Indications for cardiovascular magnetic resonance in children with congenital and acquired heart disease: an expert consensus paper of the Imaging Working Group of the AEPC and the Cardiovascular Magnetic Resonance Section of the EACVI.

This article provides expert opinion on the use of cardiovascular magnetic resonance (CMR) in young patients with congenital heart disease (CHD) and in specific clinical situations. As peculiar challenges apply to imaging children, paediatric aspects are repeatedly discussed. The first section of the paper addresses settings and techniques, including the basic sequences used in paediatric CMR, safety, and sedation. In the second section, the indication, application, and clinical relevance of CMR in the most frequent CHD are discussed in detail. In the current era of multimodality imaging, the strengths of CMR are compared with other imaging modalities. At the end of each chapter, a brief summary with expert consensus key points is provided. The recommendations provided are strongly clinically oriented. The paper addresses not only imagers performing CMR, but also clinical cardiologists who want to know which information can be obtained by CMR and how to integrate it in clinical decision-making.

2015 Update on Acute Adverse Reactions to Gadolinium based Contrast Agents in Cardiovascular MR. Large Multi-National and Multi-Ethnical Population Experience With 37788 Patients From the EuroCMR Registry.

OBJECTIVES: Specifically we aim to demonstrate that the results of our earlier safety data hold true in this much larger multi-national and multi-ethnical population. BACKGROUND: We sought to re-evaluate the frequency, manifestations, and severity of acute adverse reactions associated with administration of several gadolinium- based contrast agents during routine CMR on a European level. METHODS: Multi-centre, multi-national, and multi-ethnical registry with consecutive enrolment of patients in 57 European centres. RESULTS: During the current observation 37,788 doses of Gadolinium based contrast agent were administered to 37,788 patients. The mean dose was 24.7 ml (range 5-80 ml), which is equivalent to 0.123 mmol/kg (range 0.01 - 0.3 mmol/kg). Forty-five acute adverse reactions due to contrast administration occurred (0.12%). Most reactions were classified as mild (43 of 45) according to the American College of Radiology definition. The most frequent complaints following contrast administration were rashes and hives (15 of 45), followed by nausea (10 of 45) and flushes (10 of 45). The event rate ranged from 0.05% (linear non-ionic agent gadodiamide) to 0.42% (linear ionic agent gadobenate dimeglumine). Interestingly, we also found different event rates between the three main indications for CMR ranging from 0.05% (risk stratification in suspected CAD) to 0.22% (viability in known CAD). CONCLUSIONS: The current data indicate that the results of the earlier safety data hold true in this much larger multi-national and multi-ethnical population. Thus, the "off-label" use of Gadolinium based contrast in cardiovascular MR should be regarded as safe concerning the frequency, manifestation and severity of acute events.

Single centre experience of the application of self navigated 3D whole heart cardiovascular magnetic resonance for the assessment of cardiac anatomy in congenital heart disease.

BACKGROUND: For free-breathing cardiovascular magnetic resonance (CMR), the self-navigation technique recently emerged, which is expected to deliver high-quality data with a high success rate. The purpose of this study was to test the hypothesis that self-navigated 3D-CMR enables the reliable assessment of cardiovascular anatomy in patients with congenital heart disease (CHD) and to define factors that affect image quality. METHODS: CHD patients ≥2 years-old and referred for CMR for initial assessment or for a follow-up study were included to undergo a free-breathing self-navigated 3D CMR at 1.5T. Performance criteria were: correct description of cardiac segmental anatomy, overall image quality, coronary artery visibility, and reproducibility of great vessels diameter measurements. Factors associated with insufficient image quality were identified using multivariate logistic regression. RESULTS: Self-navigated CMR was performed in 105 patients (55% male, 23 ± 12y). Correct segmental description was achieved in 93% and 96% for observer 1 and 2, respectively. Diagnostic quality was obtained in 90% of examinations, and it increased to 94% if contrast-enhanced. Left anterior descending, circumflex, and right coronary arteries were visualized in 93%, 87% and 98%, respectively. Younger age, higher heart rate, lower ejection fraction, and lack of contrast medium were independently associated with reduced image quality. However, a similar rate of diagnostic image quality was obtained in children and adults. CONCLUSION: In patients with CHD, self-navigated free-breathing CMR provides high-resolution 3D visualization of the heart and great vessels with excellent robustness.

