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  • Mölsä, Sari (Helsingin yliopisto, 2014)
    Cranial cruciate ligament (CCL) disease is one of the most common causes of lameness in dogs. Surgical treatment is recommended to stabilize the stifle joint, alleviate pain, and delay the progression of osteoarthritis (OA). A variety of surgical techniques has been introduced and can be broken down into the more traditional intracapsular ligament replacement and extracapsular suture techniques and the newer neutralizing dynamic osteotomy techniques. Although an enormous amount of literature is available concerning this disease, surprisingly few studies have assessed surgical outcome with objective evaluation methods and comparison between groups. Previous studies have demonstrated significant improvement of limb function after CCL surgery. However, OA has been shown to progress in most patients, and this may cause deterioration in the function of the surgically treated limb over time. Long-term follow-up studies that include objective evaluation methods designed for assessing orthopedic outcome are needed. This thesis aimed to evaluate the long-term surgical outcome and signs of chronic pain after CCL surgery. Also, outcomes between the intracapsular, extracapsular and osteotomy techniques were compared. A multimodal approach, including an owner questionnaire and assessment of chronic pain using the validated Helsinki Chronic Pain Index (HCPI), orthopedic and radiographic examinations, force plate analysis, and as a new evaluation method, a physiotherapeutic examination was included. To provide reference values, clinically healthy Rottweilers and Labrador Retrievers were examined. A long-term retrospective follow-up with a mean time interval of at least 2.7 years between the surgery and evaluation was conducted. Of the 206 surgically treated dogs that were evaluated by their owners, 31.1% had a HCPI value ≥ 12, indicating pain. Of the 47 dogs evaluated by a veterinarian 31.9% showed a pain response to flexion/extension of the surgically treated joint. In addition to the unilaterally treated CCL rupture, contralateral stifle joint pathology and other orthopedic problems were frequently diagnosed during the evaluation. When symmetry of weight bearing was evaluated in dogs with no other orthopedic findings (n=21),approximately 30% of dogs had decreased dynamic and static weight bearing in the surgically treated limbs. Also, goniometric angles of the surgically treated limbs remained inferior to those of healthy limbs, and impairment of active range of motion was frequently observed. The owner assessments revealed no significant differences between the surgical techniques in long-term outcome. However, differences were seen in clinical evaluation of dynamic and static weight bearing between intracapsular and osteotomy technique groups. Although the retrospective study design and low sample size have to be acknowledged and may cause bias to the results, osteotomy techniques may offer long-term limb function that is superior to that achieved with the intracapsular technique. The low number of dogs treated with the extracapsular technique did not allow comparison of dynamic or static weight bearing to other technique groups.
  • Riihimäki, Kirsi (Helsingin yliopisto, 2014)
    This study is the first naturalistic prospective long-term follow-up with a life-chart among primary care patients with depressive disorders. Patients with lifetime MDD spent 34% of follow-up time in MDEs, 24% in partial and only 42% in full remission. Nine in ten achieved at least partial and two-thirds full remission. Baseline severity of depression and substance use comorbidity predicted time spent in MDEs: a rise in Hamilton Rating Scale for Depression (HAMD) score of ten at baseline predicted 14 months and comorbid substance use disorder 25 months more time in MDEs. One-half of those who achieved partial remission and one-third of those who reached full remission were having at least one recurrence. The recurrences were predicted by personality disorders. The time from remission to recurrence was predicted by generalized anxiety disorder and somatoform disorder. One-tenth of patients attempted suicide one to three times. The incidence rate varied robustly depending on the level of depression, being 0 per 1000 patient-years during full remission, 5.8 during partial remission and 107 during MDEs. Functional and work ability were strongly associated with duration and severity of depression. Patients who belonged to the labour force spent one-third of the follow-up off work due to depression; two-thirds were granted sick leave, and one-tenth a disability pension due to depression. Longer duration of depression, comorbid disorders and having received social assistance predicted dropping out from work. A quarter of patients suffered from concurrent borderline personality disorder (BPD). Comorbid anxiety and substance use disorders were common among them. Concurrent BPD increased the severity and duration of depression, suicidal behaviour, unemployment and economic difficulties. This study revealed often slow and incomplete recovery and a common recurrent course, which needs to be taken into account when developing services. The use of measurement scales is warranted when planning and monitoring treatment. Comorbidity, concurrent substance use disorder, anxiety disorders, somatoform disorder and BPD all need to be taken into account in clinical practice guidelines. Duration of depression appears most decisive for suicide attempts among primary care patients with depression. Efforts should focus on the continuity of care.
  • Holma, Mikael (Helsingin yliopisto, 2010)
    Much of what we know regarding the long-term course and outcome of major depressive disorder (MDD) is based on studies of mostly inpatient tertiary level cohorts and samples predating the era of the current antidepressants and the use of maintenance therapies. In addition, there is a lack of studies investigating the comprehensive significance of comorbid axis I and II disorders on the outcome of MDD. The present study forms a part of the Vantaa Depression Study (VDS), a regionally representative prospective and naturalistic cohort study of 269 secondary-level care psychiatric out- and inpatients (aged 20-59) with a new episode of DSM-IV MDD, and followed-up up to five years (n=182) with a life-chart and semistructured interviews. The aim was to investigate the long-term outcome of MDD and risk factors for poor recovery, recurrences, suicidal attempts and diagnostic switch to bipolar disorder, and the association of a family history of different psychiatric disorders on the outcome. The effects of comorbid disorders together with various other predictors from different domains on the outcome were comprehensively investigated. According to this study, the long-term outcome of MDD appears to be more variable when its outcome is investigated among modern, community-treated, secondary-care outpatients compared to previous mostly inpatient studies. MDD was also highly recurrent in these settings, but the recurrent episodes seemed shorter, and the outcome was unlikely to be uniformly chronic. Higher severity of MDD predicted significantly the number of recurrences and longer time spent ill. In addition, longer episode duration, comorbid dysthymic disorder, cluster C personality disorders and social phobia predicted a worse outcome. The incidence rate of suicide attempts varied robustly de¬pending on the level of depression, being 21-fold during major depressive episodes (MDEs), and 4-fold during partial remission compared to periods of full remission. Although a history of previous attempts and poor social support also indicated risk, time spent depressed was the central factor determining overall long-term risk. Switch to bipolar disorder occurred mainly to type II, earlier to type I, and more gradually over time to type II. Higher severity of MDD, comorbid social phobia, obsessive compulsive disorder, and cluster B personality disorder features predicted the diagnostic switch. The majority of patients were also likely to have positive family histories not exclusively of mood, but also of other mental disorders. Having a positive family history of severe mental disorders was likely to be clinically associated with a significantly more adverse outcome.
