Infective Endocarditis in a Finnish Teaching Hospital. 25 Years of Experience of Adult Patients

Infektiivinen endokardiitti yliopistollisessa keskussairaalassa vuosina 1980-2004 hoidetuilla aikuispotilailla Tausta: Infektiivinen endokardiitti on edelleen vakava sairaus. Huolimatta siitä, että taudin diagnostiikka ja hoito ovat kehittyneet, siihen liittyy edelleen merkittävää sairastuvuutta ja kuolleisuutta. Endokardiitin taudinkuvassa on viime vuosina tapahtunut muutoksia monissa maissa. Tavoitteet: Tutkia endokardiitin kliinista kuvaa ja ennustetta suomalaisessa yliopistosairaalassa vuosina 1980-2004 endokardiitin vuoksi hoidetuilla aikuispotilailla. Aineisto: Osatyössä I endokardiitin todennäköisyyttä analysoitiin 222:lla vuosina 1980-1995 endokardiittiepäilyn vuoksi hoidetulla potilaalla käyttäen apuna sekä Duken että von Reyn diagnostisia kriteereitä. Osatyössä II tutkittiin endokardiittiin liittyviä neurologisia komplikaatioita 218 varmassa tai mahdollisessa endokardiittiepisodissa. Osatyössä III tutkittiin seerumin C-reaktiivisen proteiinin (CRP) käyttökelpoisuutta hoitovasteen arvioinnissa 134:ssä varmaksi luokitellussa endokardiittiepisodissa. Osatyössä IV tutkittiin yleisbakteeri-PCRmenetelmän käyttökelpoisuutta etiologisessa diagnostiikassa 56:lla endokardiittiepäilyn vuoksi leikatulla potilaalla. Osatöissä V ja VI analysoitiin kaikki vuosina 1980-2004 hoidetut 303 endokardiittipotilasta lyhytaikais- ja 1-vuotisennusteen suhteen sekä tutkittiin endokardiitin taudinkuvassa tapahtuneita muutoksia sairaalassamme. Tulokset: Duken kriteerit osoittautuivat von Reyn kriteereitä herkemmiksi endokardiitin diagnostiikassa: 243 tutkitusta episodista 114 luokiteltiin varmoiksi endokardiiteiksi Duken kriteereillä, kun vastaavasti ainoastaan 64 luoteltiin varmoiksi von Reyn kriteereillä (p<0.001). Lisäksi peräti 115 episodissa endokardiitin diagnoosi hylättiin von Reyn kriteereillä, kun diagnoosi hylättiin Duken kriteereillä ainoastaan 37 episodissa (p<0.001). Neurologinen komplikaatio ilmeni ennen mikrobilääkehoidon aloittamista 76 %:ssa episodeja ollen ensimmäinen oire 47 %:ssa. Kuolema oli merkitsevästi yhteydessä neurologisiin komplikaatioihin. Hoitovastetta seurattaessa seerumin CRP:n lasku oli merkitsevästi nopeampaa komplikaatioitta toipuvilla potilailla kuin niillä, joille kehittyi komplikaatioita tai jotka menehtyivät tautiinsa. PCR-tutkimus poistetusta läpästä antoi ainoana menetelmänä etiologisen diagnoosin neljässä tapauksessa (2 stafylokokkilajia, 1 Streptococcus bovis,1 Bartonella quintana), joissa kaikissa mikrobilääkehoito oli ollut käytössä ennen näytteiden ottamista. Koko aineistossa kahden läpän infektio tai neurologisten komplikaatioiden, perifeeristen embolioiden tai sydämen vajaatoiminnan kehittyminen ennustivat sekä sairaalakuolleisuutta että 1-vuotiskuolleisuutta, kun taas ≥65 vuoden ikä ja sydämen ultraäänitutkimuksessa todettu vegetaatio tai Duken luokittelun mukainen pääkriteeri ennustivat kuolemaa vuoden sisällä. Korkea CRP-taso sairaalaan tullessa ennusti sekä sairaalakuolleisuutta että 1-vuotiskuolleisuutta. Huumeiden käyttäjien endokardiitit lisääntyivät tutkimusaikana merkitsevästi (p<0.001). Päätelmät: Tässä työssä vahvistetaan Duken kriteerien käyttökelpoisuus endokardiitin diagnostiikassa. Lisäksi vahvistui käsitys, että nopea diagnoosi ja mikrobilääkehoidon aloittaminen ovat parhaat keinot ehkäistä neurologisia komplikaatioita ja parantaa endokardiittipotilaiden ennustetta. CRP:n normalisoituminen on endokardiittipotilailla hyvän ennusteen merkki. Suoraan läppäkudoksesta tehty PCR-tutkimus on hyödyllinen, kun taudin aiheuttaja on kasvuominaisuuksiltaan vaativa tai potilas on saanut mikrobilääkehoitoa ennen viljelynäytteiden ottamista. Muutamat aiemmissa tutkimuksissa todetut huonon ennusteen merkit ennustavat huonoa ennustetta myös tämän tutkimuksen potilailla. Uutena löydöksenä ilmeni, että korkea CRP-arvo sairaalaan tullessa merkitsee sekä huonoa lyhyt- että pitkäaikaisennustetta. Huumeiden käyttäjien endokardiittien ilmaantuminen on tärkein epidemiologinen muutos 25 vuoden tutkimusaikana.

