Matkalla marginaalista valtavirtaan? : Huumeiden käytön lopettaneiden elämäntapa ja toipuminen

On a journey from marginal to mainstream? The lifestyle and recovery of former drug users This thesis studies the lifestyle and recovery of former users of illicit drugs through their experiences. The study describes the life of people with drug problems both during the time they used drugs regularly and after they stopped the use entirely. The focus is on the development of the lifestyle of 32 persons who no longer use drugs. They may have stopped using drugs independently or with the help of a treatment. In this study, persons who have given up drug use with the help of a psychosocially oriented treatment are called non-medicinally treated former users (n=19) whereas opioid addicts who have stopped using drugs through substitution treatment are referred to as substitution treatment patients (n=13). The research material was gathered from theme interviews. The criteria for the focus group of the study included the following: a) the interviewees had had a serious drug problem in their past; b) they had not used drugs for at least one year prior to the interview; c) they were not in an institutional care at the time of the study. This thesis is basically a lifestyle study in which the aspects of lifestyle are used to describe the everyday life of former drug users. The study reviews the whole spectrum of everyday routines, especially the social interaction and subjective experiences of people. The second concept used in this study is recovery, which is described as a process that starts from the abstinence from substances and adoption of the recovery culture and continues as a comprehensive change of the lifestyle, identity and values of an individual. Disengaging from a drug-oriented lifestyle and connected social network as well as finding an individual frame of reference is a demanding process. Years of drug use have often caused complex health and social disadvantages as well as problems with work, education, livelihood, accommodation and human relationships. The effect of the past on the present arises at all levels. The interviews revealed a recovery culture maintaining the lifestyle as well as an adaptive and optimistic approach to the future among those participating in the study. The study shows that an adequate distance from acute substance use is a precondition for the beginning of the recovery process, yet abstinence in itself tells nothing about the actual recovery. The study describes how some recovering users find a meaning in life easily whereas others have to work actively for their recovery. Detaching oneself from the feeling of adopted abnormality connected with substance addiction forms an important basis for satisfying abstinence. Peer groups support the development of counter-cultures and abstinence or the support is received from the community formed in the substitution treatment clinic.

Huumeriippuvuudesta toipuminen Nimettömien Narkomaanien toveriseurassa

The subjects of this study are Narcotics Anonymous (NA), a non-profit, peer-support-based fellowship, its recovery programme, and the former drug addicts who consider themselves members of the fellowship. The study data consist of episodic interviews (n=24) and questionnaires (n=212). In the collection of questionnaire data, survey research methods had to be applied judiciously. This study analyses NA members background and their substance abuse and treatment history, as well as factors that have contributed to or hindered their bonding with NA. A recovery model is presented that stems from NA s written and oral tradition, and which has been conceptualised into NA s recovery theory. At its simplest, NA s recovery theory can be described in two sentences: 1) There are drug dependent addicts who have an addiction disease. 2) Through an NA way of life, recovery is possible. In this study, addiction and addiction disease are described through recovery stories shared at NA. It also describes how the way of life offered by NA supports recovery from drug addiction, the way of life which recovering addicts have adopted, and how they have done so. The study also presents results that, based on the study data, emerge from participation in the NA programme, and describes how the NA recovery theory works in practice, i.e. how NA members utilise the tools provided by the fellowship and how the lives of recovering addicts change during their membership. Furthermore, this study also discusses criticism of NA. According to the study, NA affects the lives of recovering drug addicts in a number of ways. People of different ages and with a variety of personal, treatment and drug abuse histories seem to benefit from membership of NA. Viewed from the outside, NA may appear as strictly normative, but in practice each member can adapt the programme in a way that suits him/her best. Indeed, flexibility is one of the strengths of NA, but without more extensive knowledge of the fellowship, it is possible that the norms reflected in NA texts or the fanaticism of individual NA members may drive some people away. Due to the increasing number of NA members, the association is also able to provide more alternatives. This study confirms the view that peer support is important, as well as the fact that an official treatment system is required in parallel with peer support activities. NA can never fully replace professional support, neither should it be left with sole responsibility for recovering addicts. Keywords: Narcotics Anonymous, peer support, recovery study, recovery, substance addiction, drug treatment, drugs, explorative research

Phytoplankton quantity as an indicator of eutrophication in Finnish coastal waters : Applications within the Water Framework Directive