  • Tiippana-Kinnunen, Tarja (Helsingin yliopisto, 2014)
    This 15-year follow-up focused on radiographic outcome, functional capacity, work disability and comorbidity in 86 patients (age 18-65 years), with early (≤ 12 months of disease duration) rheumatoid arthritis (RA) collected in 1986-1989 in Helsinki area and treated with early initiated DMARD therapy. The outcome was determined in relation to DMARD continuity, early disease activity, early radiographic remission (ERR) and baseline comorbidity. Of the 70 patients evaluated at 15-year examination, 50 (71%) needed continuous DMARD therapy (group A). In 20 patients (29%) DMARDs were discontinued due to clinical remission. Of these disease flared up and DMARDs were reintroduced in 9 patients (45%, group B) and 11 (55%) remained in remission (group C). The 15-year outcome was most favourable in group C: 64% of patients being in remission, according to American Collage of Rheumatology criteria, compared with 0% in B and 6% in A. Final functional capacity [mean Health Assessment Questionnaire (HAQ)] was 0.24 in C, 0.38 in B and 0.60 in A and radiographic outcome assessed with mean Larsen score (LS) 12, 25 and 54, respectively. As conclusion, patients whose DMARDs are discontinued due to remission, should be followed up closely for a flare-up of the disease. For those whose disease flares up, DMARDs should be reintroduced immediately. The 15-year LS of 69 patients determined in relation to ERR [an increase of LS ≤ 1 Larsen unit (LU) between two sequential sets of small joint radiographs during the first 2 years]. Mean 15-year LS of the small joints (14) and LS of the large joints (0.8) were lower in patients with sustained ERR (both year 1 and year 2), compared with 33 and 1.9 in patients with temporary ERR (either year 1 or year 2) or with 67 and 6.3 in patients with radiographic progression ≥ 2 LU during both first years. Considering these findings, radiographic remission should be a treatment goal in RA and early progression in small joints should be taken as a warning sign for later damage of large joints. Of 80 patients with adequate data, 20% had at least one comorbid condition at baseline and 60 % had comorbidities at the 15-year visit or at time od death, most commonly hypertension (30%), cardiovascular diseases (14%), malignancies (11%) or osteoporosis (11%). Elderly patients with baseline comorbidity showed higher disease activity both during first year of RA and at endpoint than younger patients without comorbidities. Of the 86 patients, 42 (49%) retired due to work disability (WD) during 15 years or before death, most of these due to RA. The Kaplan-Meier estimated cumulative RA-related WD was less frequent in patients with low disease activity during first 12 months (3% at year 5, 10% at year 10 and 22% at year 15) than in those with moderate or high disease activity (28%, 55% and 64%, respectively). The results of this study showed that most patients with RA need continuous DMARD treatment and emphasize the importance of targeting to clinical remission and to radiographic remission in early phase of the disease for the long-term outcome in RA.
  • Pelttari, Hanna (Helsingin yliopisto, 2012)
    The goal of initial therapy in differentiated thyroid cancer (DTC) is to minimize disease related mortality and morbidity by surgically removing the primary tumour and all metastasized tumour tissue. A second goal is to minimize risk of recurrence and metastatic spread by facilitating post-operative radio-iodine ablation (RRA), permitting accurate long-term surveillance. Recurrences are relatively common even in patient population at low-risk for cancer-specific death, occurring in 10-40% of cases. The treatment and follow-up schemes have varied between centres and there is ongoing debate about appropriate methods for primary therapy and surveillance. With the increasing incidence of DTC, the need for new factors prognostic of disease recurrence is growing; most of the prognostic systems have been validated with cancer-specific death as outcome. We designed an observational retrospective study to assess the outcome of a large cohort of patients with low-risk thyroid carcinoma and with a uniform primary therapy. All patients belong to TNM stage I or II and were considered disease-free after initial therapy. We evaluated the safety and efficacy of a surveillance paradigm, comprising yearly thyroglobulin (TG) measurements on L-T4 therapy and neck ultrasonography (US) every second year, with an increase in TG to a detectable level being an indication for further investigations. We examined the health-related quality of life (HRQoL) of the patient cohort after long-term follow-up using a validated multidimensional method (15D®). We studied factors correlating with disease recurrence, including patient demographics, tumour characteristics and parameters with primary therapy, in 495 low-risk patients treated at Helsinki University Central Hospital over a 15-year period. Post-operative and post-ablative TG concentrations, age, tumour size, local infiltration and nodal metastasis at primary surgery, number of neck US, fine-needle aspiration biopsies (FNABs) and operations performed, presence of BRAF mutation in papillary tumour tissue, disease recurrences and cancer-specific deaths were evaluated. The majority of patients had total thyroidectomy and radio-active iodine remnant ablation as initial treatment. The median follow-up was 16 (range 10 24) years. Fifty-one patients (10.3%) experienced disease recurrence during follow-up. A combination of neck US and high TG revealed most recurrences. In multiple logistic regression analysis, post-ablative measurable TG concentrations (odds ratio (OR) 3.72, confidence interval (CI) 1.71 8.05, P = 0.0009) and presence of local infiltration on primary surgery (OR 2.66, CI 1.03 6.90, P = 0.04) were the only independent predictors of recurrence. BRAF V600E mutation is common (prevalence 67%) in this low-risk papillary thyroid cancer patient group but does not predict recurrence after long-term follow-up after initial treatment with total thyroidectomy (TTE) and RRA. HRQoL was preserved in DTC patients compared to a large age- and gender-standardized sample of the general Finnish population (n = 6001). After long-term follow-up, overall HRQoL is comparable with that of the general population. DTC patients demonstrate an age-related decline in HRQoL, similar to that seen in the population in general. We conclude that post-ablative TG concentration is a strong predictor of disease recurrence in DTC. Although longer follow-up is needed, monitoring low-risk differentiated thyroid carcinoma patients with neck US and TG measured on L-T4 appears safe and effective.The same principles have now been adapted also by many international centres.
