Paul and death : a study in psychological coping

The present investigation looks into the attitudes toward death in Paul’s authentic letters, and puts them in relation to modern theories of psychological coping. Drawing on psychologically-oriented hermeneutic theory, and theories about psychological coping in particular, I argue that each case of psychological coping must be understood in its historical situation as strategies emanating from a specific person’s subjective appraisal (cf. Pargament, Lazarus and Folkman). Paul’s letters frequently refer to persecution and violent death. To aid in psychological coping is often integral to the purpose of the letters, which makes the perspective of psychological coping akin to their genre. In the course of a tentatively assumed chronological order of 1 Thessalonians, Galatians, 1 Corinthians, 2 Corinthians, Romans, Philippians, and Philemon, Paul moves from the perception of Jesus dying for the faithful to the understanding of dying with Jesus. His coping strategies concerning death are gradually transformed from conservative and deferring coping styles, to a more self-directing coping style, to collaborative and transformative coping styles, and finally to a new sense of deferring coping style in prison. The last case of deferring coping carries the traits of generosity and flexibility even in the face of death, which is in contrast to his previous letters. Through his correspondence, we see Paul’s attitude toward death transformed from denial to reaction, to processing, to acceptance (cf. Lindemann, Kübler-Ross, Bowlby, Parkes, among others). His strategies also shift in accordance with these understandings. Denial is accompanied by diversion, threat by aggression, processing by rumination, and acceptance by joy. The study shows the hermeneutic benefits of reading Paul’s letters as the rhetorically framed expressions of a person in a particular historical situation. The letters open small windows through which we can glimpse the coping process of a person of antiquity. In adopting the method of psychological exegesis, the study shows that the variety of attitudes toward death in Paul’s letters makes sense from the perspective of psychological coping. The psychological aspect of these letters is an underexamined richness that can extend into areas of contemporary individual and group identity, and from there to public policy and ethics.

Survival and Quality of Life among Patients with Severe Lower Extremity Peripheral Arterial Disease

Lower extremity peripheral arterial disease (PAD) is associated with decreased functional status, diminished quality of life (QoL), amputation, myocardial infarction, stroke, and death. Nevertheless, public awareness of PAD as a morbid and mortal disease is low. The aim of this study was to assess the incidence of major lower extremity amputation due to PAD, the extent of reamputations, and survival after major lower extremity amputation (LEA) in a population based PAD patient cohort. Furthermore, the aim was to assess the functional capacity in patients with LEA, and the QoL after lower extremity revascularization and major amputation. All 210 amputees due to PAD in 1998–2002 and all 519 revascularized patients in 1998–2003 were explored. 59 amputees alive in 2004 were interviewed using a structured questionnaire of QoL. Two of each amputee age-, gender- and domicile-matched controls filled in and returned postal self-administered QoL questionnaire as well as 231 revascularized PAD patients (the amount of these patients who engaged themselves to the study), and one control person for each patient completed postal self-administered QoL questionnaire. The incidence rate of major LEA was 24.1/100 000 person-years and it was considerably high during the years studied. The one-month mortality rate was 21%, 52% at one-year, and the overall mortality rate was 80%. When comparing the one-year mortality risk of amputees, LEAs were associated with a 7.4-fold annual mortality risk compared with the reference population in Turku. Twenty-two patients (10%) had ipsilateral transversions from BK to AK amputation. Fifty patients (24%) ended up with a contralateral major LEA within two to four amputation operations. Three bilateral amputations were performed at the first major LEA operation. Of the 51 survivors returning home after their first major LEA, 36 (71%) received a prosthesis; (16/36, 44%) and were able to walk both in- and outdoors. Of the 68 patients who were discharged to institutional care, three (4%) had a prosthesis one year after LEA. Both amputees and revascularized patients had poor physical functioning and significantly more depressive symptoms than their controls. Depressive symptoms were more common in the institutionalized amputees than the home-dwelling amputees. The surviving amputees and their controls had similar life satisfaction. The amputees felt themselves satisfied and contented, whether or not they lived in long-term care or at home. PAD patients who had undergone revascularizations had poorer QoL than their controls. The revascularized patients’ responses on their perceived physical functioning gave an impression that these patients are in a declining life cycle and that revascularizations, even when successful, may not be sufficient to improve the overall function. It is possible that addressing rehabilitation issues earlier in the care may produce a more positive functional outcome. Depressive symptoms should be recognized and thoroughly considered at the same time the patients are recovering from their revascularization operation. Also primary care should develop proper follow-up, and community organizations should have exercise groups for those who are able to return home, since they very often live alone. In rehabilitation programs we should consider not only physical disability assessment but also QoL.

