Preterm Birth and Surgical Treatment of the Uterine Cervix

Cervical cancer is the second most common cancer among women globally. Most, probably all cases, arise through a precursor, cervical intraepithelial neoplasia (CIN). Effective cytological screening programmes and surgical treatments of precancerous lesions have dramatically reduced its prevalence and related mortality. Although these treatments are effective, they may have adverse effects on future fertility and pregnancy outcomes. The aim of this study was to evaluate the effects of surgical treatment of the uterine cervix on pregnancy and fertility outcomes, with the focus particularly on preterm birth. The general preterm birth rates and risk factors during 1987–2005 were studied. Long-term mortality rates of the treated women were studied. In this study, information from The Medical Birth Register (MBR), The Hospital Discharge Register (HDR), The Cause-of-Death Register (CDR), and hospital records were used. Treatments were performed during 1987–2003 and subsequent deliveries, IVF treatments and deaths were analyzed. The general preterm birth rate in Finland was relatively stable, varying from 5.1% to 5.4% during the study period (1987 to 2005), although the proportion of extremely preterm births had decreased substantially by 12%.The main risk factor as regards preterm birth was multiplicity, followed by elective delivery (induction of delivery or elective cesarean section), primiparity, in vitro fertilization treatment, maternal smoking and advanced maternal age. The risk of preterm birth and low birth weight was increased after any cervical surgical treatment; after conization the risk of preterm birth was almost two-fold (RR 1.99, 95% CI 1.81– 2.20). In the conization group the risk was the highest for very preterm birth (28–31 gestational weeks) and it was also high for extremely preterm birth (less than 28 weeks). In this group the perinatal mortality was also increased. In subgroup analysis, laser ablation was not associated with preterm birth. When comparing deliveries before and after Loop conization, we found that the risk of preterm birth was increased 1.94-fold (95% CI 1.10–3.40). Adjusting for age, parity, or both did not affect our results. Large or repeat cones increased the risk of preterm birth when compared with smaller cones, suggesting that the size of the removed cone plays a role. This was corroborated by the finding that repeat treatment increased the risk as much as five-fold when compared with the background preterm birth rate. We found that the proportion of IVF deliveries (1.6% vs. 1.5%) was not increased after treatment for CIN when adjusted for year of delivery, maternal age, or parity. Those women who received both treatment for CIN and IVF treatment were older and more often primiparous, which explained the increased risk of preterm birth. We also found that mortality rates were 17% higher among women previously treated for CIN. This excess mortality was particularly seen as regards increased general disease mortality and alcohol poisoning (by 13%), suicide (by 67%) and injury death (by 31%). The risk of cervical cancer was high, as expected (SMR 7.69, 95% CI 4.23–11.15). Women treated for CIN and having a subsequent delivery had decreased general mortality rate (by -22%), and decreased disease mortality (by -37%). However, those with preterm birth had increased general mortality (SMR 2.51, 95% CI 1.24–3.78), as a result of cardiovascular diseases, alcohol-related causes, and injuries. In conclusion, the general preterm birth rate has not increased in Finland, as in many other developed countries. The rate of extremely preterm births has even decreased. While other risk factors of preterm birth, such as multiplicity and smoking during pregnancy have decreased, surgical treatments of the uterine cervix have become more important risk factors as regards preterm birth. Cervical conization is a predisposing factor as regards preterm birth, low birth weight and even perinatal mortality. The most frequently used treatment modality, Loop conization, is also associated with the increased risk of preterm birth. Treatments should be tailored individually; low-grade lesions should not be treated at all among young women. The first treatment should be curative, because repeat treatments are especially harmful. The proportion of IVF deliveries was not increased after treatment for CIN, suggesting that current treatment modalities do not strongly impair fertility. The long-term risk of cervical cancer remains high even after many years post-treatment; therefore careful surveillance is necessary. In addition, accidental deaths and deaths from injury were common among treated women, suggesting risk-taking behavior of these women. Preterm birth seems be associated with extremely high mortality rates, due to cardiovascular, alcohol-related and injury deaths. These women could benefit from health counseling, for example encouragement in quitting smoking.

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.

