Early detection of severe sepsis in the emergency room in adults - Clinical utility of prognostic markers

Vaikean sepsiksen varhainen tunnistaminen päivystyspoliklinikalla – merkkiaineiden käyttökelpoisuus aikuispotilaiden arvioinnissa Päivystyspotilaan vakavan yleisinfektion eli sepsiksen varhainen tunnistaminen ja taudin vaikeusasteen arviointi on päivystävälle lääkärille tärkeä haaste. Arvioimme prospektiivisessa kohorttitutkimuksessa eri merkkiaineiden hyödyllisyyttä sepsiksen varhaisessa tunnistamisessa ja vaikeusasteen arvioinnissa. Työssä I ja III oli 539 päivystyspotilasta, joilta kliinikko päätti ottaa veriviljelyn sepsistä epäillen. Tutkimuksessa II oli 525 potilasta ja tutkimuksessa IV 537 potilasta. Tutkimuksessa I plasman C-reaktiivisen proteiinin (CRP) pitoisuuksia verrattiin plasman prokalsitoniinin (PCT) ja interleukiinin (IL-6) pitoisuuksiin. Tutkimuksessa II verrattiin plasman baktersidisen/ permeabiliteettia lisäävän proteiinin (BPI), ryhmän IIA fosfolipaasi A2:n (PLA2GIIA) ja CRP:n pitoisuuksia sekä valkosolujen määriä toisiinsa. Tutkimuksessa III arvioitiin liukoisen urokinaasi-tyyppisen plasminogeenin aktivaattorireseptorin (suPAR) ja tutkimuksessa IV pentraksiini 3:n (PTX3) määrityksen käyttökelpoisuutta. Tutkimuksessa I todettiin päivystystilanteessa mitattujen korkeiden PCT - ja IL-6 - pitoisuuksien ennustavan vaikean sepsiksen kehittymistä paremmin kuin korkean CRP:n. Tutkimuksessa II plasman PLA2GIIA vaikutti hiukan paremmalta vaikean sepsiksen ennustajalta kuin CRP tai veren valkosolutaso, mutta BPI ei ollut hyödyllinen. Tutkimuksessa III korkea plasman suPAR- pitoisuus osoittautui itsenäiseksi kuolleisuuden riskitekijäksi ja se liittyi myös vaikean sepsiksen kehittymiseen. Tutkimuksessa IV korkea PTX3 - pitoisuus toimi samaan tapaan kuin suPAR. Kokonaisuutena PCT osoittautui parhaaksi merkkiaineeksi ennustamaan elinhäiriön kehittymistä ja suPAR kuolleisuutta. PTX3 ei tarjonnut merkittävää lisäetua PCT:iin ja suPAR:iin verrattuna. CRP osoitti suhteellisen hyvin bakteeri-infektion esiintymistä, mutta ennusteellista arvoa sillä ei ollut. suPAR on kiinnostava kuolleisuuden ja elinhäiriön kehittymisen merkkiaine.

School Bullies’ Quest for Power: Implications for Group Dynamics and Intervention

Bullying is characterized by an inequality of power between perpetrator and target. Findings that bullies can be highly popular have helped redefine the old conception of the maladjusted school bully into a powerful individual exerting influence on his peers from the top of the peer status hierarchy. Study I is a conceptual paper that explores the conditions under which a skillful, socially powerful bully can use the peer group as a means of aggression and suggests that low cohesion and low quality of friendships make groups easier to manipulate. School bullies’ high popularity should be a major obstacle for antibullying efforts, as bullies are unlikely to cease negative actions that are rewarding, and their powerful position could discourage bystanders from interfering. Using data from the Finnish program KiVa, Study II supported the hypothesis that antibullying interventions are less effective with popular bullies in comparison to their unpopular counterparts. In order to design interventions that can address the positive link between popularity and aggression, it is necessary to determine in which contexts bullies achieve higher status. Using an American sample, Study III examined the effects of five classroom features on the social status that peers accord to aggressive children, including classroom status hierarchy, academic level and grade level, controlling for classroom mean levels of aggression and ethnic distribution. Aggressive children were more popular and better liked in fifth grade relative to fourth grade and in classrooms of higher status hierarchy. Surprisingly, the natural emergence of status hierarchies in children’s peer groups has long been assumed to minimize aggression. Whether status hierarchies hinder or promote bullying is a controversial question in the peer relations’ literature. Study IV aimed at clarifying this debate by testing the effects of the degree of classroom status hierarchy on bullying. Higher hierarchy was concrrently associated with bullying and predictive of higher bullying six months later. As bullies’ quest for power is increasingly acknowledged, some researchers suggest teaching bullies to attain the elevated status they yearn for through prosocial acts. Study V cautions against such solutions by reviewing evidence that prosocial behaviors enacted with the intention of controlling others can be as harmful as aggression.