Cost-minimization analysis of three decision strategies for cardiac revascularization : results of the "suspected CAD"cohort of the european cardiovascular magnetic resonance registry.

BACKGROUND: Coronary artery disease (CAD) continues to be one of the top public health burden. Perfusion cardiovascular magnetic resonance (CMR) is generally accepted to detect CAD, while data on its cost effectiveness are scarce. Therefore, the goal of the study was to compare the costs of a CMR-guided strategy vs two invasive strategies in a large CMR registry. METHODS: In 3'647 patients with suspected CAD of the EuroCMR-registry (59 centers/18 countries) costs were calculated for diagnostic examinations (CMR, X-ray coronary angiography (CXA) with/without FFR), revascularizations, and complications during a 1-year follow-up. Patients with ischemia-positive CMR underwent an invasive CXA and revascularization at the discretion of the treating physician (=CMR + CXA-strategy). In the hypothetical invasive arm, costs were calculated for an initial CXA and a FFR in vessels with ≥50 % stenoses (=CXA + FFR-strategy) and the same proportion of revascularizations and complications were applied as in the CMR + CXA-strategy. In the CXA-only strategy, costs included those for CXA and for revascularizations of all ≥50 % stenoses. To calculate the proportion of patients with ≥50 % stenoses, the stenosis-FFR relationship from the literature was used. Costs of the three strategies were determined based on a third payer perspective in 4 healthcare systems. RESULTS: Revascularizations were performed in 6.2 %, 4.5 %, and 12.9 % of all patients, patients with atypical chest pain (n = 1'786), and typical angina (n = 582), respectively; whereas complications (=all-cause death and non-fatal infarction) occurred in 1.3 %, 1.1 %, and 1.5 %, respectively. The CMR + CXA-strategy reduced costs by 14 %, 34 %, 27 %, and 24 % in the German, UK, Swiss, and US context, respectively, when compared to the CXA + FFR-strategy; and by 59 %, 52 %, 61 % and 71 %, respectively, versus the CXA-only strategy. In patients with typical angina, cost savings by CMR + CXA vs CXA + FFR were minimal in the German (2.3 %), intermediate in the US and Swiss (11.6 % and 12.8 %, respectively), and remained substantial in the UK (18.9 %) systems. Sensitivity analyses proved the robustness of results. CONCLUSIONS: A CMR + CXA-strategy for patients with suspected CAD provides substantial cost reduction compared to a hypothetical CXA + FFR-strategy in patients with low to intermediate disease prevalence. However, in the subgroup of patients with typical angina, cost savings were only minimal to moderate.

Ventricularisation of the left atrium: a rare cause of left ventricular dysfunction in a patient with mitral valve prolapse

Case: A 11 yo girl with Marfan syndrome was referred to cardiac MR (CMR) to measure the size of her thoracic aorta. She had a typical phenotype with arachnodactyly, abnormally long arms, and was tall and slim (156 cm, 28 kg, body mass index 11,5 kg/m2). She complained of no symptoms. Cardiac auscultation revealed a prominent mid-systolic click and an end-systolic murmur at the apex. A recent echocardiogram showed a moderately dilated left ventricle with normal function and a mitral valve prolapse with moderate mitral valve regurgitation. CMR showed a dilatation of the aortic root (38 mm, Z-score 8.9) and a severe prolapse of the mitral valve with regurgitation. The ventricular cavity was moderately dilated (116 ml/m2) and its contraction was hyperdynamic (stroke volume (SV): 97 ml; LVEF 72%, with the LV volumes measured by modified Simpson method from the apex to the mitral annulus). In this patient however, the mitral prolapse was characterized by a severe backward movement of the valve toward the left atrium (LA) in systole and the dyskinetic movement of the atrioventricular plane caused a ventricularisation of a part of the LA in systole (Figure). This resulted in a significant reduction of LVEF: more than ¼ of the apparent SV was displaced backwards into the ventricularized LA volume, reducing the effective LVEF to 51% (effective SV 69ml). Moreover, by flow measurement, the SV across the ascending aorta was 30 ml (cardiac index 2.0 l/min/m2) allowing the calculation of a regurgitant fraction across the mitral valve of 56%, which was diagnostic for a severe mitral valve insufficiency. Conclusion: This case illustrates the phenomenon of a ventricularisation of the LA where the severe prolapse gives the illusion of a higher attachement of the mitral leaflets within the atrial wall. Besides the severe mitral regurgitation, this paradoxical backwards movement of the valve causes an intraventricular unloading during systole reducing the apparent LVEF of 72% to an effective LVEF of only 51%. In addition, forward flow fraction is only 22% after accounting for the regurgitant volume, as well. This combined involvement of the mitral valve could explain the discrepancy between a low output state and an apparently hyperdynamic LV contraction. Due to its ability to precisely measure flows and volumes, CMR is particularly suited to detect this phenomenon and to quantify its impact on the LV pump function.

