysit perustuivat poikittaisasetelmaan, ja käytetty aineisto oli Helsinki Health Studyn vuosien 2000 ja 2002 välillä kerättyä aineistoa. Analyyseihin käytetyssä aineistossa oli 3740:stä 8002:een tutkittavaa. Tulosten perusteella fyysisillä (sekä fysikaalisilla) työoloilla on merkittävä vaikutus yhteiskuntaluokkien välisiin eroihin yleisessä sairastavuudessa, toimintakyvyn heikentymisessä, tuki- ja liikuntaelinsairastavuudessa sekä itsearvioidussa terveydentilassa. Naisilla lähes puolet heikentyneen toimintakyvyn ja koetun terveydentilan luokkaeroista vaikutti olevan selitettävissä fyysisellä työkuormituksella. Hallintamahdollisuuksien ei havaittu merkittävästi muuttavan fyysisen kuormituksen vaikutusta toimintakykyyn. Fyysisen kuormittavuuden terveysvaikutus voimistui kasvavan iän mukaan enemmän naisilla kuin miehillä. Osa, mutta ei koko fyysisen kuormituksen vaikutus yhteiskuntaluokkien eroihin heikentyneessä terveydessä vaikutti välittyvän tuki- ja liikuntaelinsairastavuuden kautta. Terveys ja sairaus eivät ole yhtenäisiä tiloja, ja siksi monet eri sosiaalisesti ja rakenteellisesti määräytyvät olosuhteet todennäköisesti vaikuttavat yhteiskunnallisten terveyserojen syntymiseen. Fyysis-materiaalisten olojen vaikutusta terveyserojen syntyyn nyky-yhteiskunnassa on mahdollisesti aliarvioitu. Yhteiskuntaluokkien väliset erot fyysis-materiaalisissa olosuhteissa eivät ole kadonneet, ja nämä erot todennäköisesti vaikuttavat terveyserojen syntyyn.

Transcending “the Impossible” : From Dead End to Expansive Learning

This dissertation investigates changes in bank work and the experience of impossibility attached to these by workers at the local level from the viewpoint of work-related well-being and collective learning. A special challenge in my work is to conceptualize the experience of impossibility as related to change, and as a starting point and tool for development work. The subject of the dissertation, solving the impossible as a collective learning process, came up as a central theme in an earlier project: Work Units between the Old and the New (1997 – 1999). Its aim was to investigate how change is constructed as a long-term process, starting from the planning of the change until its final realization in everyday banking work. I studied changes taking place in the former Postipankki (Postal Bank), later called Leonia. The three-year study involved the Branch Office of Martinlaakso, and was conducted from the perspective of well-being in a change process. The sense of impossibility involved in changes turned out to be one of the most crucial factors impairing the sense of well-being. The work community that was the target of my study did not have the available tools to construct the change locally, or to deal with the change-related impossibility by solving it through a mutual process among themselves. During the last year of the project, I carried out an intervention for development in the Branch Office, as collaboration between the researchers and the workers. The purpose of the intervention was to resolve such perceived change-related impossibility as experienced repeatedly and considered by the work community as relevant to work-related well-being. The documentation of the intervention – audio records from development sessions, written assignments by workers and assessment or evaluation interviews – constitute the essential data for my dissertation. The earlier data, collected and analysed during the first two years, provides a historical perspective on the process, all the way from construction of the impossibility towards resolving and transcending it. The aim of my dissertation is to understand the progress of developmental intervention as a shared, possibly expansive learning process within a work community and thus to provide tools for perceiving and constructing local change. I chose the change-related impossibility as a starting point for development work in the work community and as a target of conceptualization. This, I feel, is the most important contribution of my dissertation. While the intervention was in progress, the concept of impossibility started emerging as a stimulating tool for development work. An understanding of such a process can be applied to development work outside banking work as well. According to my results, it is pivotal that a concept stimulating development is strongly connected with everyday experiences of and speech about changes in work activity, as well as with the theoretical framework of work development. During this process, development work on a local level became of utmost interest as a case study for managing change. Theoretically, this was conceptualized as so-called second-order work and this concept accompanies us all the way through the research process. Learning second-order work and constructing tools based on this work have proved crucial for promoting well-being in the change circumstances in a local work unit. The lack of second-order work has led to non-well-being and inability to transcend the change-related sense of impossibility in the work community. Solving the impossible, either individually or situationally, did not orient the workers towards solving problems of impossibility together as a work community. Because the experience of the impossibility and coming to terms with transcending it are the starting point and the target of conceptualization in this dissertation, the research provides a fresh viewpoint on the theoretical framework of change and developmental work. My dissertation can facilitate construction of local changes necessitated by the recent financial crisis, and thus promote fluency and well-being in work units. It can also support change-related well-being in other areas of working life.

