Uusintamurtumien ehkäisy kaatumisen aiheuttaman yläraajamurtuman kokeneilla yli 50-vuotiailla henkilöillä

Tarkoitus: Tarkoituksena oli selvittää murtumien tehostetun ehkäisyohjelman vaikutuksia yläraajamurtuman saaneiden yli 50-vuotiaiden henkilöiden elämäntapoihin, murtumien riskitekijöihin, kaatumisiin, kaatumisvammoihin ja elämänlaatuun. Aineisto: 219 yli 50-vuotiasta kotona asuvaa, kaatumisen seurauksena yläraajamurtuman saanutta henkilöä satunnaistettiin koe- (n = 105) ja kontrolliryhmiin (n = 114). Menetelmä: Koeohjelma sisälsi yksilöllisen, yhdessä lääkärin, terveydenhoitajan ja tutkittavan kanssa laaditun hoito- ja kuntoutussuunnitelman sekä kutsun murtumien ehkäisyn koulutusohjelmaan. Kontrolliryhmän tutkittavat saivat kehotuksen hakeutua murtumahoitajan ohjaukseen. Seuranta-aika oli 14 kuukautta. Tulokset analysoitiin ryhmissä tapahtuneina muutoksina alkuja loppumittausten välillä sekä ryhmien välisenä erona muutoksissa. Tulokset: Keskimääräinen luun tiheys lannerangassa lisääntyi koeryhmässä (p<0,001) ja kontrolliryhmässä (p = 0,038), ryhmien välinen ero ei ollut tilastollisesti merkitsevä (p = 0,134). Reisiluun kaulassa luun tiheys ei muuttunut kummassakaan ryhmässä. Päivittäinen kalsiumin saanti lisääntyi koeryhmässä keskimäärin 167 mg (p<0,001) ja kontrolliryhmässä 30 mg (p = 0,475), ryhmien välinen ero oli tilastollisesti merkitsevä (p = 0,031). Kala-ateriat ja päivittäinen D-vitamiinilisä sekä kenkien liukuesteiden säännöllinen käyttö liukkaalla lisääntyivät molemmissa ryhmissä, mutta ryhmien välillä ei ollut eroa. Viiteen tuolilta nousukertaan käytetty aika vähentyi koeryhmässä keskimäärin 0,49 sekuntia (p = 0,185) ja lisääntyi kontrolliryhmässä 0,39 (p = 0,475), ero ryhmien välillä oli tilastollisesti merkitsevä (p = 0,02). Kymmenen metrin kävelyssä ei tapahtunut tulosten keskiarvossa muutoksia kummassakaan ryhmässä. Ortostatismi vähentyi kontrolliryhmässä (p = 0,049), ja masentuneisuus vähentyi koeryhmässä (p = 0,041), mutta ryhmien välillä ei näissä ollut merkitsevää eroa. Osteoporoosilääkkeiden käyttö lisääntyi molemmissa ryhmissä, ryhmien välillä ei ollut eroa. Alkoholin käytössä oli vähäisiä mutta ei merkittäviä muutoksia. Muissa testatuissa muuttujissa, kuten liikunnan viikoittainen määrä, tupakointi, näkökyky, tasapaino ja elämänlaatu, ei ollut merkitseviä muutoksia ryhmissä tai ryhmien välillä. Kaatumisten (koeryhmä 33, kontrolliryhmä 35) ja murtumien (koeryhmä 5 ja kontrolliryhmä 3) määrissä ei myöskään ollut merkitseviä eroja ryhmien välillä. Johtopäätökset: Noin neljällä viidestä kaatumisen seurauksena yläraajamurtuman saaneista, yli 50 vuotta täyttäneistä henkilöistä oli alentunut luun tiheys, ja noin joka toisella oli lisääntynyt kaatumisriski. Kaatumisen riskitekijöiden kliiniset mittaukset olivat nopeita toteuttaa ja auttoivat ehkäisytoimenpiteiden suunnittelussa. Murtuman saaneet olivat motivoituneita murtumien riskitekijöiden selvittämiseen ja myös toteuttamaan annettua lääkehoitoa. Elämäntavoissa helpoimmin toteutuivat muutokset ruokailutottumuksissa. Liikuntatottumuksien muuttaminen sen sijaan onnistui melko huonosti. Ryhmien välillä oli merkitsevä ero ainoastaan kalsiumin päivittäisessä käytössä ja tuolilta nousutestissä. Murtumariskien tunnistaminen, niiden syiden selvittäminen ja toimenpiteiden käynnistäminen riskien vähentämiseksi tulisi kuulua jokaisen pienienergisen murtuman saaneen potilaan kokonaisvaltaiseen hyvään hoitoon.