  • Kosola, Silja (Helsingin yliopisto, 2013)
    Since survival rates after pediatric liver transplantation (LT) have improved, the focus of interest has shifted to gradually evolving histological changes, long-term complications, and quality of life. Histological changes and complications are closely associated with each other and the immunosuppressive medication used, and may in turn affect the LT recipient s perception of quality of life. This thesis investigates the survival and complication rates, usefulness of protocol liver biopsies and long-term histological status of the liver graft, and cholesterol metabolism profile after pediatric LT. The effect of immunosuppression on biopsy-proven changes and cholesterol metabolism is also evaluated. In the quality of life assessment, the effects of different complications are explored. The study population includes all 99 children less than 18 years who underwent LT in Finland between 1987 and 2007. Retrospective data on LT indications, surgical procedures, surgical and medical complications, immunosuppression, and annual follow-up visits were collected from patient records and the national LT registry. For 12 patients transplanted for hepatoblastoma (HB) or hepatocellular carcinoma (HCC), also relevant cancer treatment details were gathered. Cross-sectional data included liver biopsies of 54 LT recipients (82% of survivors), serum levels of noncholesterol sterols (surrogate markers of cholesterol metabolism) and fibroblast growth factor 21 (FGF21) in 49 LT recipients (74%), and health-related quality of life (HRQoL) assessment of 57 LT recipients (86%) at median 10-11 years posttransplant. Serum levels of noncholesterol sterols and FGF21 were compared to 93 controls matched for age and gender, and the HRQoL measurements to 141 randomly picked controls matched for age, gender, and place of residence. Of the 12 patients with liver malignancies, six had HB and six HCC. All patients received neoadjuvant chemotherapy, but no routine chemotherapy was administered after LT. Median time from diagnosis to LT was 7 (2-133) months. At LT, none of the patients had radiological evidence of extrahepatic disease. The overall survival rates at one, five, and ten years after LT were 100%, 80%, and 67%, respectively. Survival was similar between the tumor types, and two deaths occurred secondary to tumor recurrence, one of each type. Biopsies of 18 patients (33%) showed near-normal histology with minimal changes. Portal inflammation was present in 14 samples (26%), and was less frequent in patients whose immunosuppression included steroids (14% vs. 47%; p = 0.008). Fibrosis was found in 21 biopsies (39%), and fibrosis staging correlated negatively with serum prealbumin levels (r = -0.364, p = 0.007) and positively with portal inflammation (r = 0.350, p = 0.010) and periportal cytokeratin 7 staining (r = 0.529, p less than 0.001). Microvesicular steatosis was detected in 23 biopsies (43%; 5-80% of hepatocytes), and correlated with the patients body-mass-index (r = 0.458, p less than 0.001) but not with steroid use. The histological findings were mainly mild and led to treatment changes in ten patients (19%), while only one minor complication was encountered. Serum lipid levels were similar in LT recipients and controls. LT recipients, however, displayed increased whole-body synthesis and decreased absorption of cholesterol compared to controls (lathosterol to cholesterol ratio 129 ± 55 vs. 96 ± 41, respectively, p less than 0.001; campesterol to cholesterol ratio 233 ± 91 vs. 316 ± 107, respectively, p less than 0.001). Low-dose methylprednisolone and azathioprine were negatively associated with the lathosterol/sitosterol ratio (r = -0.492, p less than 0.001 and r = -0.383, p = 0.007, respectively) reflecting a favorable effect on cholesterol metabolism. FGF21 levels were higher in LT recipients than in controls (248 pg/mL vs. 77 pg/mL, p less than 0.001). Under school-aged LT recipients and controls had similar HRQoL, and 54% of LT recipients aged over 7 scored within the controls normal range on all HRQoL domains. Biliary complications, reoperations, and obesity were independently associated with decreased HRQoL (p less than 0.05 for all). For those LT recipients already attending adult health care, physical functioning and general health yielded reduced scores (p less than 0.05). Still 64% of adults considered their health excellent. Sexual health was similar to controls although LT recipients may experience problems with their orgasm strength (p = 0.050). In conclusion, continued use of low-dose steroids seems to be associated with milder changes of both liver graft histology and cholesterol metabolism. Normal HRQoL and sexual health are achievable in long-term survivors of pediatric LT.
