Toiminnanohjauksen arviointi ikääntyneillä aivoinfarktipotilailla : ennustearvo myöhempään toimintakykyyn

Objective: Cognitive impairment as a consequence of a stroke is common. Advanced age increases the frequency of poststroke cognitive deficits. Particularly executive dysfunction has an important role in poststroke disability. Complex by their nature, however, measuring executive function is difficult. The Hayling test, Design fluency task and Questioning task are some of the less common assessment methods of executive functions, and thus, they are not widely studied. The aim of the present study was to assess the feasibility of these tests in elderly patients three months after ischemic stroke. Performances on these tests were compared to conventional assessment methods of executive functions, and their predictive value on functional disability in follow-up was examined. Methods: 62 stroke patients and 39 control subjects, aged 55-85, underwent comprehensive neurological and neuropsychological examinations three months after the index stroke. Executive functions were studied with the Trail Making test, Stroop test, Wisconsin card sorting test, Verbal fluency task as well as with the Hayling test, Design fluency task and Questioning task. The modified Rankin Scale (mRS) and the Lawton's Instrumental activities of daily living -scale (IADL) were used to assess functional abilities at three months, and the mRS after 15 months follow-up. Results and conclusions: The Hayling test and Questioning task and the four conventional tests of executive functions differentiated stroke patients from healthy controls. Furthermore, the executive functions predicted functional dependence in the elderly stroke patients. The Hayling test was most consistently associated with functional disability as evaluated with mRS and IADL three months after the stroke, and predicted functional disability as evaluated with mRS at 15 months follow-up. Of all executive functions tests, the Hayling test proved to be the most constant predictor of functional abilities in elderly stroke patients. However, there is no golden standard for measuring executive functions, and in the future, more sensitive methods are needed. Nevertheless, the present study confirms the importance of assessing executive functions in clinical populations, when predicting functional disability even in the long-term.Tavoitteet: Aivoinfarktin seurauksena vaikeudet kognition eri osa-alueilla ovat suhteellisen tavallisia ja ne yleistyvät iän myötä. Erityisesti toiminnanohjaustoimintojen tiedetään vaikuttavan aivoinfarktin jälkeiseen toimintakykyyn. Toiminnanohjauksen kliininen arviointi on kuitenkin haastavaa. Hayling-testi, Kuviosujuvuustehtävä ja Kysymystehtävä eivät ole yleistyneet kliiniseen käyttöön toiminnanohjauksen arvioinnissa ja aiempien niitä koskevien tutkimusten määrä on varsin rajallinen. Tässä tutkimuksessa tutkittiin näiden tehtävien toimivuutta ikääntyneillä aivoinfarktipotilailla kolmen kuukauden kuluttua aivoinfarktista. Suoriutumista näissä vakiintumattomissa tehtävissä verrattiin suoriutumiseen perinteisissä toiminnanohjauksen arviointiin käytetyissä menetelmissä. Lisäksi tutkittiin, ennustaako näissä tehtävissä suoriutuminen ikääntyneiden aivoinfarktipotilaiden toimintakykyä seuranta-aikana. Menetelmät: 62 aivoinfarktipotilasta ja 39 tervettä henkilöä, iältään 55–85 vuotiaita, tutkittiin laajasti sekä neurologisesti että neuropsykologisesti, kun aivoinfarktista oli kuulunut kolme kuukautta. Toiminnanohjausta arvioitiin Trail Making-testillä, Stroop-testillä, Wisconsinin korttien lajittelutehtävällä, Sanasujuvuustehtävällä sekä Hayling-testillä, Kuviosujuvuustehtävällä ja Kysymystehtävällä. Itsenäistä toimintakykyä arjen perustoiminnoissa tutkittiin modified Rankin Scale -kyselylomakkeella (mRS) ja itsenäistä toimintakykyä monimutkaisemmissa toiminnoissa Instrumental activities of daily living -kyselylomakkeella (IADL). Lisäksi 15 kuukauden seurannan jälkeen toimintakykyä arvioitiin mRS-kyselylomakkeella. Tulokset ja johtopäätökset: Perinteisten toiminnanohjauksen arviointimenetelmien lisäksi Hayling-testi ja Kysymystehtävä erottelivat aivoinfarktipotilaita terveistä verrokeista. Lisäksi aineistossamme toiminnanohjaus ennusti myöhempää toimintakykyä. Hayling-testi oli johdonmukaisesti yhteydessä mRS- ja IADL-kyselylomakkeilla tutkittuun toimintakykyyn kolmen kuukauden kohdalla ja ennusti mRS-kyselyllä tutkittua toimintakykyä 15 kuukauden seurannassa. Hayling-testi osoittautui pysyvimmäksi arviointimenetelmäksi ikääntyneiden aivoinfarktipotilaiden toimintakyvyn ennustajana. Toiminnanohjauksen tarkka arviointi on haastavaa ja tulevaisuudessa tarvitaan vielä tarkempia ja herkempiä menetelmiä sen mittaamiseen. Tämä tutkimus vahvistaa toiminnanohjauksen arvioinnin tärkeyden, kun halutaan ennustaa tulevaisuuden toimintakykyä