"Dov'è la sinistra?" Hemispatial neglect in stroke

As long as the incidence of stroke continues to grow, patients with large right hemisphere lesions suffering from hemispatial neglect will require neuropsychological evaluation and rehabilitation. The inability to process information especially that coming from the left side accompanied by the magnetic orientation to the ipsilesional side represents a real challenge for rehabilitation. This dissertation is concerned with crucial aspects in the clinical neuropsychological practice of hemispatial neglect. In studying the convergence of the visual and behavioural test batteries in the assessment of neglect, nine of the seventeen patients, who completed both the conventional subtests of the Behavioural Inattention Test and the Catherine Bergego Scale assessments, showed a similar severity of neglect and thus good convergence in both tests. However, patients with neglect and hemianopia had poorer scores in the line bisection test and they displayed stronger neglect in behaviour than patients with pure neglect. The second study examined, whether arm activation, modified from the Constraint Induced Movement Therapy, could be applied as neglect rehabilitation alone without any visual training. Twelve acute- or subacute patients were randomized into two rehabilitation groups: arm activation training or traditional voluntary visual scanning training. Neglect was ameliorated significantly or almost significantly in both training groups due to rehabilitation with the effect being maintained for at least six months. In studying the reflections of hemispatial neglect on visual memory, the associations of severity of neglect and visual memory performances were explored. The performances of acute and subacute patients with hemispatial neglect were compared with the performances of matched healthy control subjects. As hypothesized, encoding from the left side and immediate recall of visual material were significantly compromised in patients with neglect. Another mechanism of neglect affecting visual memory processes is observed in delayed visual reproduction. Delayed recall demands that the individual must make a match helped by a cue or it requires a search for relevant material from long-term memory storage. In the case of representational neglect, the search may succeed but the left side of the recollected memory still fails to open. Visual and auditory evoked potentials were measured in 21 patients with hemispatial neglect. Stimuli coming from the left or right were processed differently in both sensory modalities in acute and subacute patients as compared with the chronic patients. The differences equalized during the course of recovery. Recovery from hemispatial neglect was strongly associated with early rehabilitation and with the severity of neglect. Extinction was common in patients with neglect and it did not ameliorate with the recovery of neglect. The presence of pusher symptom hampered amelioration of visual neglect in acute and subacute stroke patients, whereas depression did not have any significant effect in the early phases after the stroke. However, depression had an unfavourable effect on recovery in the chronic phase. In conclusion, the combination of neglect and hemianopia may explain part of the residual behavioural neglect that is no longer evident in visual testing. Further research is needed in order to determine which specific rehabilitation procedures would be most beneficial in patients suffering the combination of neglect and hemianopia. Arm activation should be included in the rehabilitation programs of neglect; this is a useful technique for patients who need bedside treatment in the acute phase. With respect to the deficit in visual memory in association with neglect, the possible mechanisms of lateralized deficit in delayed recall need to be further examined and clarified. Intensive treatment induced recovery in both severe and moderate visual neglect long after the first two to first three months after the stroke.

