Venous thromboembolism and obstruction after pacemaker implantation. - A Prospective Study of 150 Consecutive Cardiac Pacing Device Implantations

Background: Pacemaker implantation (PMI) may predispose to venous thromboembolism (VTE) and obstruction (VO). This prospective study aimed at quantifying changes in venous calibers, and at determining the incidence of symptomatic and asymptomatic VTE/VO after PMI. Further goals included an assessment of the role of transesophageal echocardiography (TEE) in the diagnosis of lead-related central venous thrombi (CVT), and determination of predictors for VTE/VO. Methods: 150 (mean age 67; 61% male) consecutive patients with first PMI were enrolled and followed for 6 months. Contrast venography was performed at baseline and 6 months after PMI to measure venous diameters, and to detect stenosis, total occlusions and thrombi. TEE was conducted in 66 patients. Based on clinical suspicion, work-up for pulmonary embolism (PE) or acute deep vein thrombosis (DVT) were performed as needed. A total of 50 cases underwent longer-term (mean 2.4 years) follow-up venography. All cases with VTE/VO during the initial 6 months, and their matched controls, were selected for a case-control study focused on possible predictive role of laboratory and patient-related factors for the development of VTE/VO. Results: 10 (7 %) patients were found to have baseline venous abnormalities (e.g. 8 obstructions). Mean venous diameters diminished significantly during the first 6 months, but no further reduction occurred in late follow-up. New VO was discovered in 19 patients (14 %; 14 stenosis, 5 total occlusions; all asymptomatic). Small non-obstructive thrombi were found in 20/140 (14 %) 6-month venograms. TEE at 6 months disclosed CVT in 6 (9 %) patients. One (0.7 %) patient had acute symptomatic upper-extremity DVT, and PE was discovered in 5/150 (3.3 %) patients during the first 6 months with no further cases thereafter. At 6 months, the total number of cases with VTE/VO amounted to 47 (31.3 %). Additionally, the later 2-year venograms (n=50) disclosed 4 (8 %) total occlusions and 1 (2 %) stenosis. In the case-control study, no parameter was predictive of venous end-points as a single variable, but there appeared to be significant clustering of traditional VTE risk-factors among the cases. Laboratory parameters showed a definite acute hypercoagulative state induced by PMI, but its degree did not predict subsequent development of VTE/VO. Conclusions: This study shows that VTE/VO is relatively common after PMI with an overall incidence of at least 30 %. Although the majority of the lesions are asymptomatic and clinically benign, cases of PE were also encountered, and totally occluded veins may hamper future upgrading or replacement of pacing system. Venous complications seem difficult to prognosticate as firm predictors were not identified from a wide range of parameters analyzed in this study, although clustering of classic VTE risk factors may be a predisposing factor. Parameters related to implantation procedure or pacing systems and the severity of implantation-induced trauma did not emerge as predictors.

Airway surgery for obstructive sleep apnea and partial upper airway obstruction during sleep