The tackling of coastal eutrophication requires water protection measures based on status assessments of water quality. The main purpose of this thesis was to evaluate whether it is possible both scientifically and within the terms of the European Union Water Framework Directive (WFD) to assess the status of coastal marine waters reliably by using phytoplankton biomass (ww) and chlorophyll a (Chl) as indicators of eutrophication in Finnish coastal waters. Empirical approaches were used to study whether the criteria, established for determining an indicator, are fulfilled. The first criterion (i) was that an indicator should respond to anthropogenic stresses in a predictable manner and has low variability in its response. Summertime Chl could be predicted accurately by nutrient concentrations, but not from the external annual loads alone, because of the rapid affect of primary production and sedimentation close to the loading sources in summer. The most accurate predictions were achieved in the Archipelago Sea, where total phosphorus (TP) and total nitrogen (TN) alone accounted for 87% and 78% of the variation in Chl, respectively. In river estuaries, the TP mass-balance regression model predicted Chl most accurately when nutrients originated from point-sources, whereas land-use regression models were most accurate in cases when nutrients originated mainly from diffuse sources. The inclusion of morphometry (e.g. mean depth) into nutrient models improved accuracy of the predictions. The second criterion (ii) was associated with the WFD. It requires that an indicator should have type-specific reference conditions, which are defined as "conditions where the values of the biological quality elements are at high ecological status". In establishing reference conditions, the empirical approach could only be used in the outer coastal water types, where historical observations of Secchi depth of the early 1900s are available. The most accurate prediction was achieved in the Quark. In the inner coastal water types, reference Chl, estimated from present monitoring data, are imprecise - not only because of the less accurate estimation method but also because the intrinsic characteristics, described for instance by morphometry, vary considerably inside these extensive inner coastal types. As for phytoplankton biomass, the reference values were less accurate than in the case of Chl, because it was possible to estimate reference conditions for biomass only by using the reconstructed Chl values, not the historical Secchi observations. An paleoecological approach was also applied to estimate annual average reference conditions for Chl. In Laajalahti, an urban embayment off Helsinki, strongly loaded by municipal waste waters in the 1960s and 1970s, reference conditions prevailed in the mid- and late 1800s. The recovery of the bay from pollution has been delayed as a consequence of benthic release of nutrients. Laajalahti will probably not achieve the good quality objectives of the WFD on time.    The third criterion (iii) was associated with coastal management including the resources it has available. Analyses of Chl are cheap and fast to carry out compared to the analyses of phytoplankton biomass and species composition; the fact which has an effect on number of samples to be taken and thereby on the reliability of assessments. However, analyses on phytoplankton biomass and species composition provide more metrics for ecological classification, the metrics which reveal various aspects of eutrophication contrary to what Chl alone does.

Recovery responses of acidified Finnish lakes under declining acid deposition

The present work provides a regional-scale assessment of the changes in acidifying deposition in Finland over the past 30 years and the current pattern in the recovery of acid-sensitive lakes from acidification in relation to changes in sulphate deposition. This information is needed for documenting the ecosystem benefits of costly emission reduction policies and further actions in air pollution policy. The development of sulphate deposition in Finland reflects that of European SO2 emissions. Before the 1990s, reductions in sulphur emissions in Europe had been relatively small and sulphate deposition showed no consistent trends. Due to emission reduction measures that were then taken, sulphate deposition started to clearly decline from the late 1980s. The bulk deposition of sulphate has declined 40-60% in most parts of the country during 1990-2003. The decline in sulphate deposition exceeded the decline of base cation deposition, which resulted in a decrease in acidity and acidifying potential of deposition over the 1990s. Nitrogen deposition also decreased since the late 1980s, but less than that of sulphate, and levelling off during the 1990s. Sulphate concentrations in all types of small lakes throughout Finland have declined from the early 1990s. The relative decrease in lake sulphate concentrations (average 40-50%) during 1990-2003 was rather similar to the decline in sulphate deposition, indicating a direct response to the reduction in deposition. There are presently no indications of elevated nitrate concentrations in forested headwater lakes. Base cation concentrations are still declining in many lakes, especially in south Finland, but to a lesser extent than sulphate allowing buffering capacity (alkalinity) to increase, being significant in 60% of the study lakes. Chemical recovery is resulting in biological recovery with populations of acid-sensitive fish species increasing. The recovery has been strongest in lakes in which sulphate has been the major acidifying agent, and recovery has been the strongest and most consistent in lakes in south Finland. The recovery of lakes in central Finland and north Finland is not as widespread and strong as observed in south. Many catchments, particularly in central Finland, have a high proportion of peatlands and therefore high TOC concentrations in lakes, and runoff-induced surges of organic acids have been an important confounding factor suppressing the recovery of pH and alkalinity in these lakes. Chemical recovery is progressing even in the most acidified lakes, but the buffering capacity of many lakes is still low and still sensitive to acidic input. Further reduction in sulphur emissions are needed for the alkalinity to increase in the acidified lakes. Increasing total organic carbon (TOC) concentrations are indicated in small forest lakes in Finland. The trends appear to be related to decreasing sulphate deposition and improved acid-base status of the soil, and the rise in TOC is integral to recovery from acidification. A new challenge is climate change with potential trends in temperature, precipitation and runoff, which are expected to affect future chemical and biological recovery from acidification. The potential impact on the mobilization and leaching of organic acids may become particularly important in Finnish conditions. Long-term environmental monitoring has evidently shown the success of international emission abatement strategies. The importance and value of integrated monitoring approach including physical, chemical and biological variables is clearly indicated, and continuous environmental monitoring is needed as a scientific basis for further actions in air pollution policy.