The effectiveness of vocationally oriented multidisciplinary rehabilitation (ASLAK®) amongst public sector employees

In Finland, vocationally oriented medical rehabilitation (ASLAK®) is a common preventive rehabilitation measure with the primary goal of preserving and improving work ability. The ASLAK® programme has been used for almost 30 years, although limited data exist on its effectiveness. The aims of this study were to determine whether the increased risk of work disability predicts the participants’ likelihood to be granted ASLAK® rehabilitation and to assess the effectiveness of the programme in decreasing the risk of work disability and modifying health-risk behaviours. This study is a part of the on-going Finnish Public Sector Study conducted by the Finnish Institute of Occupational Health. Data on 53 416 employees (81% women) were gathered from employers’ records, national health registers and repeated survey responses. During the 5-year follow-up, increased levels of the risk factors for work disability did not predict participation in the rehabilitation programme. During the 2.8-year followup (range 0.04–5.0 years), the risk of long-term work disability (sick leave >90 days or retirement) overall or, more specifically, due to musculoskeletal or mental diseases did not differ between the rehabilitants who participated in ASLAK® in 1997–2005 and their propensity score matched controls. There was no evidence of ASLAK® being effective in changing participants’ health-risk behaviours or in improving perceived general or mental health. The results suggest that potential participant recognition, mainly taking place in occupational health care, may fail to identify those with a higher risk of work disability. No evidence on the effectiveness of the programme was found in the study cohort when measured by the selected indicators.

The holistic military capability life cycle model

Abstract - This paper reviews existing military capability models and the capability life cycle. It proposes a holistic capability life-cycle model (HCLCM) that combines capability systems with related capability models. ISO 15288 standard is used as a framework to construct the HCLCM. The HCLCM also shows how capability models and systems relate to each other throughout the capability life cycle. The main contribution of this paper is conceptual in nature. The model complements the existing, but still evolving, understanding of the military capability life cycle in a holistic and systemic way. The model also increases understanding and facilitates communication among various military capability stakeholders.

Clinical, hematological, total plasma protein and fibrinogen parameters of magellanic penguins ( Spheniscus magellanicus ) pre- and post-rehabilitation

Abstract: Magellanic penguins (Spheniscus magellanicus) usually arrive in poor body conditions at Brazilian beaches during the winter. Hematology provides valuable information about clinical and immunity status of the animals. The aims of this study were to determine the hematologic, total plasma protein (TPP) and fibrinogen profiles of young and adult magellanic penguins in PROAMAR and CETAS-SC, relating these results with the state of health and survival possibility of the animals. In Paraná 14 animals were evaluated in pre and eight in post-rehabilitation and 29 animals were evaluated in Santa Catarina after rehabilitation. Before rehabilitation, all animals showed weakness. In hematological exams of these animals, we found that anemia was present in 83% of the penguins that died and 50% of those which survived. The heterophils/lymphocytes (H/L) ratio was 3.87±0.57 in animals that died, significantly higher than the average of 2.20±0.30 for animals that survived. These two parameters are useful to assess the survival possibility of animals to rehabilitation. The body condition score was positively correlated with hematocrit and TPP, and negatively correlated with H/L ratio. After rehabilitation, the values were similar to other animals of the family Spheniscidae, with averages ranging from 1.64 to 1.90x106 erythrocytes/μL; 43.38 to 48.80% of hematocrit; 12.45 to 13.52g/dL of hemoglobin; 8,684 to 14,011 leukocytes/μL; 4,767 to 8,041 heterophils/μL; 3,215 to 4,951 lymphocytes/μL; 95 to 655 eosinophils/μl; 179.8 to 277.9 monocytes/μL; 141 to 184.9 basophils/μL; and 1.26 to 1.74 of H/L ratio. These parameters can therefore be used as reference values and release parameters for young and adult Magellanic penguins in captivity on the rehabilitation centers.

Physiologic parameters in female Red-billed curassows (Crax blumenbachii) in rehabilitation

Abstract: The present paper reports blood gas analysis, hematologic and micro bacteriologic information on four female Red-billed curassows, rescued from illegal wild animal trading, that were undergoing habilitation for reintroduction into the wild through Projeto Centrofauna/Botucatu-SP. There is a lack of physiological data on this species, endemic to the region of Atlantic Forest (Mata Atlântica), now under threat of extinction. This lack of information makes the clinical evaluation of these birds very difficult and has a direct and adverse effect on any of these birds received for medical treatment in hospitals, veterinary clinics and centers for research and conservation, as well as in reintroduction centers.