Vascular Function in Chronic Kidney Disease and in Renovascular Disease

Cardiovascular mortality is 15 to 30 times higher in patients with chronic kidney disease than in the age-adjusted general population. Even minor renal dysfunction predicts cardiovascular events and death in the general population. In patients with atherosclerotic renovascular disease the annual cardiovascular event and death rate is even higher. The abnormalities in coronary and peripheral artery function in the different stages of chronic kidney disease and in renovascular disease are still poorly understood, nor have the cardiac effects of renal artery revascularization been well characterized, although considered to be beneficial. This study was conducted to characterize myocardial perfusion and peripheral endothelial function in patients with chronic kidney disease and in patients with atherosclerotic renovascular disease. Myocardial perfusion was measured with positron emission tomography (PET) and peripheral endothelial function with brachial artery flow-mediated dilatation. It has been suggested that the poor renal outcomes after the renal artery revascularization could be due to damage in the stenotic kidney parenchyma; especially the reduction in the microvascular density, changes mainly evident at the cortical level which controls almost 80% of the total renal blood flow. This study was also performed to measure the effect of renal artery stenosis revascularization on renal perfusion in patients with renovascular disease. In order to do that a PET-based method for quantification of renal perfusion was developed. The coronary flow reserve of patients with chronic kidney disease was similar to the coronary flow reserve of healthy controls. In renovascular disease the coronary flow reserve was, however, markedly reduced. Flow-mediated dilatation of brachial artery was decreased in patients with chronic kidney disease compared to healthy controls, and even more so in patients with renovascular disease. After renal artery stenosis revascularization, coronary vascular function and renal perfusion did not improve in patients with atherosclerotic renovascular disease, but in patients with bilateral renal artery stenosis, flow-mediated dilatation improved. Chronic kidney disease does not significantly affect coronary vascular function. On the contrary, coronary vascular function was severely deteriorated in patients with atherosclerotic renovascular disease, possibly because of diffuse coronary artery disease and/or diffuse microvascular disease. The peripheral endothelial function was disturbed in patients with chronic kidney disease and even more so in patient with atherosclerotic renovascular disease. Renal artery stenosis dilatation does not seem to offer any benefits over medical treatment in patients with renovascular disease, since revascularization does not improve coronary vascular function or renal perfusion.

Kainic acid-induced seizures: inflammation and excitotoxic neuronal damage in the developing rat hippocampus

Epileptic seizures are harmful to the developing brain. During epileptic seizures, overactivation of glutamate receptors (GluR) leads to neuronal degeneration, defined as excitotoxicity. The hippocampus is especially vulnerable to excitotoxic neuronal death, but its mechanism has remained incompletely known in the developing brain. Recently, signs of activation of inflammatory processes after epileptic seizures have been detected in the hippocampus. The purpose of this thesis was to study the inflammatory reaction and death mechanisms in excitoxic neurodegeneration induced by the glutamate analogue kainic acid (KA) in the developing hippocampus. Organotypic hippocampal slice cultures (OHCs), prepared from 6-7-day-old rats (P6-7) and treated with KA, served as an in vitro model. KA-induced status epilepticus in P9 and P21 rats was used as an in vivo model. The results showed that the pyramidal cell layers of the hippocampus were the most susceptible to irreversible and age-specific neurodegeneration, which occurred in the juvenile (P21), but not in the immature (P9), rat hippocampus. The primary death mechanism was necrosis as there were no significant changes in the expression of selected apoptosis markers and morphological cellular features of necrosis were found. Inflammatory response was similarly age-dependent after KA treatment as a rapid, fulminant and wide response was detected in the juvenile, but not in the immature, rat brain. An anti-inflammatory drug treatment, given before KA, was not neuroprotective in OHCs, possibly because of the timing of the treatment. In summary, the results suggest that KA induces an age-dependent inflammatory response and necrotic neurodegeneration, which may cause disturbances in hippocampal connectivity and promote epileptogenesis.