This study analyzed the feasibility and efficacy of surgical therapies in patients with sleep-disordered breathing ranging from partial upper airway obstruction during sleep to severe obstructive sleep apnea syndrome. The surgical procedures evaluated were tracheostomy, laser-assisted uvulopalatoplasty (LUPP) and uvulopalatopharyngoplasty (UPPP) with laser or ultrasound scalpel. Obstructive sleep apnea and partial upper airway obstruction during sleep were measured with the static charge-sensitive bed (SCSB) and pulse oximeter. The patients with severe obstructive sleep apnea syndrome were treated with tracheostomy. Palatal surgery was performed only if the upper airway narrowing occurred exclusively at the soft palate level in patients with partial upper airway obstruction during sleep. The ultrasound scalpel technique was compared to laser-assisted UPPP. The efficacy of LUPP to reduce partial upper airway obstruction during sleep was assessed and histology of uvulopalatal specimen was compared to body fat distributional parameters and sleep study findings. Tracheostomy was effective therapy in severe obstructive sleep apnea. Partial upper airway obstruction and arterial oxyhemoglobin desaturation index during sleep decreased significantly after LUPP. The minimal retropalatal airway dimension increased and soft palate collapsibility decreased at the level where the velopharyngeal obstruction had occurred before the surgery. Ultrasound scalpel did not offer any significant benefits over the laser-assisted technique, except fewer postoperative haemorrhage events. The loose connective tissue as a manifestation of edema was the only histological finding showing correlation with partial upper airway obstruction parameters of SCSB. Tracheostomy remains a life-saving therapy and also long-term option when adherence to CPAP fails in patients with obstructive sleep apnea syndrome. LUPP effectively reduces partial upper airway obstruction during sleep provided that obstruction at the other levels than the soft palate and uvula were preoperatively excluded. Technically the ultrasound scalpel or laser surgeries are equal. In patients with partial upper airway obstruction the loose connective tissue is more important than fat accumulation in the soft palate. This supports the hypothesis that edema is a primary trigger for aggravation of upper airway narrowing during sleep at the soft palate level and evolution towards partial or complete upper airway obstruction during sleep.

Sleep-Disordered Breathing in Women

Sleep-disordered breathing (SDB) is underdiagnosed in women, probably due to the different gender-related manifestation. We investigated the differences in presentation, symptoms and co-morbidities of SDB in men and in pre- and postmenopausal women by a clinical, retrospective, cross-sectional study of 601 consecutively referred women and 233 age- and BMI-matched male-female pairs studied with the static-chargesensitive bed (SCSB) and an oximeter. Data on the use of nasal CPAP were gathered from the Paimio hospital database, and the co-morbidity information was based on reimbursed medication data from the National Agency for Medicines and the Social Insurance institution. The abnormal breathing episodes at night were more frequent in men than in women, and in postmenopausal women compared to premenopausal ones. Partial upper airway obstruction was the most common type of SDB in both genders but especially in females. BMI and the major symptoms of SDB were similar in pre- and postmenopausal women, and a menopause effect on symptoms was not found. CPAP adherence did not differ between symptomatic patients with partial upper airway obstruction and those presenting with conventional obstructive sleep apnea. Comorbidities were more frequent in SDB patients than in the general Finnish population. Compared to sleep apnea, partial upper airway obstruction was associated with a threefold prevalence of asthma and/or COPD in both genders, and with a 60% reduced prevalence of hypertension in females matched for age and BMI. Our results emphasize that partial upper airway obstruction is not a milder form of SDB but a different entity, the severity of which is underestimated when using the conventional apnea-hypopnea index. It seems clinically relevant to diagnose and treat the co-morbidities and SDB also in patients with partial upper airway obstruction, especially in elderly and symptomatic women.

A Practical Micro Mechanical Model Based Local Approach Methodology for the Analysis of Ductile Fracture of Welded T-Joints