HIV outbreak among injecting drug users in Finland

An HIV outbreak among Finnish injecting drug users (IDUs) occurred in 1998. By the end of 2005, 282 IDUs were in-fected, most of them by recombinant virus CRF01_AE of HIV. After a rapid spread, the outbreak subsided, and the prevalence of HIV among IDUs remained low (<2%). The purpose of the study was to describe the outbreak in order to recognise factors that have influenced the spread and restriction of the outbreak, and thus to find tools for HIV preven-tion. Data on Finnish IDUs newly diagnosed HIV-positive between 1998 and 2005 was collected through interviews and patient documents. Study I compared markers of disease progression between 93 Finnish IDUs and 63 Dutch IDUs. In study II, geographical spread of the HIV outbreak was examined and compared with the spatial distribution of employed males. In study III, risk behaviour data from interviews of 89 HIV-positive and 207 HIV-negative IDUs was linked, and prevalence and risk factors for unprotected sex were evaluated. In study IV, data on 238 newly diagnosed IDUs was combined with data on 675 sexually transmitted HIV cases, and risk factors for late HIV diagnosis (CD4 cell count <200/µL, or AIDS at HIV diagnosis) were analysed. Finnish IDUs infected with CRF01_AE exhibited higher viral loads than did Amsterdam IDUs infected with subtype B, but there was no difference in CD4 development. The Finnish IDU outbreak spread and was restricted socially in a marginalised IDU population and geographically in areas characterised by low proportions of employed males. Up to 40% of the cases in the two clusters outside the city centre had no contact with the centre, where needle exchange services were available since 1997. Up to 63% of HIV-positive and 80% of HIV-negative sexually active IDUs reported inconsistent condom use, which was associated with steady relationships and recent inpatient addiction care. Com-pared to other transmission groups, HIV-positive IDUs were diagnosed earlier in their infection. The proportion of late diagnosed HIV cases in all transmission groups was 23%, but was only 6% among IDUs diagnosed during the first four years of the epidemic. The high viral load in early HIV infection may have contributed to the rapid spread of recombinant virus in the Finnish outbreak. The outbreak was restricted to a marginalised IDU population, and limited spatially to local pockets of pov-erty. To prevent HIV among IDUs, these pockets should be recognised and reached early through outreach work and the distribution of needle exchange and other prevention activities. To prevent the sexual transmission of HIV among IDUs, prevention programmes should be combined with addiction care services and targeted at every IDU. The early detection of the outbreak and early implementation of needle exchange programmes likely played a crucial role in re-versing the IDU outbreak.

Older male and female drivers in car-dependent settings: How much do they use other modes, and do they compensate for reduced driving to maintain mobility?

Among the societal and health challenges of population ageing is the continued transport mobility of older people who retain their driving licence, especially in highly car-dependent societies. While issues surrounding loss of a driving licence have been researched, less attention has been paid to variations in physical travel by mode among the growing proportion of older people who retain their driving licence. It is unclear how much they reduce their driving with age, the degree to which they replace driving with other modes of transport, and how this varies by age and gender. This paper reports research conducted in the state of Queensland, Australia, with a sample of 295 older drivers (>60 years). Time spent driving is considerably greater than time spent as a passenger or walking across age groups and genders. A decline in travel time as a driver with increasing age is not redressed by increases in travel as a passenger or pedestrian. The patterns differ by gender, most likely reflecting demographic and social factors. Given the expected considerable increase in the number of older women in particular, and their reported preference not to drive alone, there are implications for policies and programmes that are relevant to other car-dependent settings. There are also implications for the health of older drivers, since levels of walking are comparatively low.

The biology and pathogenesis of hepatitis viruses

Viral hepatitis is caused mainly by infection with one of the five hepatitis viruses, which use the liver as their primary site of replication. Each of these, known as hepatitis A through E viruses (HAV to HEV), belong to different virus families, have unique morphology, genomic organization and replication strategy. These viruses cause similar clinical manifestations during the acute phase of infection but vary in their ability to cause chronic infection. While HAV and HEV cause only acute disease with no chronic sequelae, HBV, HCV and HDV cause varying degrees of chronicity and liver injury, which can progress to cirrhosis and liver cancers. Though specific serological tests are available for the known hepatitis viruses, nearly 20% of all hepatitis cases show no markers. Antiviral therapy is also recommended for some hepatitis viruses and a preventive vaccine is available only for hepatitis B. More research and public awareness programmes are needed to control the disease. This review will provide an overview of the hepatitis viruses and the disease they cause.