Simultaneous acute pulmonary embolism and isolated septal myocardial infarction in a young patient

While the overall incidence of myocardial infarction (MI) has been decreasing since 2000 [1], there is an increasing number of younger patients presenting with MI [2]. Few studies have focused on MI in very young patients, aged 35 years or less, as they only account for a minority of all patients with myocardial infarction [3]. According to the age category, MI differs in presentation, treatment and outcome, as illustrated in table 1. Echocardiography is considered mandatory according to scientific guidelines in the management and diagnosis of MI [4,5,6]. However, new imaging techniques such as cardiac magnetic resonance (CMR) and computed tomography (CT) are increasingly performed and enable further refinement of the diagnosis of MI. These techniques allow, in particular, precise location and quantification of MI. In this case, MI was located to the septum, which is an unusual presentation of MI. The incidence of pulmonary embolism (PE) has also increased in young patients over the past years [7]. Since symptoms and signs of PE may be non-specific, establishing its diagnosis remains a challenge [8]. Therefore, PE is one of the most frequently missed diagnosis in clinical medicine. Because of the widespread use of CT and its improved visualization of pulmonary arteries, PE may be discovered incidentally [9]. In the absence of a congenital disorder, multiple and/or simultaneous disease presentation is uncommon in the young. We report the rare case of a 35 year old male with isolated septal MI and simultaneous PE. The diagnosis of this rare clinical entity was only possible by means of newer imaging techniques.

Tietoturvan huomioiminen tietojärjestelmien ulkoistamisessa; Case: Lappeenrannan sosiaali- ja terveystoimi

Tässä diplomityössä tarkastellaan tietoturvan huomioimista tietojärjestelmien ja niiden palveluiden ulkoistamisen yhteydessä. Ulkoistuksen myötä tietohallinnon rooli on muuttunut. Ennen organisaatio on itse määrittänyt halutun tietoturvatason ja varmistanut sitä kautta oman tiedon turvaamisen. Ulkoistamalla omia tietojärjestelmiä tai palveluita, joutuu organisaatio määrittelemään myös näille ulkoistetuille palveluille tietoturvatason ja valvomaan tason saavuttamista ja kehittämistä. Tämä on tuonut muutosta ja sitä kautta paineita ymmärtää ulkoistamista ja sen vaativia toimenpiteitä myös tietoturvan kannalta. Työssä paneudutaan ulkoistamisen teoreettiseen taustaan käymällä läpi ulkoistamisen syitä ja motiiveja. Tässä osassa kuvataan myös erityisesti niitä elementtejä, jotka ovat keskeisiä tietojärjestelmien ja tietohallinnon ulkoistamiselle. Suomen lainsäädäntö ei tunne yhtä ainoaa lakia, joka ottaa kantaa tietoturvaan tai – suojaan, vaan tietoturvan määrittäviä lakeja ja säädöksiä on useita. Tässä työssä tarkastellaan yleisimpiä tietoturvaan vaikuttavia lainsäädäntöjä ja standardeja. Tietoturvan tasoon ulkoistetuissa järjestelmissä voidaan vaikuttaa vain sopimus- käytännön kautta. Ulkoistamisen ja sitä kautta tietoturvan yksi tärkeimpiä elementtejä on sopimuskäytäntö, joten sen läpikäynti tutkimuksessa on yksi oleellisimmista asioista. Tutkimuksen empiirisessä osassa käydään läpi Lappeenrannan kaupungin sosiaali- ja terveystoimen tietojärjestelmien ulkoistamisprosessi ja peilataan sitä teoreettiseen taustaan. Tietoturvan ulkoistamisprosessi esitellään sen eri osa-alueiden kautta niin, että siinä huomioidaan erikseen tekninen tietoturva, dokumentaatio ja tietoturvaorganisaatio sekä henkilöturvallisuus.