This thesis concentrates on developing a practical local approach methodology based on micro mechanical models for the analysis of ductile fracture of welded joints. Two major problems involved in the local approach, namely the dilational constitutive relation reflecting the softening behaviour of material, and the failure criterion associated with the constitutive equation, have been studied in detail. Firstly, considerable efforts were made on the numerical integration and computer implementation for the non trivial dilational Gurson Tvergaard model. Considering the weaknesses of the widely used Euler forward integration algorithms, a family of generalized mid point algorithms is proposed for the Gurson Tvergaard model. Correspondingly, based on the decomposition of stresses into hydrostatic and deviatoric parts, an explicit seven parameter expression for the consistent tangent moduli of the algorithms is presented. This explicit formula avoids any matrix inversion during numerical iteration and thus greatly facilitates the computer implementation of the algorithms and increase the efficiency of the code. The accuracy of the proposed algorithms and other conventional algorithms has been assessed in a systematic manner in order to highlight the best algorithm for this study. The accurate and efficient performance of present finite element implementation of the proposed algorithms has been demonstrated by various numerical examples. It has been found that the true mid point algorithm (a = 0.5) is the most accurate one when the deviatoric strain increment is radial to the yield surface and it is very important to use the consistent tangent moduli in the Newton iteration procedure. Secondly, an assessment of the consistency of current local failure criteria for ductile fracture, the critical void growth criterion, the constant critical void volume fraction criterion and Thomason's plastic limit load failure criterion, has been made. Significant differences in the predictions of ductility by the three criteria were found. By assuming the void grows spherically and using the void volume fraction from the Gurson Tvergaard model to calculate the current void matrix geometry, Thomason's failure criterion has been modified and a new failure criterion for the Gurson Tvergaard model is presented. Comparison with Koplik and Needleman's finite element results shows that the new failure criterion is fairly accurate indeed. A novel feature of the new failure criterion is that a mechanism for void coalescence is incorporated into the constitutive model. Hence the material failure is a natural result of the development of macroscopic plastic flow and the microscopic internal necking mechanism. By the new failure criterion, the critical void volume fraction is not a material constant and the initial void volume fraction and/or void nucleation parameters essentially control the material failure. This feature is very desirable and makes the numerical calibration of void nucleation parameters(s) possible and physically sound. Thirdly, a local approach methodology based on the above two major contributions has been built up in ABAQUS via the user material subroutine UMAT and applied to welded T joints. By using the void nucleation parameters calibrated from simple smooth and notched specimens, it was found that the fracture behaviour of the welded T joints can be well predicted using present methodology. This application has shown how the damage parameters of both base material and heat affected zone (HAZ) material can be obtained in a step by step manner and how useful and capable the local approach methodology is in the analysis of fracture behaviour and crack development as well as structural integrity assessment of practical problems where non homogeneous materials are involved. Finally, a procedure for the possible engineering application of the present methodology is suggested and discussed.

Separation of Gas Bubbles from Circulation Waters and Pulp Suspensions in Open Channel Flow

The objective of this thesis was to study the removal of gases from paper mill circulation waters experimentally and to provide data for CFD modeling. Flow and bubble size measurements were carried out in a laboratory scale open gas separation channel. Particle Image Velocimetry (PIV) technique was used to measure the gas and liquid flow fields, while bubble size measurements were conducted using digital imaging technique with back light illumination. Samples of paper machine waters as well as a model solution were used for the experiments. The PIV results show that the gas bubbles near the feed position have the tendency to escape from the circulation channel at a faster rate than those bubbles which are further away from the feed position. This was due to an increased rate of bubble coalescence as a result of the relatively larger bubbles near the feed position. Moreover, a close similarity between the measured slip velocities of the paper mill waters and that of literature values was obtained. It was found that due to dilution of paper mill waters, the observed average bubble size was considerably large as compared to the average bubble sizes in real industrial pulp suspension and circulation waters. Among the studied solutions, the model solution has the highest average drag coefficient value due to its relatively high viscosity. The results were compared to a 2D steady sate CFD simulation model. A standard Euler-Euler k-ε turbulence model was used in the simulations. The channel free surface was modeled as a degassing boundary. From the drag models used in the simulations, the Grace drag model gave velocity fields closest to the experimental values. In general, the results obtained from experiments and CFD simulations are in good qualitative agreement.