Yhteisön turvallisista kahleista vaikeaan vapauteen : Tutkimus uskonnollisesta ryhmästä irtautumisesta

Only abstract. Paper copies of master’s theses are listed in the Helka database (http://www.helsinki.fi/helka). Electronic copies of master’s theses are either available as open access or only on thesis terminals in the Helsinki University Library.Vain tiivistelmä. Sidottujen gradujen saatavuuden voit tarkistaa Helka-tietokannasta (http://www.helsinki.fi/helka). Digitaaliset gradut voivat olla luettavissa avoimesti verkossa tai rajoitetusti kirjaston opinnäytekioskeilla.Endast sammandrag. Inbundna avhandlingar kan sökas i Helka-databasen (http://www.helsinki.fi/helka). Elektroniska kopior av avhandlingar finns antingen öppet på nätet eller endast tillgängliga i bibliotekets avhandlingsterminaler.Tutkimusongelmani on uskonnollisesta ryhmästä irtautuminen. Kiinnostukseni kohteena on, mikä saa ihmisen jättämään uskonnollisen ryhmänsä ja hylkäämään aiemmin totuutena pitämänsä opin, millainen tämä prosessi on ja mitä se merkitsee irtautuneelle. Tarkoitukseni on kuvata ja ymmärtää tätä prosessia ja sen seurauksia prosessin kokeneiden kertomusten avulla. Löytyykö kertomuksista jotain yhteistä, mahdollista "uskonnollisesta ryhmästä irtautumisen - mallia" Aineistona käytin eri uskonnollisista ryhmistä irtautuneiden henkilöiden haastatteluja. Haastatteluissa käytin ns. narratiivista menetelmää; haastateltavat kertoivat itse "uskonnollisen elämäkertansa" Analyysissä keskityin haastateltavan puheen sisältöön, siihen mitä hän kertoi. Sisällönanalyysin keinoin etsin haastatteluista esiin nousevia teemoja, sekä mahdollista mallia, jonka mukaan irtautuminen yhteisöstä tapahtui. Taustana tutkimukselle tarkastelen uskonnon merkityksen muuttumista yhteiskunnan muuttuessa. Uskonnon merkitys yhteiskunnassa ja yksilöiden elämää ohjaavana tekijänä on vaihdellut eri aikoina. Traditionaalisessa yhteiskunnassa uskonnon merkitys oli keskeinen, modernissa sen merkitys väheni ja tilalle tuli rationalismi. Maailmaa alettiin selittää turvautumatta jumalallisiin voimiin. Modernisaation edetessä uskonnon merkityksen ennustettiin vähenevän ja sekularisaation vahvistuvan. Näin ei kuitenkaan ole käynyt, vaan uusia uskonnollisia liikkeitä on syntynyt runsaasti. Liikkeiden määrän kasvaessa myös liikkeistä eroaminen on yleistynyt. Tarkastelenkin uskonnollista yhteisöä sellaisena traditionaalisena yhteisönä, joka tarjoaa jäsenilleen jatkuvuutta ja turvaa modernissa/postmodernissa, alati muuttuvassa maailmassa. Yhteisö tarjoaa normeja ja ohjeita siitä, kuinka elämä tulee elää. Haastateltavat olivat hyvin vahvasti sitoutuneet yhteisöihinsä. Yhteisöön sitouduttiin sekä asenne- että käyttäytymisen tasoilla. Jotta voidaan puhua lopullisesta irtautumisesta, on sen tapahduttava molemmilla tasoilla. Aineiston perusteella irtautumisprosessista voidaan erottaa neljä erillistä kronologisesti etenevää vaihetta: alkusysäys, epävarmuuden aika, käännekohta ja lopullinen irtautuminen. Irtautumisprosessi oli vaikea. Yhteisöstä oli usein vaikea irrottautua siitä huolimatta, että usko sen oppeihin oli mennyt. Irtautumisen jälkeen maailma ja oma itse oli hahmotettava uudesta näkökulmasta, sillä enää ei voitu nojautua yhteisön määrittelemiin uskomuksiin

Women in the chamber : the influence of the Strindbergian theatrical legacy on Danish dogma films

