Ortopedian ja traumatologian järjestämistä koskevat periaatteet 2020-luvulla : Selvityshenkilöiden raportti

Ortopedinen kirurgia edustaa sairaaloissa merkittävää osaa operatiivisesta toiminnasta. Erikoisala on kehittynyt nopeasti ja leikkaushoidon indikaatioasettelu on muuttunut. Selvityshenkilöt esittävät, että ortopedista ja traumatologista toimintaa on suunniteltava päivystyskirurgian ja vuodeosastohoitoa vaativan kirurgian näkökulmasta. Traumatologialla on keskeinen rooli päivystyksessä. Myös monet kiireettömistä ortopedisista potilaista tarvitsevat päivystyspalveluja leikkauksenjälkeisen toipumisen turvaamiseksi. ERVA- alueille tulisi olla vastuu ja velvollisuus järjestää potilaiden hoito alueellaan mielekkäällä tavalla siten, että yksiköissä on riittävä osaaminen ja resurssi. Alueelliset erityispiirteet on pystyttävä huomioimaan. Selvityshenkilöt esittävät, että tekonivelkirurgia tulisi koota sairaaloihin, joissa lonkan ja polven tekonivelleikkausten vuosittaisen määrän on vähintään 600 kappaletta (yli 300 lonkka- ja yli 300 polvitekonivelleikkausta). Osa kiireettömistä uusintatekonivelleikkauksista tulisi keskittää vain niihin keskuksiin, jossa on välineistö ja osaaminen harvinaistenkin tilojen hoitamiseksi. Tällaisessa yksikössä tulisi tehdä yhteensä vähintään 100 polven ja lonkan uusintaleikkausta vuositasolla. Selkäkirurgia tulisi keskittää sairaaloihin, joissa on moniammatillisiin selkäkeskus (spine cen-ter) käsittäen ortopedian ja traumatologian, fysiatrian ja radiologian ja tarvittaessa neurokirurgian osaamisen. Leikkaavissa sairaaloissa tulisi vuosittaisen leikkausmäärän olla yli 150 toimenpidettä ja lääkärikohtaisen leikkausmäärän vähintään 50. Reumapotilaiden operatiivinen hoito tulisi toteuttaa yksiköissä, joissa on reumatologinen yksikkö ja joissa on mahdollisimman laajalti osaamista eri ortopedian ja traumatologian aloilta erityisesti tekonivelkirurgiasta, selkäkirurgiasta, käsikirurgiasta ja jalkateränkirurgiasta. Potilasmäärän vähenemisen vuoksi toiminta tulisi jatkossa keskittää viiteen sairaalaan nykyisen seitsemän sairaalaan sijaan. Selvitystyön tavoitteena on ollut luoda edellytyksiä yhtenäisille hoitokäytännöille ja siten hoi-don saatavuudelle kansalaisen näkökulmasta koko maan alueella sopimalla työnjaosta, vaativien hoitojen keskittämisestä suurempiin yksiköihin sekä määrittämällä ortopediassa yhtenäisiä hoidon kriteereitä

Promoting mobility after hip fracture (ProMo): study protocol and selected baseline results of a year-long randomized controlled trial among community-dwelling older people

Background. To cope at their homes, community-dwelling older people surviving a hip fracture need a sufficient amount of functional ability and mobility. There is a lack of evidence on the best practices supporting recovery after hip fracture. The purpose of this article is to describe the design, intervention and demographic baseline results of a study investigating the effects of a rehabilitation program aiming to restore mobility and functional capacity among community-dwelling participants after hip fracture. Methods/Design. Population-based sample of over 60-year-old community-dwelling men and women operated for hip fracture (n = 81, mean age 79 years, 78% were women) participated in this study and were randomly allocated into control (Standard Care) and ProMo intervention groups on average 10 weeks post fracture and 6 weeks after discharged to home. Standard Care included written home exercise program with 5-7 exercises for lower limbs. Of all participants, 12 got a referral to physiotherapy. After discharged to home, only 50% adhered to Standard Care. None of the participants were followed-up for Standard Care or mobility recovery. ProMo-intervention included Standard Care and a year-long program including evaluation/modification of environmental hazards, guidance for safe walking, pain management, progressive home exercise program and physical activity counseling. Measurements included a comprehensive battery of laboratory tests and self-report on mobility limitation, disability, physical functional capacity and health as well as assessments for the key prerequisites for mobility, disability and functional capacity. All assessments were performed blinded at the research laboratory. No significant differences were observed between intervention and control groups in any of the demographic variables. Discussion. Ten weeks post hip fracture only half of the participants were compliant to Standard Care. No follow-up for Standard Care or mobility recovery occurred. There is a need for rehabilitation and follow-up for mobility recovery after hip fracture. However, the effectiveness of the ProMo program can only be assessed at the end of the study. Trial registration. Current Controlled Trials ISRCTN53680197peerReviewe