Työlähtöiset menetelmät työterveyshuollossa : Oppimisen johtaminen uuden toimintakonseptin käyttöönotto- ja vakiinnuttamisvaiheessa

Working life is changing. The core of the change is change in the production and service concepts of organizations. Changes at work are connected to problems in the well-being of employees. To respond to this challenge, occupational health care must develop a course of action. A group of occupational health care units has developed new activity theory-based methods, the object of which is to change the service concept of occupational health care. The focus is on the changes and disturbances in work activity. My aim was to study this development from the perspective of knowledge management; to clarify directors'/ managers' conceptions of the content and object of their managerial work and the tensions included in these conceptions; to examine the learning process involved in these methods and to bring to light the problems, developmental needs and challenges during the implementation and consolidation phases of the process. This was a case study which included 10 occupational health care units using or being trained to use activity theory-based methods. My data consisted of interviews with directors/managers and recordings of the meetings; 20 directors/ managers are represented; I interviewed seven directors/ managers who represented four units. Directors'/ managers' conceptions of the content and object of managerial work were divided into eight categories of description, which I connected to the historical forms of organizations and types of management. Intuitive and rational management are historically older forms of management. The categories of description representing intuitive and rational management contained many internal tensions, i.e. they do not satisfy the demands of the environment. On the other hand, the categories of description which represented management by results and the control of the development process contained very few or no tensions at all; they are effective in the present environment of occupational health care. The learning process of activity theory-based methods has been expansive in nature. The occupational health care units studied are in different phases of the learning process, and these processes have been different. In three units the focus was on work development; in one unit the focus was on development of the service concept. The most central problems, challenges and developmental needs during the implementation phase were related to learning and spreading of methods inside one's own unit, and during the consolidation phase to working with partners.

Healthcare-Associated Infections in Pediatrics

Healthcare-associated infections (HAIs) are known to increase the risk for patient morbidity and mortality in different healthcare settings and thereby to cause additional costs. HAIs typically affect patients with severe underlying conditions. HAIs are prevalent also among pediatric patients, but the distribution of the types of infection and the causative agents differ from those detected in adults. The aim of this study was to obtain information on pediatric HAIs in Finland through an assessment of the surveillance of bloodstream infections (BSIs), through two outbreak investigations in a neonatal intensive care unit (NICU), and through a study of postoperative HAIs after open-heart surgery. The studies were carried out at the Hospital for Children and Adolescents of Helsinki University Central Hospital. Epidemiological features of pediatric BSIs were assessed. For the outbreak investigations, case definitions were set and data collected from microbiological and clinical records. The antimicrobial susceptibilities of the Serratia marcescens and the Candida parapsilosis isolates were determined and they were genotyped. Patient charts were reviewed for the case-control and cohort studies during the outbreak investigations, as well as for the patients who acquired surgical site infections (SSIs) after having undergone open-heart surgery. Also a prospective postdischarge study was conducted to detect postoperative HAIs in these patients. During 1999-2006, the overall annual BSI rate was 1.6/1,000 patient days (range by year, 1.2–2.1). High rates (average, 4.9 and 3.2 BSIs/1,000 patient days) were detected in hematology and neonatology units. Coagulase-negative staphylococci were the most common pathogens both hospital-wide and in each patient group. The overall mortality was 5%. The genotyping of the 15 S. marcescens isolates revealed three independent clusters. All of the 26 C. parapsilosis isolates studied proved to be indistinguishable. The NICU was overcrowded during the S. marcescens clusters. A negative correlation between C. parapsilosis BSIs and fluconazole use in the NICU was detected, and the isolates derived from a single initially susceptible strain became less susceptible to fluconazole over time. Eighty postoperative HAIs, including all severe infections, were detected during hospitalization after open-heart surgery; 34% of those HAIs were SSIs and 25% were BSIs. The postdischarge study found 65 infections that were likely to be associated with hospitalization. The majority (89%) of them were viral respiratory or gastrointestinal infections, and these often led to rehospitalizations. The annual hospital-wide BSI rates were stable, and the significant variation detected in some units could not be seen in overall rates. Further studies with data adequately adjusted for risk factors are needed to assess BSI rates in the patient groups with the highest rates (hematology, neonatology). The outbreak investigations showed that horizontal transmission was common in the NICU. Overcrowding and lapses in hand hygiene probably contributed to the spreading of the pathogens. Following long-term use of fluconazole in the NICU, resistance to fluconazole developed in C. parapsilosis. Almost one-fourth of the patients who underwent open-heart surgery acquired at least one HAI. All severe HAIs were detected during hospitalization. The postdischarge study found numerous viral infections, which often caused rehospitalization.

