Long-term results of obstetric brachial plexus surgery

Background: Brachial plexus birth palsy (BPBP) most often occurs as a result of foetal-maternal disproportion. The C5 and C6 nerve roots of the brachial plexus are most frequently affected. In contrast, roots from the C7 to Th1 that result in total injury together with C5 and C6 injury, are affected in fewer than half of the patients. BPBP was first described by Smellie in 1764. Erb published his classical description of the injury in 1874 and his name became linked with the paralysis that is associated with upper root injury. Since then, early results of brachial plexus surgery have been reasonably well documented. However, from a clinical point of view not all primary results are maintained and there is also a need for later follow-up results. In addition most of the studies that are published emanate from highly specialized clinics and no nation wide epidemiological reports are available. One of the plexus injuries is the avulsion type, in which the nerve root or roots are ruptured at the neural cord. It has been speculated whether this might cause injury to the whole neural system or whether shoulder asymmetry and upper limb inequality results in postural deformities of the spine. Alternatively, avulsion could manifest as other signs and symptoms of the whole musculoskeletal system. In addition, there is no available information covering activities of daily living after obstetric brachial plexus surgery. Patients and methods: This was a population-based cross-sectional study on all patients who had undergone brachial plexus surgery with at least 5 years of follow-up. An incidence of 3.05/1000 for BPBP was obtained from the registers for this study period. A total of 1706 BPBP patients needing hospital treatment out of 1 717 057 newborns were registered in Finland between 1971 and 1997 inclusive. Of these BPBP patients, 124 (7.3%) underwent brachial plexus surgery at a mean age of 2.8 months (range: 0.4―13.2 months). Surgery was most often performed by direct neuroraphy after neuroma resection (53%). Depending on the phase of the study, 105 to 112 patients (85-90%) participated in a clinical and radiological follow-up assessment. The mean follow up time exceeded 13 years (range: 5.0―31.5 years). Functional status of the upper extremity was evaluated using Mallet, Gilbert and Raimondi scales. Isometric strength of the upper limb, sensation of the hand and stereognosis were evaluated for both the affected and unaffected sides then the differences and their ratios were calculated and recorded. In addition to the upper extremity, assessment of the spine and lower extremities were performed. Activities of daily living (ADL), participation in normal physical activities, and the use of physiotherapy and occupational therapy were recorded in a questionnaire. Results: The unaffected limb functioned as the dominant hand in all, except four patients. The mean length of the affected upper limb was 6 cm (range: 1-13.5 cm) shorter in 106 (95%) patients. Shoulder function was recorded as a mean Mallet score of 3 (range: 2―4) which was moderate. Both elbow function and hand function were good. The mean Gilbert elbow scale value was 3 (range: -1―5) and the mean Raimondi hand scale was 4 (range:1―5). One-third of the patients experienced pain in the affected limb including all those patients (n=9) who had clavicular non-union resulting from surgery. A total of 61 patients (57%) had an active shoulder external rotation of less than 0° and an active elbow extension deficiency was noted in 82 patients (77%) giving a mean of 26° (range: 5°―80°). In all, expect two patients, shoulder external rotation strength at a mean ratio 35% (range: 0―83%) and in all patients elbow flexion strength at a mean ratio of 41% (range: 0―79%) were impaired compared to the unaffected side. According to radiographs, incongruence of the glenohumeral joint was noted in 15 (16%) patients, whereas incongruence of the radiohumeral joint was found in 20 (21%) patients. Fine sensation was normal for 34/49 (69%) patients with C5-6 injury, for 15/31 (48%) with C5-7 and for only 8/25 (32%) of patients with total injury. Loss of protective sensation or absent sensation was noted in some palmar areas of the hand for 12/105 patients (11%). Normal stereognosis was recorded for 88/105 patients (84%). No significant inequalities in leg length were found and the incidence of structural scoliosis (1.7%) did not differ from that of the reference population. Nearly half of the patients (43%) had asynchronous motion of the upper limbs during gait, which was associated with impaired upper limb function. Data obtained from the completed questionnaires indicated that two thirds (63%) of the patients were satisfied with the functional outcome of the affected hand although one third of all patients needed help with ADL. Only a few patients were unable to participate in physical activities such as: bicycling, cross-country skiing or swimming. However, 71% of the patients reported problems related to the affected upper limb, such as muscle weakness and/or joint stiffness during the aforementioned activities. Incongruity of the radiohumeral joints, extent of the injury, avulsion type injury, age less than three months of age at the time of plexus surgery and inexperience of the surgeon was related to poor results as determined by multivariate analyses. Conclusions: Most of the patients had persistent sequelae, especially of shoulder function. Almost all measurements for the total injury group were poorer compared with those of the C5-6 type injury group. Most of the patients had asymmetry of the shoulder region and a shorter affected upper limb, which is a probable reason for having an abnormal gait. However, BPBP did not have an effect on normal growth of the lower extremities or the spine. Although, participation in physical activities was similar to that of the normal population, two-thirds of the patients reported problems. One-third of the patients needed help with ADL. During the period covered by this study, 7.3% BPBP of patients that needed hospital treatment had a brachial plexus operation, which amounts to fewer than 10 operations per year in Finland. It seems that better results of obstetric plexus surgery and more careful follow-up including opportunities for late reconstructive procedures will be expected, if the treatment is solely concentrated on by a few specialised teams.

