Henkilökunnan päihdeongelmat leikkaus- ja teho-osastoilla Suomessa

Anestesiahenkilökunnalla on useissa kansainvälisissä tutkimuksissa todettu esiintyvän enemmän päihteiden väärinkäyttöä kuin muilla erikoisaloilla. Tämän on arveltu johtuvan lääkkeiden helposta saatavuudesta, työn stressaavuudesta tai tahattomasta altistumisesta leikkaussalissa höyrystyneille lääkeaineille. Suomalaisia tutkimuksia aiheesta ei ole julkaistu. Tutkielman tarkoituksena on selvittää sähköpostikyselyiden ja asiantuntijahaastatteluiden avulla henkilökunnan päihdeongelmien yleisyyttä Suomen leikkaus- ja teho-osastoilla. Tavoitteena on myös saada tietoa muun muassa väärinkäytetyistä aineista, ovatko väärinkäyttäjät saaneet hoitoa ongelmaansa ja ovatko he myöhemmin pystyneet palaamaan entiseen työhönsä. Saatujen tulosten mukaan Suomen leikkaus- ja teho-osastojen henkilökunnalla ei näyttäisi esiintyvän sen enempää päihdeongelmia kuin väestössä keskimäärin. Alkoholi on selvästi yleisimmin väärinkäytetty aine, mutta myös opioidien ja bentsodiatsepiinien väärinkäyttöä esiintyy. Huolestuttavaa on, että vaikka suurin osa väärinkäyttäjistä sai hoitoa ongelmaansa, heistä vain kolmasosa pystyi palaamaan entiseen työhönsä ongelmitta. Tutkielmaa käytetään hyväksi Huume- ja päihdetyöryhmän työskentelyssä ja loppuraportissa. Alkuvuodesta 2011 ilmestyvässä loppuraportissa on toimenpide-ehdotuksia, joiden avulla leikkaus- ja teho-osastoilla voidaan ennaltaehkäistä henkilökunnan päihdeongelmia sekä lääkeainevarkauksia.

Maallikon suorittama defibrillaatio sydänpysähdyspotilaan hoitoketjussa

Sudden cardiac arrest (CA) is one of the leading causes of death in Europe. It has been estimated that about 40 % of CA victims have ventricular fibrillation (VF) at the time of the first heart rhythm analysis. The treatment for VF is immediate cardiopulmonary resuscitation (CPR) and rapid defibrillation. The automated external defibrillator (AED) and the concept of public access defibrillation (PAD) may be a key to shortening defibrillation delays. Recent studies have shown that PAD programs are associated with high survival rates from VF when devices have been placed in certain risk sites and used by trained laypersons. Today many public places are equipped with AEDs. The purpose of this study was to find new ways of utilizing layperson defibrillation and promote the concept of public access defibrillation (PAD). The study explored the use of AEDs by non-medical first responders in Finland and cabin crew on board a commercial aircraft. A simulated study was performed to explore the role of dispatcher assistance in layperson CPR and defibrillation. A 15-year follow-up study of 59 one-year survivors after successful out-of-hospital resuscitation was performed to evaluate the long-term quality of life of the CA patients. Although there are many AEDs in use by non-medical first responders in Finland, the results of the study showed that there are large variations between individual first response units. This is considered to be caused by the lack of national standards and regulations that would define a full integration of first-responder programmes into the Emergency Medical Services system. The goal of rapid defibrillation in five minutes after the onset of CA is difficult to achieve in Finland due to sparse population and long distances. Local PAD programs may shorten the defibrillation delays. Dispatcher assistance in defibrillation by a layperson not trained to use an AED seems feasible and does not compromise the performance of CPR. In a simulated study, the quality of mouth-to-mouth ventilation performed by laypersons was found to be better after CPR training compared with performance with dispatcher assistance before training. Training was not found to have an influence on the quality of compressions or defibrillation compared with dispatcher assistance of untrained laypersons. The target groups for CPR and defibrillation training need further evaluation. The placements of the AEDs in public areas should be known by the emergency response center and the location should be marked with an international sign. The finding that once a good neurological outcome after CA is achieved, it can be maintained for more than 10 years, encourages further efforts to improve the survival of CA patients.