Objective Evaluation of Nasal Dimensions in Children with Acoustic Rhinometry

Aims: This study was carried out to investigate the usefulness of acoustic rhinometry in the evaluation of intranasal dimensions in children. The aim was to define reference values for school children. In addition, the role of the VAS scale in the subjective evaluation of nasal obstruction in children was studied. Materials and methods: Measurements were done with Acoustic Rhinometry A1. The values of special interest were the minimal cross-sectional area (MCA) and the anterior volume of the nose (VOL). The data for reference values included 124 voluntary school children with no permanent nasal symptoms, aged between 7 and 14 years. Data were collected at baseline and after decongestion of the nose; the VAS scale was filled in before measurements. The subjects in the follow-up study (n=74, age between 1 and 12 years) were receiving intranasal spray of insulin or placebo. The nasal symptoms were recorded and acoustic rhinometry was measured at each control visit. Results: In school children, the mean total MCA was 0.752 cm2 (SD 0.165), and the mean total VOL was 4.00 cm3 (SD 0.63) at baseline. After decongestion, a significant increase in the mean TMCA and in the mean TVOL was found. A correlation was found between TMCA and age, and between TVOL and height of a child. There was no difference between boys and girls. A correlation was found between unilateral acoustic values and VAS at baseline, but not after decongestion. No difference wasfound in acoustic values or symptoms between the insulin and placebo group in the follow-up study of two years. Conclusions: Acoustic rhinometry is a suitable objective method to examine intranasal dimensions in children. It is easy to perform and well tolerated. Reference values for children between 7 and 14 years were established.

Verhopäällystyspastojen analyysimenetelmät

Diplomityön tarkoitus oli selvittää verhopäällystyspastoille sopivia analyysimenetelmiä. Verhopäällystyksessä onnistunut päällystystapahtuma vaatii venymäviskositeetin ja pintajännityksen hyvää hallintaa. Kirjallisuusosassa käsiteltiin verhopäällystystä, verhopäällystyspastojen koostumusta, reologiaa ja pintajännitystä. Kirjallisuusosassa käsiteltiin lisäksi verhopäällystyspastojen reologian ja pintajännityksen mittaamiseen soveltuvia mittausmenetelmiä. Verhopäällystyksen luonteen vuoksi kirjallisuusosassa syvennyttiin venymäviskositeetin ja dynaamisen pintajännityksen mittaamiseen tarkoitettuihin menetelmiin. Kokeellisessa osassa tutkittiin päällystyspastasarjojen reologiaa ja pintajännitystä verhopäällystystä varten. Osaan päällystyspastoista luotiin venymäviskositeettia ja osasta laskettiin pintajännitystä. Venymäviskositeetin mittaamista varten työssä käytettiin ACAV A2 -reometriin liitettyjä teräsreikälevyjä. Dynaamisen pintajännityksen mittaamista varten työssä käytettiin KSV BPA-800P -pintajännitysmittaria. ACAV A2 -reometriin liitettyjen teräsreikälevyjen (reiän sisähalkaisija 0,5 tai 0,7 mm) avulla mitattiin venymäviskositeettia kuvaavia Eulerin lukuarvoja onnistuneesti suurilla kiintoainepitoisuuksilla (50, 60 tai 65 p %). Erikoispaksuntajan määrää lisäämällä onnistuttiin luomaan huomattavaa venymäviskositeettia. Kiintoainepitoisuuden kasvaessa kasvoi myös venymäviskositeetti. Tavanomaisille paksuntajille mitattiin hieman kohonneita venymäviskositeetteja verrattuna referenssipäällystyspastaan. Pigmenttikoostumuksella (kalsiumkarbonaatti/kaoliini) ei näyttänyt olevan vaikutusta venymäviskositeettiin, tai vaikutus oli suhteellisen pieni. Dynaamisen pintajännityksen mittaamista varten käytössä ollut KSV BPA-800P -pintajännitysmittari ei toiminut luotettavasti, vaikka näytteitä laimennettiin. Kiintoainepitoisuudessa 10 p-% olleilla laimennoksilla saavutettiin analysoinnin kannalta parhaat tulokset. Tuloksista saatiin kuitenkin viitteitä, että kyseinen mittari voisi olla potentiaalinen menetelmä dynaamisen pintajännityksen mittaamiseksi.