Origins of production errors and significance of employee empowerment in reducing production error amount in sheet metal fabricating industry

The market place of the twenty-first century will demand that manufacturing assumes a crucial role in a new competitive field. Two potential resources in the area of manufacturing are advanced manufacturing technology (AMT) and empowered employees. Surveys in Finland have shown the need to invest in the new AMT in the Finnish sheet metal industry in the 1990's. In this run the focus has been on hard technology and less attention is paid to the utilization of human resources. In manymanufacturing companies an appreciable portion of the profit within reach is wasted due to poor quality of planning and workmanship. The production flow production error distribution of the sheet metal part based constructions is inspectedin this thesis. The objective of the thesis is to analyze the origins of production errors in the production flow of sheet metal based constructions. Also the employee empowerment is investigated in theory and the meaning of the employee empowerment in reducing the overall production error amount is discussed in this thesis. This study is most relevant to the sheet metal part fabricating industrywhich produces sheet metal part based constructions for electronics and telecommunication industry. This study concentrates on the manufacturing function of a company and is based on a field study carried out in five Finnish case factories. In each studied case factory the most delicate work phases for production errors were detected. It can be assumed that most of the production errors are caused in manually operated work phases and in mass production work phases. However, no common theme in collected production error data for production error distribution in the production flow can be found. Most important finding was still that most of the production errors in each case factory studied belong to the 'human activity based errors-category'. This result indicates that most of the problemsin the production flow are related to employees or work organization. Development activities must therefore be focused to the development of employee skills orto the development of work organization. Employee empowerment gives the right tools and methods to achieve this.

Tuutulaulu

Soitinnus: lauluääni, piano.

Historia Regiae Academiae Aboensis

Invocatio: I.N.J.