Pain measurement and management in elderly patients : Clinical studies in long term hospital care and after cardiac surgery

The proportion of patients over 75 years of age, receiving all different types of healthcare, is constantly increasing. The elderly undergo surgery and anaesthetic procedures more often than middle-aged patients. Poor pain management in the elderly is still an issue. Although the elderly consumes the greatest proportion of prescribed medicines in Western Europe, most clinical pharmacological studies have been performed in healthy volunteers or middle-aged patients. The aim of this study was to investigate pain measurement and management in cognitively impaired patients in long term hospital care and in cognitively normal elderly patients after cardiac surgery. This thesis incorporated 366 patients, including 86 home-dwelling or hospitalized elderly with chronic pain and 280 patients undergoing cardiac surgery with acute pain. The mean age of patients was 77 (SD ± 8) years and approximately 8400 pain measurements were performed with four pain scales: Verbal Rating Scale (VRS), the Visual Analogue Scale (VAS), the Red Wedge Scale (RWS), and the Facial Pain Scale (FPS). Cognitive function, depression, functional ability in daily life, postoperative sedation and postoperative confusion were assessed with MMSE, GDS, Barthel Index, RASS, and CAM-ICU, respectively. The effects and plasma concentrations of fentanyl and oxycodone were measured in elderly (≥ 75 years) and middle-aged patients (≤ 60 years) and the opioid-sparing effect of pregabalin was studied after cardiac surgery. The VRS pain scores after movement correlated with the Barthel Index. The VRS was most successful in the groups of demented patients (MMSE 17-23, 11-16 and ≤ 10) and in elderly patients on the first day after cardiac surgery. The elderly had a higher plasma concentration of fentanyl at the end of surgery than younger patients. The plasma concentrations of oxycodone were comparable between the groups. Pain intensity on the VRS was lower and the sedation scores were higher in the elderly. Total oxycodone consumption during five postoperative days was reduced by 48% and the CAM-ICU scores were higher on the first postoperative day in the pregabalin group. The incidence of postoperative pain during movement was lower in the pregabalin group three months after surgery. This investigation demonstrates that chronic pain did not seem to impair daily activities in home-dwelling Finnish elderly. The VRS appeared to be applicable for elderly patients with clear cognitive dysfunction (MMSE ≤17) and it was the most feasible pain scale for the early postoperative period after cardiac surgery. After cardiac surgery, plasma concentrations of fentanyl in elderly were elevated, although oxycodone concentrations were at similar level compared to middle-aged patients. The elderly had less pain and were more sedated after doses of oxycodone. Therefore, particular attention must be given to individual dosing of the opioids in elderly surgical patients, who often need a smaller amount for adequate analgesia than middle-aged patients. The administration of pregabalin reduced postoperative oxycodone consumption after cardiac surgery. Pregabalin-treated patients had less confusion, and additionally to less postoperative pain on the first postoperative day and during movement at three months post-surgery. Pregabalin might be a new alternative as analgesic for acute postoperative and chronic pain management in the elderly. Its clinical role and safety remains to be verified in large-scale randomized and controlled studies. In the future, many clinical trials in the older category of patients will be needed to facilitate improvements in health care methods.

Laskimonsisäisen rasvaemulsion käyttö lääkemyrkytyksissä

Puudutemyrkytysten hoitoon suositellaan joissain maissa laskimonsisäisesti annettavaa rasvaemulsiota. Suomessa kansallista suositusta ei kuitenkaan ole, eikä kyseisen hoidon yleisyyttä ole aiemmin kotimaassa tutkittu puudute-­ tai muissakaan lääkemyrkytyksissä. Tutkimuksen tavoitteena on selvittää millaiseen näyttöön hoito perustuu käymällä läpi aiheesta julkaistu kirjallisuus sekä selvittää sähköpostikyselyn avulla kuinka yleisesti anestesiaosastoilla on laadittu omia ohjeistuksia rasvaemulsion käytöstä puudutemyrkytystapauksissa. Lisäksi selvitetään onko kyseistä hoitoa jo käytetty, hoitosuositusten perustaa, käytettyjä rasvaemulsiota ja missä niitä säilytetään. Kysely lähetettiin myös kahteen ensihoitoyksikköön muiden lääkemyrkytysten hoitoon laadittujen ohjeistusten osalta. Hieman yli puolella Suomen anestesiaosastoista on laadittuna oma ohjeistus laskimonsisäisen rasvaemulsion käytöstä puudutemyrkytyksissä, vaikka hoidon tehosta on ristiriitaisaa näyttöä eikä kontrolloituja ihmistutkimuksia ole julkaistu. Ensihoitoyksiköillä taas ei ole omia suosituksia hoidosta. Hoitoa on myös käytetty viidellä anestesiaosastolla. Hoitosuositukset eri osastoilla on kuitenkin johdettu useista eri lähteistä. Käytetyin rasvaemulsio on Intralipid® ja myrkytysten hoitoon tarkoitettuja emulsioita säilytetään pääasiassa leikkaussalissa tai sen yhteydessä.

