Sydämentahdistimet - millaisia, keille ja mitä kliinikon tulee huomioida?

Vertaisarvioitu. English summary.Tahdistinlaitteita käytetään sydämen hidaslyöntisyyden, kammioperäisten rytmihäiriöiden ja sydämen vaikean vajaatoiminnan hoidossa. Tahdistin ohjelmoidaan yksilöllisesti, jotta hoito olisi tehokasta ja turvallista. Hidaslyöntisyyden tahdistuksessa tavoitteena on korjata sydämen johtoratavaurion aiheuttama haitta ja palauttaa sydämen normaali sähköinen aktivaatiojärjestys välttäen aiheetonta kammiotahdistusta. Rytmihäiriötahdistin pysäyttää pitkäkestoisen kammiotakykardian tai kammiovärinän. Vajaatoiminnan tahdistinhoidossa pyritään parantamaan vasemman kammion toimintaa optimoimalla vasemman kammion täyttö sekä yhtäaikaistamalla kammioseinämien supistus biventrikulaarisella tahdistuksella. Osassa vajaatoimintatahdistimista on mahdollisuus myös rytmihäiriötahdistinhoitoon. Hisin kimpun tahdistus mahdollistaa fysiologisen kammioiden aktivaation johtoratajärjestelmän kautta ilman oikean kammion tahdistukseen liittyviä haittoja. Johdottomalla tahdistimella ja ihonalaisella rytmihäiriötahdistimella voidaan välttää tahdistinhoitoon liittyviä johto-ongelmia ja infektiokomplikaatioita.Peer reviewe

The Rab8 GTPase selectively regulates AP-1B–dependent basolateral transport in polarized Madin-Darby canine kidney cells

The AP-1B clathrin adaptor complex plays a key role in the recognition and intracellular transport of many membrane proteins destined for the basolateral surface of epithelial cells. However, little is known about other components that act in conjunction with AP-1B. We found that the Rab8 GTPase is one such component. Expression of a constitutively activated GTP hydrolysis mutant selectively inhibited basolateral (but not apical) transport of newly synthesized membrane proteins. Moreover, the effects were limited to AP-1B–dependent basolateral cargo; basolateral transport of proteins containing dileucine targeting motifs that do not interact with AP-1B were targeted normally despite overexpression of mutant Rab8. Similar results were obtained for a dominant-negative allele of the Rho GTPase Cdc42, previously implicated in basolateral transport but now shown to be selective for the AP-1B pathway. Rab8-GFP was localized to membranes in the TGN-recycling endosome, together with AP-1B complexes and the closely related but ubiquitously expressed AP-1A complex. However, expression of active Rab8 caused a selective dissociation of AP-1B complexes, reflecting the specificity of Rab8 for AP-1B–dependent transport

EuroEco (European Health Economic Trial on Home Monitoring in ICD Patients): a provider perspective in five European countries on costs and net financial impact of follow-up with or without remote monitoring

Aim: Remote follow-up (FU) of implantable cardiac defibrillators (ICDs) allows for fewer in-office visits in combination with earlier detection of relevant findings. Its implementation requires investment and reorganization of care. Providers (physicians or hospitals) are unsure about the financial impact. The primary end-point of this randomized prospective multicentre health economic trial was the total FU-related cost for providers, comparing Home Monitoring facilitated FU (HM ON) to regular in-office FU (HM OFF) during the first 2 years after ICD implantation. Also the net financial impact on providers (taking national reimbursement into account) and costs from a healthcare payer perspective were evaluated. Methods and results: Atotal of 312 patients with VVI-or DDD-ICD implants from 17 centres in six EU countries were randomised to HMON or OFF, of which 303 were eligible for data analysis. For all contacts (in-office, calendar-or alert-triggered web-based review, discussions, calls) time-expenditure was tracked. Country-specific cost parameters were used to convert resource use into monetary values. Remote FU equipment itself was not included in the cost calculations. Given only two patients from Finland (one in each group) a monetary valuation analysis was not performed for Finland. Average age was 62.4 +/- 13.1 years, 81% were male, 39% received a DDD system, and 51% had a prophylactic ICD. Resource use with HM ON was clearly different: less FU visits (3.79 +/- 1.67 vs. 5.53 +/- 2.32; P < 0.001) despite a small increase of unscheduled visits (0.95 +/- 1.50 vs. 0.62 +/- 1.25; P < 0.005), more non-office-based contacts (1.95+3.29 vs. 1.01 +/- 2.64; P < 0.001), more Internet sessions (11.02 +/- 15.28 vs. 0.06 +/- 0.31; P < 0.001) and more in-clinic discussions (1.84 +/- 4.20 vs. 1.28 +/- 2.92; P < 0.03), but with numerically fewer hospitalizations (0.67 +/- 1.18 vs. 0.85 +/- 1.43, P = 0.23) and shorter length-of-stay (6.31 +/- 15.5 vs. 8.26 +/- 18.6; P = 0.27), although not significant. For the whole study population, the total FU cost for providers was not different for HM ON vs. OFF [mean (95% CI): (sic)204 169-238) vs. (sic)213 (182-243); range for difference ((sic)-36 to 54), NS]. From a payer perspective, FU-related costs were similar while the total cost per patient (including other physician visits, examinations, and hospitalizations) was numerically (but not significantly) lower. There was no difference in the net financial impact on providers [profit of (sic)408 (327-489) vs. (sic)400 (345-455); range for difference ((sic)-104 to 88), NS], but there was heterogeneity among countries, with less profit for providers in the absence of specific remote FU reimbursement (Belgium, Spain, and the Netherlands) and maintained or increased profit in cases where such reimbursement exists (Germany and UK). Quality of life (SF-36) was not different. Conclusion: For all the patients as a whole, FU-related costs for providers are not different for remote FU vs. purely in-office FU, despite reorganized care. However, disparity in the impact on provider budget among different countries illustrates the need for proper reimbursement to ensure effective remote FU implementation

