Treatment of illicit opioid and γ-hydroxybutyrate overdose by Helsinki emergency medical services

Aims: To examine the characteristics, incidence, treatment and outcome of presumed opioid, γ-hydroxybutyrate (GHB) and γ-butyrolactone (GBL) overdoses involving users of illicit drugs in Helsinki. GHB/GBL were included in this study, despite not being opioids, due to the relative ease with which they can cause potentially fatal respiratory depression. The incidence and time interval of recurrent opioid toxicity after prehospital administration of naloxone, an opioid antagonist, was studied in presumed heroin overdose patients. Naloxone has been reported to have many adverse effects and the effects of naloxone administered during an opioid overdose on the cardiovascular system and catecholamine levels in piglets were studied. Materials and methods: Patients included in these published retrospective studies were from the following time periods: Study I: 1995-2002, II: 1997-2000, III: 1995-2000, V: 2006-2007. Presumed opioid overdose patients were examined in studies I, II and III. GHB/GBL overdoses among injecting drug users was examined in study V. Recurrent opioid toxicity after prehospital naloxone administration in heroin overdose patients was examined in study III. The effects of naloxone (80 μg/kg i.v.) on the cardiovascular system and catecholamine levels administered during morphine overdose (8mg/kg i.v.) and under propofol anesthesia with spontaneous breathing were studied in eight piglets (IV). In this thesis, previously unpublished data on the incidence of opioid overdose between 2001-2007 and comparison of the characteristics of buprenorphine and heroin overdose patients encountered in 1995-2005 are also included. Results: Helsinki Emergency Medical Service (EMS) ambulances were dispatched annually to 34,153- 45,118 calls from 1995 to 2007. Of them, 7-8% were coded as intoxications or overdoses. During this time, 436 patients were treated by the EMS for presumed opioid overdose. The peak incidence of opioid overdoses was in the year 2000 (113 cases), after which they declined to 6-26 cases annually. The annual incidence of buprenorphine related overdoses increased from 4 (4% of opioid overdoses) in the year 2000 to 8 (30% of opioid overdoses) in 2007. The annual number of GHB related overdose patients treated by Helsinki EMS increased from 21 to 73 between 2004-2007. There appeared to be a peak in the incidence of both GHB/GBL and opioid related overdoses on Saturdays. Characteristics of opioid overdose patients The median age of opioid overdose patients was 28 years (22;33, 25- and 75-percentiles), and 84% were male. Buprenorphine overdose patients had more polydrug, such as alcohol and/or benzodiazepines, use in comparison with heroin overdose patients, 70% versus 33%, respectively. Severe respiratory depression was reported less often with buprenorphine overdoses compared to heroin overdoses, in 67.0% versus 85.4%, respectively. Outcome of heroin overdose patients with cardiac arrest Ninety four patients suffered cardiac arrest due to acute drug poisoning/overdose and were thus considered for resuscitation. Resuscitation was attempted in 72 cases. Cardiac arrest was caused by heroin overdose for 19 patients of which three (16%) were discharged alive. Other agents also induced cardiac arrest in 53 patients, of which six (11%) were discharged alive. The arrest was either EMS witnessed or occurring after the emergency call for all survivors of heroin induced cardiac arrest. Characteristics of GHB/GBL overdose patients The records of 100 GHB/GBL related overdose patients from 2006-2007 were retrieved. The median age of GHB/GBL overdose patients encountered on weekend nights was 24 years (22;27, 25- and 75-percentiles) and 49% were male. Polydrug use was reported in 62-80% of the cases. Thirty nine patients were encountered on Friday-Saturday or Saturday-Sunday night between 11 pm-6 am. The remaining sixty one patients were outside this time frame. There was a statistically significant difference between these two groups in history of chronic injecting drug use (33% vs. 59%, respectively, p=0.012). Recurrent heroin toxicity after prehospital naloxone administration Study III included 145 presumed heroin overdose patients. After prehospital care, 84 patients refused further care and were not transported to an Emergency Department (ED). Seventy one (85%) of them were administered naloxone by the EMS. During a 12-h follow up period, none of these patients developed severe recurrent opioid toxicity. The remaining 61 patients were transported to an ED. Prior to transportation, 52 (85%) patients were administered naloxone by the EMS. Fifteen of them were administered naloxone also in the ED and recurrent opioid toxicity was evident either on arrival at the ED or shortly thereafter. Prehospital naloxone was administered either intravenously, intramuscularly (i.m.) or subcutaneously (s.c.). There was a tendency for more frequent recurrent heroin toxicity among the patients with only intravenous administration of prehospital naloxone (13/36) compared with the patients with intramuscular or subcutaneous prehospital naloxone (2/16), p=0.106. The effects of naloxone on the cardiovascular system and catecholamine levels in piglets The administration of morphine to piglets resulted in an obvious respiratory depression, which was reversed by naloxone. Two severely hypoxemic piglets developed cardiac arrest after naloxone administration. In the other six animals, the administration of naloxone did not provoke arrhythmias, cardiac ischemia or visible evidence of pulmonary edema. There was a statistically significant (p=0.012) increase in norepinephrine levels after morphine administration and before naloxone administration: from 1.9 (1.3-2.3) ng/ml at baseline, to 31.7 (8.3-83.0) ng/ml (median, 25 and 75 percentiles parentheses) after morphine administration. After the administration of naloxone, the catecholamine levels continued to increase in only one of the animals. Conclusions: The incidence of buprenorphine related overdoses increased during the study period, but was still lower in comparison to those involving heroin. Injecting drug users have also started to use GHB/GBL. While recreational drug users use GHB/GBL during weekend nights, a GHB/GBL overdose patient encounter during weekdays has a more probable history of injecting drug use. Patients with cardiac arrest after heroin overdose have a poor prognosis. It appears to be safe to leave heroin overdose patients on scene after prehospital treatment with naloxone. Although no statistically significant difference was observed, it seems prudent to administer part of the total naloxone dose s.c. or i.m. to reduce the risk of recurrent respiratory depression. If transported to an ED, an observation period of one to two hours after the last naloxone dose seems adequate. The treating physician must be vigilant, however, due to the high prevalence of polydrug use and high morbidity after non fatal heroin overdose. Furthermore, care should be taken regarding possible chronic disorders and drug rehabilitation should be addressed. In the experimental animal study, two animals developed cardiac arrest after receiving naloxone while in hypoxemia and bradycardia. Further studies are required to assess the effect of naloxone during opioid-induced hypercapnia and hypoxemia in animals addicted to opioids.