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.

Kipu ja kuolema : kärsimyksen representaatioita suomalaisessa eutanasiapuheessa

Nimeke sisällysluettelossa: Kuolema ja kipu

Statistical Analysis of an SEIR Epidemic Model

This thesis was focussed on statistical analysis methods and proposes the use of Bayesian inference to extract information contained in experimental data by estimating Ebola model parameters. The model is a system of differential equations expressing the behavior and dynamics of Ebola. Two sets of data (onset and death data) were both used to estimate parameters, which has not been done by previous researchers in (Chowell, 2004). To be able to use both data, a new version of the model has been built. Model parameters have been estimated and then used to calculate the basic reproduction number and to study the disease-free equilibrium. Estimates of the parameters were useful to determine how well the model fits the data and how good estimates were, in terms of the information they provided about the possible relationship between variables. The solution showed that Ebola model fits the observed onset data at 98.95% and the observed death data at 93.6%. Since Bayesian inference can not be performed analytically, the Markov chain Monte Carlo approach has been used to generate samples from the posterior distribution over parameters. Samples have been used to check the accuracy of the model and other characteristics of the target posteriors.

Free PAPP-A: a Novel Marker in Acute Coronary Syndrome Patients

In recent years, one important objective of cardiovascular research has been to find new markers that would improve the risk stratification and diagnosis of patients presenting with symptoms of acute coronary syndrome (ACS). Pregnancy-associated plasma protein A (PAPP-A) is a large metalloproteinase involved in insulin-like growth factor signalling. It is expressed in various tissues and seems to be involved in many physiological and pathological processes, such as folliculogenesis, bone formation, wound healing, pregnancy and atherosclerosis. The aim of this thesis was to investigate PAPP-A in ACS patients. Circulating concentrations of PAPP-A had been previously shown to be elevated in ACS. In this study it was revealed that the form of PAPP-A causing this elevation was the free noncomplexed PAPP-A. Thus, the form of PAPP-A in the circulation of ACS patients differed from the complexed PAPP-A form abundantly present in the circulation during pregnancy. A point-of-care method based on time-resolved immunofluorometric assays was developed, which enabled the rapid detection of free PAPP-A. The method was found to perform well with serum and heparin plasma samples as well as with heparinized whole blood samples. With this method the concentrations of free PAPP-A in healthy individuals were shown to be negligible. When the clinical performance of the method was evaluated with serum samples from ACS patients, it was shown that the free PAPP-A concentration in the admission sample was an independent predictor of myocardial infarction and death. Moreover, as a prognostic marker, free PAPP-A was revealed to be superior to total PAPPA, i.e. the combination of free and complexed PAPP-A, which has been measured by the other groups in this field. As heparin products are widely used as medication in ACS patients, the effect of heparin products on free PAPP-A molecule and circulating concentrations were also investigated in this study. It was shown that intravenous administration of low molecular weight or unfractionated heparin elicits a rapid release of free PAPP-A into the circulation in haemodialysis patients and patients undergoing angiography. Moreover, the interaction between PAPP-A and heparin was confirmed in gel filtration studies. Importantly, the patients included in the clinical evaluation of the free PAPP-A detection method developed had not received any heparin product medication before the admission sample and thus the results were not affected by the heparin effect. In conclusion, free PAPP-A was identified as a novel marker associated with ACS. The point-of-care methods developed enable rapid detection of this molecule which predicts adverse outcome when measured in the admission sample of ACS patients. However, the effect revealed of heparin products on circulating PAPP-A concentrations should be acknowledged when further studies are conducted related to free or total PAPP-A in ACS.