The relationships between work stressors and organizational performance in long-term care for elderly residents

This study investigates the relationships between work stressors and organizational performance in terms of the quality of care provided by the long-term care facilities. Work stressors are first examined in relation to the unit's structural factors, resident characteristics, and to the unit specialization. The study is completed by an investigation into the associations of work stressors such as job demands or time pressure, role ambiguity, resident-related stress, and procedural injustice to organizational performance. Also the moderating effect of job control in the job demands organizational performance relationship is examined. The study was carried out in the National Research and Development Centre for Welfare and Health (STAKES). Survey data were drawn from 1194 nursing employees in 107 residential-home and health-center inpatient units in 1999 and from 977 employees in 91 units in 2002. Information on the unit resident characteristics and the quality of care was provided by the Resident Assessment Instrument (RAI). The results showed that large unit size or lower staffing levels were not consistently related to work stressors, whereas the impairments in residents' physical functioning in particular initiated stressful working conditions for employees. However, unit specialization into dementia and psychiatric residents was found to buffer the effects that the resident characteristics had on employee appraisals of work stressors, in that a high proportion of behavioral problems was related to less time pressure and role conflicts for employees in specialized units. Unit specialization was also related to improved team climates and the organizational commitment of employees. Work stressors associated with problems in care quality. Time pressure explained most of the differences between units in how the employees perceived the quality of physical and psychosocial care they provide for the residents. A high level of job demands in the unit was also found to be related to some increases in all clinical quality problems. High job control buffered the effects of job demands on the quality of care in terms of the use of restraints on elderly residents. Physical restraint and especially antipsychotic drug use were less prevalent in units that combined both high job demands and high control for employees. In contrast, in high strain units where heavy job demands coincided with a lack of control for employees, quality was poor in terms of the frequent use of physical restraints. In addition, procedural injustice was related to the frequent use of antianxiety of hypnotic drugs for elderly residents. The results suggest that both job control and procedural justice may have improved employees' abilities to cope when caring for the elderly residents, resulting in better organizational performance.

Climatic adaptation of Norway spruce (Picea abies (L.) Karsten) in Finland based on male flowering phenology.