A multibody dynamic model of the cross-country ski-skating technique

The objective of this thesis is the development of a multibody dynamic model matching the observed movements of the lower limb of a skier performing the skating technique in cross-country style. During the construction of this model, the formulation of the equation of motion was made using the Euler - Lagrange approach with multipliers applied to a multibody system in three dimensions. The description of the lower limb of the skate skier and the ski was completed by employing three bodies, one representing the ski, and two representing the natural movements of the leg of the skier. The resultant system has 13 joint constraints due to the interconnection of the bodies, and four prescribed kinematic constraints to account for the movements of the leg, leaving the amount of degrees of freedom equal to one. The push-off force exerted by the skate skier was taken directly from measurements made on-site in the ski tunnel at the Vuokatti facilities (Finland) and was input into the model as a continuous function. Then, the resultant velocities and movement of the ski, center of mass of the skier, and variation of the skating angle were studied to understand the response of the model to the variation of important parameters of the skate technique. This allowed a comparison of the model results with the real movement of the skier. Further developments can be made to this model to better approximate the results to the real movement of the leg. One can achieve this by changing the constraints to include the behavior of the real leg joints and muscle actuation. As mentioned in the introduction of this thesis, a multibody dynamic model can be used to provide relevant information to ski designers and to obtain optimized results of the given variables, which athletes can use to improve their performance.

Numerical Simulation of Stochastic Di erential Equations

Stochastic differential equation (SDE) is a differential equation in which some of the terms and its solution are stochastic processes. SDEs play a central role in modeling physical systems like finance, Biology, Engineering, to mention some. In modeling process, the computation of the trajectories (sample paths) of solutions to SDEs is very important. However, the exact solution to a SDE is generally difficult to obtain due to non-differentiability character of realizations of the Brownian motion. There exist approximation methods of solutions of SDE. The solutions will be continuous stochastic processes that represent diffusive dynamics, a common modeling assumption for financial, Biology, physical, environmental systems. This Masters' thesis is an introduction and survey of numerical solution methods for stochastic differential equations. Standard numerical methods, local linearization methods and filtering methods are well described. We compute the root mean square errors for each method from which we propose a better numerical scheme. Stochastic differential equations can be formulated from a given ordinary differential equations. In this thesis, we describe two kind of formulations: parametric and non-parametric techniques. The formulation is based on epidemiological SEIR model. This methods have a tendency of increasing parameters in the constructed SDEs, hence, it requires more data. We compare the two techniques numerically.

Excessive functions, Appell polynomials and optimal stopping

The main topic of the thesis is optimal stopping. This is treated in two research articles. In the first article we introduce a new approach to optimal stopping of general strong Markov processes. The approach is based on the representation of excessive functions as expected suprema. We present a variety of examples, in particular, the Novikov-Shiryaev problem for Lévy processes. In the second article on optimal stopping we focus on differentiability of excessive functions of diffusions and apply these results to study the validity of the principle of smooth fit. As an example we discuss optimal stopping of sticky Brownian motion. The third research article offers a survey like discussion on Appell polynomials. The crucial role of Appell polynomials in optimal stopping of Lévy processes was noticed by Novikov and Shiryaev. They described the optimal rule in a large class of problems via these polynomials. We exploit the probabilistic approach to Appell polynomials and show that many classical results are obtained with ease in this framework. In the fourth article we derive a new relationship between the generalized Bernoulli polynomials and the generalized Euler polynomials.

Clinical and genetic markers in disease progression – a study among subjects with obstructive lung diseases