Investigating the effect of Eye Movement Desensitization and Reprocessing (EMDR) on postoperative pain intensity in adolescents undergoing surgery: A randomized controlled trial

Aim To investigate the efficacy of Eye Movement Desensitization and Reprocessing for postoperative pain management in adolescents. Background Eye Movement Desensitization and Reprocessing is an inexpensive, non-pharmacological intervention that has successfully been used to treat chronic pain. It holds promise in the treatment of acute, postsurgical pain based on its purported effects on the brain and nervous system. Design A randomized controlled trial was used. Methods Fifty-six adolescent surgical patients aged between 12-18 years were allocated to gender-balanced Eye Movement Desensitization and Reprocessing (treatment) or non-Eye Movement Desensitization and Reprocessing (control) groups. Pain was measured using the Wong-Baker FACES® Pain Rating Scale (WBFS) before and after the intervention (or non-intervention for the control group). Findings A Wilcoxon signed-rank test demonstrated that the Eye Movement Desensitization and Reprocessing group experienced a significant reduction in pain intensity after treatment intervention, whereas the control group did not. Additionally, a Mann–Whitney U-test showed that, while there was no significant difference between the two groups at time 1, there was a significant difference in pain intensity between the two groups at time 2, with the Eye Movement Desensitization and Reprocessing group experiencing lower levels of pain. Conclusion These results suggest that Eye Movement Desensitization and Reprocessing may be an effective treatment modality for postoperative pain.

Ion Transport in a Polymer-Plastic Solid Soft Matter Electrolyte in the Light of Solvent Dynamics and Ion Association

Ion transport in a recently demonstrated promising soft matter solid plastic-polymer electrolyte is discussed here in the context of solvent dynamics and ion association. The plastic-polymer composite electrolytes display liquid-like ionic conductivity in the solid state,compliable mechanical strength (similar to 1 MPa), and wide electrochemical voltage stability (>= 5 V). Polyacrylonitrile (PAN) dispersed in lithium perchlorate (LiClO4)-succinonitrile (SN) was chosen as the model system for the study (abbreviated LiClO4-SN:PAN). Systematic observation of various mid-infrared isomer and ion association bands as a function of temperature and polyme concentration shows an effective increase in trans conformer concentration along with free Li+ ion concentration. This strongly supports the view that enhancement in LiClO4-SN:PAN ionic conductivity over the neat plastic electrolyte (LiClO4-SN) is due to both increase in charge mobility and concentration. The ionic conductivity and infrared spectroscopy studies are supported by Brillouin light scattering. For the LiClO4-SN:PAN composites, a peak at 17 GHz was observed in addition to the normal trans-gauche isomerism (as in neat SN) at 12 GHz. The fast process is attributed to increased dynamics of those SN molecules whose energy barrier of transition from gauche to trans has reduced under influences induced by the changes in temperature and polymer concentration. The observations from ionic conductivity, spectroscopy, and light scattering studies were further supplemented by temperature dependent nuclear magnetic resonance H-1 and Li-7 line width measurements.