  • Sistonen, Saara (2010)
    Esophageal atresia (EA), a common congenital anomaly comprising interrupted esophagus with or without a tracheoesophageal fistula (TEF), affects one in 2840 newborns. Over half have associated anomalies. After EA repair in infancy, gastroesophageal reflux (GER) and esophageal dysmotility and respiratory problems are common. As there exist no previous population-based long-term follow-up-studies on EA, its long-term sequelae are unclear. The aims of this study were to assess the cancer incidence (I), esophageal morbidity and function (II), respiratory morbidity (III), and the spinal defects (IV) in adults with repaired EA. All patients treated for EA at the Hospital for Children and Adolescents, University of Helsinki, from 1947 to 1985 were identified, and those alive with their native esophagus were contacted, and the first hundred who replied made up the study group. The patients were interviewed, they filled in symptom questionnaires, and they underwent esophageal endoscopy and manometry, pulmonary function tests, and a full orthopedic evaluation was performed with radiographs of the spine. The questionnaire was also sent by mail to adults with repaired EA not attending the clinical study, and to 287 general population-derived controls matched for age, gender, and municipality of residence. Incidence of cancer among the study population was evaluated from the population-based countrywide cancer registry. 169 (72%) adults with repaired EA replied; 101 (42%) (58 male) participated in the clinical studies at a median age of 36 years (range, 22-56). Symptomatic GER occurred in 34% and dysphagia in 85% of the patients and in 8% and 2% of the controls (P<0.001 for both). The main endoscopic findings included hiatal hernia (28%), Barrett´s esophagus (11%), esophagitis (8%), and stenotic anastomosis (8%). Histology revealed esophagitis in 25 individuals, and epithelial metaplasia in another 21. At immunohistochemistry, CDX2-positive columnar epithelial metaplasia was present in all 21 individuals, and 6 of these also demonstrated goblet cells and MUC2 positivity. In all histological groups, GER and dysphagia were equally common (P=ns). Esophageal manometry demonstrated non-propagating peristalsis in most of the patients, and low ineffective pressure of the distal esophageal body in all. The changes were significantly worse in those with epithelial metaplasia (P≤0.022). Anastomotic complications (OR 8.6-24, 95%CI 1.7-260, P=0.011-0.008), age (OR 20, 95%CI 1.3-310, P=0.034), low distal esophageal body pressure (OR 2.6, 95%CI 0.7-10, P=0.002), and defective esophageal peristalsis (OR 2.2, 95%CI 0.4-11, P=0.014) all predicted development of epithelial metaplasia. Despite the high incidence of esophageal metaplasia, none of the EA patients had suffered esophageal cancer, according to the Finnish Cancer Registry. Although three had had cancer (SIR, 1.0; 95% CI, 0.20-2.8). The overall cancer incidence among adults with repaired EA did not differ from that of the general Finnish population. Current respiratory symptoms occurred in 11% of the patients and 2% of the controls (P<0.001). Of the patients, 16%, and 6% of the controls had doctor-diagnosed asthma (P<0.001). A total of 56% and 70% of the patients and 20% and 50% of the controls had a history of pneumonia and of bronchitis (P<0.001 for both). Respiratory-related impaired quality of life was observable in 11% of the patients in contrast to 6% of the controls (P<0.001). PFT revealed obstruction in 21 of the patients, restriction in 21, and both in 36. A total of 41 had bronchial hyper-responsiveness (BHR) in HCT, and 15 others had an asthma-like response. Thoracotomy-induced rib fusion (OR 3.4, 95%CI 1.3-8.7, P=0.01) and GER-associated epithelial metaplasia in adulthood (OR 3.0, 95%CI 1.0-8.9, P=0.05) were the most significant risk factors for restrictive ventilatory defect. Vertebral anomalies were evident in 45 patients, predominating in the cervical spine in 38. The most significant risk factor for the occurrence of vertebral anomalies was any additional anomaly (OR 27, 95%C I8-100). Scoliosis (over 10 degrees) was observable in 56 patients, over 20 degrees in 11, and over 45 degrees in one. In the EA patients, risk for scoliosis over 10 degrees was 13-fold (OR 13, 95%CI 8.3-21) and over 20 degrees, 38-fold (OR 38, 95%CI 14-106) when compared to that of the general population. Thoracotomy-induced rib fusion (OR 3.6, 95%CI 0.7-19) and other associated anomalies (OR 2.1, 95%CI 0.9-2.9) were the strongest predictive factors for scoliosis. Significant esophageal morbidity associated with EA extends into adulthood. No association existed between the esophageal symptoms and histological findings. Surgical complications, increasing age, and impaired esophageal motility predicted development of epithelial metaplasia after repair of EA. According to our data, the risk for esophageal cancer is less than 500-fold that of the general population. However, the overall cancer incidence among adults with repaired EA did not differ from that of the general population. Adults with repaired EA have had significantly more respiratory symptoms and infections, as well as more asthma, and allergies than does the general population. Thoracotomy-induced rib fusion and GER-associated columnar epithelial metaplasia were the most significant risk factors for the restrictive ventilatory defect that occurred in over half the patients. Over half the patients with repaired EA are likely to develop scoliosis. Risk for scoliosis is 13-fold after repair of EA in relation to that of the general population. Nearly half the patients had vertebral anomalies. Most of these deformities were diagnosed neither in infancy nor during growth. The natural history of spinal deformities seems, however, rather benign, with spinal surgery rarely indicated.
  • Palmu, Sauli (Helsingin yliopisto, 2013)
    Every fourth injured child seeking medical aid has sustained a fracture. Tibial fracture (annual incidence in less than 17 year old citizens in Finland is 1/1000) is the third most common fracture in children and femoral fracture (0.3/1000) among the most common pediatric injuries leading to hospitalization. Long-term treatment result of these fractures is not well known and there are no studies of treatment injuries in this pediatric patient population. Altogether 94 tibial and 74 femoral fractures were treated under anesthesia in Aurora Hospital, Helsinki between 1980-89. All but 5 of the tibial fractures were manipulated under anesthesia and casted. A remanipulation was performed in 41 patients. Femoral fractures were treated with skeletal traction in 62 patients, with internal fixation in 8 patients and by cast-immobilization 4 patients. A patients assessment form and an invitation to participate in a clinical and radiological examination at a mean follow-up of more than 20 years (16-32) was sent to all 168 patients. Six of the 58 tibial fracture patients that responded reported pain as their only memory of treatment. Results of tibial fracture treatment were satisfactory with few exceptions: functionally significant axial malalignment, limb length discrepancies nor arthritis was not found excluding four patients with >20° rotational deformity of the tibia. On the contrary 21/52 of the femoral fracture patients examined had angular malalignment of the femur exceeding 10°. Ten patients walked with a limp and leg-length discrepancy of more than 15 mm was measured in 8 patients. Knee arthritis had developed in 6/15 patients who were older than 10 years at the time of the injury. There was a positive correlation between angular deformity and knee arthritis. Treatment injuries were evaluated using patient compensation data from the Finnish Patient Insurance Centre (PIC): 50 claims involving tibial fracture treatment, 30 involving femoral fracture treatment were filed during the study period between 1997-2004. Compensation was granted in 35/50 claims after tibial fracture treatment and in 16/30 after femoral fracture treatment. The most common reasons for compensations in tibial fractures were missed diagnosis and inappropriate casting technique and delay in treatment, unnecessary or inappropriate treatment in femoral fractures. Most of the treatment injuries were regarded in retrospect as avoidable. Satisfactory long-term results in pediatric tibial fractures treated with closed manipulation and cast-immobilization can be expected. Many children require remanipulation to maintain satisfactory alignment, however. Over 10 year old patients with femoral malunion run a high risk of early knee arthritis. Most treatment injuries in pediatric tibial and femoral fractures can be avoided by accurate primary diagnostics, correct casting techniques and appropriate surgery.
