Ballistic Trauma in Finland : An Epidemiologic and Clinical Study of Firearm and Explosion Injuries

The occurrence and nature of civilian firearm- and explosion-injuries in Finland, and the nature of severe gunshot injuries of the extremities were described in seven original articles. The main data sources used were the National Hospital Discharge Register, the Cause-of-Death Register, and the Archive of Death Certificates at Statistics Finland. The present study was population based. Epidemiologic methods were used in six and clinical analyses in five papers. In these clinical studies, every original hospital record and death certificate was critically analyzed. The trend of hospitalized firearm injuries has slightly declined in Finland from the late 1980s to the early 2000s. The occurrence decreased from 5.1 per 100 000 person-years in 1990 to 2.6 in 2003. The decline was found in the unintentional firearm injuries. A high incidence of unintentional injuries by firearms was characteristic of the country, while violence and homicides by firearms represented a minor problem. The incidence of fatal non-suicidal firearm injuries has been stable, 1.8 cases per 100 000 person-years. Suicides using firearms were eight times more common during the period studied. This is contrary to corresponding reports from many other countries. However, the use of alcohol and illegal drugs or substances was detected in as many as one-third of the injuries studied. The median length of hospitalization was three days and it was significantly associated (p<0.001) with the type of injury. The mean length of hospital stay has decreased from the 1980s to the early 2000s. In this study, there was a special interest in gunshot injuries of the extremities. From a clinical point of view, the nature of severe extremital gunshot wounds, as well as the primary operative approach in their management, varied. The patients with severe injuries of this kind were managed at university and central hospital emergency departments, by general surgeons in smaller hospitals and by cardiothoracic or vascular surgeons in larger hospitals. Injuries were rarities and as such challenges for surgeons on call. Some noteworthy aspects of the management were noticed and these should be focused on in the future. On the other hand, the small population density and the relatively large geographic area of Finland do not favor high volume, centralized trauma management systems. However, experimental war surgery has been increasingly taught in the country from the 1990s, and excellent results could be expected during the present decade. Epidemiologically, explosion injuries can be considered a minor problem in Finland at present, but their significance should not be underestimated. Fatal explosion injuries showed up sporadically. An increase occurred from 2002 to 2004 for no obvius reason. However, in view of the historical facts, a possibility for another rare major explosion involving several people might become likely within the next decade. The national control system of firearms is mainly based on the new legislations from 1998 and 2002. However, as shown in this study, there is no reason to assume that the national hospitalization policies, or the political climate, or the legislation might have changed over the study period and influenced the declining development, at least not directly. Indeed, the reason for the decline to appear in the incidence of unintentional injuries only remains unclear. It may derive from many practical steps, e.g. locked firearm cases, or from the stability of the community itself. For effective reduction of firearm-related injuries, preventive measures, such as education and counseling, should be targeted at recreational firearm users. To sum up, this study showed that the often reported increasing trend in firearm as well as explosion-related injuries has not manifested in Finland. Consequently, it can be recognized that, overall, the Finnish legislation together with the various strategies have succeeded in preventing firearm- and explosion-related injuries in the country.

[Medium-term results after m. vastus medialis obliquus-plasty for lateral patellar dislocation]

Progressive retropatellar arthrosis is often seen in dated rigid distal realignment (i.e. osteotomy of tuberositas) at long-term follow-ups. Therefore, operations for lateral dislocation of the patella are still discussed controversially. Dynamic, proximal realignments seem to have lower rates of arthrosis but higher rates of redislocation. Recently, in anatomic and biomechanic studies, the m. vastus medialis obliquus (vmo) was found to be one of the most important proximal restraints to lateral dislocation of the patella.A total of 28 patients (mean age 21.5 years) were treated between 1994 and 2003 with a plasty of the vmo for lateral patellar dislocation. The technique was performed for most etiologies of femoropatellar instability.For this proximal soft tissue technique, the muscle tendon is detached from its patellar insertion. Subsequently, the tendon is reinserted at the patella 10-15 mm more distally and fixed with Mitek anchors. Full weight bearing in extension is possible immediately after surgery. An active vastus medialis training is started after 6 weeks.Of the patients, 27 were evaluated clinically and radiologically in 2004 (a mean of 5 years postoperatively). A total of 83% of the patients estimated the result to be good or excellent, 10% were satisfied and 7% were discontent. The mean Lysholm-Knee-Score was 83.1 points. Two patients suffered a patella redislocation (7%). A statistically significant improvement of the congruence angle was noted in the radiographs, even in medium-term controls. In 89% of the cases no or only little retropatellar arthrosis was observed. These 5 year results are comparable to those of other techniques for distal or proximal realignments. The rate of redislocation was below average. Compared to the rate of retropatellar arthrosis in long-term results of rigid distal realignment, our patients demonstrated a relative low rate after 5 years. We attribute this to the minimal interference in physiological joint mechanics and to the restored anatomy. In terms of future long-term results, our findings are promising. The idea of a proximal dynamic stabilization and the causal operative approach at the origin of pathology using vmo-plasty was confirmed in recent anatomic and biomechanic studies. Over or under correction of soft tissues could be adapted. More rigid techniques of distal realignment do not allow an adaptation to this extent and can lead to prearthrotic hyperpression in the medial femoropatellar and femorotibial joints.

