Patient injury claims for posterior cruciate ligament injury: a nationwide registry study in Finland.

BACKGROUND AND PURPOSE: Posterior cruciate ligament (PCL) injuries usually occur in combination with other ligamentous knee injuries. The outcome varies and may be poor due to suboptimal treatment. We investigated claims following PCL injury treatment on a nationwide scale. PATIENTS AND METHODS: All patient PCL injury claims filed in Finland from 1997 to 2015 were collected from the Patient Insurance Centre (PIC) register. We reviewed and analyzed all records to determine the causes of claims. General background data were obtained from the National Care Register for Social Welfare and Health Care (HILMO). RESULTS: We found out from HILMO background data that, during the 19-year study period, 1,891 PCL and 1,380 multiligament reconstructions were performed in 99 different hospitals. The number of PCL injuries treated conservatively is unknown. During this same period, 49 claims arrived at the PIC, and 39/49 of these patients were operated on. 12/49 claims were compensated. Of these 12 claims, 6 were compensated for technical errors and 4 were compensated for diagnostic delays. CONCLUSION: The number of patient injury claims was few, and compensated claims were even fewer. Technical errors and diagnostic delays were the most common reasons for reimbursement.

Anterior cruciate ligament reconstruction-related patient injuries: a nationwide registry study in Finland.

Background and purpose - Treatment outcomes of anterior cruciate ligament (ACL) injuries are generally good, but complications after ACL reconstruction (ACLR) can result in long-lasting problems. Patient injury claims usually fall on the more severe end of the complication spectrum. They are important to investigate because they may reveal the root causes of adverse events, which are often similar regardless of the complication's severity. Therefore, we analyzed ACL-related patient injuries in Finland, the reasons for these claims, causes of complications, and grounds for compensation.Patients and methods - We analyzed all claims filed at the Patient Insurance Centre (PIC) between 2005 and 2013 in which the suspected patient injury occurred between 2005 and 2010. This study also reviewed all original patient records and available imaging studies. General background data were obtained from the National Care Register for Social Welfare and Health Care (HILMO).Results - There were 248 patient injury claims, and 100 of these were compensated. Compensated claims were divided into 4 main categories: skill-based errors (n = 46), infections (n = 34), knowledge-based errors (n = 6), and others (n = 14). Of the compensated skill-based errors, 34 involved graft malposition, 26 of them involved the femoral-side tunnel. All compensated infections were deep surgical site infections (DSSI).Interpretation - This is the first nationwide study of patient injuries concerning ACLRs in Finland. The most common reasons for compensation were DSSI and malposition of the drill tunnel. Therefore, it would be possible to decrease the number of serious complications by concentrating on infection prevention and optimal surgical technique.

Patient injury claims involving fractures of the distal radius.

Background and purpose - Optimal treatment for distal radius fractures remains controversial, with a significant number of fractures resulting in complications and long-term morbidity. We investigated patient injury claims related to distal radius fractures to detect the critical steps in the treatment leading to avoidable adverse events Patients and methods - We analyzed all compensated patient injury claims in Finland between 2007 and 2011. Claims were collected from the Patient Insurance Center's (PIC) nationwide claim register. Patients of all ages were included. Each claim decision, original patient records, and radiographs related to treatment were reviewed. Results - During the study period, the PIC received 584 claims regarding distal radius fractures, of which 208 (36%) were compensated. Pain and impaired wrist function were the most common subjective reasons to file claims among compensated patients. In 66/208 patients, more than 1 adverse event leading to patient injury was detected. The detected adverse events could be divided into 3 main groups: diagnostic errors (36%, n = 103), decision/planning errors (30%, n = 87), and insufficient technical execution (32%, n = 91). Issues related to malalignment were the main concerns in each group. Diagnostic errors were often related to incorrect assessment of the fracture (re)displacement (75%, n = 78). All of the decision-making errors concerned physicians' decisions to accept unsatisfactory fracture alignment. The most common technical error was insufficient reduction (29%, n = 26). Interpretation - We identified avoidable adverse events behind patient injuries related to distal radius fracture treatment. This study will help physicians to recognize the critical steps in the treatment of this common fracture and enhance patient safety.

Patient injuries in primary total hip replacement.