Current Care Guidelines for Cardiopulmonary Resuscitation : Implementation, skills and attitudes

Background: The national resuscitation guidelines were published in Finland in 2002 and are based on international guidelines published in 2000. The main goal of the national guidelines, available on the Internet free of charge, is early defibrillation by nurses in an institutional setting. Aim: To study possible changes in cardiopulmonary resuscitation (CPR) practices, especially concerning early defibrillation, nurses and students attitudes of guideline implementation and nurses and students ability to implement the guideline recommendations in clinical practices after publication of the Current Care (CC) guidelines for CPR 2002. Material and methods: CPR practices in Finnish health centres; especially concerning rapid defibrillation programmes, as well as the implementation of CC guidelines for CPR was studied in a mail survey to chief physicians of every health centre in Finland (Study I). The CPR skills using an automated external defibrillator (AED) were compared in a study including Objective stuctured clinical examination (OSCE) of resuscitation skills of nurses and nursing students in Finnish and Swedish hospital and institution (Studies II, III). Attitudes towards CPR-D and CPR guidelines among medical and nursing students and secondary hospital nurses were studied in surveys (Studies IV, V). The nurses receiving different CPR training were compared in a randomized trial including OSCE of CPR skills of nurses in Finnish Hospital (Study VI). Results: Two years after the publication, 40.7% of Finnish health centres used national resuscitation guidelines. The proportion of health centres having at least one AED (66%) and principle of nurse-performed defibrillation without the presence of a physician (42%) had increased. The CPR-D training was estimated to be insufficient regarding basic life support and advanced life support in the majority of health centres (Study I). CPR-D skills of nurses and nursing students in two specific Swedish and Finnish hospitals and institutions (Study II and III) were generally inadequate. The nurses performed better than the students and the Swedish nurses surpassed the Finnish ones. Geriatric nurses receiving traditional CPR-D training performed better than those receiving an Internet-based course but both groups failed to defibrillate within 60 s. Thus, the performance was not satisfactory even two weeks after traditional training (Study VI). Unlike the medical students, the nursing students did not feel competent to perform procedures recommended in the cardiopulmonary resuscitation guidelines including the defibrillation. However, the majority of nursing students felt confident about their ability to perform basic life support. The perceived ability to defibrillate correlated significantly with a positive attitude towards nurse-performed defibrillation and negatively with fear of damaging the patient s heart by defibrillation (Study IV). After the educational intervention, the nurses found their level of CPR-D capability more sufficient than before and felt more confident about their ability to perform defibrillation themselves. A negative attitude toward defibrillation correlated with perceived negative organisational attitudes toward cardiopulmonary resuscitation guidelines. After CPR-D education in the hospital, the majority (64%) of nurses hesitated to perform defibrillation because of anxiety and 27 % hesitated because of fear of injuring the patient. Also a negative personal attitude towards guidelines increased markedly after education (Study V). Conclusions: Although a significant change had occurred in resuscitation practices in primary health care after publication of national cardiopulmonary resuscitation guidelines the participants CPR-D skills were not adequate according to the CPR guidelines. The current way of teaching is unlikely to result in participants being able to perform adequate and rapid CPR-D. More information and more frequent training are needed to diminish anxiety concerning defibrillation. Negative beliefs and attitudes toward defibrillation affect the nursing students and nurses attitudes toward cardiopulmonary resuscitation guidelines. CPR-D education increased the participants self-confidence concerning CPR-D skills but it did not reduce their anxiety. AEDs have replaced the manual defibrillators in most institutions, but in spite of the modern devices the anxiety still exists. Basic education does not provide nursing students with adequate CPR-D skills. Thus, frequent training in the workplace has vital importance. This multi-professional program supported by the administration might provide better CPR-D skills. Distance learning alone cannot substitute for traditional small-group learning, tutored hands-on training is needed to learn practical CPR-D skills. Standardized testing would probably help controlling the quality of learning. Training of group-working skills might improve CPR performance.