Corneal recovery after uncomplicated and complicated PRK and LASIK

Refractive errors, especially myopia, seem to increase worldwide. Concurrently, the number of surgical refractive corrections has increased rapidly, with several million procedures performed annually. However, excimer laser surgery was introduced after a limited number of studies done with animals and to date there still are only few long-term follow-up studies of the results. The present thesis aims to evaluate the safety and functional outcome of, as well as to quantify the cellular changes and remodelling in the human cornea after, photorefractive keratectomy (PRK) and laser assisted in situ keratomileusis (LASIK). These procedures are the two most common laser surgical refractive methods. In Study I, myopic ophthalmic residents at Helsinki University Eye Hospital underwent a refractive correction by PRK. Five patients were followed up for 6 months to assess their subjective experience in hospital work and their performance in car driving simulator and in other visuomotor functions. Corneal morphological changes were assessed by in vivo confocal microscopy (ivCM). Study II comprised 14 patients who had undergone a PRK operation in 1993-1994. Visual acuity was examined and ivCM examinations performed 5 years postoperatively. In Study III 15 patients received LASIK refractive correction for moderate to high myopia (-6 - -12 D). Their corneal recovery was followed by ivCM for 2 years. Diffuse lamellar keratitis (DLK) is a common but variable complication of LASIK. Yet, its aetiology remains unknown. In Study IV we examined six patients who had developed DLK as a consequence of formation of an intraoperative or post-LASIK epithelial defect, to assess the corneal and conjunctival inflammatory reaction. In the whole series, the mean refractive correction was -6.46 diopters. The best spectacle corrected visual acuity (BSCVA) improved in 30 % of patients, whereas in four patients BSCVA decreased slightly. The mean achieved refraction was 0.35 D undercorrected. After PRK, the stromal scar formation was highest at 2 to 3 months postoperatively and subsequently decreased. At 5 years increased reflectivity in the subepithelial stroma was observed in all patients. Interestingly, no Bowman s layer was detected in any patient. Subbasal nerve fiber bundle(snfb) regeneration could be observed already at 2 months in 2 patients after PRK. After 5 years, all corneas presented with snfb, the density of which, however, was still lower than in control corneas. LASIK induced a hypocellular area on both sides of the flap interface. A decrease of the most anterior keratocyte density was also observed. In the corneas that developed DLK, inflammatory cell-type objects were present in the flap interface in half of the patients. The other patients presented only with keratocyte activation and highly reflective extracellular matrix. These changes resolved completely with medication and time. Snfb regeneration was first detected at one month post-LASIK, but still after two years the density of snfb, however, was only 64 % of the preoperative values. The performance of ophthalmological examinations and microsurgery without spectacles was easier postoperatively, which was appreciated by the residents. Both PRK and LASIK showed moderate to good accuracy and high safety. In terms of visual perception and subjective evaluation, few patients stated any complaints in the whole series of studies. Instead, the majority of patients experienced a marked improvement in everyday life and work performance. PRK and LASIK have shown similar results, with good long term morphological healing. It seems evident that, even without the benefit of over-20-year follow-up results, these procedures are sufficiently safe and accurate for refractive corrections and corneal reshaping.

Studies on the assessment of the adequacy of anesthesia

Several hypnosis monitoring systems based on the processed electroencephalogram (EEG) have been developed for use during general anesthesia. The assessment of the analgesic component (antinociception) of general anesthesia is an emerging field of research. This study investigated the interaction of hypnosis and antinociception, the association of several physiological variables with the degree of intraoperative nociception, and aspects of EEG Bispectral Index Scale (BIS) monitoring during general anesthesia. In addition, EEG features and heart rate (HR) responses during desflurane and sevoflurane anesthesia were compared. A propofol bolus of 0.7 mg/kg was more effective than an alfentanil bolus of 0.5 mg in preventing the recurrence of movement responses during uterine dilatation and curettage (D C) after a propofol-alfentanil induction, combined with nitrous oxide (N2O). HR and several HR variability-, frontal electromyography (fEMG)-, pulse plethysmography (PPG)-, and EEG-derived variables were associated with surgery-induced movement responses. Movers were discriminated from non-movers mostly by the post-stimulus values per se or normalized with respect to the pre-stimulus values. In logistic regression analysis, the best classification performance was achieved with the combination of normalized fEMG power and HR during D C (overall accuracy 81%, sensitivity 53%, specificity 95%), and with the combination of normalized fEMG-related response entropy, electrocardiography (ECG) R-to-R interval (RRI), and PPG dicrotic notch amplitude during sevoflurane anesthesia (overall accuracy 96%, sensitivity 90%, specificity 100%). ECG electrode impedances after alcohol swab skin pretreatment alone were higher than impedances of designated EEG electrodes. The BIS values registered with ECG electrodes were higher than those registered simultaneously with EEG electrodes. No significant difference in the time to home-readiness after isoflurane-N2O or sevoflurane-N2O anesthesia was found, when the administration of the volatile agent was guided by BIS monitoring. All other early and intermediate recovery parameters were also similar. Transient epileptiform EEG activity was detected in eight of 15 sevoflurane patients during a rapid increase in the inspired volatile concentration, and in none of the 16 desflurane patients. The observed transient EEG changes did not adversely affect the recovery of the patients. Following the rapid increase in the inhaled desflurane concentration, HR increased transiently, reaching its maximum in two minutes. In the sevoflurane group, the increase was slower and more subtle. In conclusion, desflurane may be a safer volatile agent than sevoflurane in patients with a lowered seizure threshold. The tachycardia induced by a rapid increase in the inspired desflurane concentration may present a risk for patients with heart disease. Designated EEG electrodes may be superior to ECG electrodes in EEG BIS monitoring. When the administration of isoflurane or sevoflurane is adjusted to maintain BIS values at 50-60 in healthy ambulatory surgery patients, the speed and quality of recovery are similar after both isoflurane-N2O and sevoflurane-N2O anesthesia. When anesthesia is maintained by the inhalation of N2O and bolus doses of propofol and alfentanil in healthy unparalyzed patients, movement responses may be best avoided by ensuring a relatively deep hypnotic level with propofol. HR/RRI, fEMG, and PPG dicrotic notch amplitude are potential indicators of nociception during anesthesia, but their performance needs to be validated in future studies. Combining information from different sources may improve the discrimination of the level of nociception.

