Aggression and its Management in Adolescent Forensic Psychiatric Care

The overall goal of this study was to explore and identify good aggression management methods and on that basis to produce recommendations for aggression management in the adolescent forensic setting. The study was conducted in three phases. In Phase I, staff’s (n = 58) perception of adolescent aggressive behaviour and methods to manage it was examined. In Phase II, staff’s (n = 30) perception of treatment settings and treatment interventions available were studied. In Phase III, the effectiveness of an aggression management programme was evaluated. The data were collected during the period 2004-2007. Participants perceived adolescent aggressive behaviour in a similar way and described aggressive behaviour as being a comprehensible phenomenon. Management methods used to control aggressive situations were alike, although the practical solutions varied between the study units, especially regarding coercive methods. Staff members proposed more time and better opportunities to discuss and evaluate the aggression situation in order to improve the methods used. The treatment settings were similar in studied forensic units and interventions were primarily focused on psychological aspects, including management of aggressive behavior. A comprehensive aggression management programme proved to be effective in decreasing incidents of violence. The use of coercive methods in aggression situations decreased and injuries to the staff became less frequent. If staff members intend to apply high quality management methods in aggression situations they have to share a consistent understanding of aggressive behaviour and need to be aware of the various methods available. In addition, they should learn more about assessment methods in order to improve aggression management. International comparison of aggression, methods for managing it and service provision creates a starting point for developing equal care provision and realization within and between European countries.

Developing Service-based Solutions for Water Treatment in Finnish Mining Industry

The aim of this master’s thesis is to analyze the mining industry customers' current and future needs for the water treatment services and discover new business development opportunities in the context of mine water treatment. In addition, the study focuses on specifying service offerings needed and evaluate suitable revenue generation models for them. The main research question of the study is: What kind of service needs related to water treatment can be identified in the Finnish mining industry? The literature examined in the study focused on industrial service classification and new service development process as well as the revenue generation of services. A qualitative research approach employing a case study method was chosen for the study. The present study uses customer and expert interviews as primary data source, complemented by archival data. The primary data was gathered by organizing total of 13 interviews, and the interviews were analyzed by using qualitative content analysis. The abductive-logic was chosen as the way of conducting scientific reasoning in this study. As a result, new service proposals were developed for Finnish mine industry suppliers. The main areas of development were on asset efficiency services and process support services. The service needs were strongly associated with suppliers’ know-how of water treatment process optimization, cost-effectiveness as well as on alternative technologies. The study provides an insight for managers that wish to pursue a water treatment services as a part of their business offering.

Coercion, Perceived Care and Quality of Life Among Patients in Psychiatric Hospitals

The goals of the study were to describe patients’ perceptions of care after experiencing seclusion/restraint and their quality of life. The goal was moreover to identify methodological challenges related to studies from the perspective of coerced patients. The study was conducted in three phases between September 2008 and April 2012. In the first phase, the instrument Secluded/ Restrained Patients’ Perception of their Treatment (SR-PPT) was developed and validated in Japan in cooperation with a Finnish research group (n = 56). Additional data were collected over one year from secluded/restrained patients using the instrument (n = 90). In the second phase, data were collected during the discharge process (n = 264). In the third phase, data were collected from electronic databases. Methodological and ethical issues were reviewed (n = 32) using systematic review method. Patients perceived that co-operation with the staff was poor; patients’ opinions were not taken into account, treatment targets collated and treatment methods were seen in different ways. Patients also felt that their concerns were not well enough understood. However, patients received getting nurses’ time. In particular, seclusion/restraint was considered unnecessary. The patients felt that they benefited from the isolation in treating their problems more than they needed it, even if the benefit was seen to be minor. Patients treated on forensic wards rated their treatment and care significantly lower than in general units. During hospitalization secluded/restrained patients evaluated their quality of life, however, better than did non-secluded/restrained patients. However, no conclusion is drawn to the effect that the better quality of life assessment is attributable to the seclusion/restraint because patients’ treatment period after the isolation was long and because of many other factors, as rehabilitation, medication, diagnostic differences, and adaptation. According to the systematic mixed studies review variation between study designs was found to be a methodological challenge. This makes comparison of the results more difficult. A research ethical weakness is conceded as regards descriptions of the ethical review process (44 %) and informed consent (32 %). It can be concluded that patients in psychiatric hospital care and having a voice as an equal expert require special attention to clinical nursing, decision-making and service planning. Patients and their family members will be consulted in plans of preventive and alternative methods for seclusion and restraint. The study supports the theory that in ethical decision-making situations account should be taken of medical indications, in addition to the patients’ preferences, the effect of treatment on quality of life, and this depends on other factors. The connection between treatment decisions and a patient’s quality of life should be evaluated more structurally in practice. Changing treatment culture towards patients’ involvement will support daily life in nursing and service planning taking into account improvements in patients’ quality of life.