Rukoile ja työtä tee. Onni Puhakan kehitys innovaattorista oman tien kulkijaksi

Pray and work. The development of Onni Puhakka: from innovator to nonconformist This ethnological biographical study examines the modernization which began in the mid-1800s, continued into the mid-1900s, and has changed Finnish society in many ways. This era has been studied on a general level quite extensively, but this work explores the life and everyday experiences of Onni Puhakka (1870−1955), a farmer who spent most of his life in the town of Liperi. The goal is to find new perspectives on the development of the modernization process in society through the experiences of an individual. In this study, a central theme is the rural co-operative movement represented in Finland by Pellervo as well as its development in this country and as a significant undertaking in Onni Puhakka’s life. The co-operative movement was one of the most significant sectors affecting modernization in rural communities. The main character in the study is the grandfather of the present author, and thus this research belongs to the newly accepted ethnological research tradition of studying one’s own community. Written documents, mainly collected and preserved by Onni Puhakka himself during his lifetime, form the research material. The material consists mainly of Puhakka’s extensive correspondence, personal notes and diaries, documents related to his farm, and photographs taken by him. Earlier research and other written material examining the general development of the period were used to provide a background for the study. The co-operative movement formed a comprehensive ideology for Onni Puhakka, in which the possibilities for the development of both individuals and the community were combined. His life was based on a religious conviction, and he felt that the co-operative movement was the application of Christian love for one’s neighbour in practice. At the beginning of his active working career, Puhakka was an innovator, a reformer at the forefront of progress, but quite soon he became a sworn critic of the development of the co-operative movement in particular. One of Puhakka’s criticisms of the co-operative movement was the shifting of decision-making power to professional managers and central organizations, far from the reach of local actors. A fundamental reason for his dissatisfaction was the development within the co-operative movement in which the ideological background was forgotten, and economic goals and making a profit took an excessive significance. This assessment of the co-operative movement made by Onni Puhakka and his predictions about its development were not unfounded. This has been shown by several studies examining the development of both the Pellervo and working class cooperative movements. The professionalization of management, managerialism, as well as the direct links between professional managers of local co-operatives and central organizations have lead to the situation in which fewer and fewer people make the decisions, and management has as its goal economic success and growth. Co-operative enterprises that have grown in size have become estranged from the everyday life of their members. Instead of taking care of relations with the membership of the co-op, competitive ability and the market share have become the most important concerns of the management. As the membership has become alienated, their interest in large-scale co-ops has also become largely economic. A significant change among the membership of the Pellervo movement occurred at the stage when the co-operative movement shifted from rural areas to urban centres. This meant that the commitment of the membership became much looser than it had been in the farmers’ production and consumer co-ops. From the point of view of its members, the nature of the co-operative movement has become diametrically opposed to its point of departure: the active members who previously formed the subject of the co-operative movement have become the object of the economic activities of that same movement. The co-operative movement has been transformed from the progressive agent of change of its early years into a business activity which no longer has any significant task as a social reformer. This study confirms the observations of the latest research on modernization which states that modernization has not been a straightforward and inevitable development that has lead to the present situation. For example, the criticism directed by Puhakka toward the co-operative movement includes information that shows that a few others who were initially actively involved also criticized the development of the movement. Despite his occasional frustration, Onni Puhakka continued his criticism and attempts to get the co-operative movement to change its course and return to its ‘roots’. In the early years of the cooperative movement he probably did not differ much from the other pioneers in the sense that many of them had adopted and internalized the same values and motive for being involved that he had. However, Puhakka differed from his colleagues in the sense that he was able to believe in what he called the “fundamental values” of the co-operative movement longer than many of them.

Kansalaisyhteiskunnat uskontojen, valtion ja filantropian virittämässä kentässä

kirjallisuusarvostelu

Simulation of structural stress history based on dynamic analysis

Modern machine structures are often fabricated by welding. From a fatigue point of view, the structural details and especially, the welded details are the most prone to fatigue damage and failure. Design against fatigue requires information on the fatigue resistance of a structure’s critical details and the stress loads that act on each detail. Even though, dynamic simulation of flexible bodies is already current method for analyzing structures, obtaining the stress history of a structural detail during dynamic simulation is a challenging task; especially when the detail has a complex geometry. In particular, analyzing the stress history of every structural detail within a single finite element model can be overwhelming since the amount of nodal degrees of freedom needed in the model may require an impractical amount of computational effort. The purpose of computer simulation is to reduce amount of prototypes and speed up the product development process. Also, to take operator influence into account, real time models, i.e. simplified and computationally efficient models are required. This in turn, requires stress computation to be efficient if it will be performed during dynamic simulation. The research looks back at the theoretical background of multibody dynamic simulation and finite element method to find suitable parts to form a new approach for efficient stress calculation. This study proposes that, the problem of stress calculation during dynamic simulation can be greatly simplified by using a combination of floating frame of reference formulation with modal superposition and a sub-modeling approach. In practice, the proposed approach can be used to efficiently generate the relevant fatigue assessment stress history for a structural detail during or after dynamic simulation. In this work numerical examples are presented to demonstrate the proposed approach in practice. The results show that approach is applicable and can be used as proposed.

Inventering den 31.12.1945 av förråden av konsumtionsförnödenheter

21 x 29 cm

Kulutustarvikevarastojen inventointi 31.12.1945

21 x 29 cm