Lapsuus, perhe, kuolema

Kirjallisuusarvostelu

Kampen for livet i vemodets slør : å leve i spenningsfeltet mellom livets mulighet og dødens nødvendighet

The overallpurpose of this research is to develop knowledge about health and suffering in connection with serious cancer disease through the development of a contextual model describing how patients live their lives between the possibility of life and the necessity of death. The research takes its point of departure from a caring science perspective, and Gadamer's hermeneutical philosophy is chosen as the overall methodology. In addition to the caring science perspective, the existential philosophy of Kierkegaard constructs a framework of interpretation. The research consists of three empirical studies. In two of the studies 21 patients participated, whilst 8 nurses took part in the remaining study. The patients were seriously ill and the nurses had long experience of caring for seriously ill patients. Scientific conversations were used for data collection. The findings from the patient studies show that the relationship with one-self, others, God or the supernatural and nature, constitute the unit of meaning, in which the struggle between health and suffering takes place. This struggle takes the form of a dialectic movement between being delivered and being accommodated and confirmed. The patients strive, in their delivery, for health and integration, for being a self by being reconciled with one self. The patients are lonely in this struggle, as conversations related to existence and death seldom occurs with either the natural or the professional caregivers. Themes related to patients' death remain mainly unarticulated. The patients' life struggle appears on the existential level as a threefold struggle against time and annihilation, towards being accommodatedand confirmed and for restoration and reconciliation. Through the hermeneutic process the struggle at the ontological level appears as a struggle of the will between anxiety and love. The patients in this research experience their life's tragedy. A holistic interpretation of living under the pressure created between the possibility of life and the necessity of death appears to be a struggle for life in the veil of pensiveness. The nurses want to be involved in the patients' struggle, and they show a deep desire to support the dignity of the patients. The depth in the nurses' view of their responsibility for the patient as an entityof body, soul and spirit seems to be related to the nurses' understanding of life.

Karneval i klassrum – kunskap på hjul : en studie av elevers möten med clown analyserade med narrativ metod och poetisk etnografi

The aim of this study is to contribute to the knowledge about learning in and through art related to pupils’ study processes developing clown characters in secondary school. The pre understanding of this qualitative piece of micro ethnographic research is that the elaboration of clown has openness to play, creative activity and imagination. The art form clown inspires and motivates. The clown character creates a kind and friendly atmosphere, calls upon smile, which promotes learning. It is an art form promoting deep and personal reflection and evoking questions regarding identity formation. The pre understanding finally is that existential themes are brought to articulation in the art form clown. The problem formulation for the hermeneutic phenomenological study is an exploration of the meaning potential of an arts educational work with clown from the pupils’ as well as the teacher’s perspective. The study elaborates the following research questions: 1.) How are the pupils staging themselves in the work with clown? a) How are they constructing the clown character? b) How do they reflect upon their construction? c) What are the characteristics of the working process in the elaboration of clown? 2.) What is characteristic of the teacher’s contribution to the arts educational work? 3.) What is characteristic of the meaning making in the elaboration of clown? One group of 21 pupils and their drama teacher in a Swedish secondary school in six workshops (each one 90 minutes) elaborating the clown theme is the group under study through video observation, interviews, students’ logs and drawings, teacher log and researcher’s field notes. The theoretical framework comprises three perspectives on clown: a perspective on the culture of carnival, a drama education perspective and a performance perspective. Through a content analysis of texts about clown a set of characteristics for the clown is used as analytical concepts in the subsequent analysis of the pupils’ working process when they create three clown characters: August, the white clown and the bag lady. The results are presented as fictive narratives built on the video observations and the interviews. The presentation is brought to even more condensation through poetic ethnographic writing of haiku poems by the researcher. This ethnographic writing is idiomatic to the art form under study, and can be seen as a metaphorical meta commentary to the narratives. As a main result the researcher has developed a model describing the different aspects of the clown characters and the meaning potential of the clown as learning regarding exploration of identity and elaboration of existential questions regarding life, loneliness, love, religion and death.

