Meningoencephalitis caused by a zygomycete fungus (Basidiobolus) associated with septic shock in an immunocompetent patient: 1-year follow-up after treatment

Zygomycosis is an infection caused by opportunistic fungi of the Zygomycetes class, specifically those from the Mucorales and Entomophthorales orders. It is an uncommon disease, mainly restricted to immunocompromised patients. We report a case of a 73-year-old male patient with a history of fever (39°C) lasting for 1 day, accompanied by shivering, trembling, and intense asthenia. The patient was admitted to the intensive care unit with complex partial seizures, and submitted to orotracheal intubation and mechanical ventilation under sedation with midazolam. The electroencephalogram showed evidence of non-convulsive status epilepticus. There is no fast specific laboratory test that permits confirmation of invasive fungal disease. Unless the physician suspects this condition, the disease may progress rapidly while the patient is treated with broad-spectrum antibiotics. Differential diagnosis between fungal and bacterial infection is often difficult. The clinical presentation is sometimes atypical, and etiological investigation is not always successful. In the present case, the histopathological examination of the biopsy obtained from the right temporal lobe indicated the presence of irregular, round, thick-walled fungi forming papillae and elongated structures of irregular diameter, with no septa, indicative of zygomycete (Basidiobolus). Treatment with liposomal amphotericin B and fluconazole was initiated after diagnosis of meningoencephalitis by zygomycete, with a successful outcome.

More than 10 years survival with sequential therapy in a patient with advanced renal cell carcinoma: a case report

Although radical nephrectomy alone is widely accepted as the standard of care in localized treatment for renal cell carcinoma (RCC), it is not sufficient for the treatment of metastatic RCC (mRCC), which invariably leads to an unfavorable outcome despite the use of multiple therapies. Currently, sequential targeted agents are recommended for the management of mRCC, but the optimal drug sequence is still debated. This case was a 57-year-old man with clear-cell mRCC who received multiple therapies following his first operation in 2003 and has survived for over 10 years with a satisfactory quality of life. The treatments given included several surgeries, immunotherapy, and sequentially administered sorafenib, sunitinib, and everolimus regimens. In the course of mRCC treatment, well-planned surgeries, effective sequential targeted therapies and close follow-up are all of great importance for optimal management and a satisfactory outcome.

Late emergence of A594V and L595W mutations related to ganciclovir resistance in a patient with HCMV retinitis and long-term HIV progression

The emergence of ganciclovir (GCV) resistance during the treatment of human cytomegalovirus (HCMV) infection is a serious clinical challenge, and is associated with high morbidity and mortality. In this case report, we describe the emergence of two consecutive mutations (A594V and L595W) related to GCV resistance in a patient with HCMV retinitis and long-term HIV progression after approximately 240 days of GCV use. Following the diagnosis of retinitis, the introduction of GCV did not result in viral load reduction. The detected mutations appeared late in the treatment, and we propose that other factors (high initial HCMV load, previous GCV exposure, low CD4+ cell count), in addition to the presence of resistance mutations, may have contributed to the treatment failure of HCMV infection in this patient.

Random-start controlled ovarian stimulation for emergency fertility preservation in a patient with myelodysplastic syndrome: a case report

This study reports a case of a gonadotropin-releasing hormone agonist trigger in a young female with myelodysplastic syndrome (MDS) who underwent fertility preservation using random-start controlled ovarian stimulation. This method involves the stimulation of the ovary regardless of a patient's menstrual-cycle phase. A review of the related literature is also provided. A 17-year-old patient was diagnosed with MDS and required initiation of peripheral blood stem cell transplantation within a maximum of 3 weeks and was in the luteal phase of the menstrual cycle when the possibility of attempting preservation of fertility was presented to her. She opted for a random-start controlled ovarian stimulation with gonadotropins. With successful hemorrhagic prophylaxis, 17 oocytes were retrieved including 10 mature and 7 immature oocytes. Of the immature oocytes, 3 were successfully matured in vitro and a vitrification protocol was used to freeze the 13 mature oocytes.