Effects of forestry extension on the use of allowable cut in non-industrial private forests.

XVIII IUFRO World Congress, Ljubljana 1986.

Public and private technical assistance programs for non-industrial private forest landowners in the southern United States.

XVIII IUFRO World Congress, Ljubljana 1986.

Light scattering in random media with wavelength-scale structures : astronomical and industrial applications

Light scattering, or scattering and absorption of electromagnetic waves, is an important tool in all remote-sensing observations. In astronomy, the light scattered or absorbed by a distant object can be the only source of information. In Solar-system studies, the light-scattering methods are employed when interpreting observations of atmosphereless bodies such as asteroids, atmospheres of planets, and cometary or interplanetary dust. Our Earth is constantly monitored from artificial satellites at different wavelengths. With remote sensing of Earth the light-scattering methods are not the only source of information: there is always the possibility to make in situ measurements. The satellite-based remote sensing is, however, superior in the sense of speed and coverage if only the scattered signal can be reliably interpreted. The optical properties of many industrial products play a key role in their quality. Especially for products such as paint and paper, the ability to obscure the background and to reflect light is of utmost importance. High-grade papers are evaluated based on their brightness, opacity, color, and gloss. In product development, there is a need for computer-based simulation methods that could predict the optical properties and, therefore, could be used in optimizing the quality while reducing the material costs. With paper, for instance, pilot experiments with an actual paper machine can be very time- and resource-consuming. The light-scattering methods presented in this thesis solve rigorously the interaction of light and material with wavelength-scale structures. These methods are computationally demanding, thus the speed and accuracy of the methods play a key role. Different implementations of the discrete-dipole approximation are compared in the thesis and the results provide practical guidelines in choosing a suitable code. In addition, a novel method is presented for the numerical computations of orientation-averaged light-scattering properties of a particle, and the method is compared against existing techniques. Simulation of light scattering for various targets and the possible problems arising from the finite size of the model target are discussed in the thesis. Scattering by single particles and small clusters is considered, as well as scattering in particulate media, and scattering in continuous media with porosity or surface roughness. Various techniques for modeling the scattering media are presented and the results are applied to optimizing the structure of paper. However, the same methods can be applied in light-scattering studies of Solar-system regoliths or cometary dust, or in any remote-sensing problem involving light scattering in random media with wavelength-scale structures.