Starting Insulin Treatment in Type 2 Diabetes

Type 2 diabetes is a disorder of glucose metabolism characterized by chronic hyperglycemia. Initially type 2 diabetes is characterized by insulin resistance and impaired function of beta cells, leading progressively to insulin deficiency. Type 2 diabetes is treated with diet and other lifestyle changes, and with medication modulating e.g. insulin resistance, liver glucose production and insulin secretion. Injectable insulin is added to the treatment when lifestyle changes and other medication are insufficient to maintain adequate control of hyperglycemia. The aim of the treatment is to remove the symptoms of diabetes and to prevent late complications of diabetes. Insulin was traditionally started at hospital wards, but from the early 1990’s also in outpatient care. The first substudy of this thesis examined retrospectively initiation practices and how successfully insulin treatment was introduced in 1990 – 1996 in Southwestern Finland. This study aimed also at identifying the best methods of controlling plasma glucose. It showed that in the 1990’s the incidence of insulin treatment increased and was initiated more often in outpatient care than previously. The use of combination treatment also increased, first with sulfonylureas and later with metformin as the oral drug. In combination therapy the insulin dose was smaller than with insulin monotherapy. HbA1c improved similarly in middle-aged and older age groups. Weight increase associated with insulin initiation was smaller when combined with oral agents. A prospective insulin initiation study (1994 – 1998) tested the hypothesis that hyperglycemia (fasting and postprandial hyperglycemia) may affect the outcome of insulin initiation. The type of hyperglycemia was determined by the relation of fasting plasma glucose to HbA1c. Treatment was initiated with insulin Lente or human NPH insulin. In patients treated with insulin monotherapy twice daily the decline in HbA1c was markedly greater for postprandial than fasting hyperglycemia patients suggesting that hyperglycemia type has significance in the selection of the insulin regimen. Another insulin initiation study showed that patients with fasting hyperglycemia starting on insulin (2004-2005) were significantly more prone to overweight than patients with postprandial hyperglycemia. Irrespective of the insulin preparation (insulin NPH or insulin glargine), patients with fasting hyperglycemia had a greater weight increase compared to patients with postprandial hyperglycemia. Special attention should be paid to prevention of weight increase in these patients.

From statin efficacy to everyday effectiveness: Studying the gap in between.

Statins are indicated for preventing cardiovascular disease events. Patients with diabetes have a risk of major cardiovascular events double the risk of their peers without diabetes. Thus, clinical treatment guidelines recommend statins for the management of diabetic dyslipidemia. The evidence base for statin use in cardiovascular disease derives from the randomized controlled statin trials designed to prove statin efficacy under ideal conditions, among a homogenous study population meeting strict trial eligibility criteria. This thesis was implemented as four pharmacoepidemiological statin studies using register data on realworld statin users. The overall purpose was to evaluate the trends, patterns and effectiveness of statin use in everyday life. More specifically, nationwide secular trends in statin use in Finland were analysed, especially among patient groups which had been underrepresented in the statin trials. Furthermore, the benchmarking statin trials in diabetes, the Heart Protection Study and the Collaborative Atorvastatin Diabetes Study, were evaluated for their representativeness for real-world diabetes care with the emphasis placed on adherence to statin use. The association between good adherence and the incidence of major cardiovascular events in the real-world was further investigated in diabetes. These studies demonstrate that statin initiations increased from 1995 to 2005 in Finland. The increase was most pronounced among those aged at least 75 years and was observed already before the publication of rigorous trial data conducted in elderly subjects. Thus, statins seem to have been initiated in clinical practice also going beyond the strict trial eligibility criteria. Nonetheless, low adherence to statin use among the real-world patients with diabetes was found not only to limit the representativeness of the trials for clinical care but also to attenuate in all likelihood their benefits in the real-world. In fact, good adherence to statin use was found to associate with a decreased risk for major cardiovascular events in patients with diabetes. In conclusion, these studies highlight the importance of good adherence to statin use in clinical practice in order to obtain the full therapeutic value demonstrated in the statin trials. Simply increasing the number of statin users will not alone suffice in sharing our common resources appropriately.