Anthesis was studied at the canopy level in 10 Norway spruce stands from 9 localities in Finland from 1963 to 1974. Distributions of pollen catches were compared to the normal Gaussian distribution. The basis for the timing studies was the 50 per cent point of the anthesis-fitted normal distribution. Development up to this point was given in calendar days, in degree days (>5 °C) and in period units. The count of each parameter began on March 19 (included). Male flowering in Norway spruce stands was found to have more annual variation in quantity than in Scots pine stands studied earlier. Anthesis in spruce in northern Finland occurred at a later date than in the south. The heat sums needed for anthesis varied latitudinally less in spruce than in pine. The variation of pollen catches in spruce increased towards north-west as in the case of Scots pine. In the unprocessed data, calendar days were found to be the most accurate forecast of anthesis in Norway spruce both for a single year and for the majority of cases of stand averages over several years. Locally, the period unit could be a more accurate parameter for the stand average. However, on a calendar day basis, when annual deviations between expected and measured heat sums were converted to days, period units were narrowly superior to days. The geographical correlations respect to timing of flowering, calculated against distances measured along simulated post-glacial migration routes, were stronger than purely latitudinal correlations. Effects of the reinvasion of Norway spruce into Finland are thus still visible in spruce populations just as they were in Scots pine populations. The proportion of the average annual heat sum needed for spruce anthesis grew rapidly north of a latitude of ca. 63° and the heat sum needed for anthesis decreased only slighty towards the timberline. In light of flowering phenology, it seems probable that the northwesterly third of Finnish Norway spruce populations are incompletely adapted to the prevailing cold climate. A moderate warming of the climate would therefore be beneficial for Norway spruce. This accords roughly with the adaptive situation in Scots pine.

Differences in the climatic adaptation of silver birch (Betula pendula) and downy birch (B. pubescens) in Finland based on male flowering phenology.

Male flowering was studied at the canopy level in 10 silver birch (Betula pendula Roth) stands from 8 localities and in 14 downy birch (B. pubescens Ehrh.) stands from 10 localities in Finland from 1963 to 1973. Distributions of cumulative pollen catches were compared to the normal Gaussian distribution. The basis for the timing of flowering was the 50 per cent point of the anthesis-fitted normal distribution. To eliminate effects of background pollen, only the central, normally distributed part of the cumulative distribution was used. Development up to the median point of the distribution was measured and tested in calendar days, in degree days (> 5 °C) and in period units. The count of each parameter began on and included March 19. Male flowering in silver birch occurred from late April to late June depending on latitude, and flowering in downy birch took place from early May to early July. The heat sums needed for male flowering varied in downy birch stands latitudinally but there was practically no latitudinal variation in heat sums needed for silver birch flowering. The amount of male flowering in stands of both birch species were found to have a large annual variation but without any clear periodicity. The between years pollen catch variation in stands of either birch species did not show any significant latitudinal correlation in contrast to Norway spruce stands. The period unit heat sum gave the most accurate forecast of the timing of flowering for 60 per cent of the silver birch stands and for 78.6 per cent of the for downy birch stands. Calendar days, however, gave the best forecast for silver birch in 25 per cent of the cases, while degree days gave the best forecast for downy birch in 21.4 per cent of the cases. Silver birch seems to have a local inclination for a more fixed flowering date compared to downy birch, which could mean a considerable photoperiodic influence on flowering time of silver birch. Silver birch and downy birch had different geographical correlations. Frequent hybridization of birch species occurs more often in northern Finland in than in more southern latitudes. The different timing in flowering caused increasing scatter in flowering times in the north, especially in the case of downy birch. The chance of simultaneous flowering of silver birch and downy birch so increased northwards due to a more variable climate and also higher altitudinal variations. Compared with conifers, the reproduction cycles of both birch species were found to be well protected from damage by frost.

Copper Diffusion Barrier Deposition on Integrated Circuit Devices by Atomic Layer Deposition Technique

