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.

Unraveling the helix of change : An activity-theoretical study of health care change efforts and their consequences

M.A. (Educ.) Anu Kajamaa from the University of Helsinki, Center for Research on Activity, Development and Learning (CRADLE), examines change efforts and their consequences in health care in the public sector. The aim of her academic dissertation is, by providing a new conceptual framework, to widen our understanding of organizational change efforts and their consequences and managerial challenges. Despite the multiple change efforts, the results of health care development projects have not been very promising, and many developmental needs and managerial challenges exist. The study challenges the predominant, well-framed health care change paradigm and calls for an expanded view to explore the underlying issues and multiplicities of change efforts and their consequences. The study asks what kind of expanded conceptual framework is needed to better understand organizational change as transcending currently dominant oppositions in management thinking, specifically in the field of health care. The study includes five explorative case studies of health care change efforts and their consequences in Finland. Theory and practice are tightly interconnected in the study. The methodology of the study integrates the ethnography of organizational change, a narrative approach and cultural-historical activity theory. From the stance of activity theory, historicity, contradictions, locality and employee participation play significant roles in developing health care. The empirical data of the study has mainly been collected in two projects, funded by the Finnish Work Environment Fund. The data was collected in public sector health care organizations during the years 2004-2010. By exploring the oppositions between distinct views on organizational change and the multi-site, multi-level and multi-logic of organizational change, the study develops an expanded, multidimensional activity-theoretical framework on organizational change and management thinking. The findings of the study contribute to activity theory and organization studies, and provide information for health care management and practitioners. The study illuminates that continuous development efforts bridged to one another and anchored to collectively created new activity models can lead to significant improvements and organizational learning in health care. The study presents such expansive learning processes. The ways of conducting change efforts in organizations play a critical role in the creation of collective new practices and tools and in establishing ownership over them. Some of the studied change efforts were discontinuous or encapsulated, not benefiting the larger whole. The study shows that the stagnation and unexpected consequences of change efforts relate to the unconnectedness of the different organizational sites, levels and logics. If not dealt with, the unintended consequences such as obstacles, breaks and conflicts may stem promising change and learning processes.

Independent and mediating organizational commitment effects of trust in leadership on employees' job satisfaction and : a study within social and health care sector

The purpose of this study was to examine whether trust in supervisor and trust in senior management enhance employees' job satisfaction and organizational commitment, and whether trust mediates the relationship between perceived justice and these outcomes. Trust in supervisor was expected to mediate the effects of distributive justice and interactional justice, and trust in senior management was expected to mediate the effects of procedural justice. Theoretical background of the study is based on the framework for trust in leadership developed by Dirks and Ferrin (2002). According to the framework, perceived fairness of leaders' actions helps employees to draw inferences about the basis of the relationship and about leaders' characters. This allows trust formation. Reciprocation of care and concern in the relationship and confidence in leaders' characters are likely to enhance employees' job satisfaction and organizational commitment. This study was conducted with cross-sectional data (A/ = 960) of employees from social and health care sector. Hypotheses were studied using correlation analysis and several hierarchical regression analyses. Significances of the mediations were assessed using the Sobel test. Results partially supported the hypotheses. Trust in leadership was positively related to job satisfaction and organizational commitment. Trust in senior management mediated the relationship between procedural justice and the outcomes. Some support was also found for the mediating effect of trust in supervisor in the relationship between distributive justice and organizational commitment. Due to high correlation between trust in supervisor anil interactional justice, it wasn't possible to study the mediating e fleet of trust in supervisor in the relationship between interactional justice and the outcomes. Against expectations, results indicated that trust in senior management had a mediating effect in the relationship between distributive justice and organizational commitment, and in the relationship between interactional justice and organizational commitment. Results also indicated that trust in supervisor had a mediating effect in the relationship between procedural justice and organizational commitment.