  • Kirjavainen , Mikko (Helsingin yliopisto, 2010)
    Background: Brachial plexus birth palsy (BPBP) most often occurs as a result of foetal-maternal disproportion. The C5 and C6 nerve roots of the brachial plexus are most frequently affected. In contrast, roots from the C7 to Th1 that result in total injury together with C5 and C6 injury, are affected in fewer than half of the patients. BPBP was first described by Smellie in 1764. Erb published his classical description of the injury in 1874 and his name became linked with the paralysis that is associated with upper root injury. Since then, early results of brachial plexus surgery have been reasonably well documented. However, from a clinical point of view not all primary results are maintained and there is also a need for later follow-up results. In addition most of the studies that are published emanate from highly specialized clinics and no nation wide epidemiological reports are available. One of the plexus injuries is the avulsion type, in which the nerve root or roots are ruptured at the neural cord. It has been speculated whether this might cause injury to the whole neural system or whether shoulder asymmetry and upper limb inequality results in postural deformities of the spine. Alternatively, avulsion could manifest as other signs and symptoms of the whole musculoskeletal system. In addition, there is no available information covering activities of daily living after obstetric brachial plexus surgery. Patients and methods: This was a population-based cross-sectional study on all patients who had undergone brachial plexus surgery with at least 5 years of follow-up. An incidence of 3.05/1000 for BPBP was obtained from the registers for this study period. A total of 1706 BPBP patients needing hospital treatment out of 1 717 057 newborns were registered in Finland between 1971 and 1997 inclusive. Of these BPBP patients, 124 (7.3%) underwent brachial plexus surgery at a mean age of 2.8 months (range: 0.4―13.2 months). Surgery was most often performed by direct neuroraphy after neuroma resection (53%). Depending on the phase of the study, 105 to 112 patients (85-90%) participated in a clinical and radiological follow-up assessment. The mean follow up time exceeded 13 years (range: 5.0―31.5 years). Functional status of the upper extremity was evaluated using Mallet, Gilbert and Raimondi scales. Isometric strength of the upper limb, sensation of the hand and stereognosis were evaluated for both the affected and unaffected sides then the differences and their ratios were calculated and recorded. In addition to the upper extremity, assessment of the spine and lower extremities were performed. Activities of daily living (ADL), participation in normal physical activities, and the use of physiotherapy and occupational therapy were recorded in a questionnaire. Results: The unaffected limb functioned as the dominant hand in all, except four patients. The mean length of the affected upper limb was 6 cm (range: 1-13.5 cm) shorter in 106 (95%) patients. Shoulder function was recorded as a mean Mallet score of 3 (range: 2―4) which was moderate. Both elbow function and hand function were good. The mean Gilbert elbow scale value was 3 (range: -1―5) and the mean Raimondi hand scale was 4 (range:1―5). One-third of the patients experienced pain in the affected limb including all those patients (n=9) who had clavicular non-union resulting from surgery. A total of 61 patients (57%) had an active shoulder external rotation of less than 0° and an active elbow extension deficiency was noted in 82 patients (77%) giving a mean of 26° (range: 5°―80°). In all, expect two patients, shoulder external rotation strength at a mean ratio 35% (range: 0―83%) and in all patients elbow flexion strength at a mean ratio of 41% (range: 0―79%) were impaired compared to the unaffected side. According to radiographs, incongruence of the glenohumeral joint was noted in 15 (16%) patients, whereas incongruence of the radiohumeral joint was found in 20 (21%) patients. Fine sensation was normal for 34/49 (69%) patients with C5-6 injury, for 15/31 (48%) with C5-7 and for only 8/25 (32%) of patients with total injury. Loss of protective sensation or absent sensation was noted in some palmar areas of the hand for 12/105 patients (11%). Normal stereognosis was recorded for 88/105 patients (84%). No significant inequalities in leg length were found and the incidence of structural scoliosis (1.7%) did not differ from that of the reference population. Nearly half of the patients (43%) had asynchronous motion of the upper limbs during gait, which was associated with impaired upper limb function. Data obtained from the completed questionnaires indicated that two thirds (63%) of the patients were satisfied with the functional outcome of the affected hand although one third of all patients needed help with ADL. Only a few patients were unable to participate in physical activities such as: bicycling, cross-country skiing or swimming. However, 71% of the patients reported problems related to the affected upper limb, such as muscle weakness and/or joint stiffness during the aforementioned activities. Incongruity of the radiohumeral joints, extent of the injury, avulsion type injury, age less than three months of age at the time of plexus surgery and inexperience of the surgeon was related to poor results as determined by multivariate analyses. Conclusions: Most of the patients had persistent sequelae, especially of shoulder function. Almost all measurements for the total injury group were poorer compared with those of the C5-6 type injury group. Most of the patients had asymmetry of the shoulder region and a shorter affected upper limb, which is a probable reason for having an abnormal gait. However, BPBP did not have an effect on normal growth of the lower extremities or the spine. Although, participation in physical activities was similar to that of the normal population, two-thirds of the patients reported problems. One-third of the patients needed help with ADL. During the period covered by this study, 7.3% BPBP of patients that needed hospital treatment had a brachial plexus operation, which amounts to fewer than 10 operations per year in Finland. It seems that better results of obstetric plexus surgery and more careful follow-up including opportunities for late reconstructive procedures will be expected, if the treatment is solely concentrated on by a few specialised teams.