Developmental norms for eight instruments used in the neuropsychological assessment of children: studies in Brazil

Norms for a battery of instruments, including Denckla's and Garfield's tests of Motor Persistence, Benton's Right-Left Discrimination, two recall modalities (Immediate and Delayed) of the Bender Test, Wechsler's Digit Span, the Color Span Test and the Human Figure Drawing Test, were developed for the neuropsychological assessment of children in the greater Rio de Janeiro area. Additionally, the behavior of each child was assessed with the Composite Teacher Rating Scale (Brito GNO and Pinto RCA (1991) Journal of Clinical and Experimental Neuropsychology, 13: 417-418). A total of 398 children (199 boys and 199 girls balanced for age) with a mean age of 9.3 years (SD = 2.8), who were attending a public school in Niterói, were the subjects of this study. Gender and age had significant effects on performance which depended on the instrument. Nonachievers performed worse than achievers in most neuropsychological tests. Comparison of our data to the available counterparts in the United States revealed that American children outperformed Brazilian children on the Right-Left Discrimination, Forward Digit Span, Color Span and Human Figure Drawing Tests. Further analysis showed that the neurobehavioral data consist of different factorial dimensions, including Human Body Representation, Motor Persistence of the Legs, Orbito-Orobuccal Motor Persistence, Attention-Memory, Visuospatial Memory, Neuropsychomotor Speed, Hyperactivity-Inattention, and Anxiety-Negative Socialization. We conclude that gender and age should be taken into account when using the normative data for most of the instruments studied in the present report. Furthermore, we stress the need for major changes in the Brazilian public school system in order to foster the development of secondary cognitive abilities in our children

Urinary secretory IgA after nutritional rehabilitation

We studied the secretory IgA (sIgA) response of the mucosal urinary tract of malnourished children before and after nutritional rehabilitation. sIgA concentration (mg/l) was determined by ELISA in 187 children aged 3 months to 5 years. The children, who frequented a day care center, were divided into four groups, according to nutritional status: 57 were eutrophic, 49 were undergrown, 57 were moderately malnourished and 24 were severely malnourished. In addition, dip slide (Urotube, Roche) and dip-stick (Combur 9-Boehringer) tests showed that children had no bacteriuria or any other urinary abnormalities. Plasma albumin concentration (g/dl) was significantly lower (P<0.005) in the severely malnourished group (mean 3.0 ± 0.3 SD) than in the eutrophic group (mean 4.0 ± 0.5 SD). When each nutritional state was analyzed, no significant differences in the sIgA were found between the 0 |-| 1 and 1 -| 5 year age range. In the moderately and severely malnourished groups, sIgA (0.36 and 0.45, respectively) was significantly lower than in the eutrophic (0.69) and undergrown (0.75) groups. Ninety-five children were included in the 8-month follow-up study; 30 children were excluded from the follow-up because 4 had bacteriuria, 11 had leukocyturia, 8 had proteinuria and 7 had hematuria. Among the malnourished children, 40% showed nutritional improvement (P<0.05) and significantly increased sIgA as compared to reference values for the eutrophic and undergrown groups. These data suggest that malnourished children have a significantly lower urinary sIgA than eutrophic children. After nutritional rehabilitation, they develop local immunity with a significant increase in sIgA.