Poly-ols Based Sol-Gel Synthesis of Zinc Oxide Thin Films

We demonstrate that the structural and optical properties of a sol-gel deposited zinc oxide thin film can be tuned by varying the composition of the sol, consisting of ethylene glycol and glycerol. A systematic study of the effect of the composition of sol on the mean grain size, thickness, and defect density of the zinc oxide film is presented. About 20% glycerol content in the sol is observed to improve the quality of the film, as evaluated by X-ray diffraction and photoluminescence studies. Thus, optimizing the composition of the sol for about 60 nm thick ZnO film using 20% glycerol resulted in the zinc oxide film that is about 80% transparent in visible spectrum, exhibiting electrical resistivity of about 18 Omega cm and field-effect mobility of 0.78 cm(2)/(V s). (C) 2010 The Electrochemical Society. DOI: 10.1149/1.3515894] All rights reserved.

Kinetic evolution studies of silver nanoparticles in a bio-based green synthesis process

Silver nanoparticles are being extensively studied due to their widespread applications and unique properties. In the present study, the growth kinetics of silver nanoparticles as synthesized on reduction of silver nitrate solution by aqueous extract of Azadirachta indica leaves was investigated. The formation of silver nanoparticles was preliminarily monitored by measuring the absorption maxima at different time intervals after adding the reducing agent to the silver salt solution (0.5, 1, 1.5, 2, 2.5, 3, 3.5 and 4 h). At different time points characterization studies were conducted using X-ray diffraction studies, FT-IR techniques, zeta potential studies and transmission electron microscopy. The total available silver in the reaction medium was determined at different durations using ICP-OES. The changes in reduction potential in the medium were also monitored using potentiometric analysis. The results confirm a definite change in the medium pertaining to formation of the stable nanoparticles after 2 h, and a significant increase in the agglomeration tendency after 4 h of interaction. The growth kinetic data of the nanoparticles till 3.5 h was found to fit the LSW model confirming diffusion limited growth. (C) 2011 Elsevier B.V. All rights reserved.

An aqueous-solution based low-temperature pathway to synthesize giant dielectric CaCu3Ti4O12-Highly porous ceramic matrix and submicron sized powder

A simple, cost-effective and environment-friendly pathway for preparing highly porous matrix of giant dielectric material CaCu3Ti4O12 (CCTO) through combustion of a completely aqueous precursor solution is presented. The pathway yields phase-pure and impurity-less CCTO ceramic at an ultra-low temperature (700 degrees C) and is better than traditional solid-state reaction schemes which fail to produce pure phase at as high temperature as 1000 degrees C (Li, Schwartz, Phys. Rev. B 75, 012104). The porous ceramic matrix on grinding produced CCTO powder having particle size in submicron order with an average size 300 nm. On sintering at 1050 degrees C for 5 h the powder shows high dielectric constants (>10(4) at all frequencies from 100 Hz to 100 kHz) and low loss (with 0.05 as the lowest value) which is suitable for device applications. The reaction pathway is expected to be extended to prepare other multifunctional complex perovskite materials. (C) 2010 Elsevier B.V. All rights reserved.

Effect of TiO2 electrode thickness on photovoltaic properties of dye sensitized solar cell based on randomly oriented Titania nanotubes

Anatase titania nanotubes (TNTs) have been synthesized from P25 TiO2 powder by alkali hydrothermal method followed by post annealing. The microstructure analysis by X-ray diffraction (XRD), transmission electron microscopy (TEM) and scanning electron microscopy (SEM) revealed the formation of anatase nanotubes with a diameter of 9-10 nm. These NTs are used to make photo anode in dye-sensitized solar cells (DSSCs). Layer by layer deposition with curing of each layer at 350 C is employed to realize films of desired thickness. The performance of these cells is studied using photovoltaic measurements. Electrochemical impedance spectroscopy (EIS) is used to quantitatively analyze the effect of thickness on the performance of these cells. These studies revealed that the thickness of TiO2 has a pronounced impact on the cell performance and the optimum thickness lies in the range of 10-14 mu m. In comparison to dye solar cells made of P25, TNTs based cells exhibit an improved open circuit voltage and fill factor (FF) due to an increased electron lifetime, as revealed by EIS analysis. (C) 2011 Elsevier B.V. All rights reserved.