  • Heikkinen, Marja (Helsingin yliopisto, 2008)
    The aim of the study was to evaluate long-term results of operative treatment for Hirschsprung's disease(HD) and internal anal sphincter achalasia. Fecal continence and quality of life were evaluated by a questionnaire in 100 adult patients who had undergone surgery for HD, during 1950-75. Fecal continence was evaluated using a numerical scoring described by Holschneider. Fifty-four of the 100 patients underwent clinical examination, rigid sigmoidoscopy and manometric evaluation. In anorectal manometry basal resting pressure(BRP)and maximal squeeze pressure(MSP) were measured and voluntary sphincter force(VSF) was calculated by subtracting the BRP from MSP. The results of operative treatment for adult HD were compared with the results of the patients operated in childhood. In adult HD the symptoms are such mild that the patients attain adolescence or even adulthood. The patients with HD and cartilage-hair-hypoplasia were specifically evaluated. The outcome of the patients with internal anal sphincter achalasia operated on by myectomy was evaluated by a questionnaire and continence was evaluated using a numerical scoring described by Holschneider. Of the 100 patients operated on for HD 38 patients had completely normal bowel habits. A normal or good continence score was found in 91 our of 100 patients. Nine patients had fair continence. One of the patients with fair continence had Down's syndrome and two were mentally retarded for other reasons. Only one patient suffered from constipation. In anorectal manometry the difference in BRP between patients with normal and good continence was statistically significant, whereas the difference between good and fair continence groups was not statistically significant. The differences on MSP and VSF between patient groups with different continence outcome were not statistically significant. The differences between patient groups and normal controls were statistically significant in BRP and MSP. In VSF there was not statistically significant difference between the patients and the normal controls. The VSF reflects the working power of the muscles including external sphincter, levator ani and gluteal muscles. The patients operated at adult age had as good continence as patients operated in childhood. The patients with HD and cartilage-hair-hypoplasia had much more morbidity and mortality than non-cartilage-hair-hypoplasia HD patients. The mortality was as high as 38%. In patients with internal anal sphincter achalasia the constipation was cured or alleviated by myectomy whereas a significant number suffered from soiling-related social problems.
  • Nieminen, Tuomo (Helsingin yliopisto, 2014)
    Atmospheric aerosol particles affect our lives in various ways. One of the largest sources of aerosols is their formation in the atmosphere via nucleation from precursor vapours. These new particle formation (NPF) events have been observed to occur globally. The climatic effects of secondary aerosol are among the largest uncertainties limiting our scientific understanding of future and past climate changes. Characterizing the processes controlling the formation and growth of aerosols is crucial in order to estimate their effects on air quality, human health, and eventually, global climate. The work presented in this thesis is based on measurements of aerosol formation under various conditions at 12 field sites across Europe, as well as long-term, comprehensive observations of aerosol properties at a boreal forest site in Finland. The results show that new particle formation is a frequent phenomenon at both clean background and polluted Central European sites. On the sites where measurements of both charged and neutral particles were performed, the total particle formation rates at 2 nm size varied in the range 0.9 32 cm-3 s-1, whereas the charged particle formation rates were on the order of 0.05 0.16 cm-3 s-1. Further evidence of the minor role of ions in continental boundary layer particle formation was obtained from the long-term observations, which did not show any connection between variation in the galactic- cosmic-ray-induced ionization and new particle formation. In confirmation of earlier observations, sulphuric acid was found to be closely connected to particle formation rates, but to have only a minor role in their subsequent growth. At the boreal forest site, a long-term decreasing trend in the concentrations of sulphuric acid and aerosol particles was observed, whereas the particle formation and growth rates had a slight increasing trend. Finally, a proxy for the global distribution of nucleation-mode particle concentrations based on satellite data was developed. The results of this thesis give tools to quantify the source rate of atmospheric aerosol from new particle formation in various environments. The characteristics of particle formation determined in this thesis can be used in global models to evaluate the climatic effects of NPF events. The results support previous observations of atmospheric NPF, and give significant new results in particular about the role of ions in NPF in various environments, and the long-term changes in NPF.