Periprocedural prognostic factors in coronary interventions – retrospective studies

Background: Approximately 11,000 revascularization procedures, either percutaneous coronary interventions (PCI) or coronary artery bypass grafting surgery (CABG), are performed yearly in Finland for coronary artery disease. Periprocedural risk factors for mortality and morbidity as well as long-term outcome have been extensively studied in general populations undergoing revascularization. Treatment choice between PCI and CABG in many high risk groups and risk-stratification, however, needs clarification and there is still room for improvement in periprocedural outcomes. Materials and methods: Cohorts of patients from Finnish hospitals revascularized between 2001 and 2011 were retrospectively analyzed. Patient records were reviewed for baseline variables and postprocedural outcomes (stroke, myocardial infarction, quality of life measured by the EQ-5D –questionnaire, repeat revascularization, bleeding episodes). Data on date and mode of death was acquired from Statistics Finland. Statistical analysis was performed to identify predictors of adverse events and compare procedures. Results: Postoperative administration of blood products (red blood cells, fresh frozen plasma, platelets) after isolated CABG independently and dose-dependently increases the risk of stroke. Patients 80 years or older who underwent CABG had better survival at 5 years compared to those who underwent PCI. After adjusting for baseline differences survival was similar. Patients on oral anticoagulation (OAC) for atrial fibrillation (AF) treated with CABG had better survival and overall outcome at 3 years compared to PCI patients. There was no difference in incidence of stroke or bleeding episodes. Differences in outcome remained significant after adjusting for propensity score. Lower health-related quality of life (HRQOL) scores as measured by the visual analogue scale (VAS) of the EQ-5D questionnaire at 6 months after CABG predicted later major adverse cardiac and cerebrovascular events (MACCE). Deteriorating function and VAS scores between 0 and 6 months on the EQ-5D also independently predicted later MACCE. Conclusions: Administration of blood products can increase the risk of stroke after CABG and liberal use of transfusions should be avoided. In the frail subpopulations of patients on OAC and octogenarians CABG appears to offer superior long-term outcome as compared to PCI. Deteriorating HRQOL scores predict later adverse events after CABG. Keywords: percutaneous coronary intervention, coronary artery bypass grafting, age over 80, transfusion, anticoagulants, coronary artery disease, health-related quality of life, outcome.

Customer orientation of sales personnel: Implications for service quality

Prior customer orientation research has concentrated mainly on studying the economical potential of customer orientation to companies. Service quality research instead has concentrated on emphasizing the evaluation of service quality from the customer’s perspective. This means that the service providers lack important information regarding customer orientation and service quality they would need for managerial purposes such as selecting and training employees. Therefore, there is an emerging need to study how customer orientation and service quality relate to company processes, policies and employees, and this study answers to those calls. The objective of this study was to examine what is the role of sales personnel’s’ customer orientation in quality of service delivery and what features support the development of customer orientation among sales personnel. Also the components customer orientation were studied extensively in order to understand how they relate to service quality. The empiric part of the study was conducted as a qualitative research by interviewing seven sales people from operative, tactical and strategic levels of the case corporation in order to get a broader view for customer orientation. The findings propose that both organizational factors and individual factors are affecting customer orientation construct inseparably. Organizational factors are bundled in this study under standards, support and systems, whereas individual factors are formed of employees’ personal attributes, motivation and self-perceived decision making authority. The findings suggest that in the service delivery process at an operative level, customer orientation appears largely in the employees’ individualistic characteristics. Their social and technical skills and motivation to serve customers are the most identifiable factors for customer orientation and consequently, quality service. However, organizational standards, support and systems are strongly dictating the frames the operative sales people operate in, having an influence on how the employees are experiencing their decision making authority and in the end, customer orientation. When looking at the service delivery process at tactical and strategic levels, customer orientation is affecting mainly in the organizational constructs through setting standards, support and systems. However, tactical and strategic level employees influence the operative level through individual customer orientation components as well. The findings indicate that their emotion and personal interaction skills are affecting the overall service delivery process mainly through supervisor support and motivation of the operative level employees. Based on this study it can be argued that an organization can operate as a facilitator and create certain frames for customer oriented sales behavior through standards, support and systems. However, as the impact of individual customer orientation factors on sales people’s service quality seems decisive, from an organizational perspective it puts pressures on the recruitment.