Mitä hyötyä tehohoidosta? : Tehohoitoa sisältäneiden hoitojaksojen vaikuttavuuden arviointi

Intensive care is to be provided to patients benefiting from it, in an ethical, efficient, effective and cost-effective manner. This implies a long-term qualitative and quantitative analysis of intensive care procedures and related resources. The study population consists of 2709 patients treated in the general intensive care unit (ICU) of Helsinki University Hospital. Study sectors investigate intensive care patients mortality, quality of life (QOL), Quality-Adjusted Life-Years (QALY units) and factors related to severity of illness, length of stay (LOS), patient s age, evaluation period as well as experiences and memories connected with the ICU episode. In addition, the study examines the qualities of two QOL measures, the RAND 36 Item Health Survey 1.0 (RAND-36) and the 5 Item EuroQol-5D (EQ-5D) and assesses the correlation of the test results. Patients treated in 1995 responded to the RAND-36 questionnaire in 1996. All patients, treated from 1995-2000, received a QOL questionnaires in 2001, when 1 7 years had lapsed from the intensive treatment. Response rate was 79.5 %. Main Results 1) Of the patients who died within the first year (n = 1047) 66 % died during the intensive care period or within the following month. The non-survivors were more aged than the surviving patients, had generally a higher than average APACHE II and SOFA score depicting the severity of illness, their ICU LOS was longer and hospital stay shorter than of the surviving patients (p < 0.001). Mortality of patients receiving conservative treatment was higher than of those receiving surgical treatment. Patients replying to the QOL survey in 2001 (n = 1099) had recovered well: 97 % of those lived at home. More than half considered their QOL as good or extremely good, 40 % as satisfactory and 7 % as bad. All QOL indexes of those of working-age were considerably lower (p < 0.001) than comparable figures of the age- and gender-adjusted Finnish population. The 5-year monitoring period made evident that mental recovery was slower than physical recovery. 2) The results of RAND-36 and EQ-5D correlated well (p < 0.01). The RAND-36 profile measure distinguished more clearly between the different categories of QOL and their levels. EQ-5D measured well the patient groups general QOL and the sum index was used to calculate QALY units. 3) QALY units were calculated by multiplying the time the patient survived after ICU stay or expected life-years by the EQ-5D sum index. Aging automatically lowers the number of QALY units. Patients under the age of 65 receiving conservative treatment benefited from treatment to a greater extent measured in QALY units than their peers receiving surgical treatment, but in the age group 65 and over patients with surgical treatment received higher QALY ratings than recipients of conservative treatment. 4) The intensive care experience and QOL ratings were connected. The QOL indices were statistically highest for those recipients with memories of intensive care as a positive experience, albeit their illness requiring intensive care treatment was less serious than average. No statistically significant differences were found in the QOL indices of those with negative memories, no memories or those who did not express the quality of their experiences.

Measurements of adequacy of anesthesia and level of consciousness during surgery and intensive care