  • Berghem, Fiia (2013)
    Tutkimuksen tavoitteena oli selvittää lonkkakuvaustuloksen ja kliinisen oireilun välistä yhteyttä saksanpaimenkoirilla. Työ liittyi laajempaan lonkkatutkimusprojektiin, jonka tarkoituksena oli paikantaa lonkkadysplasiaan vaikuttavia geenejä eri roduissa sekä selvittää lonkkadysplasian kehittymiseen ja siihen liittyvään kliiniseen oireiluun vaikuttavia ympäristötekijöitä. Lonkkadysplasia on yleinen ortopedinen sairaus suurilla koiraroduilla. Se on kvantitatiivinen ominaisuus, jonka ilmenemiseen vaikuttavat perintötekijöiden lisäksi useat eri ympäristötekijät, kuten ruokinta ja liikunta. Lonkkadysplasialle alttiit koirat syntyvät normaalilonkkaisina ja kehittävät merkkejä lonkkien löysyydestä heti ensimmäisten elinviikkojen aikana. Nivelen löysyys mahdollistaa lonkkaluun pään subluksaation ja altistaa sekä pehmytkudos- että luustorakenteet epänormaalille kuormitukselle. Tämän seurauksena lonkkanivel kehittyy väärän malliseksi ja epänormaali kuormitus jatkuu. Lonkkadysplasian seurauksena kehittyy osteoartriittia, josta johtuu suurin osa aikuisten koirien lonkkadysplasiaan liittyvistä oireista. Kroonisten kipuoireiden tunnistamisessa voidaan käyttää sitä varten kehitettyä indeksiä (Helsinki Chronic Pain Index, HCPI) tai erilaisia visuaalisia arviointiasteikkoja. Tutkimus toteutettiin kyselykaavakkeella, johon koirien omistajat kävivät vastaamassa internetissä. Lomakkeessa kysyttiin koiran perustietojen ja linjan lisäksi mm. lonkkakuvaustuloksesta, oireista, yleistilasta, käytetyistä hoidoista ja muista vioista. Yleistilaa koskevien kysymysten perusteella laskettiin HCPI, ja lomakkeessa oli lisäksi kaksi visuaalista arviointiasteikkoa koiran liikuntavaikeuksien ja elämänlaadun arviointiin. Lomakkeeseen oli tullut aineiston käsittelyn aloittamiseen mennessä 260 vastausta koskien saksanpaimenkoiria, joilla oli virallinen lonkkakuvaustulos. Tulokset käsiteltiin tilastollisesti. Tulosten perusteella lonkkadysplasiasta kärsivät koirat oireilevat yleisemmin, nuorempina, ja niillä on enemmän erilaisia oireita kuin lonkiltaan terveiksi kuvatuilla koirilla. Aineiston perusteella dysplastisille koirille tyypillisimpiä oireita ovat jänislaukka, vaikeudet päästä ylös levon jälkeen ja vaikeudet hypätä. Sen sijaan kivun ääntely ja peitsaaminen eivät näyttäneet saksanpaimenkoirilla liittyvän lonkkadysplasiaan. Myös HCPI oli korkeampi huonon lonkkakuvaustuloksen saaneilla koirilla, mikä kertoo niiden kärsivän useammin kroonisesta kivusta. Lonkkakuvaustuloksen lisäksi HCPI:iin vaikuttivat koiran ikä, paino, osa käytetyistä hoidoista sekä selkä-, polvi- ja kyynärviat. Saksanpaimenkoiran eri linjojen välillä ei ollut eroa lonkkadysplasian esiintyvyydessä, mutta sen sijaan käyttölinjaisuus näytti suojaavan lonkkadysplasiaan liittyviltä kliinisiltä oireilta näyttelylinjaisiin verrattuna.
  • Markkola, Anne (2001)
    Tutkimuksessa pyrittiin löytämään menetelmiä, joilla voitaisiin luotettavasti mitata koiran nivelrikon aiheuttamaa kroonista kipua ja arvioida kipuhoidon tarvetta. Tutkimukseen valittiin 41 koiraa, joilla oli diagnosoitu lonkkaniveldysplasiasta johtuva nivelrikko ja jotka omistajien mukaan kärsivät kroonisesta kivusta. Koirista otettiin verinäytteet, joista analysoitiin adrenaliinin, noradrenaliinin, ß-endorfiinin, antidiureettisen hormonin ja kortisolin pitoisuudet. Kaksi riippumatonta eläinlääkäriä arvioi videolta koirien liikkumista. Koirien lonkat röntgenkuvattiin. Omistajat täyttivät kyselykaavakkeen koiransa käyttäytymisestä ja mielialasta sekä arvioivat koiransa kokemaa kipua ja liikkumisvaikeuksia visuaalisilla analogiasteikoilla (kipujana ja liikkumisjana).Verinäytteiden kontrolliryhmään valittiin 22 omistajien mukaan tervettä koiraa, joilla ei ollut minkäänlaisia kipuoireita. Kyselykaavakkeen ja visuaalisten analogiasteikoiden kontrolliryhmään valittiin 24 omistajien mukaan tervettä ja kivutonta koiraa. Eläinlääkäreiden ja omistajien arviot koirien liikkumisvaikeuksista korreloivat positiivisesti keskenään. Adrenaliinin, antidiureettisen hormonin ja kortisolin pitoisuudet plasmassa olivat korkeammat kroonisesta kivusta kärsivillä koirilla kuin kontrolliryhmän koirilla, kun taas ß-endorfiinipitoisuudet olivat korkeammat kontrolliryhmän koirilla. Koirilla, joilla röntgenologisesti todettiin luupiikkimuodostusta tai irtopaloja lonkkanivelessä, oli omistajien arvioiden mukaan enemmän liikkumisvaikeuksia mutta ei kipuja kuin muilla tutkimukseen osallistuneilla koirilla. Yksittäisen koirapotilaan kroonisen kivun arvioimiseen ei tutkimuksessa löydetty luotettavaa hormonaalista tai röntgenologista muuttujaa. Tutkimuksen perusteella eläinlääkäri voi arvioida koiran kipua ainoastaan sen liikkumisen perusteella. Omistajan kertomuksella koiran käyttäytymisestä, mielialasta ja liikkumisesta on nivelrikkokivun arvioinnissa keskeinen rooli. Eläinlääkärin tulee tulkita omistajan kertomuksesta koiran kivusta kertovat seikat ja/tai opettaa omistaja tulkitsemaan koiransa kipuoireita.
  • Niemi, Kirsi (Helsingfors universitet, 2009)
    One idea to optimize the level of congestion is to use the price mechanism to make road users more aware of the congestion externality they impose on others. The basic idea is that motorists should pay for the additional congestion they create when entering a congested road. The economic approach to analyzing congestion policies and traffic congestion can be summarized as viewing a congested road as a distorted market on which travelers demand a service (the use of the road), and supply is defined by the capacity of the road(s). A distortion exists because travel time losses from congestion constitute an externality, individual users typically ignore the implied travel time losses for others and consider only their own travel times when deciding whether or when to use the road. The situation where all prices are equal to marginal cost is often called as a „first-best? situation in the economic literature. The equality between prices and marginal costs secures equality between marginal benefits and marginal costs. For the theorem to hold first-best congestion pricing must be applied on all links of the road network. However, many practical policy proposals foresee implementation of prices on only a limited number of road links. Examples include toll cordons, pay-lanes, and congestion charging schemes in the cities as in London and Stockholm. The purpose of this study is to evaluate how well the congestion charging schemes of London and Stockholm are suited to Helsinki region. The issue of congestion charging is current also in Helsinki region because traffic jams will get worse in the future. The congestion charge is expected to „„reduce congestion, increase accessibility and improve the environment”. Some other measures which are in use today could achieve a similar impact, but not as cost-effectively as congestion charging. This study also evaluates three different congestion charging models (the single-cordon model, the multiple-cordon model and the zone model) that were presented in The Helsinki Region Congestion Charging Study by the Ministry of Transport and Communications (30/2009). According to the Ministry of Transport and Communications the socio-economic benefits of congestion charging would exceed the costs.