Oppimisen kohteen ja oppijan vastavuoroinen kehitys : Teleyrityksen asiakaspalvelun työyhteisöjen oppimiskäytäntöjen uudistaminen osana teknologis-taloudellista kumousta

Reciprocal development of the object and subject of learning. The renewal of the learning practices of front-line communities in a telecommunications company as part of the techno-economical paradigm change. Current changes in production have been seen as an indication of a shift from the techno-economical paradigm of a mass-production era to a new paradigm of the information and communication technological era. The rise of knowledge management in the late 1990s can be seen as one aspect of this paradigm shift, as knowledge creation and customer responsiveness were recognized as the prime factors in business competition. However, paradoxical conceptions concerning learning and agency have been presented in the discussion of knowledge management. One prevalent notion in the literature is that learning is based on individuals’ voluntary actions and this has now become incompatible with the growing interest in knowledge-management systems. Furthermore, commonly held view of learning as a general process that is independent of the object of learning contradicts the observation that the current need for new knowledge and new competences are caused by ongoing techno-economic changes. Even though the current view acknowledges that individuals and communities have key roles in knowledge creation, this conception defies the idea of the individuals’ and communities’ agency in developing the practices through which they learn. This research therefore presents a new theoretical interpretation of learning and agency based on Cultural-Historical Activity Theory. This approach overcomes the paradoxes in knowledge-management theory and offers means for understanding and analyzing changes in the ways of learning within work communities. This research is also an evaluation of the Competence-Laboratory method which was developed as part of the study as a special application of Developmental Work Research methodology. The research data comprises the videotaped competence-laboratory processes of four front-line work communities in a telecommunications company. The findings reported in the five articles included in this thesis are based on the analyses of this data. The new theoretical interpretation offered here is based on the assessment that the findings reported in the articles represent one of the front lines of the ongoing historical transformation of work-related learning since the research site represents one of the key industries of the new “knowledge society”. The research can be characterized as elaboration of a hypothesis concerning the development of work related learning. According to the new theoretical interpretation, the object of activity is also the object of distributed learning in work communities. The historical socialization of production has increased the number of actors involved in an activity, which has also increased the number of mutual interdependencies as well as the need for communication. Learning practices and organizational systems of learning are historically developed forms of distributed learning mediated by specific forms of division of labor, specific tools, and specific rules. However, the learning practices of the mass production era become increasingly inadequate to accommodate the conditions in the new economy. This was manifested in the front-line work communities in the research site as an aggravating contradiction between the new objects of learning and the prevailing learning practices. The constituent element of this new theoretical interpretation is the idea of a work community’s learning as part of its collaborative mastery of the developing business activity. The development of the business activity is at the same time a practical and an epistemic object for the community. This kind of changing object cannot be mastered by using learning practices designed for the stable conditions of mass production, because learning has to change along the changes in business. According to the model introduced in this thesis, the transformation of learning proceeds through specific stages: predefined learning tasks are first transformed into learning through re-conceptualizing the object of the activity and of the joint learning and then, as the new object becomes stabilized, into the creation of new kinds of learning practices to master the re-defined object of the activity. This transformation of the form of learning is realized through a stepwise expansion of the work community’s agency. To summarize, the conceptual model developed in this study sets the tool-mediated co-development of the subject and the object of learning as the theoretical starting point for developing new, second-generation knowledge management methods. Key words: knowledge management, learning practice, organizational system of learning, agency

Kaveriporukasta liiketoiminnaksi : Tuotannon häiriöt ja organisaation oppiminen nopeasti muuttuvassa yrityksessä