Transfer from aluminum to copper metallization and decreasing feature size of integrated circuit devices generated a need for new diffusion barrier process. Copper metallization comprised entirely new process flow with new materials such as low-k insulators and etch stoppers, which made the diffusion barrier integration demanding. Atomic Layer Deposition technique was seen as one of the most promising techniques to deposit copper diffusion barrier for future devices. Atomic Layer Deposition technique was utilized to deposit titanium nitride, tungsten nitride, and tungsten nitride carbide diffusion barriers. Titanium nitride was deposited with a conventional process, and also with new in situ reduction process where titanium metal was used as a reducing agent. Tungsten nitride was deposited with a well-known process from tungsten hexafluoride and ammonia, but tungsten nitride carbide as a new material required a new process chemistry. In addition to material properties, the process integration for the copper metallization was studied making compatibility experiments on different surface materials. Based on these studies, titanium nitride and tungsten nitride processes were found to be incompatible with copper metal. However, tungsten nitride carbide film was compatible with copper and exhibited the most promising properties to be integrated for the copper metallization scheme. The process scale-up on 300 mm wafer comprised extensive film uniformity studies, which improved understanding of non-uniformity sources of the ALD growth and the process-specific requirements for the ALD reactor design. Based on these studies, it was discovered that the TiN process from titanium tetrachloride and ammonia required the reactor design of perpendicular flow for successful scale-up. The copper metallization scheme also includes process steps of the copper oxide reduction prior to the barrier deposition and the copper seed deposition prior to the copper metal deposition. Easy and simple copper oxide reduction process was developed, where the substrate was exposed gaseous reducing agent under vacuum and at elevated temperature. Because the reduction was observed efficient enough to reduce thick copper oxide film, the process was considered also as an alternative method to make the copper seed film via copper oxide reduction.

Kertomuksia kirkon työntekijäksi kasvamisesta : Kirkon nuorisotyötä opiskelevien spiritualiteetin ja ammatillisen identiteetin muotoutuminen

The aim of the study was to analyse Church Youth Work Leader students different processes of developing their spirituality and professional identity. The study was carried out in connection with the church-orientated education at the Diaconia University of Applied Sciences (Diak). The method of the study was narrative analysis. The data consisted of stories written (N=46) and told (N=10) by students, that were collected over three years in two units of Diak. The data was analysed in two ways: first with categorical-content analysis, and then with holistic-content analysis and holistic-form reading in order to establish the comprehensive views of complete narratives. The theoretical starting-point was to regard spirituality widely, including religion and faith. In the first data analysis, this theory was focused so that spirituality was namely Christian spirituality including personal faith and worship, membership in the Christian community and persons values and ideas about the meaning of life. The results of the investigation were presented in five model narratives. The story of a social care worker represents the process of a student orientating to social work. In this story spirituality manifested as a part of social and personal identity but not as a part of professional identity. The vocation for helping people led the student to social care work. In the story of a counselor, students good connection to their home parish took a central role. They had good experiences working as young Christian volunteers, and during their studies this volunteer role became professional role. Spirituality was strongly joined to professional identity. The story of an educator represents a vocation for spiritual work and youth work in the church. In this story students also had good connections to their home parishes. Spirituality manifested as a part of personal, social and professional identity. In the story of a spiritual worker or preacher, each person s spiritual vocation was remarkable. Spirituality was extremely individual and it defined the personal, social and professional identity. Spiritual devotion caused a change in students orientation from the church to social services. The story of a searcher tells about a student who is still looking for her or his own profession. The focus of the story was on personal growth and considering one s values and the meaning of life. Spirituality was manifested in personal identity. The results indicate that the practical placements in the second academic year have an important effect on students professional orientation and professional identity. The connection to the local parish has also significant meaning for students spiritual formation and development into church professions.

Halvennettu työ : Pätkätyö ja sukupuoli sopimusyhteiskuntaa edeltävissä työmarkkinakäytännöissä

Unvalued Work. Gender and fragmented labour before national collective bargaining Systematically irregular work creates economic and social insecurity. A novelty? To think that globalisation results in unprecedented labour conditions turns out to be questionable when the idea is put in perspective. In the light of history there is nothing new in the frequency of today s short-term employment, for instance, ranking genders in labour relations in an old custom. Unvalued Work (Halvennettu työ) examines the regulation and management of labour before the time of collective bargaining. In the study present trends engage in a dialogue with empirical findings from the past. Preventing trade unions to take the initiative has been and remains an employer interest. The analysis focuses on female employment in the 1920s and 1930s. The inferences challenge to ask on what conditions the history of Finnish labour relations warrants on the whole speaking of contractual security, stable earnings and regular waged work that provides livelihood. Success in selling one s labour is not synonymous with good employment that yields decent income. Juxtaposing labour relations between the world wars and the 21st century helps us to understand the currently transforming labour market. Present policies are informed by past choices and patterns of thought. Unvalued Work (Halvennettu työ) offers instruments for making sense of today s labour relations.