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

Crossing Boundaries : Transferring eHealth services across the Northern Periphery

Health care organisations in Finland, Norway, Scotland and Sweden face similar challenges when it comes to providing health services in the sparsely populated rural areas. Vast distances, centralized health services, harsh climate and limited access to public transport can make accessing health services difficult. In order to provide health services for the population of the Northern Periphery it is necessary to develop health care service models which can address the problems of isolation, remoteness and centralized health services. One way of overcoming these issues is to develop eHealth services that focus on increasing access to health services in the rural areas. As health care organisations’ resources are often limited, the possibilities to develop, test and implement eHealth services can be restricted. Thus, transferring existing eHealth services across organisational and national boundaries can be beneficial, as the services have already been tested in practice. Taking advantage of the knowledge health care organisations in different countries have can support organisations in their drive to develop service provision models that reach out to the population of the Northern Periphery. The main objective of this thesis is to understand how local conditions influence the outcomes of eHealth transfer. In order to do so the transnational implementation of five eHealth services was investigated in five case studies. This research gives insight into how differences in organisational structure, ICT infrastructure and the size of the patient base impact health care organisations’ possibility to transfer and utilize existing eHealth services. In addition, this research offers rich insights into how these factors impact the sustainability of eHealth services. The case studies also illustrate how stakeholder collaboration and knowledge exchange impact the process of transferring eHealth services, and how patients’ and professionals’ level of trust in eHealth services can materialize in practice. In addition, this thesis demonstrates why the benefits obtained with a specific eHealth service may, or may not be duplicable in another organisational context. The research discussed in this thesis also contributes to the understanding of how assessing organisational readiness prior to transferring and eHealth services can facilitate the implementation process

Groping around in the dark for adequate COPD management : a qualitative study on experiences in long-term care

Background: Chronic obstructive pulmonary disease (COPD) is one of the most common and deadliest chronic diseases worldwide. Since COPD is a chronic and progressive disease, treatment is necessary throughout life. For people with COPD who cannot live independently, long-term care facilities are often required. However, knowledge is very limited about aspects of importance for effective COPD management in these settings in accordance with current treatment guidelines. The aim of this study was to explore aspects of importance in long-term care facilities for providing interventions according to treatment guidelines for people with COPD, from the perspective of healthcare professionals, in an effort to prove novel knowledge that could be used to facilitate implementation of treatment guidelines in these settings. Methods: A qualitative study was performed in northern Sweden. In Sweden, municipalities are responsible for providing long-term care. Interviews with 36 healthcare professionals (nurses, physiotherapists, occupational therapists and dieticians) in municipal healthcare were conducted and analysed using qualitative content analysis with triangulation by the authors. Results: The overarching theme that emerged from the analysis was Groping around in the dark for adequate COPD management. This represents healthcare professionals’ experiences of working with a complex diagnosis somewhat overlooked in the municipal healthcare, an underdog in the healthcare system. The groping around in the dark theme further represents the healthcare professionals’ lack of COPD-related competence, lack of interprofessional collaboration, and insufficient communication with the county council. The fragile group of people with COPD and their relatives were considered in need of support adapted to their context, but routines and resources for COPD management were limited. This lack of routines and resources also resulted in professionals being pragmatic and adopting short-term solutions without focusing on specific needs related to the diagnosis. Conclusions: The COPD management in long-term care settings showed several insufficiencies, indicating a large gap between clinical practice and treatment guidelines for COPD. It is crucial to improve COPD management in long-term care settings. Consequently, several actions are needed, such as increasing professional competence, establishing new routines, acknowledging and making COPD a higher priority, as well as adapting treatment guidelines to the context

Ultrasonography of the late-stage knee osteoarthritis prior to total knee arthroplasty : comparison of the ultrasonographic, radiographic and intra-operative findings