Asthma, COPD, and asthma and COPD overlap syndrome (ACOS) are chronic pulmonary diseases with an obstructive component. In COPD, the obstruction is irreversible and the disease is progressive. The aim of the study was to define and analyze factors that affected disease progression and patients’ well-being, prognosis and mortality in Chronic Airway Disease (CAD) cohort. The main focus was on COPD and ACOS patients. Retrospective data from medical records was combined with genetic and prospective follow-up data. Smoking is the biggest risk factor for COPD and even after the diagnosis of the disease, smoking plays an important role in disease development and patient’s prognosis. Sixty percent of the COPD patients had succeeded in smoking cessation. Patients who had managed to quit smoking had lower mortality rates and less psychiatric diseases and alcohol abuse although they were older and had more cardiovascular diseases than patients who continued smoking. Genetic polymorphism rs1051730 in the nicotinic acethylcholine receptor gene (CHRNA3/5) associated with heavy smoking, cancer prevalence and mortality in two Finnish independent cohorts consisting of COPD patients and male smokers. Challenges in smoking cessation and higher mortality rates may be partly due to individual patient’s genetic composition. Approximately 50% of COPD patients are physically inactive and the proportion was higher among current smokers. Physically active and inactive patients didn’t differ from each other in regard to age, gender or comorbidities. Bronchial obstruction explained inactivity only in severe disease. Subjective sensation of dyspnea, however, had very strong association to inactivity and was also associated to low health related quality of life (HRQoL). ACOS patients had a significantly lower HRQoL than either the patients with asthma or with COPD even though they were younger than COPD patients, had better lung functions and smaller tobacco exposure.

Hiljaisen tiedon hyödyntäminen verkostoituneen yrityksen ict-ryhmässä

Työn alustavana tavoitteena oli havaita yrityksen ict-ryhmässä käytettävien teknisten välineiden, informaation hallinnan järjestelmien ja ryhmän työtilojen vaikutus hiljasen tiedon jakamiseen tai sen estymiseen. Työssä tarkasteltiin myös vaikutusta ryhmän oppimiseen sekä ryhmään muodostuvan hiljaisen tiedon syntymisen ja henkilöitymisen syihin sekä hiljaisen tiedon laatuun. Lisäksi työssä pyritään löytämään tapoja, joiden avulla hiljaista tietoa voidaan hyödyntää ja jakaa ryhmässä siten että se mahdollistaa myös ryhmän oppimisen. Haastatteluissa nousivat esiin informaation hallintaongelmat, jotka johtuvat informaation hajautumisesta informaation eri hallinta järjestelmiin, tietoturvamääräysten aiheuttamiin esteisiin ja kriittisen teknisen dokumentaation tallentamiseen. Nämä vaikeuttavat tallennetun informaation hyödyntämistä ict-ryhmässä. Tämä osaltaan aiheuttaa hiljaisen tiedon henkilöitymistä ryhmässä ja hiljaisen tiedon jakamisen menetelmien jää hyödyntämättä. Haastatteluissa osoittautui, että hiljaisen tiedon hyödyntämisongelmat johtuvat osittain ryhmän sisäisten yhteyksien verkoston rakenteesta. Vahvojen linkkien vähyys ryhmässä ja vahvojen linkkien suuntautuminen ryhmän ulkoisiin verkostoihin vaikeuttaa hiljaisen tiedon siirtymistä ryhmässä ja aiheuttaa hiljaisen tiedon henkilöitymistä. Kiire todettiin ryhmän kannalta ongelmalliseksi hiljaisen tiedon jakamisen ja hyödyntämisen esteeksi. Tiedon adaptaatioon ja omaksumiseen liittyvät ongelmat ovat sidoksissa aikaan ja hiljaisen tiedon henkilöitymiseen ryhmässä. Ryhmätyö ja ryhmän päivittäisessä toiminnassa käytettävissä olevat hiljaisen tiedon jakamisen menetelmät osoittautuvat sopivimmiksi edistämään ryhmän yhteistyökykyä sekä sosiaalisen rakenteen ja luottamuksen kehittymistä. Ne poistavat myös tiedon omaksumisen ja adaptaation esteitä. Ryhmätyö vaikuttaa myönteisesti ryhmän kollektiiviseen osaamiseen ja ryhmän hiljaisen tiedon kehittymiseen. Lisäksi se parantaa teknisen dokumentaation ymmärrettävyyttä.