In 1995 Lars von Trier and Thomas Vinterberg wrote the Dogma Manifesto, a document that brought worldwide attention to Danish cinema through the Dogma films made according to the manifesto's rules. While the Danish Dogma films have been widely regarded as constituting the latest new wave movement, the films have not been studied in relation to the Scandinavian artistic and cultural traditions. Moreover, the actor's role in creating this new kind of cinema has also been ignored. By analysing the first six Danish Dogma films, this thesis explores the influence of the Strindbergian theatrical legacy on the Dogma filmmakers' approach to performance. The focus is on Dogma's representation of women and the performance of woman actors found in the films. First, the thesis compares the Dogma manifesto with Strindberg's manifesto of naturalism and studies the impact of these manifestos on redefining the female actor's craft. Second, the thesis argues that the Dogma films continue the Strindbergian chamber drama tradition; the use of authentic space is studied on a formal and thematic level, along with its influence on the creation of authentic performances. The discussion of chamber dramas segues into an examination of hysteria as a dramatic tool to analyse women's rebellion in a domestic space. Hysteria is also juxtaposed with another non-verbal dramatic means of expression, which is the use of silence in the women actors' performances. The discussion of dynamic use of silence and speech as well as the representation of words as an inauthentic means of expression is inseparable from an analysis of women, modernism and the use of close up capturing the actor's silent face. Finally, the interrogation of the use of words that hide ugly realities leads to an examination of construction of a hell-on-earth, transcendental experience within the realistic framework, the conflict between spiritual minds and sexual bodies. The thesis argues that the Dogma actors' performances of excess and theatricality mark a shift in the Scandinavian performance tradition: Moreover, it illuminates the importance of contextualizing women actors' performances culturally, nationally and historically

DOGMAtic iconoclasm : performative aspects of realism and excess in Lars von Trier's Breaking the waves and The idiots

This study is an exploration of several aspects of performance in Lars von Trier's Breaking the Waves and The Idiots , focusing especially on the seemingly oppositional concepts of realism and excess. The emphasis here is on the new form of filmmaking that Lars von Trier, together with Thomas Vinterberg, initiated by writing the Dogma Manifesto as a set of filmmaking "rules" in 1995. A close analysis of Emily Watson and Bodil Jorgensen's performances in these two films illuminates the filmmaker's unique approach to performance and also demonstrates the strong impact this new kind of a cinema had on the actor's craft. Through an investigation of the use of performance, von Trier's filmmaking will be placed within the context of Scandinavian theatrical and filmic traditions. The study examines how von Trier's films show the prominent influence of the late nineteenth century Scandinavian theatrical tradition that is most fully embodied by Ibsen and Strindberg; this obvious influence aligns von Trier with other Scandinavian filmmakers like Dreyer and Bergman, whose work also shows the influence of modernist theatre. Von Trier's films, especially through the use of performance, redefine the traditional Scandinavian approach to cinema. This analysis of performance leads to a consideration of the significance of contextualizing performance culturally, historically and socially

Arteriovenous Malformations of the Posterior Fossa : Focus on Surgically Treated Patients Presenting with Hemorrhage

BACKGROUND: Arteriovenous malformations (AVMs) of the posterior fossa are demanding lesions that often present with rupture. Studies including outcome analyses in surgically operated patients with ruptured infratentorial AVMs are scarce. Certain anatomic and demographic features have shown associations with postoperative outcomes. METHODS: Eighty-six patients with infratentorial AVM were collected from our AVM database. Fifty-four patients were admitted from 1990 onward, and their demographic, lesion, and treatment characteristics were analyzed. The cohort was further refined to 38 consecutive patients with surgically treated ruptured infratentorial AVM admitted to our center between 1990 and 2014, and statistical analyses of factors influencing outcomes were conducted. RESULTS: Twenty-seven patients (69%) had a favorable outcome at early follow-up and 24 (67%) had a favorable outcome at final follow-up. Factors associated with poor outcome in early recovery on univariate analyses were deep venous drainage of the lesion (odds ratio (OR 5.3; P = 0.037) and high Hunt & Hess score (P = 0.003). In the multivariate model, independent predictors for poor outcome were deep venous drainage (OR, 14.5; P = 0.010) and older age at admission (OR, 1.06; P = 0.028). The sole independent predictor for poor outcome at last follow-up was deep venous drainage (OR, 5.00; P = 0.046). The total follow-up time was 370 person-years. CONCLUSIONS: AVMs of the posterior fossa usually present with rupture and thus require prompt clinical treatment. The majority of surgically treated patients recover favorably. Our data show that venous drainage patterns have the greatest influence on the patient's postoperative condition. Other influencing factors include the severity of hemorrhage and patient age at admission.Peer reviewe