The adequacy of anesthesia has been studied since the introduction of balanced general anesthesia. Commercial monitors based on electroencephalographic (EEG) signal analysis have been available for monitoring the hypnotic component of anesthesia from the beginning of the 1990s. Monitors measuring the depth of anesthesia assess the cortical function of the brain, and have gained acceptance during surgical anesthesia with most of the anesthetic agents used. However, due to frequent artifacts, they are considered unsuitable for monitoring consciousness in intensive care patients. The assessment of analgesia is one of the cornerstones of general anesthesia. Prolonged surgical stress may lead to increased morbidity and delayed postoperative recovery. However, no validated monitoring method is currently available for evaluating analgesia during general anesthesia. Awareness during anesthesia is caused by an inadequate level of hypnosis. This rare but severe complication of general anesthesia may lead to marked emotional stress and possibly posttraumatic stress disorder. In the present series of studies, the incidence of awareness and recall during outpatient anesthesia was evaluated and compared with that of in inpatient anesthesia. A total of 1500 outpatients and 2343 inpatients underwent a structured interview. Clear intraoperative recollections were rare the incidence being 0.07% in outpatients and 0.13% in inpatients. No significant differences emerged between outpatients and inpatients. However, significantly smaller doses of sevoflurane were administered to outpatients with awareness than those without recollections (p<0.05). EEG artifacts in 16 brain-dead organ donors were evaluated during organ harvest surgery in a prospective, open, nonselective study. The source of the frontotemporal biosignals in brain-dead subjects was studied, and the resistance of bispectral index (BIS) and Entropy to the signal artifacts was compared. The hypothesis was that in brain-dead subjects, most of the biosignals recorded from the forehead would consist of artifacts. The original EEG was recorded and State Entropy (SE), Response Entropy (RE), and BIS were calculated and monitored during solid organ harvest. SE differed from zero (inactive EEG) in 28%, RE in 29%, and BIS in 68% of the total recording time (p<0.0001 for all). The median values during the operation were SE 0.0, RE 0.0, and BIS 3.0. In four of the 16 organ donors, EEG was not inactive, and unphysiologically distributed, nonreactive rhythmic theta activity was present in the original EEG signal. After the results from subjects with persistent residual EEG activity were excluded, SE, RE, and BIS differed from zero in 17%, 18%, and 62% of the recorded time, respectively (p<0.0001 for all). Due to various artifacts, the highest readings in all indices were recorded without neuromuscular blockade. The main sources of artifacts were electrocauterization, electromyography (EMG), 50-Hz artifact, handling of the donor, ballistocardiography, and electrocardiography. In a prospective, randomized study of 26 patients, the ability of Surgical Stress Index (SSI) to differentiate patients with two clinically different analgesic levels during shoulder surgery was evaluated. SSI values were lower in patients with an interscalene brachial plexus block than in patients without an additional plexus block. In all patients, anesthesia was maintained with desflurane, the concentration of which was targeted to maintain SE at 50. Increased blood pressure or heart rate (HR), movement, and coughing were considered signs of intraoperative nociception and treated with alfentanil. Photoplethysmographic waveforms were collected from the contralateral arm to the operated side, and SSI was calculated offline. Two minutes after skin incision, SSI was not increased in the brachial plexus block group and was lower (38 ± 13) than in the control group (58 ± 13, p<0.005). Among the controls, one minute prior to alfentanil administration, SSI value was higher than during periods of adequate antinociception, 59 ± 11 vs. 39 ± 12 (p<0.01). The total cumulative need for alfentanil was higher in controls (2.7 ± 1.2 mg) than in the brachial plexus block group (1.6 ± 0.5 mg, p=0.008). Tetanic stimulation to the ulnar region of the hand increased SSI significantly only among patients with a brachial plexus block not covering the site of stimulation. Prognostic value of EEG-derived indices was evaluated and compared with Transcranial Doppler Ultrasonography (TCD), serum neuron-specific enolase (NSE) and S-100B after cardiac arrest. Thirty patients resuscitated from out-of-hospital arrest and treated with induced mild hypothermia for 24 h were included. Original EEG signal was recorded, and burst suppression ratio (BSR), RE, SE, and wavelet subband entropy (WSE) were calculated. Neurological outcome during the six-month period after arrest was assessed with the Glasgow-Pittsburgh Cerebral Performance Categories (CPC). Twenty patients had a CPC of 1-2, one patient had a CPC of 3, and nine patients died (CPC 5). BSR, RE, and SE differed between good (CPC 1-2) and poor (CPC 3-5) outcome groups (p=0.011, p=0.011, p=0.008, respectively) during the first 24 h after arrest. WSE was borderline higher in the good outcome group between 24 and 48 h after arrest (p=0.050). All patients with status epilepticus died, and their WSE values were lower (p=0.022). S-100B was lower in the good outcome group upon arrival at the intensive care unit (p=0.010). After hypothermia treatment, NSE and S-100B values were lower (p=0.002 for both) in the good outcome group. The pulsatile index was also lower in the good outcome group (p=0.004). In conclusion, the incidence of awareness in outpatient anesthesia did not differ from that in inpatient anesthesia. Outpatients are not at increased risk for intraoperative awareness relative to inpatients undergoing general anesthesia. SE, RE, and BIS showed non-zero values that normally indicate cortical neuronal function, but were in these subjects mostly due to artifacts after clinical brain death diagnosis. Entropy was more resistant to artifacts than BIS. During general anesthesia and surgery, SSI values were lower in patients with interscalene brachial plexus block covering the sites of nociceptive stimuli. In detecting nociceptive stimuli, SSI performed better than HR, blood pressure, or RE. BSR, RE, and SE differed between the good and poor neurological outcome groups during the first 24 h after cardiac arrest, and they may be an aid in differentiating patients with good neurological outcomes from those with poor outcomes after out-of-hospital cardiac arrest.

Depressive Disorders in Primary Health Care

The Vantaa Primary Care Depression Study (PC-VDS) is a naturalistic and prospective cohort study concerning primary care patients with depressive disorders. It forms a collaborative research project between the Department of Mental and Alcohol Research of the National Public Health Institute, and the Primary Health Care Organization of the City of Vantaa. The aim is to obtain a comprehensive view on clinically significant depression in primary care, and to compare depressive patients in primary care and in secondary level psychiatric care in terms of clinical characteristics. Consecutive patients (N=1111) in three primary care health centres were screened for depression with the PRIME-MD, and positive cases interviewed by telephone. Cases with current depressive symptoms were diagnosed face-to-face with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P). A cohort of 137 patients with unipolar depressive disorders, comprising all patients with at least two depressive symptoms and clinically significant distress or disability, was recruited. The Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II), medical records, rating scales, interview and a retrospective life-chart were used to obtain comprehensive cross-sectional and retrospective longitudinal information. For investigation of suicidal behaviour the Scale for Suicidal Ideation (SSI), patient records and the interview were used. The methodology was designed to be comparable to The Vantaa Depression Study (VDS) conducted in secondary level psychiatric care. Comparison of major depressive disorder (MDD) patients aged 20-59 from primary care in PC-VDS (N=79) was conducted with new psychiatric outpatients (N =223) and inpatients (N =46) in VDS. The PC-VDS cohort was prospectively followed up at 3, 6 and 18 months. Altogether 123 patients (90%) completed the follow-up. Duration of the index episode and the timing of relapses or recurrences were examined using a life-chart. The retrospective investigation revealed current MDD in most (66%), and lifetime MDD in nearly all (90%) cases of clinically significant depressive syndromes. Two thirds of the “subsyndromal” cases had a history of major depressive episode (MDE), although they were currently either in partial remission or a potential prodromal phase. Recurrences and chronicity were common. The picture of depression was complicated by Axis I co-morbidity in 59%, Axis II in 52% and chronic Axis III disorders in 47%; only 12% had no co-morbidity. Within their lifetimes, one third (37%) had seriously considered suicide, and one sixth (17%) had attempted it. Suicidal behaviour clustered in patients with moderate to severe MDD, co-morbidity with personality disorders, and a history of treatment in psychiatric care. The majority had received treatment for depression, but suicidal ideation had mostly remained unrecognised. The comparison of patients with MDD in primary care to those in psychiatric care revealed that the majority of suicidal or psychotic patients were receiving psychiatric treatment, and the patients with the most severe symptoms and functional limitations were hospitalized. In other clinical aspects, patients with MDD in primary care were surprisingly similar to psychiatric outpatients. Mental health contacts earlier in the current MDE were common among primary care patients. The 18-month prospective investigation with a life-chart methodology verified the chronic and recurrent nature of depression in primary care. Only one-quarter of patients with MDD achieved and maintained full remission during the follow-up, while another quarter failed to remit at all. The remaining patients suffered either from residual symptoms or recurrences. While severity of depression was the strongest predictor of recovery, presence of co-morbid substance use disorders, chronic medical illness and cluster C personality disorders all contributed to an adverse outcome. In clinical decision making, beside severity of depression and co-morbidity, history of previous MDD should not be ignored by primary care doctors while depression there is usually severe enough to indicate at least follow-up, and concerning those with residual symptoms, evaluation of their current treatment. Moreover, recognition of suicidal behaviour among depressed patients should also be improved. In order to improve outcome of depression in primary care, the often chronic and recurrent nature of depression should be taken into account in organizing the care. According to literature management programs of a chronic disease, with enhancement of the role of case managers and greater integration of primary and specialist care, have been successful. Optimum ways of allocating resources between treatment providers as well as within health centres should be found.

