HEART – the Hounslow Early Active Recovery Team: implementing an inclusive strength-based model of care for people with early psychosis

In recent years in the UK, the National Health Service has made policy commitments to delivering mental health services based on recovery principles. In general though, the UK mental health service providers are in the early stages of implementing recovery principles and approaches in front-line services. This paper describes the work of the Hounslow Early Active Recovery Team (HEART), which has made substantial progress in placing recovery principles and approaches at the heart of the work of an early intervention for psychosis team working in an ethnically diverse area of West London. As evidence of the success of the HEART, in its first year and half, the team has achieved high levels of customer satisfaction with its work and a recent audit has revealed that 57% of respondents were in employment or education contrasting with the extremely high unemployment rates reported in several UK studies of people with serious mental health problems.     

Axillofemoral bypass operations in Kuopio University Hospital 1985-1996

BACKGROUND AND AIMS: Axillofemoral bypass has been used since the 1960's in poor-risk patients with aortoiliac atherosclerotic occlusive disease to improve arterial circulation in the lower extremities. This article describes the outcome of 84 consecutive operations in our hospital. MATERIAL AND METHODS: During the period 1.1.1985-31.5.1996, 84 axillofemoral bypass operations were performed in our hospital. In this retrospective study, information was based on patient records and clinical follow-up examination for surviving patients living in the area of Kuopio province and operated before the end of 1995. Patencies and survivals were established using the life table method. RESULTS: The primary patency rate was 81.1 % at one year, 64.3 % at three years and 56.7 % at five years. The secondary patency rates were 92.1%, 67.1% and 57.7 %, respectively. The operative mortality rate was 6.0%. Eighty-five percent of the patients were alive one year after the operation, compared to 50 % after five years. Serious complications were rare, but local wound complications occurred in 29 %. Vascular reoperations were needed in 29 %, particularly thrombectomies. CONCLUSIONS: Axillofemoral bypass gives acceptable results in the treatment of lower leg ischaemia in elderly poor-risk patients.     

Tricortical versus quadricortical syndesmosis fixation in ankle fractures: a prospective, randomized study comparing two methods of syndesmosis fixation

OBJECTIVE: To assess short-term functional results in 2 types of syn-desmotic fixation, comparing the traditional rigid quadricortical syndesmotic screw fixation with a more dynamic tricortical screw fixation. DESIGN:: Prospective, randomized clinical study. SETTING: University clinic, level 1 trauma center. PATIENTS: Sixty-four patients with closed ankle fractures in which the syndesmosis was found to be unstable intraoperatively. INTERVENTION: The unstable syndesmoses were fixed with either one 4.5-mm cortical screw through both tibial cortices (n = 30) or two 3.5-mm cortical screws engaging only 1 cortex of the tibia (n = 34). The quadricortical screws were routinely removed after 2 months, whereas the tricortical screws were removed only in the case of discomfort. Rehabilitation was the same in both groups. RESULTS: The Olerud Molander functional score (0-100) was significantly higher in the tricortical group (77 points) compared with the quadricortical group (66 points) (P = 0.025) at 3 months. After 1 year, however, the functional score was not significantly higher (P = 0.192) in the tricortical group (92.6 points) compared with the quadricortical group (85.7 points). Pain was significantly lower in the tricortical group (P = 0.017) after 3 months, but there was no significant difference after 1 year. There was no significant difference in dorsiflexion between the groups at any point of time. No losses of fixation were detected. The tricortical screws were removed in 2 patients due to migration. CONCLUSIONS: Syndesmosis fixation with 2 tricortical screws is safe and improves early function. After 1 year, however, there were no significant differences between the 2 groups in functional score, pain, and dorsiflexion.     

Microstructural properties of bone in rat vertebra after long-term clodronate treatment

 Bisphosphonates (BPs) are known to increase bone mineral density, but it is not known how this increase manifests at low hierarchic levels of the bone structure. The present study aimed to clarify the effects of the long-term use of clodronate on the microstructure and chemical composition of bone. The second lumbar vertebral body (L2) in growing rats, subjected to 32 weeks' treatment with clodronate at either a therapeutic dose of 2 mg/kg, or a high dose of 10 mg/kg, or physiological saline (control group), was studied by scanning electron microscopy for morphology, by backscattered electron image (BSE) for density, and by energy dispersive spectrometry for material analysis. BSE images showed that the degree of mineralization in the different areas of trabecular bone of the vertebral body varied in both the control and the study groups, but this variation seemed to be different in the control and study groups. BSE analysis showed that there was more high-density bone (white area) in the low-dose clodronate group than in the controls, but the difference between the high-dose clodronate group and the control group was not significant. The density of the white area (high-density bone) was slightly increased in the low-dose clodronate group. There were no differences in the density of the gray area (low-density bone) between the groups. Neither the distribution of Ca, P, or Mg, nor the total mineral content, was affected by the clodronate treatment. Our results indicate that long-term clodronate treatment at the therapeutic level increases the proportion of high-density bone in the vertebral body in non-osteoporotic rats. Received: October 29, 2001 / Accepted: January 25, 2002     

Effects of in utero and lactational TCDD exposure on bone development in differentially sensitive rat lines.