Mental Disorders among Burn Patients

ABSTRACT Mental disorders and suicide attempts among acute burn patients were investigated in a collaborative research project between National Institute for Health and Welfare and Departments of Psychiatry and Plastic surgery in University of Helsinki in Finland. This project was realized in two parts. The first cohort of burn patients consisted of all burn patients admitted to the Helsinki Burn Centre during 1989 97. In this retrospective cohort, 5.7% (N=46) of the total of 811 burn patients had attempted suicide. The burn severity of suicide attempters was markedly higher than in the other burn patients. Suicide attempters were more often unemployed or on disability pension and had psychiatric history before the injury. The second sample was a prospective cohort of all acute consecutive burn patients admitted to the Helsinki Burn Centre during 18 months in 2006- 2007. All subjects (N=107) of the cohort were interviewed with the Structured Clinical Interview for DSM-IV for Axis I and II mental disorders (SCID-I and SCID-II) at baseline and then 86 % of all (N=92) with SCID-I at the end of six-month follow-up. Most (61%) patients had at least one lifetime mental disorder before burn; 47 % substance-related, 10% psychotic and 23% personality disorders. The overall prevalence of Axis I mental disorders increased significantly from the month prior to burn to acute care but decreased significantly from acute care to six months. However, more than one half (55%) of the cohort suffered from some mental disorder during follow-up. Less than one half of the burn patients with estimated need for psychiatric care received psychiatric care. Burn severity independently and strongly predicted risk for mental disorders during follow-up and pre-burn psychiatric history, severe burns and estimated need for psychiatric care significantly predicted psychiatric care received. The proportion of patients with self-inflicted burns is not high but mental disorders are common among burn patients. Mental disorders may predispose to burns. After burn injury, more than half of the patients suffer from mental disorders and a strong relationship exists between burn severity and some post-burn mental disorders. A minority of the patients with unequivocal need for psychiatric care actually receive it. Psychiatric consultations and care follow mainly the course of acute burn treatment.

Numerical simulations of crack tip fields in polycrystalline plastic solids

In this paper, modes I and II crack tip fields in polycrystalline plastic solids are studied under plane strain, small scale yielding conditions. Two different initial textures of an Al–Mg alloy, viz., continuous cast AA5754 sheets in the recrystallized and cold rolled conditions, are considered. The former is nearly-isotropic, while the latter displays distinct anisotropy. Finite element simulations are performed by employing crystal plasticity constitutive equations along with a Taylor-type homogenization as well as by using the Hill quadratic yield theory. It is found that significant texture evolution occurs close to the notch tip which profoundly influences the stress and plastic strain distributions. Also, the cold rolling texture gives rise to higher magnitude of plastic strain near the tip.

Numerical simulations of crack tip fields in polycrystalline plastic solids

In this paper, modes I and II crack tip fields in polycrystalline plastic solids are studied under plane strain, small scale yielding conditions. Two different initial textures of an Al-Mg alloy, viz.,continuous cast AA5754 sheets in the recrystallized and cold rolled conditions, are considered. The former is nearly-isotropic, while the latter displays distinct anisotropy. Finite element simulations are performed by employing crystal plasticity constitutive equations along with a Taylor-type homogenization as well as by using the Hill quadratic yield theory. It is found that significant texture evolution occurs close to the notch tip which profoundly influences the stress and plastic strain distributions. Also, the cold rolling texture gives rise to higher magnitude of plastic strain near the tip. (C) 2010 Elsevier Ltd. All rights reserved.

Plastic response of orthotropic spherical shells under blast loading

The plastic response of a segment of a simply supported orthotropic spherical shell under a uniform blast loading applied on the convex surface of the shell is presented. The blast is assumed to impart a uniform velocity to the shell surface initially. The material of the shell is orthotropic obeying a modified Tresca yield hypersurface conditions and the associated flow rules. The deformation of the shell is determined during all phases of its motion by considering the motion of plastic hinges in different regimes of flow. Numerical results presented include the permanent deformed configuration of the shell and the total time of shell response for different degrees of orthotropy. Conclusions regarding the plastic behaviour of spherical shells with circumferential and meridional stiffening under uniform blast load are presented.