Salmonella peritonitis in a patient on automated peritoneal dialysis

We describe the clinical course of a case of peritonitis caused by Salmonella sp. after an episode of intestinal salmonellosis, and a brief review of the literature is also done.

Continuity of patient care in day surgery

Continuity is a part of high-quality patient care. The purpose of this study was to analyse what factors are important in the continuity of patients’ care, and how well continuity is achieved in different stages of the care of day surgical patients. Day surgery has become significantly more prevalent in the past few decades, and in order for it to be carried out successfully, continuity in care is particularly essential. The study was carried out in two stages. In the first stage (2001–2005) of the study, continuity was examined through a review of literature from the perspective of critical pathways, naming the continuity categories of time flow, coordination flow, caring relationship flow, and information flow. The first stage also entailed an analysis of matters important to the patient and problems concerning the achievement of care continuity, carried out by interviewing 25 day surgical patients. In the second stage (2006–2015), the degree to which the continuity of day surgical patient care was achieved was analysed from the perspective of patients (n=203, 58%) and nurses working in day surgery units (n=83, 69%), and suggestions for developing the continuity of day surgery patient care were made. In this study continuity of care was examined through a review of literature from the perspective of critical pathways, naming the continuity categories of time flow, coordination flow, caring relationship flow, and information flow. Within these categories, several important factors for the patient were found. According to both patients and nurses, continuity of care is generally achieved to a high degree. Continuity of care is improved by patients being acquainted with and meeting the staff attending to them (nurse and surgeon) before and after the operation. From patients’ perspective, there is room for improvement especially in terms of being admitted to care and in the carer-patient relationship. From nurses’ perspective, there is room for improvement in terms of the smoothness of care. Nurses evaluated the continuity of care to be the least successful before and after the operation. An extensive social and health care reform is planned in Finland in the coming years, aiming to enhance social and health care services and to create smoothly functioning service and care. As a topic of further study supporting the development of the service system, it is important to follow the patient’s progress throughout the entire chain of care, e.g. as a case study. On the other hand, there is also a need to study the views of nurses and other health care professionals in health care, e.g. in primary health care.

Erythropoietin resistance in end-stage renal disease patient with gastric antral vascular ectasia

AbstractWe observed a case of recombinant human erythropoietin resistance caused by Gastric Antral Vascular Ectasia in a 40-year-old female with ESRD on hemodialysis. Some associated factors such as autoimmune disease, hemolysis, heart and liver disease were discarded on physical examination and complementary tests. The diagnosis is based on the clinical history and endoscopic appearance of watermelon stomach. The histologic findings are fibromuscular proliferation and capillary ectasia with microvascular thrombosis of the lamina propria. However, these histologic findings are not necessary to confirm the diagnosis. Gastric Antral Vascular Ectasia is a serious condition and should be considered in ESRD patients on hemodialysis with anemia and resistance to recombinant human erythropoietin because GAVE is potentially curable with specific endoscopic treatment method or through surgical procedure.

Erythropoietin resistance in end-stage renal disease patient with gastric antral vascular ectasia

AbstractWe observed a case of recombinant human erythropoietin resistance caused by Gastric Antral Vascular Ectasia in a 40-year-old female with ESRD on hemodialysis. Some associated factors such as autoimmune disease, hemolysis, heart and liver disease were discarded on physical examination and complementary tests. The diagnosis is based on the clinical history and endoscopic appearance of watermelon stomach. The histologic findings are fibromuscular proliferation and capillary ectasia with microvascular thrombosis of the lamina propria. However, these histologic findings are not necessary to confirm the diagnosis. Gastric Antral Vascular Ectasia is a serious condition and should be considered in ESRD patients on hemodialysis with anemia and resistance to recombinant human erythropoietin because GAVE is potentially curable with specific endoscopic treatment method or through surgical procedure.