Prognostic Factors In Breast Cancer. With Special Reference to Cyclins A, B1, D1 and E, MMP-1 and Decorin

Breast cancer is a highly heterogenous malignancy, which despite of the similar histological type shows different clinical behaviour and response to therapy. Prognostic factors are used to estimate the risk for recurrence and the likelihood of treatment effectiveness. Because breast cancer is one of the most common causes of cancer death in women worldwide, identification of new prognostic markers are needed to develop more specific and targeted therapies. Cancer is caused by uncontrolled cell proliferation. The cell cycle is controlled by specific proteins, which are known as cyclins. They function at important checkpoints by activating cyclin-dependent kinase enzymes. Overexpression of different cyclins has been linked to several cancer types and altered expression of cyclins A, B1, D1 and E has been associated with poor survival. Little is known about the combined expression of cyclins in relation to the tumour grade, breast cancer subtype and other known prognostic factors. In this study cyclins A, B1 and E were shown to correlate with histological grade, Ki-67 and HER2 expression. Overexpression of cyclin D1 correlated with receptor status and non-basal breast cancer suggesting that cyclin D1 might be a marker of good prognosis. Proteolysis in the surrounding tumour stroma is increased during cancer development. Matrix metalloproteinases (MMPs) are proteolytic enzymes that are capable of degrading extracellular matrix proteins. Increased expression and activation of several MMPs have been found in many cancers and MMPs appear to be important regulators of invasion and metastasis. In this study MMP-1 expression was analysed in breast cancer epithelial cells and in cancer associated stromal cells. MMP-1 expression by breast cancer epithelial cells was found to carry an independent prognostic value as did Ki-67 and bcl-2. The results suggest that in addition to stromal cells MMP-1 expression in tumour cells control breast cancer progression. Decorin is a small proteoglycan and an important component of the extracellular matrix. Decorin has been shown to inhibit growth of tumour cells and reduced decorin expression is associated with a poor prognosis in several cancer types. There has been some suspicion wheather different cancer cells express decorin. In this study decorin expression was shown to localize only in the cells of the original stroma, while breast cancer epithelial cells were negative for decorin expression. However, transduction of decorin in decorin-negative human breast cancer cells markedly modulated the growth pattern of these cells. This study provides evidence that targeted decorin transduction to breast cancer cells could be used as a novel adjuvant therapy in breast malignancies.

Intracranial Nimodipine Implant: Feasibility and Implications for the Treatment of Subarachnoid Hemorrhage – A Pre-Clinical Study

Intracranial aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition requiring immediate neurocritical care. A ruptured aneurysm must be isolated from arterial circulation to prevent rebleeding. Open surgical clipping of the neck of the aneurysm or intra-arterial filling of the aneurysm sack with platinum coils are major treatment strategies in an acute phase. About 40% of the patients suffering from aSAH die within a year of the bleeding despite the intensive treatment. After aSAH, the patient may develop a serious complication called vasospasm. Major risk for the vasospasm takes place at days 5–14 after the primary bleeding. In vasospasm, cerebral arteries contract uncontrollably causing brain ischemia that may lead to death. Nimodipine (NDP) is used to treat of vasospasm and it is administrated intravenously or orally every four hours for 21 days. NDP treatment has been scientifically proven to improve patients’ clinical outcome. The therapeutic effect of L-type calcium channel blocker NDP is due to the ability to dilate cerebral arteries. In addition to vasodilatation, recent research has shown the pleiotropic effect of NDP such as inhibition of neuronal apoptosis and inhibition of microthrombi formation. Indeed, NDP inhibits cortical spreading ischemia. Knowledge of the pathophysiology of the vasospasm has evolved in recent years to a complex entity of early brain injury, secondary injuries and cortical spreading ischemia, instead of being pure intracranial vessel spasm. High NDP levels are beneficial since they protect neurons and inhibit the cortical spreading ischemia. One of the drawbacks of the intravenous or oral administration of NPD is systemic hypotension, which is harmful particularly when the brain is injured. Maximizing the beneficial effects and avoiding systemic hypotension of NDP, we developed a sustained release biodegradable NDP implant that was surgically positioned in the basal cistern of animal models (dog and pig). Higher concentrations were achieved locally and lower concentrations systemically. Using this treatment approach in humans, it may be possible to reduce incidence of harmful hypotension and potentiate beneficial effects of NDP on neurons. Intracellular calcium regulation has a pivotal role in brain plasticity. NDP blocks L-type calcium channels in neurons, substantially decreasing intracellular calcium levels. Thus, we were interested in how NDP affects brain plasticity and tested the hypothesis in a mouse model. We found that NDP activates Brain-derived neurotrophic factor (BDNF) receptor TrkB and its downstream signaling in a reminiscent of antidepressant drugs. In contrast to antidepressant drugs, NDP activates Akt, a major survival-promoting factor. Our group’s previous findings demonstrate that long-term antidepressant treatment reactivates developmental-type of plasticity mechanisms in the adult brain, which allows the remodeling of neuronal networks if combined with appropriate rehabilitation. It seems that NDP has antidepressant-like properties and it is able to induce neuronal plasticity. In general, drug induced neuronal plasticity has a huge potential in neurorehabilitation and more studies are warranted.