Anticommensal Responses Are Associated with Regulatory T Cell Defect in Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy Patients

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a monogenic autoimmune disease caused by mutations in the AIRE gene. Although mainly an endocrine disease, a substantial fraction of patients have gastrointestinal manifestations. In this study, we have examined the role of anticommensal responses and their regulation. APECED patients had increased levels of Abs against Saccharomyces cerevisiae (p <0.0001) and against several species of commensal gut bacteria, but not against species predominantly associated with other locations. The anticommensal Ab levels did not correlate with gastrointestinal autoantibodies, neutralizing anti-IL-17 or -IL-22 Abs, or gastrointestinal symptoms, although scarcity of the available clinical data suggests that further study is required. However, the anti-S. cerevisiae Ab levels showed a significant inverse correlation with FOXP3 expression levels in regulatory T cells (Treg), previously shown to be dysfunctional in APECED. The correlation was strongest in the activated CD45RO(+) population (rho = 20.706; p <0.01). APECED patients also had decreased numbers of FOXP3(+) cells in gut biopsies. These results show that APECED patients develop early and sustained responses to gut microbial Ags in a pattern reminiscent of Crohn's disease. This abnormal immune recognition of gut commensals is linked to a systemic Treg defect, which is also reflected as a local decrease of gut-associated Treg. To our knowledge, these data are the first to show dysregulated responses to non-self commensal Ags in APECED and indicate that AIRE contributes to the regulation of gut homeostasis, at least indirectly. The data also raise the possibility of persistent microbial stimulation as a contributing factor in the pathogenesis of APECED.Peer reviewe

Multiple sclerosis in Finland 2018-Data from the national register

Objectives Finland is a high-risk multiple sclerosis (MS) region, but a national MS register has not existed until 2014. In this paper, we present the Finnish MS register variables and data collected by 31 December 2018. Materials and Methods Numbers and data counts of MS patients in the register (ICD-10 code G35) are presented. The disease types and proportion of patients receiving disease-modifying treatments (DMTs) were analysed in five hospital districts with most complete data sets. MS prevalence in Finland was estimated using administrative hospital discharge data as an additional resource. Results There were a total of 8722 MS patients in the Finnish MS register by 31 December 2018 (71.5% females). Mean age at MS diagnosis was 38.7 years and peak prevalence was at age 50-54 years. Disease course was relapsing remitting (RRMS) in 66.7%, secondary progressive (SPMS) in 13.5%, and primary progressive (PPMS) in 7.9% of the 5365 MS patients in the selected districts with most complete data. A total of 66.0% of RRMS patients, 19.6% of SPMS patients and 9.9% of PPMS patients were receiving DMTs. By combining MS register data with databases of those hospitals that had not joined the register, the nationwide prevalence estimate was between 10 and 11 thousand patients (corresponding to crude prevalence 180-200/100 000). Conclusions The Finnish MS register is currently used in 15/21 Finnish hospital districts. By register integration into the electronic patient files, the coverage of the register has increased to approximately 80% of the estimated Finnish MS population.Peer reviewe

Synergistic associations of cognitive and motor impairments with functional outcome in covert cerebral small vessel disease

Background Cognitive and motor impairments are the key clinical manifestations of cerebral small vessel disease (SVD), but their combined effects on functional outcome have not been elucidated. This study investigated the interactions and mediating effects of cognitive and motor functions on instrumental activities of daily living (IADL) and quality of life in older individuals with various degrees of white matter hyperintensities (WMH). Methods Participants of the Helsinki Small Vessel Disease Study (n = 152) were assessed according to an extensive clinical, physical, neuropsychological and MRI protocol. Volumes of WMH and gray matter (GM) were obtained with automated segmentation. Results Cognitive (global cognition, executive functions, processing speed, memory) and motor functions (gait speed, single-leg stance, timed up-and-go) had strong interrelations with each other, and they were significantly associated with IADL, quality of life as well as WMH and GM volumes. A consistent pattern on significant interactions between cognitive and motor functions was found on informant-evaluated IADL, but not on self-evaluated quality of life. The association of WMH volume with IADL was mediated by global cognition, whereas the association of GM volume with IADL was mediated by global cognition and timed up-and-go performance. Conclusion The results highlight the complex interplay and synergism between motor and cognitive abilities on functional outcome in SVD. The combined effect of motor and cognitive disturbances on IADL is likely to be greater than their individual effects. Patients with both impairments are at disproportionate risk for poor outcome. WMH and brain atrophy contribute to disability through cognitive and motor impairment.Peer reviewe