Nursing Students’ Learning about an Empowering Discourse In Patient Education

The main purpose of this study was to describe and evaluate nursing students' learning about an empowering discourse in patient education. In Phase 1, the purpose was to describe an empowering discourse between a nurse and a patient. In Phase 2, the purpose was first to create a computer simulation program of an empowering discourse based on the description, and second, the purpose was to evaluate nursing students’ learning of how to conduct an empowering discourse using a computer simulation program. The ultimate goal was to strengthen the knowledge basis on empowering discourse and to develop nursing students’ knowledge about how to conduct an empowering discourse for the development of patient education. In Phase I, empowering discourse was described using a systematic literature review with a metasummary technique (n=15). Data were collected covering a period from January 1995 to October 2005. In Phase 2, the computer simulation program of empowering discourse was created based the description in 2006–2007. A descriptive comparative design was used to evaluate students’ (n=69) process of learning empowering discourse using the computer simulation program and a pretest–post-test design without a control group was used to evaluate students’ (n=43) outcomes of learning. Data were collected in 2007. Empowering discourse was a structured process and it was possible to simulate and learned with the computer simulation program. According to students’ knowledge, empowering discourse was an unstructured process. Process of learning empowering discourse using the computer simulation program was controlled by the students and it changed students’ knowledge. The outcomes of learning empowering discourse appeared as changes of students’ knowledge to more holistic and better-organized or only to more holistic or better-organized. The study strengthened knowledge base of empowering discourse and developed students to more knowledgeable in empowering discourse.

Datenherrschaft – an Ethically Justified Solution to the Problem of Ownership of Patient Information

Patient information systems are crucial components for the modern healthcare and medicine. It is obvious that without them the healthcare cannot function properly – one can try to imagine how brain surgery could be done without using information systems to gather and show information needed for an operation. Thus, it can be stated that digital information is irremovable part of modern healthcare. However, the legal ownership of patient information lacks a coherent and justified basis. The whole issue itself is actually bypassed by controlling pa- tient information with different laws and regulations how patient information can be used and by whom. Nonetheless, the issue itself – who owns the patient in- formation – is commonly missed or bypassed. This dissertation show the problems if the legislation of patient information ownership is not clear. Without clear legislation, the outcome can be unexpected like it seems to be in Finland, Sweden and United Kingdom: the lack of clear regulation has come up with unwanted consequences because of problematic Eu- ropean Union database directive implementation in those countries. The legal ownership is actually granted to the creators of databases which contains the pa- tient information, and this is not a desirable situation. In healthcare and medicine, we are dealing with issues such as life, health and information which are very sensitive and in many cases very personal. Thus, this dissertation leans on four philosophical theories form Locke, Kant, Heidegger and Rawls to have an ethically justified basis for regulating the patient infor- mation in a proper way. Because of the problems of property and ownership in the context of information, a new concept is needed and presented to replace the concept of owning, that concept being Datenherrschaft (eng. mastery over in- formation). Datenherrschaft seems to be suitable for regulating patient infor- mation because its core is the protection of one’s right over information and this aligns with the work of the philosophers whose theories are used in the work. The philosophical argumentation of this study shows that Datenherrschaft granted to the patients is ethically acceptable. It supports the view that patient should be controlling the patient information about themselves unless there are such specific circumstance that justifies the authorities to use patient information to protect other people’s basic rights. Thus, if the patients would be legally grant- ed Datenherrschaft over patient information we would endorse patients as indi- viduals who have their own and personal experience of their own life and have a strong stance against any unjustified paternalism in healthcare. Keywords: patient information, ownership, Datenherrschaft, ethics, Locke, Kant, Heidegger, Rawls

University students’ regulation of learning and text processing – examples from medical and teacher education