Mitä hyötyä tehohoidosta? : Tehohoitoa sisältäneiden hoitojaksojen vaikuttavuuden arviointi

Intensive care is to be provided to patients benefiting from it, in an ethical, efficient, effective and cost-effective manner. This implies a long-term qualitative and quantitative analysis of intensive care procedures and related resources. The study population consists of 2709 patients treated in the general intensive care unit (ICU) of Helsinki University Hospital. Study sectors investigate intensive care patients mortality, quality of life (QOL), Quality-Adjusted Life-Years (QALY units) and factors related to severity of illness, length of stay (LOS), patient s age, evaluation period as well as experiences and memories connected with the ICU episode. In addition, the study examines the qualities of two QOL measures, the RAND 36 Item Health Survey 1.0 (RAND-36) and the 5 Item EuroQol-5D (EQ-5D) and assesses the correlation of the test results. Patients treated in 1995 responded to the RAND-36 questionnaire in 1996. All patients, treated from 1995-2000, received a QOL questionnaires in 2001, when 1 7 years had lapsed from the intensive treatment. Response rate was 79.5 %. Main Results 1) Of the patients who died within the first year (n = 1047) 66 % died during the intensive care period or within the following month. The non-survivors were more aged than the surviving patients, had generally a higher than average APACHE II and SOFA score depicting the severity of illness, their ICU LOS was longer and hospital stay shorter than of the surviving patients (p < 0.001). Mortality of patients receiving conservative treatment was higher than of those receiving surgical treatment. Patients replying to the QOL survey in 2001 (n = 1099) had recovered well: 97 % of those lived at home. More than half considered their QOL as good or extremely good, 40 % as satisfactory and 7 % as bad. All QOL indexes of those of working-age were considerably lower (p < 0.001) than comparable figures of the age- and gender-adjusted Finnish population. The 5-year monitoring period made evident that mental recovery was slower than physical recovery. 2) The results of RAND-36 and EQ-5D correlated well (p < 0.01). The RAND-36 profile measure distinguished more clearly between the different categories of QOL and their levels. EQ-5D measured well the patient groups general QOL and the sum index was used to calculate QALY units. 3) QALY units were calculated by multiplying the time the patient survived after ICU stay or expected life-years by the EQ-5D sum index. Aging automatically lowers the number of QALY units. Patients under the age of 65 receiving conservative treatment benefited from treatment to a greater extent measured in QALY units than their peers receiving surgical treatment, but in the age group 65 and over patients with surgical treatment received higher QALY ratings than recipients of conservative treatment. 4) The intensive care experience and QOL ratings were connected. The QOL indices were statistically highest for those recipients with memories of intensive care as a positive experience, albeit their illness requiring intensive care treatment was less serious than average. No statistically significant differences were found in the QOL indices of those with negative memories, no memories or those who did not express the quality of their experiences.

Microfoundations of HRM effects: Individual and Collective Attitudes and Performance