Neuropsychological dysfunction related to earlier occupational exposure to mercury vapor

We assessed the neuropsychological test performances of 26 patients (mean age = 41.5 ± 6.1 years; mean years of education = 9.8 ± 1.8; 20 males) diagnosed with chronic occupational mercurialism who were former workers at a fluorescent lamp factory. They had been exposed to elemental mercury for an average of 10.2 ± 3.8 years and had been away from this work for 6 ± 4.7 years. Mean urinary mercury concentrations 1 year after cessation of work were 1.8 ± 0.9 µg/g creatinine. Twenty control subjects matched for age, gender, and education (18 males) were used for comparison. Neuropsychological assessment included attention, inhibitory control, verbal and visual memory, verbal fluency, manual dexterity, visual-spatial function, executive function, and semantic knowledge tests. The Beck Depression Inventory and the State and Trait Inventory were used to assess depression and anxiety symptoms, respectively. The raw score for the group exposed to mercury indicated slower information processing speed, inferior performance in psychomotor speed, verbal spontaneous recall memory, and manual dexterity of the dominant hand and non-dominant hand (P < 0.05). In addition, the patients showed increased depression and anxiety symptoms (P < 0.001). A statistically significant correlation (Pearson) was demonstrable between mean urinary mercury and anxiety trait (r = 0.75, P = 0.03). The neuropsychological performances of the former workers suggest that occupational exposure to elemental mercury has long-term effects on information processing and psychomotor function, with increased depression and anxiety also possibly reflecting the psychosocial context.

Histomorphometric analysis of the response of rat skeletal muscle to swimming, immobilization and rehabilitation

The objective of the present study was to determine to what extent, if any, swimming training applied before immobilization in a cast interferes with the rehabilitation process in rat muscles. Female Wistar rats, mean weight 260.52 ± 16.26 g, were divided into 4 groups of 6 rats each: control, 6 weeks under baseline conditions; trained, swimming training for 6 weeks; trained-immobilized, swimming training for 6 weeks and then immobilized for 1 week; trained-immobilized-rehabilitated, swimming training for 6 weeks, immobilized for 1 week and then remobilized with swimming for 2 weeks. The animals were then sacrificed and the soleus and tibialis anterior muscles were dissected, frozen in liquid nitrogen and processed histochemically (H&E and mATPase). Data were analyzed statistically by the mixed effects linear model (P < 0.05). Cytoarchitectural changes such as degenerative characteristics in the immobilized group and regenerative characteristics such as centralized nucleus, fiber size variation and cell fragmentation in the groups submitted to swimming were more significant in the soleus muscle. The diameters of the lesser soleus type 1 and type 2A fibers were significantly reduced in the trained-immobilized group compared to the trained group (P < 0.001). In the tibialis anterior, there was an increase in the number of type 2B fibers and a reduction in type 2A fibers when trained-immobilized rats were compared to trained rats (P < 0.001). In trained-immobilized-rehabilitated rats, there was a reduction in type 2B fibers and an increase in type 2A fibers compared to trained-immobilized rats (P < 0.009). We concluded that swimming training did not minimize the deleterious effects of immobilization on the muscles studied and that remobilization did not favor tissue re-adaptation.

Exercise may cause myocardial ischemia at the anaerobic threshold in cardiac rehabilitation programs

Myocardial ischemia may occur during an exercise session in cardiac rehabilitation programs. However, it has not been established whether it is elicited when exercise prescription is based on heart rate corresponding to the anaerobic threshold as measured by cardiopulmonary exercise testing. Our objective was to determine the incidence of myocardial ischemia in cardiac rehabilitation programs according to myocardial perfusion SPECT in exercise programs based on the anaerobic threshold. Thirty-nine patients (35 men and 4 women) diagnosed with coronary artery disease by coronary angiography and stress technetium-99m-sestamibi gated SPECT associated with a baseline cardiopulmonary exercise test were assessed. Ages ranged from 45 to 75 years. A second cardiopulmonary exercise test determined training intensity at the anaerobic threshold. Repeat gated-SPECT was obtained after a third cardiopulmonary exercise test at the prescribed workload and heart rate. Myocardial perfusion images were analyzed using a score system of 6.4 at rest, 13.9 at peak stress, and 10.7 during the prescribed exercise (P < 0.05). The presence of myocardial ischemia during exercise was defined as a difference ≥2 between the summed stress score and summed rest score. Accordingly, 25 (64%) patients were classified as ischemic and 14 (36%) as nonischemic. MIBI-SPECT showed myocardial ischemia during exercise within the anaerobic threshold. The 64% prevalence of ischemia observed in the study should not be looked on as representative of the whole population of patients undergoing exercise programs. Changes in patient care and exercise programs were implemented as a result of our finding of ischemia during the prescribed exercise.