Common Inflammation-Related Candidate Gene Variants and Acute Kidney Injury in 2647 Critically Ill Finnish Patients

Acute kidney injury (AKI) is a syndrome with high incidence among the critically ill. Because the clinical variables and currently used biomarkers have failed to predict the individual susceptibility to AKI, candidate gene variants for the trait have been studied. Studies about genetic predisposition to AKI have been mainly underpowered and of moderate quality. We report the association study of 27 genetic variants in a cohort of Finnish critically ill patients, focusing on the replication of associations detected with variants in genes related to inflammation, cell survival, or circulation. In this prospective, observational Finnish Acute Kidney Injury (FINNAKI) study, 2647 patients without chronic kidney disease were genotyped. We defined AKI according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. We compared severe AKI (Stages 2 and 3, n = 625) to controls (Stage 0, n = 1582). For genotyping we used iPLEX(TM) Assay (Agena Bioscience). We performed the association analyses with PLINK software, using an additive genetic model in logistic regression. Despite the numerous, although contradictory, studies about association between polymorphisms rs1800629 in TNFA and rs1800896 in IL10 and AKI, we found no association (odds ratios 1.06 (95% CI 0.89-1.28, p = 0.51) and 0.92 (95% CI 0.80-1.05, p = 0.20), respectively). Adjusting for confounders did not change the results. To conclude, we could not confirm the associations reported in previous studies in a cohort of critically ill patients.Peer reviewe

Heme oxygenase-1 repeat polymorphism in septic acute kidney injury

Acute kidney injury (AKI) is a syndrome that frequently affects the critically ill. Recently, an increased number of dinucleotide repeats in the HMOX1 gene were reported to associate with development of AKI in cardiac surgery. We aimed to test the replicability of this finding in a Finnish cohort of critically ill septic patients. This multicenter study was part of the national FINNAKI study. We genotyped 300 patients with severe AKI (KDIGO 2 or 3) and 353 controls without AKI (KDIGO 0) for the guanine-thymine (GTn) repeat in the promoter region of the HMOX1 gene. The allele calling was based on the number of repeats, the cut off being 27 repeats in the S-L (short to long) classification, and 27 and 34 repeats for the S-M-L2 (short to medium to very long) classification. The plasma concentrations of heme oxygenase-1 (HO-1) enzyme were measured on admission. The allele distribution in our patients was similar to that published previously, with peaks at 23 and 30 repeats. The S-allele increases AKI risk. An adjusted OR was 1.30 for each S-allele in an additive genetic model (95% CI 1.01-1.66; p = 0.041). Alleles with a repeat number greater than 34 were significantly associated with lower HO-1 concentration (p<0.001). In septic patients, we report an association between a short repeat in HMOX1 and AKI risk