Making home rules for mother tongues : the legal implications of linguistic diversity in the design of autonomy regimes

Principen om nationalismen där det politiska och det nationella är samspelt kan vara av markant betydelse för uppbyggande av autonomiska regimer. Likaså tillåter decentralicering och delegering av befogenheter för språk och utbildning (officiellt erkännande av språk, standardisering av språk, undervisningsspråk och relaterade läroplaner) formning av identiteter inom dessa autonomiska regimer. Resultatet är en ofullkomlig cirkulär relation där språk, samfund och politiska institutioner ömsesidigt och kontinuerligt formar varandra: lingvistiskt mångfald prägar och formger autonomiska ordningar och vice-versa. De juridiska implikationerna av territoriella och icke-territoriella former av autonomi är dock av en annan art. Emedan territoriell autonomi bygger på idéen om ett eventuellt inkluderande hemland för lingvistiska grupper, vars vistelseort är avgörande, förstärker den icke-territoriella autonomin idéen om ett exclusivt samfund bestående av själv-identifierade medlemmar som är kapabla till självstyre oavsett territoriella gränser. Denna avhandling utgör an analys av sådana juridiska implikationer genom komparativa och institutionella analyser. Avhandlingen föreslår som resultat en serie av normativa och pragmatiska rekommendationer inriktade på att främja demokratiseringsprocesser i linje med principer om multikulturalism.

2014 Ukraine crisis – Implications for corporate crisis management

In the late year 2013 events started to unfold in Ukraine’s capital city Kiev that would change the political and economic environment of the EU and Russia. The tension had been building for years between the two parties with Ukraine in the middle and during 2014 the tension blew up and events started to escalate into a crisis, which we now know as the 2014 Ukraine crisis. The crisis would include political, economic, and even military actions by all the parties involved with Ukraine slipping close to civil war. Both political and economic hardships followed for others as well with both the EU and Russia placing heavy political and economic sanctions on each other. Most notably in terms of this paper, the Russian federation placed total import embargo sanctions on food imports from the EU and some other countries. This meant that a Finnish dairy company, Valio, had to engage in corporate crisis management as almost a fifth of its total revenue was cut in a heartbeat. Valio had been prepared for some kind of complications with their Russian market as events started to unfold in Ukraine in the beginning of 2014 but never did they suspect that a complete shutdown of the Russian market would follow. The company is still recovering after more than a year after the sanctions were posed and have not been able to supplement the lost revenue streams. This research is a qualitative research aiming to find answers to the main questions: 1) What is the 2014 Ukraine crisis and what kind of special implications does it have and 2) How did the crisis affect Valio and how did Valio fare in its crisis management efforts. The data has been collected both from secondary document sources and primary sources. The main findings of this research are that the political and economic environment of the EU and Russia has gone through a profound change during the years 2013-2015. The companies and governments should re-evaluate what kind of environment they are now facing and what kinds of risks the new situation poses. This also calls for a deep academic analysis from the academic community. In corporate crisis management of Valio the main findings are that the former literature has looked into crisis management as one-time occurrence but the new crises and global events would call for a more on-going crisis analysis and active crisis management. Thus, corporate crisis management should be viewed as a cycle. Valio specifically handled the situation surprisingly well, considering that their revenue was indeed cut by a fifth. The main aspects of crisis management, which Valio did not handle as well, concern the learning curve of crisis management. They could be doing more in order to prepare for future crises better by learning from this experience. The situation is then still on-going in the autumn 2015 both in Ukraine and within Valio.

Climate Change and Ethics of Geoengineering -- Implications Of Climate Emergency Ethics

Global climate change and intentional climate modification, i.e. geoengineering include various ethical problems which are entangled as a complex ensemble of questions regarding the future of the biosphere. The possibilities of catastrophic effects of climate change which are also called “climate emergency” have led to the emergence of the idea of modifying the atmospheric conditions in the form of geoengineering. The novel issue of weather ethics is a subdivision of climate ethics, and it is interested in ethical and political questions surrounding weather and climate control and modification in a restricted spatio-temporal scale. The objective of geoengineering is to counterbalance the adverse effects of climate change and its diverse corollaries in various ways on a large scale. The claim of this dissertation is that there are ethical justifications to claim that currently large-scale interventions to the climate system are ethically questionable. The justification to pursue geoengineering on the basis of considering its pros and cons, is inadequate. Moral judgement can still be elaborated in cases where decisions have to be made urgently and the selection of desirable choices is severely limited. The changes needed to avoid severe negative impacts of climate change requires commitment to mitigation as well as social changes because technical solutions cannot address the issue of climate change altogether. The quantitative emphasis of consumerism should shift to qualitative focus on the aspiration for simplicity in order to a move towards the objective of the continuation of the existence of humankind and a flourishing, vital biosphere.