The external fixation test of the lumbar spine: 30 complications in 25 of 100 consecutive patients

We retrospectively analyzed the rate and character of complications in a series of 100 consecutive external fixation tests during 1985-1991. There were 30 complications in 25 patients. The most common was pin tract infection, which was definite in 12 cases and probable in 6. Altogether 12 patients developed complications that resulted in removal or reapplication of the device. 8 cases had an incorrect position of a Schanz screw; 3 of these had neurological complications. The only variable having a significant association with complications was the duration of the test. Because of this complication rate, the indications for the test should be carefully considered.     

What went wrong in triple arthrodesis? An analysis of failures in 21 patients

Three hundred seven triple arthrodeses were done on 282 patients with rheumatic diseases between 1995 and 1999. Solid and painless fusion was achieved in 261 patients (93%, 286 arthrodeses). Twenty-one arthrodeses (in 21 patients) that failed were analyzed. Fourteen (66%) malunions, six (29%) nonunions, and one (5%) painful foot without malunion or nonunion were found. Of the failed procedures, valgus alignment was present in 13 feet and varus alignment was present in eight feet. The most common cause of failure was a misjudgment in the surgical technique, which occurred in 12 of 21 (57%) patients based on inadequate correction and repositioning of hindfoot deformity. In four (19%) patients, additional ankle destruction and instability was overlooked as a cause of malalignment. Revision triple arthrodesis was successful in 18 of 21 (86%) patients. Triple fusion offers challenges in surgical technique, postoperative treatment, and rehabilitation. Understanding the complexity of the rheumatic hindfoot is important when performing triple arthrodesis in patients with severe deformities manifesting typically as calcaneovalgus and pes planus.     

Coordination of a complex welfare system case: rehabilitation entity in Finland

The main purpose of this article is to analyse the institutional and political structures of the Finnish rehabilitation entity and the governmental efforts to improve the governance of the rehabilitation policy. Rehabilitation in Finland is a complex welfare system which has undergone several coordination attempts during the last two decades. The centrality of the coordination of this welfare system is obvious. Based on the content analysis of three Government's rehabilitation reports from 1994 to 2002 and their background papers, this article provides two main findings. First, the rehabilitation entity seems to be based on different funding strategies, different governing and different coordination models between the rehabilitation subsystems. Second, the governance discourse in the reports seems to be unchanging with a predominantly hierarchical mode. The article concludes with a discussion on the challenges to coordinate this kind of a complex welfare system as an entity and also how to overcome those challenges. Copyright © 2010 John Wiley & Sons, Ltd.     

Infants sleeping outdoors in a northern winter climate: skin temperature and duration of sleep

Aim: The aim of the study is to describe the relationships among thermal environment, skin temperatures and infants’ daytime outdoor sleep duration in northern winter conditions. Methods: This study is a cross‐over observational study. Skin temperatures of three‐month‐old infants were recorded from seven skin sites continuously throughout outdoor (n = 34) and indoor sleep (n = 33) in the families’ homes. The duration of the sleep was observed, and temperature and the air velocity of the environment were recorded. Results: Skin temperatures increased towards the end of indoor sleeping, whereas they decreased during outdoor sleeping. The cooling rate of mean skin temperature (T_sk) increased in lower outdoor temperatures (r_s = 0.628, p < 0.001) in spite of increased clothing. On some occasions, cold extremities were observed, suggesting slight deviations from thermoneutrality. Sleep time was 92 min longer in outdoors than in indoors. However, outdoor sleep duration was shortened when the cooling rate of T_sk increased (r_s = 0.611, p < 0.001). Conclusion: The longest sleep was recorded outdoors when the cooling rate of T_sk was minimal. Restriction of movements by clothing probably increases the length of sleep, and a cold environment makes swaddling possible without overheating. A decrease in ambient temperature increased the cooling rate, suggesting that the cold protection of the clothing compensated only partly for the increased heat loss.     

Repeat prescribing processes in primary care: a qualitative study

Objective To investigate the characteristics, local agreements and changes regarding repeat prescribing processes in primary health care in Finland. Setting Twenty‐eight municipal health centres nationwide. Method Twenty‐eight physicians and 28 medical receptionists were given semi‐structured telephone interviews about repeat prescribing practices. The repeat prescribing process of each health centre was displayed as a flow chart and the processes were classified according to the quality of the practical flow and the medication review. Key findings There are various ways of carrying out repeat prescribing in different health centres. In some centres, a review of the medications is recognised as part of the repeat prescribing process, but in others there is no systematic review of the patients' medication. Repeat prescribing is often performed in a busy atmosphere. Repeat prescribing systems have evolved over time without proper management, and few local guidelines exist. Conclusions There is a need to reorganise the repeat prescribing systems in primary health care. A regular review of long‐term medications, in particular, needs to become a part of the repeat prescribing process. There is a need for both local and national guidelines.     

Development rate of mutilans fingers in patients with rheumatic disease

OBJECTIVE: To describe arthritis mutilans (AM) deformity during the progression of rheumatic disease. METHODS: The development of mutilans-like hand deformities in 2 patients with juvenile chronic arthritis (JCA) and in 2 patients with adult onset rheumatoid arthritis (RA) are presented. The hands of these patients were evaluated at least at two time points during the course of disease using two different scoring methods based on differently summed Larsen grades of the hand joints. RESULTS: Two patients (one with JCA and one with RA) showed AM changes after a disease period of less than 10 years and 2 not until after 30 years. The patients with adult onset disease were young at the onset of joint disease. Early wrist fusions were performed on both patients showing a slow development rate. CONCLUSIONS: The development rate of AM is very variable, even in patients with the same diagnoses. Wrist fusion prevents shortening of the carpus and may decrease the development rate of AM.     

Scintigraphy in prediction of the salivary gland function after gland-sparing intensity modulated radiation therapy for head and neck cancer

BACKGROUND AND PURPOSE: To evaluate salivary gland scintigraphy in prediction of salivary flow following radiation therapy. PATIENTS AND METHODS: Twenty patients diagnosed with head and neck cancer were treated with intensity modulated radiation therapy with an intention to spare the salivary gland function. The total quantitative saliva secretion was measured prior to and 6 and 12 months after therapy, and the function of the major salivary glands was monitored using Tc-99m-pertechnetate scintigraphy. Two models were designed for prediction of the post-treatment salivary flow: an average model, based on the average proportions of saliva produced by each of the four major glands in healthy subjects, and an individual model, based on saliva produced by each gland as measured by scintigraphy prior to therapy. These models were compared with volume-based (Lyman) normal tissue complication probability models using two published sets of model parameters. RESULTS: The D(50) for the parotid and the submandibular gland function assessed at 6 and 12 months after radiotherapy was approximately 39Gy. The scintigraphy-based individual model predicted well the measured post-treatment saliva flow rates. The correlation coefficient between the predicted stimulated and the measured saliva flow rate was 0.77 (p<0.0001) at 6 months and 0.55 (p=0.034) at 12 months after completion of radiotherapy. The relative changes in unstimulated and stimulated salivary flow rates showed similar dependency on the cumulative radiation dose. CONCLUSIONS: Salivary gland function assessed by scintigraphy prior to radiotherapy is useful in prediction of the residual salivary flow after radiotherapy.