Increasing ionic conductivity of polymer-sodium salt complex by addition of a non-ionic plastic crystal

Ionic conductivity and other physico-chemical properties of a soft matter composite electrolyte comprising of a polymer-sodium salt complex and a non-ionic plastic crystal are discussed here. The electrolyte under discussion comprises of polyethyleneoxide (PEO)-sodium triflate (NaCF3SO3) and succinonitrile (SN). Addition of SN to PEO-NaCF3SO3 resulted in significant enhancement in ionic conductivity. At 50% SN concentration (with respect to weight of polymer), the polymer-plastic composite electrolyte room temperature (= 25 degrees C) ionic conductivity was similar to 1.1 x 10(-4) Omega(-1) cm(-1), approximately 45 times higher than PEO-NaCF3SO3. Observations from ac-impedance spectroscopy along with X-ray diffraction, differential scanning calorimetry and Fourier transform inrared spectroscopy strongly suggest the enhancement in the composite is ionicconductivity due to enhanced ion mobility via decrease in crystallinity of PEO. The free standing composite polymer-plastic electrolytes were more compliable than PEO-NaCF3SO3 thus exhibiting no detrimental effects of succinonitrile addition on the mechanical stability of PEO-NaCF3SO3. We propose that the exploratory PEO-NaCF3SO3-SN system.discussed here will eventually be developed as a prototype electrolyte.for sodium-sulfur batteries capable of operating at ambient and.sub-ambient conditions. (C) 2010 Elsevier B.V. All rights reserved.

Radioimmunoassay of polypeptide hormones using immunochemically coated plastic tubes

A method has been developed for immobilisation of antisera on fresh plastic tubes through an immunochemical bridge. This type of immobilisation has been shown to be more consistent than direct adsorption on plastic. Such immunochemically coated antisera on plastic tube has been used in the development of a noncentrifugation radioimmunoassay. This assay system has been found to be technically as sound as the conventional method.

Elasto-plastic Cracking Analysis of Reinforced Concrete

A new elasto-plastic cracking constitutive model for reinforced concrete is presented. The nonlinear effects considered cover almost all the nonlinearities exhibited by reinforced concrete under short term monotonic loading. They include concrete cracking in tension, plasticity in compression, aggregate interlock, tension softening, elasto-plastic behavior of steel, bond-slip between concrete, and steel reinforcement and tension stiffening. A new procedure for incorporating bondslip in smeared steel elements is described. A modified Huber-Hencky-Mises failure criterion for plastic deformation of concrete, which fits the experimental results under biaxial stresses better, is proposed. Multiple cracking at Gauss points and their opening and closing are considered. Matrix expressions are developed and are incorporated in a nonlinear finite element program. After the objectivity of the model is demonstrated, the model is used to analyze two different types of problems: one, a set of four shear panels, and the other, a reinforced concrete beam without shear reinforcement. The results of the analysis agree favorably with the experimental results.