In the 1990 s the companies utilizing and producing new information technology, especially so-called new media, were also expected to be forerunners in new forms of work and organization. Researchers anticipated that new, more creative forms of work and the changing content of working life were about to replace old industrial and standardized ways of working. However, research on actual companies in the IT sector revealed a situation where only minor changes to existing organizational forms were seen .Many of the independent companies faced great difficulties trying to survive the rapid changes in the products and production forms in the emerging field. Most of the research on the new media field has been conducted as surveys, and an understanding of the actual everyday work process has remained thin. My research is a longitudinal study of the early phases of one new media company in Finland. The study is an analysis of the challenges the company faced in a rapidly changing business field and the attempts to overcome these challenges. The two main analyses in the study focus on the developmental phases of the company and the disturbances in the production process. Based on these analyses, I study changes and learning at work using the methodological framework of developmental work research. Developmental work research is a Finnish variant of the cultural-historical activity theory applied to the study of learning and transformations at work. The data was gathered over a three-year period of ethnographic fieldwork. I documented the production processes and everyday life in the company as a participant observer. I interviewed key persons, video and audio-taped meetings, followed e-mail correspondence and collected various documents, such as agreements and memos. I developed a systematic method for analyzing the disturbances in the production process by combining the various data sources. The systematic analysis of the disturbances depicted a very complex and only partly managed production process. The production process had a long duration, and no single actor had an understanding of it as a whole. Most of the disturbances had to do with the customer relationships. The nature of the disturbances was latent; they were recognized but not addressed. In the particular production processes that I analyzed, the ending life span of a particular product, a CD-ROM, became obvious. This finding can be interpreted in relation to the developmental phase of the production and the transformation of the field as a whole. Based on the analysis of the developmental phases and the disturbances, I formulate a hypothesis of the contradictions and developmental potentials of the activity studied. The conclusions of the study challenge the existing understanding of how to conceptualize and study organizational learning in production work. Most theories of organizational learning do not address qualitative changes in production nor historical challenges of organizational learning itself. My study opens up a new horizon in understanding organizational learning in a rapidly changing field where a learning culture based on craft or mass production work is insufficient. There is a need for anticipatory and proactive organizational learning. Proactive learning is needed to anticipate the changes in production type, and the life cycles of products.

Äidinmaito - terveysjuomaa ja normaalibakteereita

The chemical composition of breast milk has been studied in detail in the past decades. Hundreds of new antibacterial and antiviral components have been found. Several molecules have been found to promote the proper function of neonatal intestine. However, microbiological studies of breast milk have been, until recently, focused mainly on detecting harmful and pathogenic bacteria and viruses. Natural microbial diversity of human milk has not been widely studied before the work reported in this thesis. This is mainly because breast milk has traditionally been thought to be sterile - even if a certain amount of commensal bacteria have usually been detected in milk samples. The first part of this licentiate thesis contains a short literature review about the anatomy and physiology of breast feeding, human milk chemical and microbiological composition, mastitis, intestinal flora and bacteriocins. The second part reports on the experiments of the licentiate work, concentrating on the microbial diversity in the milk of healthy breast-feeding mothers, and the ability of these bacteria to produce antibacterial substances against pathogenic bacteria. The results indicate that human milk is a source of commensal bacteria for infant intestine. 509 random isolates from 40 breast milk samples were isolated and identified by 16S rRNA sequencing. Median bacterial count was about 600 colony forming units per milliliter. Over half of the isolates were staphylococci, and almost one third streptococci. The most common species were skin bacteria Staphylococcus epidermidis and oral bacteria Streptococcus salivarius and Streptococcus mitis. Lactic acid bacteria, identified as members of Lactobacillus-, Lactococcus- and Leuconostoc -genera, were found in five milk samples. Enterococci were found in three samples. A novel finding in this study is the capability of these commensal bacteria to inhibit the growth of pathogens. In 90 precent of the milk samples commensal bacteria inhibiting the growth of Staphylococcus aureus were found. In 40 precent of samples the colonies could block the growth completely. One fifth of the isolated Staph. epidermidis strains, half of Str. salivarius strains, and all lactic acid bacteria and enterococci could inhibit or block the growth of Staph. aureus. In further study also Listeria innocua- and Micrococcus luteus active isolates were found in 33 and 11 precent of milk samples (out of 140). Furthermore, two Lactococcus lactis isolates from the breast milk were shown to produce bacteriocin nisin, which is an antimicrobial molecule used as a food preservative. The importance of these human milk commensal bacteria in the development of newborn intestinal flora and immune system, as well as in preventing maternal breast infections, should be further explored.