Towards the total synthesis of tashironin related allo-cedrane natural products: further exploitation of the oxidative dearomatization-IMDA-RCM triad based strategy

Synthetic studies directed towards allo-cedrane based, tashironin sibling natural products, involving some deft functional group manipulations on a preformed tetracyclic scaffold, are delineated. (C) 2011 Elsevier Ltd. All rights reserved.

Prediction of nonlocal scaling parameter for armchair and zigzag single-walled carbon nanotubes based on molecular structural mechanics, nonlocal elasticity and wave propagation

Atomic vibration in the Carbon Nanotubes (CNTs) gives rise to non-local interactions. In this paper, an expression for the non-local scaling parameter is derived as a function of the geometric and electronic properties of the rolled graphene sheet in single-walled CNTs. A self-consistent method is developed for the linearization of the problem of ultrasonic wave propagation in CNTs. We show that (i) the general three-dimensional elastic problem leads to a single non-local scaling parameter (e(0)), (ii) e(0) is almost constant irrespective of chirality of CNT in the case of longitudinal wave propagation, (iii) e(0) is a linear function of diameter of CNT for the case of torsional mode of wave propagation, (iv) e(0) in the case of coupled longitudinal-torsional modes of wave propagation, is a function which exponentially converges to that of axial mode at large diameters and to torsional mode at smaller diameters. These results are valid in the long-wavelength limit. (C) 2011 Elsevier Ltd. All rights reserved.

A QFT-based robust SVC controller for improving the dynamic stability of power systems

A new design technique for an SVC-based power system damping controller has been proposed. The controller attempts to place all plant poles within a specified region on the s-plane to guarantee the desired closed loop performance. The use of Horowitz's quantitative feedback theory (QFT) permits the design of a 'fixed gain controller' that maintains its performance in spite of large variations in the plant parameters during its normal course of operation. The required controller parameters are arrived at by solving an optimization problem that incorporates the control specifications. The performance of this robust controller has been evaluated on a single machine infinite bus system equipped with a mid point SVC, and the results are shown to be consistent with the expected performance of the stabilizer. (C) 1998 Elsevier Science S.A. All rights reserved.

Critical buckling temperature of single-walled carbon nanotubes embedded in a one-parameter elastic medium based on nonlocal continuum mechanics

In this paper, the critical budding temperature of single-walled carbon nanotubes (SWCNTs), which are embedded in one-parameter elastic medium (Winkler foundation) is estimated under the umbrella of continuum mechanics theory. Nonlocal continuum theory is incorporated into Timoshenko beam model and the governing differential equations of motion are derived. An explicit expression for the non-dimensional critical buckling temperature is also derived in this work. The effect of the nonlocal small scale coefficient, the Winkler foundation parameter and the ratio of the length to the diameter on the critical buckling temperature is investigated in detail. It can be observed that the effects of nonlocal small scale parameter and the Winkler foundation parameter are significant and should be considered for thermal analysis of SWCNTs. The results presented in this paper can provide useful guidance for the study and design of the next generation of nanodevices that make use of the thermal buckling properties of embedded single-walled carbon nanotubes. (C) 2011 Elsevier B.V. All rights reserved.