Background and purpose - Although the results of primary total hip replacements (THRs) are generally excellent, sometimes serious complications arise. Some of these severe complications are considered to be patient injuries. We analyzed primary THR-related patient injuries in a nationwide setting. Patients and methods - We evaluated all the primary THR-related patient injury claims in Finland between 2008 and 2010. We used the original medical records and 2 nationwide registries, the Care Register for Social Welfare and Health Care and the Patient Injury Claim Register. Results - We identified 563 claims, 44% of which were compensated (n = 250). Of these 250 compensated claims, 79% were considered to be avoidable (treatment injuries) and 21% were severe unexpected infections (with a preoperative infection risk of less than 2%). The most common type of technical error was cup malposition (31%). High-volume hospitals (with an annual primary THR volume ≥ 400) had a lower patient injury rate. In lower-volume hospitals (with an annual primary THR volume of < 400), the relative risks (RRs) of patient injury for any reason, due to technical errors, or because of cup malposition were 2-fold (95% CI: 1.6-3.1), 4-fold (95% CI: 2.3-6.2), and 9-fold (95% CI: 3-28), respectively, compared to high-volume hospitals. Interpretation - Our study provides the first comprehensive nationwide data on THR-related patient injury types. Hospital volume was associated with the quality and quantity of errors detected. An annual hospital volume of ≥ 400 primary THRs was established as a protective factor against patient injuries.

[Pseudotumors caused by hip prostheses]. / Lonkkaproteesien aiheuttamat pseudotuumorit.

More than 100000 hip replacements have been performed in Finland. In the hip replacement operations performed due to osteoarthritis, the artificial joint surfaces are made of metal, plastic or ceramics. Pseudotumors associated with metal-on-metal (MoM) sliding surfaces have received worldwide attention. Soft issue lesions, not always symptomatic, may develop around the joint replacements. These may even require joint revision surgery.

Patient-specific factors affecting survival following hip fractures-a 14-year follow-up study in Finland.

The mortality of elderly hip fracture patients is high. Eighty-five percent of all patients were followed until death. The three most protective factors for 1-year survival were ASA class; BMI; and age, and the four most protective factors for 14-year survival were age; BMI; ASA class; and subtrochanteric fracture type. OBJECTIVE: Hip fractures are associated with increased mortality. The purpose of this study was to evaluate the protective preoperative factors regarding the survival of short-term (1 year) and long-term (14 years) follow-up in a hip fracture cohort in Finland. METHODS: A total of 486 patients, operated on in 2005 and 2006, were retrospectively evaluated. Survival was analyzed using Bayesian multivariate analysis and relative survival with the life table method. All patients were followed for a minimum of 14 years. RESULTS: We analyzed 330 women and 156 men, whose mean ages were 82.4 and 72.0 years, respectively. The overall mortality rate was 7% at 1 month, 22% at 12 months, and 87% at 14 years. Protective factors against mortality at 1 year were ASA class (1-3), BMI ≥ 20 kg/m2, age < 85 years, alcohol involvement, Alzheimer's disease, no comorbidities, certain operative methods, and female sex. Factors promoting survival at 14 years were age < 75 years, BMI ≥ 20 kg/m2, ASA class (1-2), subtrochanteric fracture, certain operative methods, alcohol involvement, and no comorbidities. CONCLUSIONS: Protective factors for 1-year survival in order of importance were ASA class, BMI, and age, and, correspondingly, for 14-year survival, age, certain operative methods, BMI, and ASA class. The relative survival of hip fracture patients was lower than that of the general population.

Overexpression of vascular endothelial growth factor-B in mouse heart alters cardiac lipid metabolism and induces myocardial hypertrophy.

Vascular endothelial growth factor (VEGF)-B is poorly angiogenic but prominently expressed in metabolically highly active tissues, including the heart. We produced mice expressing a cardiac-specific VEGF-B transgene via the alpha-myosin heavy chain promoter. Surprisingly, the hearts of the VEGF-B transgenic mice showed concentric cardiac hypertrophy without significant changes in heart function. The cardiac hypertrophy was attributable to an increased size of the cardiomyocytes. Blood capillary size was increased, whereas the number of blood vessels per cell nucleus remained unchanged. Despite the cardiac hypertrophy, the transgenic mice had lower heart rate and blood pressure than their littermates, and they responded similarly to angiotensin II-induced hypertension, confirming that the hypertrophy does not compromise heart function. Interestingly, the isolated transgenic hearts had less cardiomyocyte damage after ischemia. Significantly increased ceramide and decreased triglyceride levels were found in the transgenic hearts. This was associated with structural changes and eventual lysis of mitochondria, resulting in accumulation of intracellular vacuoles in cardiomyocytes and increased death of the transgenic mice, apparently because of mitochondrial lipotoxicity in the heart. These results suggest that VEGF-B regulates lipid metabolism, an unexpected function for an angiogenic growth factor.

Randomised controlled study comparing general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty: study protocol.