Alueellinen imago ja identiteetti liikkeessä

Regions are considered to be in competition for investments, industries, inhabitants and skilled labour nationally as well as internationally. In the context of tightening competition, more and more attention has been paid to regional attractors. A positive image is an important attractor in regional competition. In Finland, many towns and regions have either implemented or are planning to implement various image-enhancing campaigns or other measures aimed at improving their image. The role of identity is very important in developing a regional image. Good regional image should be based on a strong regional identity and awareness. Related to this is the perception of one's own region as separate from others and the familiarity of the region. If a region has no place in the awareness of its residents or if the inhabitants do not identify with it, its very existence as a social construct can be questioned. This means that building the regional image, which in this context is seen as social constructivism, is extremely difficult if the degree of regional awareness and identification is low. On the other hand, regional identity is being built also by developing the regional image. In a way, regional discourses have become more marketing-oriented in that instead of trying to create a regional esprit de corps there is now more image-oriented speech aimed at striving to improve the attractivity to outsiders of the region. Even though the goal is to bring the region to the attention of non-residents, a measure of construction of regional identity for the local population is automatically effected at the same time. Regional image and identity are consequences of linguistic producing and understanding of a region. It means that both image and identity are seen as language-created social constructions. The regional image is created through various discourses, but also the construction of a regional identity as regional consciousness and identification is largely a linguistic process. Essential in this context is perceiving the region as a discursive project characterized by its representation as texts, images and symbols. The linguistic production of a region is not a neutral description of "reality", but a representation based on interpretations, experiences and different motivations. Production and perceiving vary in time, so regional image and identity are on the move. This research is driven by the ongoing change of the regional system. The municipal and service structure reform is in progress and the number of municipalities seems to be on the decrease. At the same time, European Union s regional policy and regionalism on the whole are changing the status of sub-regions. At municipal level the crucial question is how the municipal structure reform will affect regional identity. This study points out that strong sense of municipal identity is a source of opposition to changes in municipal structure, but on the other hand the deinstitutionalization of the old municipality in municipal merger does not in itself mean the weakening of municipal identity.

Infliximabi-infuusioiden akuuttien haittavaikutusten esto asetyylisalisyylihapolla lapsipotilaiden IBD- ja reumasairauksien hoidossa

IBD- ja reumasairaudet ovat elämänlaatua merkittävästi heikentäviä, kroonisia tulehduksellisia sairauksia, joiden keskivaikeiden ja vakavien muotojen hoidossa suoneen annettava biologinen TNF-alfa -tulehdustekijän vasta-aine infliksimabi (Remicade®) on vankassa asemassa. Infliksimabin hyvän tehon kääntöpuolena esiintyy yleisesti haittoja, joista infuusion aikana tai pian sen jälkeen ilmenevät allergistyyppiset reaktiot ovat hoitoa hankaloittava ja jopa vaarallinen alaluokka. Infuusioreaktioiden estoon ei nykyisellään ole todistettavasti tehokkaita keinoja. Parasetamoli ja setiritsiini osoittautuivat tässä käyttötarkoituksessa tehottomiksi. HUS:n Lasten ja nuorten sairaalassa aloitettiin 11.3.2009 hoitokokeilu asetosalisyylihapolla (ASA, Disperin®), annosteltuna painonmukaisesti per os, päämääränä selvittää prospektiivisesti ASA:n käyttömahdollisuudet infuusioreaktioiden ehkäisyssä. Tämän tutkielman aineisto kerättiin esilääkekokeilun alun ja 24.6.2010 välisellä ajalla (yhteensä 67 viikkoa) infliksimabi-infuusiossa Lasten ja nuorten sairaalan osasto 2:lla käyneiden IBD- ja reumapotilaiden asiakirjoista. Vain 1 (0,2 %) ASA:n kanssa annetuista infuusioista johti infuusioreaktioon kun aiemmin parasetamolin ja setiritsiinin kanssa todettiin 11 (2,9 %) reaktiota. GraphPad Prism 5 -ohjelmistolla tehdyn tilastoanalyysin perusteella tulokset osoittavat ASA:n olevan erittäin lupaava infuusioreaktioiden estolääke.

Painehaavapotilaille tehtyjen hoitointerventioiden määrä ja tulokset HYKS:n plastiikkakirurgian klinikassa

Keräsimme ICD-10 koodilla L89 HYKS:n plastiikkakirurgian klinikassa hoidetuista 401:stä potilaasta hoitotiedot vuosilta 2000-2008. Plastiikkakirurgiseen leikkaukseen ja hoidon arvioon päätyneiden potilaiden keski-ikä oli 60,3 (18-97v.). Painehaavan riskitekijät selvitettiin. Yksittäisistä riskitekijöistä yleisimpiä olivat paraplegia ( n=77; 17% ) ja diabetes/ASO tauti ( n=53; 12 % ). Yhteensä painehaavaleikkauksia tehtiin 347 , joista revisioleikkauksia 108 ja varsinaisia sulkuleikkauksia oli 239. Keskimäärin potilaat tarvitsivat 1.7 operaatiota. Leikatuista painehaavoista gradus III- haavoja oli 35,1% ; n= 84 ja gradus IV 25,5% ; n= 61, pinta-ala haavoilla oli keskimäärin 30,5 cm2. Istuinkyhmyjen ja sacrumin painehaavat olivat potilasaineistossamme yleisiä (20% ja 27% operoiduista painehaavoista). Gradus III haavoja leikattiin keskimäärin 1,6 kertaa ja gradus IV haavoja keskimäärin 2,0 kertaa. Postoperatiivisia poliklinikkakäyntejä tarvittiin keskimäärin 2,3, gradus III painehaavapotilailla 2,0 ja gradus IV potilailla 2,6 käyntiä. Leikkausmenetelmistä eri kielekerekonstruktiot olivat selkeästi eniten käytetty leikkausmenetelmä painehaavaleikkauksissa: 58 % rekonstruktioleikkauksista suoritettiin käyttäen jonkinlaista iho- lihaskielekettä. (134 sanaa)