2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) is a notorious model compound of highly toxic environmental pollutants, polychlorinated dibenzo-p-dioxins (PCDDs). Their toxic effects are mediated via cytosolic aryl hydrocarbon receptor (AHR). We studied the effects of several dose levels of TCDD on developing rat bone after maternal exposure at different times of gestation and lactation in three differentially sensitive rat lines. Rat lines A, B, and C differ in their sensitivity to TCDD due to mutated AHR (Ahr(hw)) in line A and another TCDD-resistance allele (B(hw)) in line B. Line C rats have no resistance alleles. Offspring were analyzed for bone mineral density and geometry by peripheral quantitative computed tomography (pQCT) and for bone biomechanics by three-point bending at mid-diaphysis of tibia and femur and by axial loading at femoral neck. TCDD treatment resulted in bone defects, mainly in offspring of the most sensitive line C at a maternal dose of 1 microg/kg. They included decreased bone length, cross-sectional area of cortex, and bone mineral density. Mechanical testing revealed significantly reduced bending breaking force and stiffness of tibia, femur, and femoral neck. The effects were exposure time-dependent, and earlier exposure caused more severe defects. Gestational exposure alone was not sufficient, but lactational exposure was required to cause the bone defects. Most of the defects were recovered at the age of 1 year. The results indicate that dioxins affect developing bone by interfering with bone growth and mechanical strength and that the effects are mainly reversible. The dioxin-resistance alleles, Ahr(hw) and B(hw) increase the resistance to these defects.     

The influence of the timing of surgery on soft tissue complications and hospital stay. A review of 84 closed ankle fractures

BACKGROUND AND AIMS: Open reduction and internal fixation of an extensively swollen ankle may lead to wound closure problems, blistering, wound edge necrosis and infection. Accordingly, internal fixation should be accomplished either before or after the period of critical soft tissue swelling. The object of the study was to investigate if the timing of surgery had any influence upon soft tissue complications and hospital stay. PATIENTS AND METHODS: The clinical course of the first 6 postoperative weeks of 84 closed ankle fractures treated by open reduction and internal fixation were reviewed. Seventeen patients were not operated on early due to lack of operative capacity and were thus operated on after 5 days or more. These patients were compared to the patients operated on within 8 hours (n = 67). The groups were comparable with respect to age, gender and fracture types. RESULTS: Despite a higher incidence of primary soft tissue injuries in the early group, the patients operated on delayed had a higher incidence of wound infections (17.6% vs. 3.0%) and hospital stay was prolonged with 12.4 days compared to early surgery. All wound infections were found in grossly displaced fractures despite adequate closed reduction immediately after arrival in the hospital. CONCLUSIONS: Delayed surgery of closed ankle fractures increases the risk of soft tissue complications and prolongs hospital stay. Immediate surgery is particularly indicated in the severely displaced ankle fracture, and if not achievable, temporary reduction and immobilization is recommended.     

Functional results of braced humeral diaphyseal fractures; why do 38% lose external rotation of the shoulder?

A total of 67 humeral diaphyseal fractures treated with functional bracing was studied. The median follow-up was 30 weeks. Sixty-one fractures (91%) healed and 6 fractures (8.9%) progressed to non-unions. Fifty-four fractures could be functionally classified according to a modified Wasmer score. Pain, range of motion in the shoulder and elbow, and changes in activities of daily life were recorded. Loss of external rotation in the shoulder was most prominent, being present in 21 (38%) of the fractures. To evaluate the cause of loss of external rotation, 21 of the patients were selected for two groups to be studied with computed tomography (CT). Twelve patients had normal clinical findings without a loss of external rotation, while 9 patients had subnormal external rotation in the shoulder of the injured limb. Fracture consolidation in malrotation was seen frequently, and a linear correlation between the clinical loss of external rotation and CT findings was indicated, but no statistical agreement could be proved. The time between injury and brace application could possibly contribute to consolidation in malrotation. Received: 22 June 1999