Mini-arthrotomy for lateral discoid menisci in children

BACKGROUND: Long-term results after partial, extended, or complete resection of lateral discoid meniscus in children revealed knee arthritis. The purpose of this study was to evaluate whether the operative approach, arthrotomy or arthroscopy, has an impact on the outcome and the development of arthritis. METHODS: A retrospective comparison of 2 well matching groups totaling 40 children with symptomatic lateral discoid meniscus (48 knees, mean age 8.9 years, 13 male and 27 female patients). Meniscus resection was performed via mini-arthrotomy in group 1 (n=17 patients, 20 knees) and arthroscopically in group 2 (n=23 patients, 28 knees). RESULTS: In the follow-up (mean 57 months in group 1, 62 months in group 2), functional results indicated a trend to better results in the International Knee Documentation Committee score (P=0.12) and in the Lysholm score for group 1 (P=0.13) but not in the Ikeuchi score (P=0.48). The comparison of the radiographic arthritis grading in the follow-up showed no significant arthritis in either group (P=0.22). The overall complication rate was similar in both groups (2/20, 10% in group 1; 3/28, 12% in group 2). CONCLUSIONS: Most likely because of the appropriate visualization of the children's joint and the easier instrumentation, the mini-arthrotomy led to slightly superior results compared with those after arthroscopic resection regarding functional outcome and 5 years after surgery. We can recommend the mini-arthrotomy for the resection of lateral discoid meniscus particularly in young children with narrow joint spaces and for surgeons that are not familiar with arthroscopies of small joints. LEVEL OF EVIDENCE: III (therapeutic study, case series with control group).

Free abdominal fluid without obvious solid organ injury upon CT imaging: an actual problem or simply over-diagnosing?

Whereas a non-operative approach for hemodynamically stable patients with free intraabdominal fluid in the presence of solid organ injury is generally accepted, the presence of free fluid in the abdomen without evidence of solid organ injury not only presents a challenge for the treating emergency physician but also for the surgeon in charge. Despite recent advances in imaging modalities, with multi-detector computed tomography (CT) (with or without contrast agent) usually the imaging method of choice, diagnosis and interpretation of the results remains difficult. While some studies conclude that CT is highly accurate and relatively specific at diagnosing mesenteric and hollow viscus injury, others studies deem CT to be unreliable. These differences may in part be due to the experience and the interpretation of the radiologist and/or the treating physician or surgeon.A search of the literature has made it apparent that there is no straightforward answer to the question what to do with patients with free intraabdominal fluid on CT scanning but without signs of solid organ injury. In hemodynamically unstable patients, free intraabdominal fluid in the absence of solid organ injury usually mandates immediate surgical intervention. For patients with blunt abdominal trauma and more than just a trace of free intraabdominal fluid or for patients with signs of peritonitis, the threshold for a surgical exploration - preferably by a laparoscopic approach - should be low. Based on the available information, we aim to provide the reader with an overview of the current literature with specific emphasis on diagnostic and therapeutic approaches to this problem and suggest a possible algorithm, which might help with the adequate treatment of such patients.

Long-term survival after multidisciplinary management of resected pancreatic adenocarcinoma.

INTRODUCTION: Actual 5-year survival rates of 10-18% have been reported for patients with resected pancreatic adenocarcinoma (PC), but the use of multimodality therapy was uncommon in these series. We evaluated long-term survival and patterns of recurrence in patients treated for PC with contemporary staging and multimodality therapy. METHODS: We analyzed 329 consecutive patients with PC evaluated between 1990 and 2002 who underwent resection. Each received a multidisciplinary evaluation and a standard operative approach. Pre- or postoperative chemotherapy and/or chemoradiation were routine. Surgical specimens of 5-year survivors were re-reviewed. A multivariate model of factors associated with long-term survival was constructed. RESULTS: Patients underwent pancreaticoduodenectomy (n = 302; 92%), distal (n = 20; 6%), or total pancreatectomy (n = 7; 2%). A total of 108 patients (33%) underwent vascular reconstruction, 301 patients (91%) received neoadjuvant or adjuvant therapy, 157 specimens (48%) were node positive, and margins were microscopically positive in 52 patients (16%). Median overall survival and disease-specific survival was 23.9 and 26.5 months. Eighty-eight patients (27%) survived a minimum of 5 years and had a median overall survival of 11 years. Of these, 21 (24%) experienced recurrence, 7 (8%) after 5 years. Late recurrences occurred most frequently in the lungs, the latest at 6.7 years. Multivariate analysis identified disease-negative lymph nodes (P = .02) and no prior attempt at resection (P = 0.01) as associated with 5-year survival. CONCLUSIONS: Our 27% actual 5-year survival rate for patients with resected PC is superior to that previously reported, and it is influenced by our emphasis on detailed staging and patient selection, a standardized operative approach, and routine use of multimodality therapy.