The general aim of the thesis was to study university students’ learning from the perspective of regulation of learning and text processing. The data were collected from the two academic disciplines of medical and teacher education, which share the features of highly scheduled study, a multidisciplinary character, a complex relationship between theory and practice and a professional nature. Contemporary information society poses new challenges for learning, as it is not possible to learn all the information needed in a profession during a study programme. Therefore, it is increasingly important to learn how to think and learn independently, how to recognise gaps in and update one’s knowledge and how to deal with the huge amount of constantly changing information. In other words, it is critical to regulate one’s learning and to process text effectively. The thesis comprises five sub-studies that employed cross-sectional, longitudinal and experimental designs and multiple methods, from surveys to eye tracking. Study I examined the connections between students’ study orientations and the ways they regulate their learning. In total, 410 second-, fourth- and sixth-year medical students from two Finnish medical schools participated in the study by completing a questionnaire measuring both general study orientations and regulation strategies. The students were generally deeply oriented towards their studies. However, they regulated their studying externally. Several interesting and theoretically reasonable connections between the variables were found. For instance, self-regulation was positively correlated with deep orientation and achievement orientation and was negatively correlated with non-commitment. However, external regulation was likewise positively correlated with deep orientation and achievement orientation but also with surface orientation and systematic orientation. It is argued that external regulation might function as an effective coping strategy in the cognitively loaded medical curriculum. Study II focused on medical students’ regulation of learning and their conceptions of the learning environment in an innovative medical course where traditional lectures were combined wth problem-based learning (PBL) group work. First-year medical and dental students (N = 153) completed a questionnaire assessing their regulation strategies of learning and views about the PBL group work. The results indicated that external regulation and self-regulation of the learning content were the most typical regulation strategies among the participants. In line with previous studies, self-regulation wasconnected with study success. Strictly organised PBL sessions were not considered as useful as lectures, although the students’ views of the teacher/tutor and the group were mainly positive. Therefore, developers of teaching methods are challenged to think of new solutions that facilitate reflection of one’s learning and that improve the development of self-regulation. In Study III, a person-centred approach to studying regulation strategies was employed, in contrast to the traditional variable-centred approach used in Study I and Study II. The aim of Study III was to identify different regulation strategy profiles among medical students (N = 162) across time and to examine to what extent these profiles predict study success in preclinical studies. Four regulation strategy profiles were identified, and connections with study success were found. Students with the lowest self-regulation and with an increasing lack of regulation performed worse than the other groups. As the person-centred approach enables us to individualise students with diverse regulation patterns, it could be used in supporting student learning and in facilitating the early diagnosis of learning difficulties. In Study IV, 91 student teachers participated in a pre-test/post-test design where they answered open-ended questions about a complex science concept both before and after reading either a traditional, expository science text or a refutational text that prompted the reader to change his/her beliefs according to scientific beliefs about the phenomenon. The student teachers completed a questionnaire concerning their regulation and processing strategies. The results showed that the students’ understanding improved after text reading intervention and that refutational text promoted understanding better than the traditional text. Additionally, regulation and processing strategies were found to be connected with understanding the science phenomenon. A weak trend showed that weaker learners would benefit more from the refutational text. It seems that learners with effective learning strategies are able to pick out the relevant content regardless of the text type, whereas weaker learners might benefit from refutational parts that contrast the most typical misconceptions with scientific views. The purpose of Study V was to use eye tracking to determine how third-year medical studets (n = 39) and internal medicine residents (n = 13) read and solve patient case texts. The results revealed differences between medical students and residents in processing patient case texts; compared to the students, the residents were more accurate in their diagnoses and processed the texts significantly faster and with a lower number of fixations. Different reading patterns were also found. The observed differences between medical students and residents in processing patient case texts could be used in medical education to model expert reasoning and to teach how a good medical text should be constructed. The main findings of the thesis indicate that even among very selected student populations, such as high-achieving medical students or student teachers, there seems to be a lot of variation in regulation strategies of learning and text processing. As these learning strategies are related to successful studying, students enter educational programmes with rather different chances of managing and achieving success. Further, the ways of engaging in learning seldom centre on a single strategy or approach; rather, students seem to combine several strategies to a certain degree. Sometimes, it can be a matter of perspective of which way of learning can be considered best; therefore, the reality of studying in higher education is often more complicated than the simplistic view of self-regulation as a good quality and external regulation as a harmful quality. The beginning of university studies may be stressful for many, as the gap between high school and university studies is huge and those strategies that were adequate during high school might not work as well in higher education. Therefore, it is important to map students’ learning strategies and to encourage them to engage in using high-quality learning strategies from the beginning. Instead of separate courses on learning skills, the integration of these skills into course contents should be considered. Furthermore, learning complex scientific phenomena could be facilitated by paying attention to high-quality learning materials and texts and other support from the learning environment also in the university. Eye tracking seems to have great potential in evaluating performance and growing diagnostic expertise in text processing, although more research using texts as stimulus is needed. Both medical and teacher education programmes and the professions themselves are challenging in terms of their multidisciplinary nature and increasing amounts of information and therefore require good lifelong learning skills during the study period and later in work life.