Uutta, vanhaa ja lainattua : Tampereen Kaupunkilähetyksen kristillissosiaalisen työn asemoituminen hyvinvointivaltion rakentumisessa vuosina 1939−1973

The main purpose of this study was to provide a full account of the Christian social work carried out at the Tampere City Mission (TCM) as well as the Missions sphere of operations from the Second World War to the early 1970s, comprising a period of significant change. The study consists of charting the processes of change and connections within the activities of the TCM and how examining these were linked to the general tendencies of the period, in lay work, social work, professionalization and the representation of gender. The positioning of the activities is described on the basis of these tendencies. The main sources for the study were the archives of the Mission, for example the minutes of meetings, correspondences as well as annual reports, and the archives of its partners, such as the City of Tampere, the Evangelical Lutheran parishes of Tampere and the State Welfare Administration. The archives of the Helsinki, Turku and Stockholm Missions supplied comparison reference and other material. In particular, social welfare and Christian social work technical journals of were used as printed sources. The principal method used was the genetic method of historiology. The research subject was also evaluated from the point of view of third sector research in addition to that of professionalization studies and gender studies. By the beginning of the research period, the TCM had turned more and more dedicatedly into a multipurpose social service organization maintaining social services such as old people s homes and children´s homes. This development continued, even though new areas of activity emerged and older ones fell into disuse. Social innovations sprang up, marriage counseling being one of them. On the national level, the TCM pioneered the provision of sheltered industrial work for intellectually disabled persons as well as housing services for them. As new activities were initiated, they overlapped with the established ones, and the TCM handed some of its child protection functions over to the municipality, in accordance with the current adaptation theory. The use of its own property to produce ever-changing social services may be the reason why the association s work continued on with vitality. Functional networks and political aid in the field of social services also bolstered the association. As in other Nordic countries, nonprofit organizations served as partners rather than competitors, with the State establishing institutional welfare arrangements. In the 1960s the municipal takeover of social services impacted the TCM activities. Rules for government subsidies and municipal allowances were not well established; hence these funds were not easily available, making improvements difficult. The TCM was a community in which women had a relatively strong position and an opportunity to make a difference. Female staff were reasonably equal to men, and women worked as heads of a several institutions. Care work employed a number of men, which went against the traditional segregation of labour between the sexes. The TCM s operations were from early on very professionalized, and were developed with particular care. Keywords: Christian social work, third sector, professionalization, gender

Industrial validation of processing maps of 316L stainless steel using hot forging, rolling, and extrusion

The development of microstructure in 316L stainless steel during industrial hot forming operations including press forging (strain rate of 0 . 15 s(-1)), rolling/extrusion (strain rate of 2-8 . 8 s(-1)), and hammer forging (strain rate of 100 s(-1)) at different temperatures in the range 600-1200 degrees C was studied with a view to validating the predictions of the processing map. The results showed that good col relation existed between the regimes indicated in the map and the product microstructures. The 316L stainless steel exhibited unstable flow in the form of flow localisation when hammer forged at temperatures above 900 degrees C, rolled below 1000 degrees C, or press forged below 900 degrees C. All these conditions must therefore be avoided in mechanical processing of the material. Conversely, in order to obtain defect free microstructures, ideally the material should be rolled at temperatures above 1100 degrees C, press forged at temperatures above 1000 degrees C, or hammer forged in the temperature range 600-900 degrees C. (C) 1996 The Institute of Materials.