Excimer laser refractive surgery : corneal wound healing and clinical results

Although the first procedure in a seeing human eye using excimer laser was reported in 1988 (McDonald et al. 1989, O'Connor et al. 2006) just three studies (Kymionis et al. 2007, O'Connor et al. 2006, Rajan et al. 2004) with a follow-up over ten years had been published when this thesis was started. The present thesis aims to investigate 1) the long-term outcomes of excimer laser refractive surgery performed for myopia and/or astigmatism by photorefractive keratectomy (PRK) and laser-in situ- keratomileusis (LASIK), 2) the possible differences in postoperative outcomes and complications when moderate-to-high astigmatism is treated with PRK or LASIK, 3) the presence of irregular astigmatism that depend exclusively on the corneal epithelium, and 4) the role of corneal nerve recovery in corneal wound healing in PRK enhancement. Our results revealed that in long-term the number of eyes that achieved uncorrected visual acuity (UCVA)≤0.0 and ≤0.5 (logMAR) was higher after PRK than after LASIK. Postoperative stability was slightly better after PRK than after LASIK. In LASIK treated eyes the incidence of myopic regression was more pronounced when the intended correction was over >6.0 D and in patients aged <30 years.Yet the intended corrections in our study were higher for LASIK than for PRK eyes. No differences were found in percentages of eyes with best corrected visual acuity (BCVA) or loss of two or more lines of visual acuity between PRK and LASIK in the long-term. The postoperative long-term outcomes of PRK with two different delivery systems broad beam and scanning laser were compared and revealed no differences. Postoperative outcomes of moderate-to-high astigmatism yielded better results in terms of UCVA and less compromise or loss of two more lines of BCVA after LASIK that after PRK.Similar stability for both procedures was revealed. Vector analysis showed that LASIK outcomes tended to be more accurate than PRK outcomes, yet no statistically differences were found. Irregular astigmatism secondary to recurrent corneal erosion due to map-dot-fingerprint was successfully treated with phototherapeutic keratectomy (PTK). Preoperative videokeratographies (VK) showed irregular astigmatism. However, postoperatively, all eyes showed a regular pattern. No correlation was found between pre- and postoperative VK patterns. Postoperative outcomes of late PRK in eyes originally subjected to LASIK showed that all (7/7) eyes achieved UCVA ≤0.5 at last follow-up (range 3 — 11 months), and no eye lost lines of BCVA. Postoperatively all eyes developed and initial mild haze (0.5 — 1) into the first month. Yet, at last follow-up 5/7 eyes showed a haze of 0.5 and this was no longer evident in 2/7 eyes. Based on these results, we demonstrated that the long-term outcomes after PRK and LASIK were safe and efficient, with similar stability for both procedures. The PRK outcomes were similar when treated by broad-beam or scanning slit laser. LASIK was better than PRK to correct moderate-to-high astigmatism, yet both procedures showed a tendency of undercorrection. Irregular astigmatism was proven to be able to depend exclusively from the corneal epithelium. If this kind of astigmatism is present in the cornea and a customized PRK/LASIK correction is done based on wavefront measurements an irregular astigmatism may be produced rather than treated. Corneal sensory nerve recovery should have an important role in the modulation of the corneal wound healing and post-operative anterior stromal scarring. PRK enhancement may be an option in eyes with previous LASIK after a sufficient time interval that in at least 2 years.