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.

Jäsenten kokema edistyminen peliongelmasta toipumisessaan kolmessa virtuaalisessa Pelivoimapiiri-vertaistukiryhmässä

Tässä tapaustutkimuksessa on seurattu kolmen virtuaalisen Pelivoimapiiri-vertaistukiryhmän (PVP) ryhmäprosessien lisäksi ryhmien aktiivisimpien jäsenten toipumista sekä heidän kokemiaan hyötyjä eri PVP-ryhmissä ja eri ryhmätoiminnan vaiheissa. Aiempia tutkimuksia, jotka olisivat perustuneet samankaltaiseen tutkimusasetelmaan, ei aineistohaussa löytynyt. Aineistona tutkimuksessa on käytetty jäsenten palveluun lähettämiä ryhmätekstiviestejä. Menetelmiä ovat sisällön erittely sekä teoriaohjaava sisällönanalyysi. Ryhmiä seuraamalla ja niitä toisiinsa vertaamalla on selvitetty, missä ryhmätoiminnan vaiheissa jäsenet ilmaisevat tyytyväisyyttään PVP-palvelua sekä oman ryhmänsä toimintaa kohtaan. Jotta PVP:ssä koettu hyöty olisi eroteltavissa muusta haetusta avusta, on myös tulkittu viestejä, joissa tästä muun avun hakemisesta puhutaan. On myös huomioitu aikaperspektiivi ja tulkittu, kannustavatko ryhmät muun avun hakemiseen ja missä ryhmätoiminnan vaiheessa muuta apua haetaan. Yksilötason sisällönanalyysi on toteutettu seuraamalla aktiivisten jäsenten viestejä ryhmätoiminnan alusta sen loppuun saakka. Viesteistä on tunnistettu jäsenten edistymistä niin Prochaskan ja DiClementen transteoreettisen muutosvaihemallin avulla kuin myös soveltamalla tutkijoiden luokitteluja siitä, miten virtuaalinen ryhmätuki voi edesauttaa yksilön toipumista. Tarkastelen, ovatko PVP-ryhmät edistäneet yksilöiden toipumista tutkijoiden määrittelemien teoreettisten mallien mukaisesti. Tulokset vahvistivat aiempia löydöksiä, joiden mukaan viestintä virtuaaliryhmissä keskittyy pääasiassa muutamalle aktiiviselle jäsenelle. Ryhmien aktiivisten vaiheiden pituudet vaihtelivat aktiivisimman ryhmän kahden–kolmen kuukauden elinkaaresta epäaktiivisimman ryhmän pariin viikkoon. Aktiivisessa vaiheessa jäsenet olivat tyytyväisimpiä palveluun, kokivat hyötyneensä palvelusta eniten ja he olivat optimistisimpia omasta toipumisestaan. Jäsenet olivat ohjattua ryhmää lukuun ottamatta suurin piirtein samalla lähtötasolla ja he olivat ryhmän alussa pääasiassa akuutissa pelaamisvaiheessa. Nopea ryhmän kokoaminen ja jäsenten samalla muutosvaiheen lähtötasolla oleminen edistivät aktiivista ryhmäkeskustelua. Seurantajäsenistä suurin osa edistyi PVP:hen osallistumisen aikana, ja monet kokivat PVP:n myötävaikuttaneen edistymiseensä. Viisi seurantajäsentä yhdeksästä ei pelannut lainkaan PVP:hen osallistumisen aikana. Kuitenkaan ei ole selvästi eroteltavissa, mikä on lopulta palvelun ansio, sillä myös muita apukeinoja käytettiin runsaasti. Aktiivisimmassa ryhmässä jäsenet raportoivat eniten muun avun hakemisesta, kehuivat eniten ryhmäänsä, ilmaisivat rakentavimmin kritiikkiä sekä olivat huolestuneimpia ryhmän aktiivisuuden laskusta. Edellä mainittu viittaa siihen, että aktiivisimman ryhmän jäsenet kokivat muihin ryhmiin verrattuna suurempaa koheesiota. Näyttäisi siltä, että ainakin tämän tyyppinen virtuaaliryhmätuki voi – monesta syystä johtuen – tarjota vain melko lyhytaikaista tukea. Moni jäsen kuitenkin kokee, varsinkin palvelun alussa, hyötyneensä tuesta. Vaikka ryhmässä tapahtuvat prosessit ovat pitkälti ennustamattomia, voitaneen virtuaaliryhmien toimintaa kuitenkin monella tavalla edistää. Tämän selvittäminen vaatii lisätutkimuksia. Tapaustutkimukselle ominaiseen tapaan tuloksista on johdettu useita kehitysehdotuksia palvelun ylläpitäjille sekä pohdittu virtuaalisten vertaistukiryhmien sovellusmahdollisuuksia tulevaisuudessa sekä kvalitatiivisen arviointitutkimuksen mahdollisuuksia.