  • Hyytinen, Heidi (Helsingin yliopisto, 2015)
    The central purpose of this doctoral thesis has been to deepen our understanding of the nature of critical thinking by combining theoretical, empirical and methodological perspectives. The concept of critical thinking has a central role both in research on the philosophy of education and in empirical research on learning and teaching in higher education. Although it is true that the philosophical and empirical analyses of critical thinking and knowledge differ fundamentally, the present thesis argues that there are shared concerns between these two scholarly traditions. The thesis consists of four studies, each of which approached this aim from different viewpoints. The methods involved both a philosophical approach and an empirical multi-method approach. The dialogue between the empirical and theoretical analyses offers new insights into conceptualising critical thinking and its prerequisites and extends our understanding of variations in critical thinking. Based on the theoretical findings of these studies, I argue that normative elements (how things ought to be) and descriptive elements (how things are) are fundamentally intertwined in the research on critical thinking. Therefore, educational research on critical thinking requires both philosophical and empirical approaches and also dialogue between these two approaches. The theoretical part of the doctoral thesis further demonstrates how philosophical research can contribute to the normative elements of the prevailing empirically-based theorisation of critical thinking, particularly by revealing some conceptual inconsistencies within this framework. The research further introduces the notion of fallibilism (human knowledge is uncertain) as a way out. Epistemological fallibilism fits the presumption of critical thinking better than relativism from the theoretical and pedagogical points of view. The empirical results revealed variation in (a) students skills and dispositions to think critically, (b) students ability to adapt their thinking and performance flexibility, (c) the nature of knowledge students consider to be relevant, (d) the knowledge that students use in problem-solving situations, as well as (e) the way students process that knowledge. Based on these variations two profiles were identified: (1) superficial processing or (2) thorough processing. Superficial processing students reproduced information in the problem-solving situation. These students did not analyse, interpret, evaluate or synthesise knowledge, and their reasoning was very poor. They palmed off justification for knowing on authorities and testimonies. In contrast to previous research, the results show that these students did not share the belief that knowledge is absolutely certain or unquestionable. Nor did these students share the view that beliefs accurately represent or correspond to reality. These students emphasised the uncertain nature of knowledge. The thorough processing students, by contrast, evaluated the quality of the information and considered its premises, as well as the implications of different conclusions. They weighed different options, analysed connections between claims, connected related ideas and gave mainly well-reasoned explanations and convincing arguments. The findings also show that the thorough processing students believed knowledge to be tentative and fallible. However, these students did not argue that all knowledge is constructed by human beings nor did they believe that all interpretations, theories and beliefs are equally right. They thus avoided slipping into relativism. The results revealed that both deeply superficial and thorough processing thinking entails problems if it is connected to an inability to adjust thinking or actions to the demands of the task. This thesis also identified several methodological challenges in assessing critical thinking. The results show that different performance-based critical thinking tests could give completely opposite pictures of a student s abilities. The results further indicated that the group-level analyses could overrun the rich variations in test performance that occurred among individual students. Additionally, the thesis reminds us that the theoretical framework has a great influence on how data are analysed and interpreted. Finally, the thesis argues that one assessment or analysis method is not enough to evaluate the complex cognitive processes of critical thinking. Instead of a sole focus on empirical or theoretical elements, more communication between the theoretical, empirical and methodological perspectives is required to deepen the understanding of critical thinking among students of higher education. Keywords: critical thinking, performance assessment, epistemology, fallibilism, relativism
  • Martin, Alice (Helsingfors universitet, 2008)
    This thesis in the field of translation studies focusses on the role of norms in the work of a literary translator. Norms are seen as guidelines for the translator; they also reflect the way the target audience either accepts or rejects the translation. Thus they are of an intersubjective nature. The theoretical background of the study is based on the views on norms of Andrew Chesterman and Gideon Toury. The writer makes use of her own editing and publishing experience, as well as her experience in translating Lewis Carroll, considering these in respect to theoretical views of norms and vice versa. The aim is also to bring to light some of the tacit knowledge related to translating, editing and publishing in Finland. The study has three angles. First, the writer introduces the norms of Finnish literary translation as gathered from her own working experience. The sources from which these norms arise and which affect them are briefly described. Six central translation norms emerge; they are described and exemplified through cases of Carroll translation. Secondly, a small-scale questionnaire study is presented. This was carried out in order to sound the normative views of other translators and to limit the role of subjectivity. The views of the informants largely support the set of norms presented by the writer, although the norms of quotability and harmony between translation and illustration do not arise. Instead, the answers give rise to a seventh, ethical norm, which is labelled the norm of integrity. Thirdly, there is a brief presentation of Lewis Carroll, his Alice books and their translation history in Finland. The retranslation hypothesis and the motives of retranslation are considered in the light of the work of Outi Paloposki and Kaisa Koskinen. The final part of the thesis plunges into actual translation work. It includes one and a half chapters of Through the Looking-Glass (Alicen seikkailut peilintakamaassa) as translated into Finnish by the writer. The translation commentary first discusses a number of recurring and general translation points; the running commentary then analyses 77 individual translation solutions and their justifications. The writer uses introspection as a way of reflecting on her own translation process, its decisive points and the role of norms therein. Keywords: Translation studies, Carroll, norms
  • Heinonen, Eeva (2000)
  • Leino, Esko (1971)