Kiinteistönvälittäjän vastuu vanhan asunnon kaupassa

Tutkielman tarkoituksena oli selvittää kiinteistönvälittäjän vastuuta vanhan asunnon kaupassa, kun toisena osapuolena on kuluttajan asemassa oleva yksityishenkilö. Työn perustana on kiinteistönvälittäjän toimintaa ohjaava voimassa oleva lainsäädäntö. Tutkimusaineistona käytettiin lisäksi kirjallisuutta ja viime vuosien oikeuskäytäntöä. Kiinteistönvälittäjän vastuu kaupan osapuolille perustuu joko sopimus- tai vahingonkorvausvastuuseen riippuen siitä, onko vahinkoa kärsinyt toimeksiantaja vai tämän vastapuoli. Vastuu edellyttää virhettä välittäjän toiminnassa, joka on tuottamuksen lisäksi syy-yhteydessä aiheutuneeseen vahinkoon. Välittäjän toimissa on virhe, jos se ei vastaa sovittua tai laissa säädettyä.

Keskijohdon ja työntekijöiden psykologiset sopimukset muutostilanteessa. Case: OP-Pohjola-ryhmä

Tässä tutkielmassa tarkasteltiin keskijohtajien ja työntekijöiden psykologisia sopimuksia OP-Pohjola-ryhmässä. Tutkielman tarkoituksena oli tuottaa uutta ymmärrystä henkilöstön ja organisaation suhteesta. Tavoitteena oli selvittää, millaisia psykologisia sopimuksia keskijohtajat ja työntekijät muodostavat, rikotaanko näitä sopimuksia ja kuinka haastateltavat reagoivat mahdollisiin rikkomuksiin. Lisäksi eri organisaatiotasojen käsityksiä ja näkemyksiä psykologisesta sopimuksesta vertailtiin keskenään. Tutkielma on laadullinen tutkielma, jonka tutkimusmenetelmänä käytettiin puolistrukturoitua haastattelua. Tutkimusaineisto kerättiin tekemällä kahdeksan haastattelua. Tutkimusta varten haastateltiin neljää keskijohtajaa ja neljää työntekijää. Empiirisen aineiston analyysissa tulkinta pohjautuu tutkimuksen teoreettiseen viitekehykseen. Tutkimustulosten mukaan haastateltujen keskijohtajien psykologiset sopimukset ovat luonteeltaan relationaalisia ja työntekijöiden sopimukset puolestaan transaktionaalisia. Molempien sopimukset sisältävät kuitenkin kumpiakin sopimusehtoja. Haastateltujen psykologisia sopimuksia on rikottu harvakseltaan. Rikkomuksiin on reagoitu keskustelemalla työnantajan kanssa tai olemalla vaiti ja sopeutumalla tilanteeseen. Tulokset myös osoittavat, että organisaatiossa vallitsee suuri luottamus ja asioista keskustellaan hyvin avoimesti.