Exploring Relationship between Pakistani Teachers’ Pedagogical Beliefs and ICT Use for Teaching and Learning

Background: The aim of present study is to investigate relationship between Pakistani teachers’ pedagogical beliefs and ICT use for teaching and learning. Previous studies found close relationship between pedagogical beliefs and teaching practices including use of ICT. However, variation in results is also reported and attributed to cultural and contextual differences. Methodology: Quantitative approach was used to study a sample of 231 Pakistani basic education teachers from middle and upper-middle range private schools, mostly from large urban centres. Results: This study confirmed previously study results that constructivist-compatible pedagogical beliefs are significantly related to both traditional and constructivist use of ICT. However, it is also found that traditional-transmission pedagogical beliefs are significantly related to traditional use of ICT – a finding not reported in previous studies. Some amounts of ICT training for pedagogical purpose exhibit significant impact on ICT use, in particular constructivist use of ICT. Similarly age also play a role as younger teachers are more likely to use ICT, however, no significant difference of pedagogical beliefs and ICT use was found between male and female teachers. Recommendation for practice and further investigation are made in chapter 5.

Consumer’s purchase intention of ethical fashion. Examining beliefs about fashion industry and attitudes towards ethical fashion

Globalization and the developments of supply chain have made inexpensive labor and the low production costs of developing countries available to businesses worldwide. Unfortunately, these developments have also led to the exploitation of human and natural resources. The increasing supply of cheap and fashionable clothing has created a contradiction between consumers’ concerns for sustainability and their purchase behavior in the fashion industry. Since the uncovering of several sweatshop scandals in the 1980’s and 1990’s ethical fashion brands have started to emerge. Ethical fashion has sparked the interest of consumers and studies have shown promising positive attitudes towards it. However, these attitudes have failed to translate into action and purchase behavior of ethical fashion has not reached the expectations. In order to translate the positive attitudes into buying companies must understand consumer’s motivations and reasons behind the purchase decision. The objective of this study is to understand the antecedents behind young consumer’s purchase intention of ethical fashion. The study is based on the theory of planned behavior which has been widely used to study consumer behavior and purchase decisions. The theory has also been used in ethical decision-making and fashion context before. According to the theory, in order to understand purchase intentions consumer’s attitudes toward buying ethical fashion were studied. The theory also states that attitudes are formed from beliefs, thus, consumer’s beliefs about the fashion industry were studied. To contribute to existing research, the effect of sweatshop issues and environmental issues were compared. The data was collected from university students (n=617) with an online survey. The results were analyzed by statistical methods and they revealed that young Finnish consumers hold positive attitudes towards buying ethical fashion as well as positive purchase intentions of ethical fashion. A strong relationship was found between positive attitudes and positive purchase intentions. Also, the more negative consumers’ beliefs of the fashion industry were the more positive their attitudes toward buying ethical fashion were. In contradiction to previous research this study revealed that environmental issues had greater effect on attitudes than sweatshop issues. Interesting differences between consumers were found depending on their field of education. Students from humanities and social sciences held the most negative beliefs as well as most positive attitudes and purchase intentions of ethical fashion.