Työ- ja pääomapanokset maidontuotannon kannattavuustekijöinä - asema- ja automaattilypsytilojen vertailu

Maatalousyrittäjä toimii muuttuvassa toimintaympäristössä, jonka muutokset asettavat yrittäjälle ja yritykselle haasteita ja vaatimuksia. Tuotantoteorian mukaisesti maatalousyrittäjän oletetaan maksimoivan voittoa ja/tai minimoimaan kustannuksia. Tavoitteen saavuttamiseksi yrittäjä sopeuttaa tuotosmääriään ja panoskäyttöään vallitsevien olosuhteiden mukaan. Tuotantoteknologialla voidaan puolestaan vaikuttaa siihen, millaisia panoksia tuotoksen aikaansaamiseksi tarvitaan. Maidontuotannossa lypsyjärjestelmä on yksi keskeinen teknologiavalinta. Kannattavuus on Suomessa kriittinen tekijä maataloustuotannon kilpailukykyä ja pitkän ajan toimintaedellytyksiä ajatellen. Yhtenä merkittävänä tuotantokustannuksiin vaikuttavana tekijänä maidontuotannossa voidaan pitää keskimäärin korkeaa työkustannusta tuoteyksikköä kohden. Rakennekehityksellä tavoitellaan suurtuotannon etuja ja yksikkökustannusten alentamista. Yrityskoon kasvattamisen yhteyteen liittyy usein uuden tuotantoteknologian käyttöönotto. Uudella teknologialla ja siihen sijoitetulla pääomalla korvataan yhä kallistuvaa työpanosta. Uutta teknologiaa edustavat mm. automaattinen lypsyjärjestelmä. Keskeisintä kehityksessä on, että viljelijöiden on ollut mahdollista vähentää työn määrää tuotettua yksikköä kohti. Tämä on helpottanut tilakoon kasvua ja samalla on ollut mahdollista kasvattaa työmenekin silti olennaisesti kasvamatta. Ensimmäiset automaattilypsyjärjestelmät otettiin Suomessa käyttöön vuonna 2000 ja vuoden 2009 lopussa niitä oli jo 563 laitetta yhteensä 465 maidontuotantotilalla. Tutkimuksen tarkoituksena oli tutkia asema- ja automaattilypsyä käyttävien tilojen tuottavuus- ja kannattavuuseroja ja miten investoinneilla pystytään korvaamaan työtä. Aineistona käytettiin maatalouden kannattavuuskirjanpitoaineistoa vuosilta 2005- 2008. Tutkimusaineistossa olivat mukana kaikki tilat, joilla tutkimusjakson alussa oli automaattinen lypsyjärjestelmä tai jotka siirtyivät siihen ajanjakson aikana. Automaattilypsytilojen vertailuryhmänä olivat maidontuotantoon keskittyneet samaan kokoluokkaan kuuluvat asemalypsytilat. Lypsyjärjestelmän valinnan maidontuottaja tekee omista lähtökohdistaan. Tässä tutkimuksessa tehty lypsyjärjestelmän taloudellinen valintaperusteiden tarkastelu osoittaa, että uuden teknologian käyttöönotto on haasteellista. Valinnan taustalla olevat odotukset eivät välttämättä toteudu ainakaan heti investoinnin jälkeisinä vuosina. Työn tuottavuus, määriteltynä työtuntia kohden tuotettuina maitokiloina, oli automaattilypsytiloilla parempi kuin asematiloilla. Pääoman tuottavuus, määriteltynä lypsykarjatalouden pääomaa (1000 €) kohti tuotettuina maitokiloina oli puolestaan asemalypsytiloilla parempi kuin automaattilypsytiloilla. Asemalypsytiloilla nettotuottavuus, työn sekä pääoman nettotuottavuudet olivat parempia kuin automaattitiloilla. Automaattitilojen kokonaistuottavuuden muutos oli 7,49 %, kun asematiloilla se oli vain 2,30 % tutkimusajanjakson aikana. Lehmää kohti työkustannukset pienenivät ja maksettujen korkojen määrät kasvoivat kummallakin lypsytavalla. Verrattaessa työkustannusten ja maksettujen korkomenojen muutosta voitiin havaita, että työkustannukset eivät automaattilypsytiloilla kuitenkaan pienentyneet niin paljon, että ne olisivat kattaneet maksettujen korkomenojen lisäyksen. Kannattavuuskertoimen perusteella kumpikaan tilaryhmä ei saavuttanut asettamiaan tavoitteita oman työn palkkavaatimuksen eikä oman pääoman korkovaatimuksen suhteen. Asemalypsytiloilla kannattavuus oli parempi ja yrittäjäntappio oli alhaisempi kuin automaattitiloilla.