Slogans of Change : Three Outlooks on Finnish Television

The study Slogans of Change. Three Outlooks on Finnish Television Contents is concerned with alleged changes of television contents during the 1990s and 2000s, such as dumbing down, tabloidisation, entertainisation , and the like. Specifically, the focus is on the ways these changes might manifest in Finnish television. The aim of the study has been threefold: 1. To operationalise public and academic discussions about changes via specific slogans emerging from the debates; 2. Consequently, to study the slogans empirically and reflect on the findings with earlier research, including studies on institutional and audience-related aspects; 3. Finally, to suggest what the findings might mean regarding discussions about television s role, and what kinds of slogans or concepts might best serve future discussions and research. The empirical outlooks presented in this study offer analyses with three different sets of opposing slogans of change. The outlooks also follow three different traditions of the study of television. The first outlook focuses on quantity, as it gives a longitudinal (1993-2004), macro-level view on programme structures. The methodological approach is derived from media economic and policy studies. The claims that frame the analysis are convergence versus diversification of programme structures. The second outlook provides quantitative and qualitative views on the characteristics and quality  the term signifying essence as well as worth  of Finnish television journalism during sample weeks from the years 2002 and 2003. This outlook follows the traditions of quantitative content analysis found in journalism studies coupled with descriptive qualitative content analyses. The slogans reflected in this section are the lightening or widening of journalism. The third outlook narrows down the material and focuses at a micro-level on form; that is, communicative conventions in a small array of selected programmes in 1993, 2000 and during 2002-2004. The analyses have been inspired by the method of conversation analysis of verbal interaction, and coupled with qualitative close readings, with the focus of different communicative situations in the programmes. The catchphrases employed in this part are emotainment versus democratainment, coupled with more specific claims of discursive hybridisation and conversationalisation. The findings depict that, empirically, changes in Finnish television contents are not clear linear trends and cannot easily be moulded into neat slogans. The quantitative outlook on programme output during 1993-2004 depicts a tendency towards differentiation of channels, paving the way for the multi-channel digital system. The change in programme structures, however, is not dramatic on the level of total output. The second outlook suggests that the dualistic concepts, such as the pair information-entertainment, are not sufficient in understanding the array and changes of programmes that could be called journalism. The outlook on communicative conventions highlights hybridisation in the manner of television talk and its relation to broader debates on contents. Despite the three dissimilar empirical approaches, unifying aspects emerge. The outlooks suggest, albeit in different ways, tendencies toward distinction and polarisation. This study proposes that in order to facilitate a more nuanced understanding of the changes in television contents, dualistic slogans should be replaced with a multi-dimensional understanding of the concept of diversity.

Eläytymisestä omiin tarinoihin : Televisiosarja katsojien keskustelussa

From sympathetic understanding to own stories. TV-series in the conversation of its viewers. The purpose of this study is to analyze viewers' conversations about TV-series as a practice in which viewers construct meaning to TV-series. In the tradition of British Cultural Studies this study understands that viewer has an active role in interpreting and constructing meaning to TV-series. In the tradition of feminist studies this study understands that gender is being constructed in social and cultural practices. In reception studies, the viewing of TV-series has usually been analyzed as a practice which is embedded at home and in a family. The studies are often based on interviews of viewers, and the analysis of the construction of meaning is based on interview material where the viewers most often talk about their viewing habits and the likes and dislikes of TV-shows and -characters. This study extends the reception and interpretation of TV-series from home to the moments of interaction between viewers. It is quite common to hear how people talk also outside of home about television and the programmes they have watched. In this study the construction of meaning is being studied in viewers' conversations. The method of analysis is conversation analysis which studies the ordered properties of everyday forms of social interaction. The data has been collected in a workplace where four women watched together (and without the presence of a researcher) two TV-series, American sitcom Golden Girls and Finnish family drama Ruusun aika (Time of a Rose), and afterwards had time and chance for discussion. There was neither a questionnaire nor an agenda for the women to discuss. The analysis of the conversation brings up three themes. In the orientation discussions the viewers aim to construct frames in which it makes sense to talk about the TV-series. The frames have mostly to do with the genre of the TV-series. The second theme is concerned with the viewers' aim to achieve sympathetic understanding of the characters in the TV-series. The third theme extends and transfers the conversation about TV-series to real or imaginary stories of own life. In the conversation the reception of a TV-series appears as being in motion: in the orientation discussions the viewers move towards the series, in the character-discussions the viewers move within the world of the series, and when telling their own stories the viewers move away from the TV-series towards their own lives. In the conversations there appears also a distinction in gender-constructions. When the viewers talk about motherhood, they adopt a serious and moralistic tone. When they talk about female sexuality and relationships between women and men they adopt carnevalistic and humorous tone. There are examples of these kinds of gender-constructions also in other studies of Finnish gender culture. Motherhood means the responsibility to good upbringing; relationships with men include something unpredictable and problematic which one handles at best in a humorous way.