The purpose of this study was to assess the effectiveness of the ultrasonography (US) on detecting osteoarthritis of the knee, and compare US and radiographic findings to intraoperative total knee arthroplasty (TKA) findings. Fifty-seven late-stage osteoarthritic knees undergoing TKA were evaluated with US and radiography. Standard knee US assessing femoral cartilage damage, osteophytes, effusion, synovitis, and meniscal extrusion was performed. On radiographs, osteophytes, joint space narrowing, and Kellgren-Lawrence grade were evaluated. Corresponding intra-operative findings were assessed during TKA as the gold standard. On the damage of the medial femoral condyle cartilage, the sensitivity of US was high (92%), whereas on the lateral condyle and sulcus area, sensitivities were 58% and 46%, respectively. On osteophytes, the detection rate of the US was remarkable especially on the medial side yielding sensitivities of 90-95%. The sensitivities for detecting effusion and synovitis were also excellent (97%). US detection rate of femoral cartilage damage was in concordance with the radiographic joint space narrowing. For the detection of osteophytes, US provided superior results to radiography particularly on the medial side. In conclusion, US can reliably assess the late-stage OA changes of the knee especially on the medial side of the knee joint.Peer reviewe

Evaluation of a Digital COPD Education Program for Healthcare Professionals in Long-Term Care – A Mixed Methods Study

Background: Lack of routines and competence among healthcare professionals have been reported as barriers to COPD management in long-term care. Online education could be used as a strategy to make COPD education more accessible. Purpose: The aim of this study was to evaluate a digital COPD education program for healthcare professionals in long-term care regarding feasibility, knowledge and working procedures. Methods: A randomized controlled feasibility trial with a convergent mixed methods design was conducted. Two municipalities in Sweden were randomized to intervention (n=20) or control (n=17). The intervention was a digital COPD education program accessible for three months. Data was collected through questionnaires on COPD-specific knowledge, conceptual knowledge, feasibility and usage of the COPD Web platform. Repeated individual interviews using a semi-structured interview guide was also performed. Quantitative and qualitative findings were merged using a mixed methods design. Results: The digital COPD education program appears feasible based on the expressed satisfaction of the healthcare workers and their reports that it supported them in their work. Across questionnaires, objective COPD-specific knowledge increased by 14 to 16 percentage points in the intervention group compared to 0 to 6 percentage points in the control group (p=0.001). The objective increase in COPD-specific knowledge was also captured in the interviews, where a perceived increase in knowledge led to increased security and focus on COPD management. Few changes in working procedures were expressed, but participants felt that attention was raised regarding COPD and the importance of preventive healthcare services. In addition, increased knowledge of healthcare services provided by other involved professions was emphasized, leading to discussions with other professions in relation to COPD management.  Conclusion: A digital COPD education program is feasible and can increase the COPD-specific knowledge of healthcare professionals in long-term care, leading to increased focus on COPD-related issues. More comprehensive measures, including organizational changes, might be needed to change working procedures

Etude de la fécondité à Dakar : premiers résultats

Background and purpose — Fast-track protocols have been successfully implemented in many hospitals as they have been shown to result in shorter length of stay (LOS) without compromising results. We evaluated the effect of fast-track implementation on the use of institutional care and results after total hip replacement (THR). Patients and methods — 3,193 THRs performed in 4 hospitals between 2009–2010 and 2012–2013 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified as fast-track (Hospital A) and non-fast-track (Hospitals B, C, and D). We analyzed LOS, length of uninterrupted institutional care (LUIC, including LOS), discharge destination, readmission, revision rate, and mortality in each hospital. We compared these outcomes for THRs performed in Hospital A before and after fast-track implementation and we also compared outcomes, excluding readmission rates, with the corresponding outcomes for the other hospitals. Results — After fast-track implementation, median LOS in Hospital A diminished from 5 to 2 days (p < 0.001) and (median) LUIC from 6 to 3 (p = 0.001) days. No statistically significant changes occurred in discharge destination. However, the reduction in LOS was combined with an increase in the 42-day readmission rate (3.1% to 8.3%) (p < 0.001). A higher proportion of patients were at home 1 week after THR (p < 0.001) in Hospital A after fast-tracking than before. Interpretation — The fast-track protocol reduces LUIC but needs careful implementation to maintain good quality of care throughout the treatment process