Previous research on Human Resource Management (HRM) has focused extensively on the potential relationships between the use of HRM practices and organizational performance. Extant research in HRM has been based on the underlying assumption that HRM practices can enhance organizational performance through their impact on positive employee attitudes and performance, that is, employee reactions to HRM. At the current state of research however, it remains unclear how employees come to perceive and react to HRM practices and to what extent employees in organizations, units and teams react to such practices in similar or widely different ways. In fact, recent HRM studies indicate that employee reactions to HRM may be far less homogeneous than assumed. This raises the question of whether or not the linkage between HRM and organizational outcomes can be explained by employee reactions in terms of attitudes and performance, if these reactions are largely idiosyncratic. Accordingly, this thesis aims to shed light on the processes that shape individuals’ reactions to HRM practices and how these processes may influence the variance or sharedness in such reactions among employees in organizations, units and teams. By theoretically developing and empirically examining the effects of employee perceptions of HRM practices from the perspective of ‘HRM as signaling’ and psychological contract theory, the main contributions of this thesis focus on the following research questions: i) How employee perceptions of the HRM practices relate to individual and collective employee attitudes and performance. ii) How employee perceptions of HRM practices relates to variance in employee attitudes and performance. iii) How collective employee performance mediates the relationship between employee perceptions of HRM practices and organizational performance. Regarding the first research questions the findings indicate that individuals do respond positively to HRM practices by adjusting their felt obligations towards the employer. This finding is in line with the idea of HRM as a signaling device where each HRM practice, implicitly or explicitly, sends signals to employees about promised rewards (inducements) and behaviors (obligations) expected in return. The relationship was also confirmed at the group level of analysis. What is more, variance was found to play an important role in that employee groups with more similar perceptions about the HRM system displayed a stronger relationship between HRM and employee obligations. Concerning the second question the findings were somewhat contradictory in that a strong HRM system was found negatively related to variance in employee performance but not employee obligations. Regarding the third question, the findings confirmed linkages between the HRM system and organizational performance at the group level and the HRM system and employee performance at the individual level. Also, the entire chain of links from the HRM system through variance in employee performance, and further through the level of employee performance to organizational performance was significant.

Regio- and stereoselectivity of oxidative coupling reactions of phenols : Spirodienones as construction units in lignin

Dimeric phenolic compounds lignans and dilignols form in the so-called oxidative coupling reaction of phenols. Enzymes such as peroxidases and lac-cases catalyze the reaction using hydrogen peroxide or oxygen respectively as oxidant generating phenoxy radicals which couple together according to certain rules. In this thesis, the effects of the structures of starting materials mono-lignols and the effects of reaction conditions such as pH and solvent system on this coupling mechanism and on its regio- and stereoselectivity have been studied. After the primary coupling of two phenoxy radicals a very reactive quinone me-thide intermediate is formed. This intermediate reacts quickly with a suitable nucleophile which can be, for example, an intramolecular hydroxyl group or another nucleophile such as water, methanol, or a phenolic compound in the reaction system. This reaction is catalyzed by acids. After the nucleophilic addi-tion to the quinone methide, other hydrolytic reactions, rearrangements, and elimination reactions occur leading finally to stable dimeric structures called lignans or dilignols. Similar reactions occur also in the so-called lignification process when monolignol (or dilignol) reacts with the growing lignin polymer. New kinds of structures have been observed in this thesis. The dimeric com-pounds with so-called spirodienone structure have been observed to form both in the dehydrodimerization of methyl sinapate and in the beta-1-type cross-coupling reaction of two different monolignols. This beta-1-type dilignol with a spirodienone structure was the first synthetized and published dilignol model compound, and at present, it has been observed to exist as a fundamental construction unit in lignins. The enantioselectivity of the oxidative coupling reaction was also studied for obtaining enantiopure lignans and dilignols. A rather good enantioselectivity was obtained in the oxidative coupling reaction of two monolignols with chiral auxiliary substituents using peroxidase/H2O2 as an oxidation system. This observation was published as one of the first enantioselective oxidative coupling reaction of phenols. Pure enantiomers of lignans were also obtained by using chiral cryogenic chromatography as a chiral resolution technique. This technique was shown to be an alternative route to prepare enantiopure lignans or lignin model compounds in a preparative scale.