Kirja elämästä ja kuolemasta

Kirjallisuusarvostelu

Tragedian tarina. Nuoren itsemurhaan päättynyt elämä vanhemman kertomana

Tutkimuksessa tarkastellaan suomalaisnuorten itsemurhia teon inhimillisen ja sosiaalisen ulottuvuuden näkökulmasta. Tutkimustehtävänä on itsemurhan tehneen lapsen vanhempien subjektiivisten kokemusten tavoittaminen. Tarkoituksena on selvittää (1) millaisia sisältöjä ja merkityksiä nuoren elämä ja itsemurha saavat vanhempien kertomuksissa, (2) millä tavoin vanhemmat ovat ennakoineet nuoren tulevaa itsemurhaa ja millaisiksi varjelevat tekijät muodostuvat vanhempien ennakointien pohjalta sekä (3) miten auttamistyö merkityksellistyy osana ennusmerkkeihin ja varjeleviin tekijöihin liittyviä kertomuksia. Tutkimus on suunnattu edistämään itsemurhien ehkäisyä. Tutkimustyyppinä on narratiivinen laadullinen tutkimus. Pääaineistona on 14 lapsen itsemurhakuoleman kokeneen vanhemman kerronnallista haastattelua. Nuorten kuoliniän vaihteluväli on 15–31 vuotta. Täydentävä aineisto koostuu vanhempien kanssa käydyistä sähköpostikeskusteluista sekä heidän antamasta kirjallisesta lisämateriaalista, johon lukeutuu vanhempien omia muistelmia, heidän itsemurhan tehneiden lasten päiväkirjamerkintöjä ja jäähyväiskirjeitä. Analysointi on väljästi ymmärrettynä aineistolähtöinen. Analyysi perustuu narratiivisuuden ja sisällönanalyysin suomiin mahdollisuuksiin tukeutuen myös elämäkerralliseen näkökulmaan. Elämä ja kuolema ovat toistensa vastakohtia ja tiloja, jotka ovat jatkuvassa vuorovaikutuksessa keskenään. Itsensä surmaamisessa merkityksellistyy tavoitteellinen toiminta, jolla on korostuneesti yhteys nuoren sosiaaliseen ympäristöön suhteineen ja tapahtumineen. Ennusmerkit, eli vanhempien jälkikäteen näkemät vihjeet ennen lapsen itsemurhaa, liittyvät useisiin samanaikaisesti tapahtuneisiin prosesseihin, joissa elämään yleisesti liittyvät osa-alueet ovat yhdistyneet toisiinsa ja sekoittuneet keskenään. Varjelevat tekijät rakentuvat ennusmerkkien kääntöpuolina eli sisältöinä, joita vanhemman näkökulmasta nuoren eläessä olisi pitänyt tapahtua. Kyse voi olla myös seikoista, joista vanhempi on jälkeenpäin pohtinut, että tämä jonkun olisi pitänyt ymmärtää tai tehdä toisin. Vanhemmat kritisoivat laajasti auttamistyötä. Kritiikki kohdistui palvelujärjestelmään ja auttamistyötä toteuttaneiden tahojen toimintaan. Vanhempien kriittinen toimijuus tekee näkyväksi yksilön ja yhteiskunnan välisen kompleksisen suhteen. Palvelujärjestelmää on kehitettävä kokemusperäisen tiedon näkökulmasta. Ammattikäytännöissä korostuu psykososiaalisen työn merkitys. Tutkimus osoittaa, että sensitiivisten aiheiden tutkiminen on tärkeää ja laadullisen kulttuurisen kontekstin huomioivain itsemurhatutkimuksen tarve on suuri.