Diaphragmless shock wave generators for industrial applications of shock waves

The prime focus of this study is to design a 50 mm internal diameter diaphragmless shock tube that can be used in an industrial facility for repeated loading of shock waves. The instantaneous rise in pressure and temperature of a medium can be used in a variety of industrial applications. We designed, fabricated and tested three different shock wave generators of which one system employs a highly elastic rubber membrane and the other systems use a fast acting pneumatic valve instead of conventional metal diaphragms. The valve opening speed is obtained with the help of a high speed camera. For shock generation systems with a pneumatic cylinder, it ranges from 0.325 to 1.15 m/s while it is around 8.3 m/s for the rubber membrane. Experiments are conducted using the three diaphragmless systems and the results obtained are analyzed carefully to obtain a relation between the opening speed of the valve and the amount of gas that is actually utilized in the generation of the shock wave for each system. The rubber membrane is not suitable for industrial applications because it needs to be replaced regularly and cannot withstand high driver pressures. The maximum shock Mach number obtained using the new diaphragmless system that uses the pneumatic valve is 2.125 +/- 0.2%. This system shows much promise for automation in an industrial environment.

PRUNE and PROBE-two modular web services for protein-protein docking

The protein-protein docking programs typically perform four major tasks: (i) generation of docking poses, (ii) selecting a subset of poses, (iii) their structural refinement and (iv) scoring, ranking for the final assessment of the true quaternary structure. Although the tasks can be integrated or performed in a serial order, they are by nature modular, allowing an opportunity to substitute one algorithm with another. We have implemented two modular web services, (i) PRUNE: to select a subset of docking poses generated during sampling search (http://pallab.serc.iisc.ernet.in/prune) and (ii) PROBE: to refine, score and rank them (http://pallab.serc.iisc.ernet.in/probe). The former uses a new interface area based edge-scoring function to eliminate > 95% of the poses generated during docking search. In contrast to other multi-parameter-based screening functions, this single parameter based elimination reduces the computational time significantly, in addition to increasing the chances of selecting native-like models in the top rank list. The PROBE server performs ranking of pruned poses, after structure refinement and scoring using a regression model for geometric compatibility, and normalized interaction energy. While web-service similar to PROBE is infrequent, no web-service akin to PRUNE has been described before. Both the servers are publicly accessible and free for use.

Modelling, simulation, and graphical user interface for industrial gas carburising process

A mathematical model has been developed for the gas carburising (diffusion) process using finite volume method. The computer simulation has been carried out for an industrial gas carburising process. The model's predictions are in good agreement with industrial experimental data and with data collected from the literature. A study of various mass transfer and diffusion coefficients has been carried out in order to suggest which correlations should be used for the gas carburising process. The model has been interfaced in a Windows environment using a graphical user interface. In this way, the model is extremely user friendly. The sensitivity analysis of various parameters such as initial carbon concentration in the specimen, carbon potential of the atmosphere, temperature of the process, etc. has been carried out using the model.

An intelligent procurement marketplace for web services composition

This paper presents an intelligent procurement marketplace for finding the best mix of web services to dynamically compose the business process desired by a web service requester. We develop a combinatorial auction approach that leads to an integer programming formulation for the web services composition problem. The model takes into account the Quality of Service (QoS) and Service Level Agreements (SLA) for differentiating among multiple service providers who are capable of fulfilling a functionality. An important feature of the model is interface aware composition.

Incentive compatible mechanisms for group ticket allocation in software maintenance services

A customer reported problem (or Trouble Ticket) in software maintenance is typically solved by one or more maintenance engineers. The decision of allocating the ticket to one or more engineers is generally taken by the lead, based on customer delivery deadlines and a guided complexity assessment from each maintenance engineer. The key challenge in such a scenario is two folds, un-truthful (hiked up) elicitation of ticket complexity by each engineer to the lead and the decision of allocating the ticket to a group of engineers who will solve the ticket with in customer deadline. The decision of allocation should ensure Individual and Coalitional Rationality along with Coalitional Stability. In this paper we use game theory to examine the issue of truthful elicitation of ticket complexities by engineers for solving ticket as a group given a specific customer delivery deadline. We formulate this problem as strategic form game and propose two mechanisms, (1) Division of Labor (DOL) and (2) Extended Second Price (ESP). In the proposed mechanisms we show that truth telling by each engineer constitutes a Dominant Strategy Nash Equilibrium of the underlying game. Also we analyze the existence of Individual Rationality (IR) and Coalitional Rationality (CR) properties to motivate voluntary and group participation. We use Core, solution concept from co-operative game theory to analyze the stability of the proposed group based on the allocation and payments.