EACTS expert consensus statement for surgical management of pleural empyema

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce hospital costs, morbidity and mortality. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research. The European Association for Cardio-Thoracic Surgery (EACTS) Thoracic Domain and the EACTS Pleural Diseases Working Group established a team of thoracic surgeons to produce a comprehensive review of available scientific evidence with the aim to cover all aspects of surgical practice related to its treatment, in particular focusing on: surgical treatment of empyema in adults; surgical treatment of empyema in children; and surgical treatment of post-pneumonectomy empyema (PPE). In the management of Stage 1 empyema, prompt pleural space chest tube drainage is required. In patients with Stage 2 or 3 empyema who are fit enough to undergo an operative procedure, there is a demonstrated benefit of surgical debridement or decortication [possibly by video-assisted thoracoscopic surgery (VATS)] over tube thoracostomy alone in terms of treatment success and reduction in hospital stay. In children, a primary operative approach is an effective management strategy, associated with a lower mortality rate and a reduction of tube thoracostomy duration, length of antibiotic therapy, reintervention rate and hospital stay. Intrapleural fibrinolytic therapy is a reasonable alternative to primary operative management. Uncomplicated PPE [without bronchopleural fistula (BPF)] can be effectively managed with minimally invasive techniques, including fenestration, pleural space irrigation and VATS debridement. PPE associated with BPF can be effectively managed with individualized open surgical techniques, including direct repair, myoplastic and thoracoplastic techniques. Intrathoracic vacuum-assisted closure may be considered as an adjunct to the standard treatment. The current literature cements the role of VATS in the management of pleural empyema, even if the choice of surgical approach relies on the individual surgeon's preference.

Usos de la escritura en la enseñanza de la historia

Se presenta una caracterización de usos de la escritura en la enseñanza de la historia, producida en el marco de una investigación en Didácticas Específicas que estudia las relaciones entre la lectura y la escritura en la enseñanza y el aprendizaje escolar de historia. Se analizan usos de la escritura relacionados con distintas finalidades, además de los que impone el funcionamiento didáctico habitual de la historia como disciplina escolar. Se señalan posibles complementariedades y tensiones entre distintas racionalidades que intervienen en la generación de propuestas de escritura, en particular la tensión entre la lógica del estudio y la lógica del ejercicio. Por último, se caracteriza un problema del uso de las producciones escritas para la evaluación, relativo al modo en que pueden operar las consignas en la posibilidad de que los alumnos desplieguen -o no- los contenidos aprendidos sobre el tema evaluado

Entre lo informativo y lo estratégico : La cuestión de los abordajes del conocimiento histórico en la enseñanza de la historia

Este trabajo se centra en las distintas maneras en las cuales un lector-profesor de historia aborda el conocimiento histórico. Esos diferentes modos de abordarlo (informativa, operativa y estratégica) están presentes tanto en el momento de la lectura de los textos historiográficos como en el de la enseñanza del conocimiento que es su fruto. Así, la noción de abordaje se presenta como el eje tanto de la producción de sentido para la lectura de un libro de historia como de la configuración de los modos en que los contenidos de enseñanza son presentados a los estudiantes. Finalmente, es su condición de herramienta de análisis para la práctica de la enseñanza la que le permite dirigir una mirada renovada y más profunda a distintas situaciones relacionadas con la práctica de la enseñanza de la historia, que van desde la planificación de una clase o un curso hasta la comprensión de encuentros y desencuentros con los estudiantes en el plano de la ejercitación y la evaluación

Usos de la escritura en la enseñanza de la historia

Se presenta una caracterización de usos de la escritura en la enseñanza de la historia, producida en el marco de una investigación en Didácticas Específicas que estudia las relaciones entre la lectura y la escritura en la enseñanza y el aprendizaje escolar de historia. Se analizan usos de la escritura relacionados con distintas finalidades, además de los que impone el funcionamiento didáctico habitual de la historia como disciplina escolar. Se señalan posibles complementariedades y tensiones entre distintas racionalidades que intervienen en la generación de propuestas de escritura, en particular la tensión entre la lógica del estudio y la lógica del ejercicio. Por último, se caracteriza un problema del uso de las producciones escritas para la evaluación, relativo al modo en que pueden operar las consignas en la posibilidad de que los alumnos desplieguen -o no- los contenidos aprendidos sobre el tema evaluado