Westerners in search of the legendary potion : ayahuasca travel in the borderland between tourism and pilgrimage

The thesis examines the phenomenon most commonly known as “ayahuasca tourism” – i.e. the practice of westerners traveling to South America and partaking in ceremonies in which a powerful entheogenic brew, ayahuasca, is consumed. While this popular phenomenon has been steadily increasing during the last decades, it has, however, been insufficiently studied by scholars. An important question which has not been properly addressed in earlier studies is how ayahuasca tourism relates to the wider occurrence of travel and how it should be perceived with reference to the theoretical frameworks on the subject of travel. Drawing on theories regarding pilgrimage and tourism, the main purpose of this thesis is to examine the relationship between ayahuasca tourism and the broader spectrum of travel. In particular, the study tests the designations “pilgrimage”, “religious tourism” and “spiritual tourism” with reference to ayahuasca tourism. Utilizing earlier literature as well as ayahuasca tourists‟ reports obtained from an Internet forum as a basis for analysis, I search for a suitable terminology to be used for the phenomenon. The study lays special emphasis on the protagonists‟ motivations, experiences and outcomes in order to take note of various aspects of the wide-ranging occurrence of ayahuasca tourism. Key findings indicate that ayahuasca tourism is best understood as a combination of pilgrimage and tourism. On the basis of the analysis I argue that ayahuasca tourism should be labeled as “pilgrimage” and/or “spiritual tourism”, and the tourists respectively as “pilgrims” and/or “spiritual tourists”. The category of “religious tourism/tourist”, on the other hand, turns out to be an inappropriate designation when describing the phenomenon. In general, through my study I show that the results are consistent with the present trend in the study of travel to perceive pilgrimage and tourism as theoretically similar phenomena. The study of ayahuasca tourism serves thus as living proof of contemporary travel, in which the categories of pilgrimage and tourism are often indistinguishable. I suggest that ayahuasca tourism is by no means exceptional on this point, but can rather be used as an illustration of modern travel forms on a general level. Thus, the present study does not only add to the research of ayahuasca tourism, but also provides additional insights into the study of travel.

Economics of Power-to-Gas integration to wastewater treatment plant

Solar and wind power produce electricity irregularly. This irregular power production is problematic and therefore production can exceed the need. Thus sufficient energy storage solutions are needed. Currently there are some storages, such as flywheel, but they are quite short-term. Power-to-Gas (P2G) offers a solution to store energy as a synthetic natural gas. It also improves nation’s energy self-sufficiency. Power-to-Gas can be integrated to an industrial or a municipal facility to reduce production costs. In this master’s thesis the integration of Power-to-Gas technologies to wastewater treatment as a part of the VTT’s Neo-Carbon Energy project is studied. Power-to-Gas produces synthetic methane (SNG) from water and carbon dioxide with electricity. This SNG can be considered as stored energy. Basic wastewater treatment technologies and the production of biogas in the treatment plant are studied. The utilisation of biogas and SNG in heat and power production and in transportation is also studied. The integration of the P2G to wastewater treatment plant (WWTP) is examined mainly from economic view. First the mass flows of flowing materials are calculated and after that the economic impact based on the mass flows. The economic efficiency is evaluated with Net Present Value method. In this thesis it is also studied the overall profitability of the integration and the key economic factors.