Preterm birth and risk factors for chronic disease : Helsinki Study of Very Low Birth Weight Adults

Background: The improved prognosis of early preterm birth has created a generation of surviving very low birth weight (< 1500 g, VLBW) infants whose health risks in adulthood are poorly known. Of every 1000 live-born infants in Finland, about 8 are born at VLBW. Variation in birth weight, even within the normal range, relates to considerable variation in the risk for several common adult disorders, including cardiovascular disease and osteoporosis. Small preterm infants frequently exhibit severe postnatal or prenatal growth retardation, or both. Much reason for concern thus exists, regarding adverse health effects in surviving small preterm infants later lives. We studied young adults, aiming at exploring whether VLBW birth and postnatal events after such a birth are associated with higher levels of risk factors for cardiovascular disease or osteoporosis. Subjects and Methods: A follow-up study for VLBW infants began in 1978; by the end of 1985, 335 VLBW survivors at Helsinki University Central Hospital participated in the follow-up. Their gestational ages ranged from 24 to 35 weeks, mean 29.2 and standard deviation 2.2 weeks. In 2004, we invited for a clinic visit 255 subjects, aged 18 to 27, who still lived in the greater Helsinki area. From the same birth hospitals, we also invited 314 term-born controls of similar age and sex. These two study groups underwent measurements of body size and composition, function of brachial arterial endothelium (flow-mediated dilatation, FMD) and carotid artery intima-media thickness (cIMT) by ultrasound. In addition, we measured plasma lipid concentrations, ambulatory blood pressure, fasting insulin, glucose tolerance and, by dual-energy x-ray densitometry, bone-mineral density. Results: 172 control and 166 VLBW participants underwent lipid measurements and a glucose tolerance test. VLBW adults fasting insulin (adjusted for body mass index) was 12.6% (95% confidence interval, 0.8 to 25.8) higher than that of the controls. The glucose and insulin concentrations 120 minutes after 75 g glucose ingestion showed similar differences (N=332) (I). VLBW adults had 3.9 mmHg (1.3 to 6.4) higher office systolic blood pressure, 3.5 mmHg (1.7 to 5.2) higher office diastolic blood pressure (I), and, when adjusted for body mass index and height, 3.1 mmHg (0.5 to 5.5) higher 24-hour mean systolic blood pressure (N=238) (II). VLBW birth was associated neither with HDL- or total cholesterol nor triglyceride concentrations (N=332) (I), nor was it associated with a low FMD or a high cIMT (N=160) (III). VLBW adults had 0.51-unit (0.28 to 0.75) lower lumbar spine Z scores and 0.56-unit (0.34 to 0.78) lower femoral neck Z scores (N=283). Adjustments for size attenuated the differences, but only partially (IV). Conclusions: These results imply that those born at VLBW, although mostly healthy as young adults, already bear several risk factors for chronic adult disease. The significantly higher fasting insulin level in adults with VLBW suggests increased insulin resistance. The higher blood pressure in young adults born at VLBW may indicate they later are at risk for hypertension, although their unaffected endothelial function may be evidence for some form of protection from cardiovascular disease. Lower bone mineral density around the age of peak bone mass may suggest increased risk for later osteoporotic fractures. Because cardiovascular disease and osteoporosis are frequent, and their prevention is relatively cheap and safe, one should focus on prevention now. When initiated early, preventive measures are likely to have sufficient time to be effective in preventing or postponing the onset of chronic disease.