The Effects of Reduction Mammaplasty

Symptomatic hypertrophic breasts cause a health burden with physical and psychosocial morbidity. The value of reduction mammaplasty in the treatment of symptomatic breast hypertrophy has been consistently reported by patients and has been well recognised by plastic surgeons for a long time. However, the scientific evidence of the effects of reduction mammaplasty has been weak or lacking. During the design of this study most of the previous studies were retrospective and the few prospective studies had methodological limitations. Therefore, an obvious need for prospective randomised studies was present. Nevertheless, practical and ethical considerations seemed to make this study design impossible, because the waiting time for the operation was several years. The legislation and subsequent introduction of the uniform criteria for access to non-emergency treatment in Finland removed these obstacles, as all patients received their treatment within a reasonable time. As a result, a randomised controlled trial with a six-month follow-up time was designed and conducted. In addition, a follow-up study with two to five years follow-up was also carried out later. The effects of reduction mammaplasty on the patients breast-related symptoms, psychological symptoms, pain and quality of life was assessed. In addition, factors affecting the outcome were investigated. This study was carried out in the Hospital District of Helsinki and Uusimaa, Finland. Eighty-two out of the approximately 300 patients on the waiting list in 2004 agreed to participate in the study. Patients were randomised either to be operated (40 patients) on or to be followed up (42 patients). The follow-up time for both groups was six months. The patients were operated on by plastic surgeons or trainees at the Department of Plastic Surgery at Helsinki University Central Hospital or at the Department of Surgery at Hyvinkää Hospital. The patients completed five questionnaires: the SF-36 and the 15D quality of life questionnaires, the Finnish Breast-Associated Symptoms questionnaire (FBAS), a mood questionnaire (Raitasalo s modification of the short form of the Beck Depression Inventory, RBDI), and a pain questionnaire (The Finnish Pain Questionnaire, FPQ). Sixty-two out of the original 82 patients agreed to participate in the prospective follow-up study. In this study, patients completed the 15D quality of life questionnaire, the Finnish Breast-Associated Symptoms questionnaire, and the RBDI mood questionnaire. After six months follow-up, patients who had undergone reduction mammaplasty had a significantly better quality of life, fewer breast-associated symptoms and less pain, and they were less depressed or anxious when compared to patients who had not undergone surgery. The change in quality of life was more than two times the minimal clinically important difference. The patients preoperative quality of life was significantly inferior when compared to the age-standardised general population. This health burden was removed with reduction mammaplasty. The health loss related to symptomatic breast hypertrophy was comparable to that of patients with major joint arthrosis. In terms of change in quality of life, the intervention effect of reduction mammaplasty was comparable to that of hip joint replacement and more pronounced than that of knee joint replacement surgery. The outcome of reduction mammaplasty was affected more by preoperative psychosocial factors than by changes in breast dimensions. The effects of reduction mammaplasty remained stable at two to five years follow-up. In terms of quality of life, symptomatic breast hypertrophy causes a considerable health loss comparable to that of major joint arthrosis. Patients who undergo surgery have fewer breast-associated symptoms and less pain, and they are less depressed or anxious and have an improved quality of life. The intervention effect is comparable to that of major joint replacement surgery, and it remains stable at two to five years follow-up. The outcome of reduction mammaplasty is affected by preoperative psychosocial factors.

Use of wetland buffer areas to reduce nitrogen transport from forested catchments: Retention capacity, emissions of N2O and CH4 and vegetation composition dynamics