Entre lo informativo y lo estratégico : La cuestión de los abordajes del conocimiento histórico en la enseñanza de la historia

Este trabajo se centra en las distintas maneras en las cuales un lector-profesor de historia aborda el conocimiento histórico. Esos diferentes modos de abordarlo (informativa, operativa y estratégica) están presentes tanto en el momento de la lectura de los textos historiográficos como en el de la enseñanza del conocimiento que es su fruto. Así, la noción de abordaje se presenta como el eje tanto de la producción de sentido para la lectura de un libro de historia como de la configuración de los modos en que los contenidos de enseñanza son presentados a los estudiantes. Finalmente, es su condición de herramienta de análisis para la práctica de la enseñanza la que le permite dirigir una mirada renovada y más profunda a distintas situaciones relacionadas con la práctica de la enseñanza de la historia, que van desde la planificación de una clase o un curso hasta la comprensión de encuentros y desencuentros con los estudiantes en el plano de la ejercitación y la evaluación

Entre lo informativo y lo estratégico : La cuestión de los abordajes del conocimiento histórico en la enseñanza de la historia

Este trabajo se centra en las distintas maneras en las cuales un lector-profesor de historia aborda el conocimiento histórico. Esos diferentes modos de abordarlo (informativa, operativa y estratégica) están presentes tanto en el momento de la lectura de los textos historiográficos como en el de la enseñanza del conocimiento que es su fruto. Así, la noción de abordaje se presenta como el eje tanto de la producción de sentido para la lectura de un libro de historia como de la configuración de los modos en que los contenidos de enseñanza son presentados a los estudiantes. Finalmente, es su condición de herramienta de análisis para la práctica de la enseñanza la que le permite dirigir una mirada renovada y más profunda a distintas situaciones relacionadas con la práctica de la enseñanza de la historia, que van desde la planificación de una clase o un curso hasta la comprensión de encuentros y desencuentros con los estudiantes en el plano de la ejercitación y la evaluación

Usos de la escritura en la enseñanza de la historia

Se presenta una caracterización de usos de la escritura en la enseñanza de la historia, producida en el marco de una investigación en Didácticas Específicas que estudia las relaciones entre la lectura y la escritura en la enseñanza y el aprendizaje escolar de historia. Se analizan usos de la escritura relacionados con distintas finalidades, además de los que impone el funcionamiento didáctico habitual de la historia como disciplina escolar. Se señalan posibles complementariedades y tensiones entre distintas racionalidades que intervienen en la generación de propuestas de escritura, en particular la tensión entre la lógica del estudio y la lógica del ejercicio. Por último, se caracteriza un problema del uso de las producciones escritas para la evaluación, relativo al modo en que pueden operar las consignas en la posibilidad de que los alumnos desplieguen -o no- los contenidos aprendidos sobre el tema evaluado

Pre-operative nutritional support in children with end-stage liver disease accepted for liver transplantation: An approach to management

Pre-operative nutritional support was studied in 28 children with end-stage liver disease awaiting orthotopic liver transplantation. Nasogastric supplemental administration of a standard semi-elemental enteral nutritional formula was compared with a similar formula enriched with branched chain amino acids, and with a group receiving oral nutrition only. The duration of treatment in all groups was similar (mean 90 days). Energy intakes in the supplemented groups were 120-150% of recommended daily intakes (RDI), whereas ad libitum intakes in the oral group ranged 58-100% RDI. A significant improvement in mean Z-score for body weight (denoting catch-up) was noted only in those children who received nasogastric supplements enriched with branched-chain amino acids. The standard enterally-fed group maintained their body weight and Z-scores did not change significantly. In contrast, body weight Z-scores in those fed orally declined significantly. Nutritional supportive therapy of malnourished children with end-stage liver disease can minimize or improve nutritional status in children awaiting liver transplantation. The use of nutritional formulae rich in branche-chain amino acids may have nutritional advantages in children with chronic liver disease which require further study and evaluation.

A co-operative formation-based collision avoidance approach for a group of autonomous vehicles (Special Issue on Adaptive Control and Signal Processing in Marine System)

This paper employs a unique decentralised cooperative control method to realise a formation-based collision avoidance strategy for a group of autonomous vehicles. In this approach, the vehicles' role in the formation and their alert and danger areas are first defined, and the formation-based intra-group and external collision avoidance methods are then proposed to translate the collision avoidance problem into the formation stability problem. The extension–decomposition–aggregation formation control method is next employed to stabilise the original and modified formations, whilst manoeuvring, and subsequently solve their collision avoidance problem indirectly. Simulation study verifies the feasibility and effectiveness of the intra-group and external collision avoidance strategy. It is demonstrated that both formation control and collision avoidance problems can be simultaneously solved if the stability of the expanded formation including external obstacles can be satisfied.