Classification of microwatersheds based on morphological characteristics

Three classification techniques, namely, K-means Cluster Analysis (KCA), Fuzzy Cluster Analysis (FCA), and Kohonen Neural Networks (KNN) were employed to group 25 microwatersheds of Kherthal watershed, Rajasthan into homogeneous groups for formulating the basis for suitable conservation and management practices. Ten parameters, mainly, morphological, namely, drainage density (D-d), bifurcation ratio (R-b), stream frequency (F-u), length of overland flow (L-o), form factor (R-f), shape factor (B-s), elongation ratio (R-e), circulatory ratio (R-c), compactness coefficient (C-c) and texture ratio (T) are used for the classification. Optimal number of groups is chosen, based on two cluster validation indices Davies-Bouldin and Dunn's. Comparative analysis of various clustering techniques revealed that 13 microwatersheds out of 25 are commonly suggested by KCA, FCA and KNN i.e., 52%; 17 microwatersheds out of 25 i.e., 68% are commonly suggested by KCA and FCA whereas these are 16 out of 25 in FCA and KNN (64%) and 15 out of 25 in KNN and CA (60%). It is observed from KNN sensitivity analysis that effect of various number of epochs (1000, 3000, 5000) and learning rates (0.01, 0.1-0.9) on total squared error values is significant even though no fixed trend is observed. Sensitivity analysis studies revealed that microwatershecls have occupied all the groups even though their number in each group is different in case of further increase in the number of groups from 5 to 6, 7 and 8. (C) 2010 International Association of Hydro-environment Engineering and Research, Asia Pacific Division. Published by Elsevier B.V. All rights reserved.

Wavelet based compression and denoising of optical tomography data

Two methods based on wavelet/wavelet packet expansion to denoise and compress optical tomography data containing scattered noise are presented, In the first, the wavelet expansion coefficients of noisy data are shrunk using a soft threshold. In the second, the data are expanded into a wavelet packet tree upon which a best basis search is done. The resulting coefficients are truncated on the basis of energy content. It can be seen that the first method results in efficient denoising of experimental data when scattering particle density in the medium surrounding the object was up to 12.0 x 10(6) per cm(3). This method achieves a compression ratio of approximate to 8:1. The wavelet packet based method resulted in a compression of up to 11:1 and also exhibited reasonable noise reduction capability. Tomographic reconstructions obtained from denoised data are presented. (C) 1999 Published by Elsevier Science B.V. All rights reserved,

A fixed-grid finite element based enthalpy formulation for generalized phase change problems: role of superficial mushy region

The enthalpy method is primarily developed for studying phase change in a multicomponent material, characterized by a continuous liquid volume fraction (phi(1)) vs temperature (T) relationship. Using the Galerkin finite element method we obtain solutions to the enthalpy formulation for phase change in 1D slabs of pure material, by assuming a superficial phase change region (linear (phi(1) vs T) around the discontinuity at the melting point. Errors between the computed and analytical solutions are evaluated for the fluxes at, and positions of, the freezing front, for different widths of the superficial phase change region and spatial discretizations with linear and quadratic basis functions. For Stefan number (St) varying between 0.1 and 10 the method is relatively insensitive to spatial discretization and widths of the superficial phase change region. Greater sensitivity is observed at St = 0.01, where the variation in the enthalpy is large. In general the width of the superficial phase change region should span at least 2-3 Gauss quadrature points for the enthalpy to be computed accurately. The method is applied to study conventional melting of slabs of frozen brine and ice. Regardless of the forms for the phi(1) vs T relationships, the thawing times were found to scale as the square of the slab thickness. The ability of the method to efficiently capture multiple thawing fronts which may originate at any spatial location within the sample, is illustrated with the microwave thawing of slabs and 2D cylinders. (C) 2002 Elsevier Science Ltd. All rights reserved.

A portable battery-operated chip thermocycler based on induction heating

A microchip thermocycler, fabricated from silicon and Pyrex #7740 glass, is described. Usual resistive heating has been replaced by induction heating, leading to much simpler fabrication steps. Heating and cooling rates of 6.5 and 4.2 degreesC/s, respectively have been achieved, by optimising the heater dimensions and heating frequency (similar to200 kHz). Four devices are mounted on a heater, resulting in low power consumption (similar to 1.4 W per device on the average). Using simple on-off electronic temperature control, a temperature stability within -0.2 degreesC is achieved. Features such as induction heating, good temperature control, battery operation, and low power consumption make the device suitable for portable applications, particularly in polymerase chain reaction (PCR) systems. (C) 2002 Elsevier Science B.V. All rights reserved.