The use of buffer areas in forested catchments has been actively researched during the last 15 years; but until now, the research has mainly concentrated on the reduction of sediment and phosphorus loads, instead of nitrogen (N). The aim of this thesis was to examine the use of wetland buffer areas to reduce the nitrogen transport in forested catchments and to investigate the environmental impacts involved in their use. Besides the retention capacity, particular attention was paid to the main factors contributing to the N retention, the potential for increased N2O emissions after large N loading, the effects of peatland restoration for use as buffer areas on CH4 emissions, as well as the vegetation composition dynamics induced by the use of peatlands as buffer areas. To study the capacity of buffer areas to reduce N transport in forested catchments, we first used large artificial loadings of N, and then studied the capacity of buffer areas to reduce ammonium (NH4-N) export originating from ditch network maintenance areas in forested catchments. The potential for increased N2O emissions were studied using the closed chamber technique and a large artificial N loading at five buffer areas. Sampling for CH4 emissions and methane-cycling microbial populations were done on three restored buffer areas and on three buffers constructed on natural peatlands. Vegetation composition dynamics was studied at three buffer areas between 1996 and 2009. Wetland buffer areas were efficient in retaining inorganic N from inflow. The key factors contributing to the retention were the size and the length of the buffer, the hydrological loading and the rate of nutrient loading. Our results show that although the N2O emissions may increase temporarily to very high levels after a large N loading into the buffer area, the buffer areas in forested catchments should be viewed as insignificant sources of N2O. CH4 fluxes were substantially higher from buffers constructed on natural peatlands than from the restored buffer areas, probably because of the slow recovery of methanogens after restoration. The use of peatlands as buffer areas was followed by clear changes in plant species composition and the largest changes occurred in the upstream parts of the buffer areas and the wet lawn-level surfaces, where the contact between the vegetation and the through-flow waters was closer than for the downstream parts and dry hummock sites. The changes in the plant species composition may be an undesired phenomenon especially in the case of the mires representing endangered mire site types, and therefore the construction of new buffer areas should be primarily directed into drained peatland areas.

Sieltä saa tyyneyttä, sieltä saa energiaa. Luontokokemukset päihdeongelmasta toipuneiden elämäntarinoissa.

Tutkimus käsittelee päihdeongelmasta toipuneiden henkilöiden luontokokemuksia. Tutkimuksen tavoitteena on selvittää, millaisia vaikutuksia luonnolla koetaan olevan ja voiko luonto auttaa päihdeongelmasta toipumisessa. Luontoympäristöä on hyödynnetty erilaisissa kuntoutuksissa jo pitkään, mutta aihealueen tutkimus on vilkastunut vasta viime vuosina. Tutkimus liittyy A-Kiltojen Liiton Selvästi metsässä -projektiin, jossa päihdeongelmista toipuville on järjestetty monimuotoista luontotoimintaa. Tutkimusaineisto on kerätty haastattelemalla viittä henkilöä, jotka ovat toipuneet päihdeongelmasta ja joille luonto on tärkeä. Haastatteluissa muodostuneita elämäntarinoita tarkastellaan narratiivien ja narratiivisen analyysin keinoin. Tutkimus on fenomenologisesti suuntautunut, joten siinä ollaan kiinnostuneita haastateltavien kokemuksista sellaisina kuin he niitä kuvaavat. Tutkimus ei kuitenkaan ole puhtaasti aineistolähtöinen, vaan se perustuu abduktiiviseen päättelyyn, jossa lähdetään liikkeelle aineistosta mutta jossa hyödynnetään myös teoriaa. Tutkimuksen taustalla vaikuttavat erityisesti ekopsykologia ja Human Issues in Horticulture -tutkimus (HIH). Ekopsykologiassa kiinnostuksen kohteena ovat luontoympäristö, ihmisen ja luonnon välinen yhteys sekä ympäristönsuojelu. HIH-tutkimus on monitieteistä ja sen sisällä tutkitaan muun muassa kasvien terveysvaikutuksia, puutarhaterapiaa, parantavia ympäristöjä sekä ympäristökasvatusta. Analyysi aloitetaan tarkastelemalla luontokokemuksia ja luonnon merkitystä haastateltavien eri elämänvaiheissa. Erikseen tarkastellaan lapsuutta, päihdeongelman aikaa, päihdeongelman ja raittiuden välistä välivaihetta sekä raittiuden aikaa. Analyysia syvennetään tarkastelemalla, miten haastateltavat kokevat luonnon vaikuttavan heidän hyvinvointiinsa. Tulokset jäsennetään holistisen ihmiskäsityksen kolmijaon, tajunta-keho-situaatio, mukaisesti. Tajuntaan luonnon koetaan vaikuttavan tarjoamalla onnistumisen kokemuksia ja voimavaroja, lisäämällä positiivisia tunteita sekä helpottamalla negatiivisten tunteiden käsittelyä. Lisäksi luonnon koetaan vahvistavan identiteettiä ja vastaavan henkisiin tarpeisiin. Kehoon luonnon koetaan vaikuttavan liikunnan kautta ja parantamalla fyysistä kuntoa. Ihmisen situaatioon eli elämäntilanteeseen luonnon koetaan vaikuttavan helpottamalla sosiaalisten suhteiden luomista sekä tarjoamalla mahdollisuuden jonkinasteiseen omavaraisuuteen. Situaation kautta vaikuttaa myös luonnossa oleva mielipaikka, jonne mennään keräämään voimia ja rauhoittumaan. Lopuksi luodaan yksi tyypillinen tarina kaikkien viiden tarinan pohjalta. Tarinan juonen mukaan henkilöllä oli lapsuudessa vahva luontosuhde, joka katkesi päihteitä käyttäessä mutta joka löytyi uudelleen kuntoutuksen ja raitistumisen myötä. Tutkimuksen mukaan luontoa kannattaisi hyödyntää entistä enemmän osana päihdehoitoa, sillä luontoympäristön on useissa muissakin tutkimuksissa todettu vaikuttavan myönteisesti ihmisten hyvinvointiin. Päihdehoidossa ollaan siirtymässä entistä avohoitopainotteisempaan suuntaan ja siksi olisi tärkeää löytää uusia menetelmiä, jotka ovat sekä edullisia että mahdollisia toteuttaa avohoidossa. Luontotoiminta täyttää mainitut kriteerit.