Critical elements underpinning the emergence of the medical game ecosystem: gamifying traumatic brain injury rehabilitation in Finland

The healthcare sector is currently in the verge of a reform and thus, the medical game research provide an interesting area of research. The aim of this study is to explore the critical elements underpinning the emergence of the medical game ecosystem with three sub-objectives: (1) to seek who are the key actors involved in the medical game ecosystem and identify their needs, (2) to scrutinise what types of resources are required in medical game development and what types of relationships are needed to secure those resources, and (3) to identify the existing institutions (‘the rules of the game’) affecting the emergence of the medical game ecosystem. The theoretical background consists of service ecosystems literature. The empirical study conducted is based on the semi-structured theme interviews of 25 experts in three relevant fields: games and technology, health and funding. The data was analysed through a theoretical framework that was designed based upon service ecosystems literature. The study proposes that the key actors are divided into five groups: medical game companies, customers, funders, regulatory parties and complementors. Their needs are linked to improving patient motivation and enhancing the healthcare processes resulting in lower costs. Several types of resources, especially skills and knowledge, are required to create a medical game. To gain access to those resources, medical game companies need to build complex networks of relationships. Proficiency in managing those value networks is crucial. In addition, the company should take into account the underlying institutions in the healthcare sector affecting the medical game ecosystem. Three crucial institutions were identified: validation, lack of innovation supporting structures in healthcare and the rising consumerisation. Based on the findings, medical games cannot be made in isolation. A developmental trajectory model of the emerging medical game ecosystem was created based on the empirical data. The relevancy of relationships and resources is dependent on the trajectory that the medical game company at that time resides. Furthermore, creating an official and documented database for clinically valdated medical games was proposed to establish the medical game market and ensure an adequate status for the effective medical games. Finally, ecosystems approach provides interesting future opportunities for research on medical game ecosystems.

Critical elements underpinning the emergence of the medical game ecosystem:gamifying traumatic brain injury rehabilitation in Finland

The healthcare sector is currently in the verge of a reform and thus, the medical game research provide an interesting area of research. The aim of this study is to explore the critical elements underpinning the emergence of the medical game ecosystem with three sub-objectives: (1) to seek who are the key actors involved in the medical game ecosystem and identify their needs, (2) to scrutinise what types of resources are required in medical game development and what types of relationships are needed to secure those resources, and (3) to identify the existing institutions (‘the rules of the game’) affecting the emergence of the medical game ecosystem. The theoretical background consists of service ecosystems literature. The empirical study conducted is based on the semi-structured theme interviews of 25 experts in three relevant fields: games and technology, health and funding. The data was analysed through a theoretical framework that was designed based upon service ecosystems literature. The study proposes that the key actors are divided into five groups: medical game companies, customers, funders, regulatory parties and complementors. Their needs are linked to improving patient motivation and enhancing the healthcare processes resulting in lower costs. Several types of resources, especially skills and knowledge, are required to create a medical game. To gain access to those resources, medical game companies need to build complex networks of relationships. Proficiency in managing those value networks is crucial. In addition, the company should take into account the underlying institutions in the healthcare sector affecting the medical game ecosystem. Three crucial institutions were identified: validation, lack of innovation supporting structures in healthcare and the rising consumerisation. Based on the findings, medical games cannot be made in isolation. A developmental trajectory model of the emerging medical game ecosystem was created based on the empirical data. The relevancy of relationships and resources is dependent on the trajectory that the medical game company at that time resides. Furthermore, creating an official and documented database for clinically validated medical games was proposed to establish the medical game market and ensure an adequate status for the effective medical games. Finally, ecosystems approach provides interesting future opportunities for research on medical game ecosystems