Determinants of outcome in critically ill patients

Assessment of the outcome of critical illness is complex. Severity scoring systems and organ dysfunction scores are traditional tools in mortality and morbidity prediction in intensive care. Their ability to explain risk of death is impressive for large cohorts of patients, but insufficient for an individual patient. Although events before intensive care unit (ICU) admission are prognostically important, the prediction models utilize data collected at and just after ICU admission. In addition, several biomarkers have been evaluated to predict mortality, but none has proven entirely useful in clinical practice. Therefore, new prognostic markers of critical illness are vital when evaluating the intensive care outcome. The aim of this dissertation was to investigate new measures and biological markers of critical illness and to evaluate their predictive value and association with mortality and disease severity. The impact of delay in emergency department (ED) on intensive care outcome, measured as hospital mortality and health-related quality of life (HRQoL) at 6 months, was assessed in 1537 consecutive patients admitted to medical ICU. Two new biological markers were investigated in two separate patient populations: in 231 ICU patients and 255 patients with severe sepsis or septic shock. Cell-free plasma DNA is a surrogate marker of apoptosis. Its association with disease severity and mortality rate was evaluated in ICU patients. Next, the predictive value of plasma DNA regarding mortality and its association with the degree of organ dysfunction and disease severity was evaluated in severe sepsis or septic shock. Heme oxygenase-1 (HO-1) is a potential regulator of apoptosis. Finally, HO-1 plasma concentrations and HO-1 gene polymorphisms and their association with outcome were evaluated in ICU patients. The length of ED stay was not associated with outcome of intensive care. The hospital mortality rate was significantly lower in patients admitted to the medical ICU from the ED than from the non-ED, and the HRQoL in the critically ill at 6 months was significantly lower than in the age- and sex-matched general population. In the ICU patient population, the maximum plasma DNA concentration measured during the first 96 hours in intensive care correlated significantly with disease severity and degree of organ failure and was independently associated with hospital mortality. In patients with severe sepsis or septic shock, the cell-free plasma DNA concentrations were significantly higher in ICU and hospital nonsurvivors than in survivors and showed a moderate discriminative power regarding ICU mortality. Plasma DNA was an independent predictor for ICU mortality, but not for hospital mortality. The degree of organ dysfunction correlated independently with plasma DNA concentration in severe sepsis and plasma HO-1 concentration in ICU patients. The HO-1 -413T/GT(L)/+99C haplotype was associated with HO-1 plasma levels and frequency of multiple organ dysfunction. Plasma DNA and HO-1 concentrations may support the assessment of outcome or organ failure development in critically ill patients, although their value is limited and requires further evaluation.

Acute renal failure in critically ill patients : With special reference to prediction of outcome

Acute renal failure (ARF) is a clinical syndrome characterized by rapidly decreasing glomerular filtration rate, which results in disturbances in electrolyte- and acid-base homeostasis, derangement of extracellular fluid volume, and retention of nitrogenous waste products, and is often associated with decreased urine output. ARF affects about 5-25% of patients admitted to intensive care units (ICUs), and is linked to high mortality and morbidity rates. In this thesis outcome of critically ill patients with ARF and factors related to outcome were evaluated. A total of 1662 patients from two ICUs and one acute dialysis unit in Helsinki University Hospital were included. In study I the prevalence of ARF was calculated and classified according to two ARF-specific scoring methods, the RIFLE classification and the classification created by Bellomo et al. (2001). Study II evaluated monocyte human histocompatibility leukocyte antigen-DR (HLA-DR) expression and plasma levels of one proinflammatory (interleukin (IL) 6) and two anti-inflammatory (IL-8 and IL-10) cytokines in predicting survival of critically ill ARF patients. Study III investigated serum cystatin C as a marker of renal function in ARF and its power in predicting survival of critically ill ARF patients. Study IV evaluated the effect of intermittent hemodiafiltration (HDF) on myoglobin elimination from plasma in severe rhabdomyolysis. Study V assessed long-term survival and health-related quality of life (HRQoL) in ARF patients. Neither of the ARF-specific scoring methods presented good discriminative power regarding hospital mortality. The maximum RIFLE score for the first three days in the ICU was an independent predictor of hospital mortality. As a marker of renal dysfunction, serum cystatin C failed to show benefit compared with plasma creatinine in detecting ARF or predicting patient survival. Neither cystatin C nor plasma concentrations of IL-6, IL-8, and IL-10, nor monocyte HLA-DR expression were clinically useful in predicting mortality in ARF patients. HDF may be used to clear myoglobin from plasma in rhabdomyolysis, especially if the alkalization of diuresis does not succeed. The long-term survival of patients with ARF was found to be poor. The HRQoL of those who survive is lower than that of the age- and gender-matched general population.