Sopimuksen muuttaminen liiketoimintasuhteessa

Tutkielman tavoitteena on selvittää sopimuksen muuttamiseen liittyviä kysymyksiä liiketoimintasuhteessa. Lähtökohtana kysymyksenasettelulle on kansallinen lainsäädäntö, sopimusoikeudelliset periaatteet sekä oikeuskirjallisuus. Sopimuksen muuttamisen liikesuhteissa mahdollistaa Suomen lainsäädännössä OikTL 36 §, jonka johdosta kohtuutonta sopimusta on mahdollista sovitella. Sovittelun mahdollisuus heikentää kuitenkin sopimuksen sitovuutta, sillä lähtökohtaisesti sopimus sitoo sovituilla ehdoilla. Sopimuksen muutostarpeen yhteydessä sopimuksen tulkinta ja osapuolten tarkoitus nousevat avainasemaan tarkasteltaessa edellytyksiä kohtuuttomuuteen vetoamiseen ja sovitteluun. Lain ohella merkityksellisessä asemassa ovat siten sopimukseen otetut ehdot ja sopimusrakenteet.

Magnetic and transport properties of LaMnO3+δ, La1-xCaxMnO3, La1-xCaxMn1-yFeyO3 and La1-xSrxMn1-yFeyO3

Interest to hole-doped mixed-valence manganite perovskites is connected to the ‘colossal’ magnetoresistance. This effect or huge drop of the resistivity, ρ, in external magnetic field, B, attains usually the maximum value near the ferromagnetic Curie temperature, TC. In this thesis are investigated conductivity mechanisms and magnetic properties of the manganite perovskite compounds LaMnO3+, La1-xCaxMnO3, La1-xCaxMn1-yFeyO3 and La1- xSrxMn1-yFeyO3. When the present work was started the key role of the phase separation and its influence on the properties of the colossal magnetoresistive materials were not clear. Our main results are based on temperature dependencies of the magnetoresistance and magnetothermopower, investigated in the temperature interval of 4.2 - 300 K in magnetic fields up to 10 T. The magnetization was studied in the same temperature range in weak (up to 0.1 T) magnetic fields. LaMnO3+δ is the parent compound for preparation of the hole-doped CMR materials. The dependences of such parameters as the Curie temperature, TC, the Coulomb gap, Δ, the rigid gap, γ, and the localization radius, a, on pressure, p, are observed in LaMnO3+δ. It has been established that the dependences above can be interpreted by increase of the electron bandwidth and decrease of the polaron potential well when p is increased. Generally, pressure stimulates delocalization of the electrons in LaMnO3+δ. Doping of LaMnO3 with Ca, leading to La1-xCaxMnO3, changes the Mn3+/Mn4+ ratio significantly and brings an additional disorder to the crystal lattice. Phase separation in a form of mixture of the ferromagnetic and the spin glass phases was observed and investigated in La1- xCaxMnO3 at x between 0 and 0.4. Influence of the replacement of Mn by Fe is studied in La0.7Ca0.3Mn1−yFeyO3 and La0.7Sr0.3Mn1−yFeyO3. Asymmetry of the soft Coulomb gap and of the rigid gap in the density of localized states, small shift of the centre of the gaps with respect to the Fermi level and cubic asymmetry of the density of states are obtained in La0.7Ca0.3Mn1−yFeyO3. Damping of TC with y is connected to breaking of the double-exchange interaction by doping with Fe, whereas the irreversibility and the critical behavior of the magnetic susceptibility are determined by the phase separation and the frustrated magnetic state of La0.7Sr0.3Mn1−yFeyO3.

Characteristics of credit risk assessment methods of major Nordic banks in allocating capital when extending credits to large corporations

Credit risk assessment is an integral part of banking. Credit risk means that the return will not materialise in case the customer fails to fulfil its obligations. Thus a key component of banking is setting acceptance criteria for granting loans. Theoretical part of the study focuses on key components of credit assessment methods of Banks in the literature when extending credits to large corporations. Main component is Basel II Accord, which sets regulatory requirement for credit risk assessment methods of banks. Empirical part comprises, as primary source, analysis of major Nordic banks’ annual reports and risk management reports. As secondary source complimentary interviews were carried out with senior credit risk assessment personnel. The findings indicate that all major Nordic banks are using combination of quantitative and qualitative information in credit risk assessment model when extending credits to large corporations. The relative input of qualitative information depends on the selected approach to the credit rating, i.e. point-in-time or through-the-cycle.