INTRODUCTION: Total knee arthroplasty is a highly effective treatment for end-stage knee osteoarthritis, and it is usually performed under spinal or general anaesthesia with or without a surgical tourniquet. Some debate about the preferred mode of anaesthesia regarding patient outcomes remains. The aim of this study, which compares general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty, is to determine the optimal type of anaesthesia regimen and assess the effect of a tourniquet on the patient's recovery following total knee arthroplasty. METHODS AND ANALYSIS: This study is a randomised, controlled, parallel-group, four-arm study comparing spinal and general anaesthesia with and without a tourniquet in 400 patients undergoing fast-track total knee arthroplasty, with a 12-month follow-up. The primary outcome is cumulative intravenous oxycodone consumption by patient-controlled analgesia during the first 24 postoperative hours. Secondary outcomes include postoperative nausea and vomiting, the length of hospital stay, the duration of the surgery, blood loss, demand for surgical unit resources, complications, readmissions, postoperative knee function, range of motion, health-related quality of life, prolonged pain and mortality. ETHICS AND DISSEMINATION: This study's protocol is in accordance with the declaration of Helsinki. The results of this study will be disseminated in international peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03364088; Pre-results.

Increased catechol-O-methyltransferase activity and protein expression in OX-42-positive cells in the substantia nigra after lipopolysaccharide microinfusion.

Activated microglial cells are found in the substantia nigra and the striatum of Parkinson's disease patients. These cells have been shown to express catechol-O-methyltransferase activity which may increase during pathological conditions. Lipopolysaccharides are potent activators of microglial cells. After paranigral lipopolysaccharide infusion to rats we observed intense microglial activation around the lesion area followed by a delayed injury in nigrostriatal pathway in 2 weeks. Simultaneously, catechol-O-methyltransferase activity in the substantia nigra was gradually increased up to 213%. In the Western blot the amount of soluble COMT and membrane bound COMT proteins were increased by 255% and 86%, respectively. Increased catechol-O-methyltransferase immunoreactivity was located primarily into the activated microglial cells in the lesion area. Interestingly, catechol-O-methyltransferase and OX-42 stained also intensively microglia/macrophage-like cells which surrounded the adjacent blood vessels. Inhibition of catechol-O-methyltransferase activity by tolcapone or entacapone did not increase lipopolysaccharide-induced neurotoxicity. We conclude that catechol-O-methyltransferase activity and protein expression were increased in the substantia nigra after inflammation induced by lipopolysaccharides. These changes in glial and perivascular catechol-O-methyltransferase activity may have clinical relevance for Parkinson's disease drug treatment due to increased metabolism of levodopa in the brain.

Resistance to salt-induced hypertension in catechol-O-methyltransferase-gene-disrupted mice.

BACKGROUND: Previous studies have indicated that catechol-O-methyltransferase (COMT) can modulate renal dopaminergic tone. OBJECTIVE: To test the hypothesis that COMT blockade protects from salt-induced hypertension. METHODS: COMT gene-disrupted (-/-) mice and wild-type controls received a high-sodium diet (NaCl 6%) for 3 weeks. Blood pressure and heart rate were recorded by radiotelemetry. Tissue and urine samples were assessed by light microscopy and high-performance liquid chromatography. The effects of nitecapone treatment were also examined. Systolic blood pressure and heart rate during normal sodium diet were similar in COMT (-/-) and wild-type mice. The high-sodium diet increased night-time systolic and diastolic blood pressures in wild-type mice, whereas blood pressure in COMT (-/-) mice remained unaltered. In wild-type mice, the sodium-induced increase in blood pressure was completely normalized by treatment with the COMT inhibitor, nitecapone. At baseline, 24-h urinary excretion of levodopa (L-DOPA), dopamine and noradrenaline was increased by 145, 85 and 74%, respectively, in COMT (-/-) mice compared with wild-type controls. In COMT (-/-) and wild-type mice, a high-sodium diet increased urinary L-DOPA excretion by 405 and 660% (reflected as 102 and 212% increases in dopamine excretion), respectively. The absolute amounts of urinary L-DOPA and dopamine remained 60 and 20% greater in COMT (-/-) mice. The high-sodium diet did not influence renal cortical COMT activity. CONCLUSION: Our findings suggest that COMT deficiency in mice increases the availability of L-DOPA, leading to enhanced dopaminergic tone, which may be associated with resistance to salt-induced hypertension. The findings of the present study also underline the importance of COMT in the regulation of blood pressure, sodium excretion and renal dopaminergic tone.

Entacapone protects from angiotensin II-induced inflammation and renal injury.