Kohti Turvallista Johtamista

Tämän toiminnallisen opinnäytetyön tarkoituksena oli kehittää yhtenäiset turvallisuutta lisäävät toimintatavat ja selkeyttää esimiesten työsuojeluroolit ravintola S:lle. Ravintola-alalla tietyt turvallisuusriskit ovat läsnä jokapäiväisessä toiminnassa, kuten tulipalo, tapaturmat, ryöstöt sekä uhkaavat asiakkaat. Luomalla uusia käytänteitä henkilökunnalla on konkreettiset valmiudet toimia näiden tilanteiden varalta. Opinnäytetyön tavoitteena on kehittää ravintola S:n työkäytänteitä, tuottaa työohjeita turvalliseen johtamiseen ja lisätä tietoisuutta mahdollisiin turvallisuusriskeihin ravintolatyössä. Muodostuneista ideoista tarjotaan toimeksiantajille havainnollisia työkaluja jatkossa käytettäväksi. Opinnäytetyön viitekehyksenä on työturvallisuuden kehittäminen. Siinä on avattu kirjallisessa muodossa ravintola-alan yleisimmät turvallisuusriskit, työsuojelun ja työhyvinvoinnin osa-alueet. Turvallisuusjohtamisessa korostuu ylimmän liikkeenjohdon rooli turvallisuudesta vastaavana ja turvallisuutta ohjaavana tekijänä. Johdon tehtävänä on asettaa yrityksensä turvallisuustoiminnalle tavoitteet, tarjota resurssit niiden saavuttamiselle ja valvoa niiden toteutusta. Johdolla on myös merkittävä rooli turvallisuuden lisäämisessä ja se voi omalla toiminnallaan edistää turvallisempia työtapoja ja myönteistä muutosta yrityksen turvallisuuteen liittyvässä toiminnassa. Henkilökunnalle järjestettiin alkukartoituskysely, jotta saatiin tietoa nykytilanteesta ja mitä tarpeita henkilökunnalla oli turvallisuuteen liittyen. Tulosten perusteella ravintolan henkilökunnalle järjestettiin ensiapukoulutus ja palokoulutus. Lopuksi prosessi nivottiin yhdeksi kokonaisuudeksi. Valmis opinnäytetyö kehitysehdotuksineen luovutettiin ravintola S:n omistajille. Opinnäytetyön tuloksena syntyi uusi toimintatapa, jolla voidaan parantaa työyhteisön työturvallisuutta. Työssä nostetaan esille turvallisuuden tärkeys ja johdon esimerkki johtaa työtä turvallisesti. Työturvallisuus on osa työtä, työtapoja ja työympäristöä. Edellytyksiä hyville työsuorituksille ja työn tuloksille luodaan, kun nämä elementit ovat turvallisia ja terveellisiä. Tasokkaalla työturvallisuussuunnitelmalla voidaan edistää henkilökunnan tyytyväisyyttä, työn sujuvuutta ja yhteishenkeä. Opinnäytetyö onnistui tavoitteessaan tuottaa uusi toimintamalli yritykselle turvallisuuteen liittyen. Opinnäytetyön toimeksiantajan arvioinnin perusteella palo- ja hätäensiapukoulutus tullaan järjestämään vuosittain. Työntekijät olivat myös tyytyväisiä koulutuksen järjestämiseen.The purpose of this functional thesis was to develop a uniform practice to increase safety and clarify the roles of supervisors of occupational safety and health for Restaurant S. In the restaurant industry, certain security risks are present in everyday activities, such as fire, accidents, robbery and threats caused by customers. By creating a new practice, the staff will have the specific capacity to act in these situations. The objective of this thesis is to develop Restaurant S's working practices, generate work instructions for safety management and raise awareness of the potential safety risks of restaurant work. The developed ideas are intended to provide illustrative tools for use in the future. The research framework covers development of occupational safety. Restaurant industry is described for the most common security risks, occupational safety and health and well-being areas. In safety management, emphasis is on the role of the senior management as being responsible for the safety and security. The management is responsible for the operation of its business, security objectives, providing resources for achieving them and monitoring their implementation. The management also has an important role in enhancing security and can promote safer working practices and a positive change in the company's security-related activities. A preliminary survey was answered by the staff in order to obtain information of the current situation and the needs of the staff in regard to safety at work. Based on the results, first aid training and fire training for the staff were organized. Finally, the process was harmonized into a single entity. This thesis introduces development suggestions that were given to Restaurant S owners. The thesis resulted in a new method of operation, which can improve workplace safety. The work highlights the importance of safety and how the management's example lead to working safely. Occupational safety and health are parts of work, working methods and the work environment. The conditions for good work performances and results will be created when the elements of safety and health are in order. A qualified safety plan can support staff satisfaction, work flow and solidarity at work. This thesis succeeded in its aim to produce a new operating method for safety at the commissioner company. According to the commissioner, fire and emergency first-aid training will be organized annually. Employees were also pleased with the conducted training

Tahdistinpotilas leikkauksessa tai muussa toimenpiteessä

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