The Effects of Reduction Mammaplasty

Symptomatic hypertrophic breasts cause a health burden with physical and psychosocial morbidity. The value of reduction mammaplasty in the treatment of symptomatic breast hypertrophy has been consistently reported by patients and has been well recognised by plastic surgeons for a long time. However, the scientific evidence of the effects of reduction mammaplasty has been weak or lacking. During the design of this study most of the previous studies were retrospective and the few prospective studies had methodological limitations. Therefore, an obvious need for prospective randomised studies was present. Nevertheless, practical and ethical considerations seemed to make this study design impossible, because the waiting time for the operation was several years. The legislation and subsequent introduction of the uniform criteria for access to non-emergency treatment in Finland removed these obstacles, as all patients received their treatment within a reasonable time. As a result, a randomised controlled trial with a six-month follow-up time was designed and conducted. In addition, a follow-up study with two to five years follow-up was also carried out later. The effects of reduction mammaplasty on the patients breast-related symptoms, psychological symptoms, pain and quality of life was assessed. In addition, factors affecting the outcome were investigated. This study was carried out in the Hospital District of Helsinki and Uusimaa, Finland. Eighty-two out of the approximately 300 patients on the waiting list in 2004 agreed to participate in the study. Patients were randomised either to be operated (40 patients) on or to be followed up (42 patients). The follow-up time for both groups was six months. The patients were operated on by plastic surgeons or trainees at the Department of Plastic Surgery at Helsinki University Central Hospital or at the Department of Surgery at Hyvinkää Hospital. The patients completed five questionnaires: the SF-36 and the 15D quality of life questionnaires, the Finnish Breast-Associated Symptoms questionnaire (FBAS), a mood questionnaire (Raitasalo s modification of the short form of the Beck Depression Inventory, RBDI), and a pain questionnaire (The Finnish Pain Questionnaire, FPQ). Sixty-two out of the original 82 patients agreed to participate in the prospective follow-up study. In this study, patients completed the 15D quality of life questionnaire, the Finnish Breast-Associated Symptoms questionnaire, and the RBDI mood questionnaire. After six months follow-up, patients who had undergone reduction mammaplasty had a significantly better quality of life, fewer breast-associated symptoms and less pain, and they were less depressed or anxious when compared to patients who had not undergone surgery. The change in quality of life was more than two times the minimal clinically important difference. The patients preoperative quality of life was significantly inferior when compared to the age-standardised general population. This health burden was removed with reduction mammaplasty. The health loss related to symptomatic breast hypertrophy was comparable to that of patients with major joint arthrosis. In terms of change in quality of life, the intervention effect of reduction mammaplasty was comparable to that of hip joint replacement and more pronounced than that of knee joint replacement surgery. The outcome of reduction mammaplasty was affected more by preoperative psychosocial factors than by changes in breast dimensions. The effects of reduction mammaplasty remained stable at two to five years follow-up. In terms of quality of life, symptomatic breast hypertrophy causes a considerable health loss comparable to that of major joint arthrosis. Patients who undergo surgery have fewer breast-associated symptoms and less pain, and they are less depressed or anxious and have an improved quality of life. The intervention effect is comparable to that of major joint replacement surgery, and it remains stable at two to five years follow-up. The outcome of reduction mammaplasty is affected by preoperative psychosocial factors.

Ultra-fine Grain Materials by Severe Plastic Deformation: Application to Steels

Severe plastic deformation techniques are known to produce grain sizes up to submicron level. This leads to conventional Hall-Petch strengthening of the as-processed materials. In addition, the microstructures of severe plastic deformation processed materials are characterized by relatively lower dislocation density compared to the conventionally processed materials subjected to the same amount of strain. These two aspects taken together lead to many important attributes. Some examples are ultra-high yield and fracture strengths, superplastic formability at lower temperatures and higher strain rates, superior wear resistance, improved high cycle fatigue life. Since these processes are associated with large amount of strain, depending on the strain path, characteristic crystallographic textures develop. In the present paper, a detailed account of underlying mechanisms during SPD has been discussed and processing-microstructure-texture-property relationship has been presented with reference to a few varieties of steels that have been investigated till date.

High-Temperature (1023 K to 1273 K 750 degrees C to 1000 degrees C]) Plastic Deformation Behavior of B-Modified Ti-6Al-4V Alloys: Temperature and Strain Rate Effects

A minor addition of B to the Ti-6Al-4V alloy, by similar to 0.1 wt pct, reduces its as-cast prior beta grain size by an order of magnitude, whereas higher B content leads to the presence of in situ formed TiB needles in significant amounts. An experimental investigation into the role played by these microstructural modifications on the high-temperature deformation behavior of Ti-6Al-4V-xB alloys, with x varying between 0 wt pct and 0.55 wt pct, was conducted. Uniaxial compression tests were performed in the temperature range of 1023 K to 1273 K (750 degrees C to 1000 degrees C) and in the strain rate range of 10(-3) to 10(+1) s(-1). True stress-true strain responses of all alloys exhibit flow softening at lower strain rates and oscillations at higher strain rates. The flow softening is aided by the occurrence of dynamic recrystallization through lath globularization in high temperature (1173 K to 1273 K 900 degrees C to 1000 degrees C]) and a lower strain rate (10(-2) to 10(-3) s(-1)) regime. The grain size refinement with the B addition to Ti64, despite being marked, had no significant effect on this. Oscillations in the flow curve at a higher strain rate (10(0) to 10(+1) s(-1)), however, are associated with microstructural instabilities such as bending of laths, breaking of lath boundaries, generation of cavities, and breakage of TiB needles. The presence of TiB needles affected the instability regime. Microstructural evidence suggests that the matrix cavitation is aided by the easy fracture of TiB needles.