OBJECTIVES AND DESIGN: Angiotensin II (Ang II)-induced renal damage is associated with perivascular inflammation and increased oxidative stress. We tested the hypothesis whether entacapone, a catechol-O-methyltransferase (COMT) inhibitor exerting antioxidative and anti-inflammatory properties, protects against the Ang II-induced inflammatory response and end-organ damage. METHODS: Samples from double-transgenic rats harbouring human renin and human angiotensinogen genes (dTGR) and normotensive Sprague-Dawley rats (SD) were assessed by light microscopy, immunohistochemistry, reverse transcriptase-polymerase chain reaction (RT-PCR), and high pressure liquid chromatography. The effects of entacapone treatment for 3 weeks were examined in dTGR and SD. RESULTS: Entacapone completely prevented cardiovascular mortality and decreased albuminuria by 85% in dTGR. Entacapone ameliorated Ang II-induced vascular and glomerular damage, leucocyte infiltration, and intercellular adhesion molecule-1 (ICAM-1) overexpression in the kidneys. Serum 8-isoprostane concentration, as well as renal nitrotyrosine and 8-hydroxydeoxyguanosine expressions, all markers of oxidative stress, were markedly increased in dTGR and normalized by entacapone. Entacapone also decreased p22phox mRNA expression in the kidney. COMT expression was increased by 500% locally in the renal vascular wall in dTGR; however, COMT activity in the whole kidney remained unchanged. Urinary dopamine excretion, a marker of renal dopaminergic tone, was decreased by 50% in untreated dTGR. Even though entacapone decreased renal COMT activity by 40%, the renal dopaminergic tone remained unchanged in entacapone-treated dTGR. CONCLUSION: Our findings suggest that entacapone provides protection against Ang II-induced renal damage through antioxidative and anti-inflammatory mechanisms, rather than by COMT inhibition-induced changes in renal dopaminergic tone.

Angeli's salt induces neurotoxicity in dopaminergic neurons in vivo and in vitro.

In this study, we investigated the hypothesis that the pro-oxidative properties of Angeli's salt (AS), a nitroxyl anion (HNO/NO-) releasing compound, cause neurotoxicity in dopaminergic neurons. The pro-oxidative properties were demonstrated in vitro by measuring hydroxylation products of salicylate and peroxidation of lipids under various redox conditions. AS (0-1000 microM) released high amounts of hydroxylating species in a concentration dependent manner. AS also increased lipid peroxidation in brain homogenates at concentrations below 100 microM, while inhibiting it at 1000 microM concentration. The AS induced pro-oxidative effects were completely suppressed by copper (II), which converts nitroxyl anion to nitric oxide, as well as by a potent nitroxyl anion scavenger glutathione. Neurotoxicity towards dopaminergic neurons was tested in rat nigrostriatal dopaminergic system in vivo and by using primary mesencephalic dopaminergic neuronal cultures in vitro. Intranigral infusion of AS (0-400 nmol) caused neurotoxicity reflected as a dose dependent decrease of striatal dopamine seven days after treatment. The effect of the 100 nmol dose was more pronounced whenmeasured 50 days after the infusion. Neurotoxicity was also confirmed as a decrease of tyrosine hydroxylase positive neurons in the substantia nigra. Neither sulphononoate, a close structural analog of AS, nor sodiumnitrite caused changes in striatal dopamine, thus reflecting lack of neurotoxicity. In primary dopaminergic neuronal cultures AS reduced [3H] dopamine uptake with concentrations over 200 microM confirming neurotoxicity. In line with the quite low efficacy to increase lipid peroxidation in vitro, infusion of AS into substantia nigra did not cause increased formation of fluorescent products of lipid peroxidation. These results support the hypothesis that AS derived species oxidize critical thiol groups, rather than membrane lipids, potentially leading to protein oxidation/dysfunction and demonstrated neurotoxicity These findings may have pathophysiological relevance in case of excess formation of nitroxyl anion.

A long-term follow-up of 221 hip fracture patients in southeastern Finland: analysis of survival and prior or subsequent fractures.

UNLABELLED: To analyze the type and effect of prior and subsequent fractures in a hip fracture cohort. MATERIALS AND METHODS: Hip fracture patients (n=221) were followed for a mean of 8 years and all prior and subsequent fractures were studied. Incidence of the first fracture and subsequent fractures according to sex, age group, and time between the first and the index hip fracture were measured. The absolute fracture risk was measured in the study subjects and in the age groups <75 years and ≥75 years. Patients' survival was analyzed with the life-table method. RESULTS: One third of the hip fracture patients had sustained previous fractures. In men, these were mostly ankle or hip fractures, and in women, wrist fractures. Of the subjects, 24% suffered a subsequent fracture, which in both sexes was usually a second hip fracture. At the end of the 8-year follow-up, 74% of the patients had died. The observed absolute fracture risk was 7% at one year and 24% at 5 years. In women, excess mortality was lowest during the first 4.8 years after the index hip fracture among patients with one fracture. However, it was highest among women with two fractures. In men, excess mortality was lowest among those with two fractures and highest among those with ≥3 fractures. There were no differences between the genders in sustaining subsequent fractures. CONCLUSIONS: The fracture risk subsequent to hip fracture was similar in both genders. Patients with prior hip fractures had the worst survival rate.