Randomised placebo-controlled trials (RPCTs) are the gold standard for evaluating novel treatments. However, this design is rarely used in the context of orthopaedic interventions where participants are assigned to a real or placebo surgery. The present study examines attitudes towards RPCTs for orthopaedic surgery among 687 orthopaedic surgeons across the USA. When presented with a vignette describing an RPCT for orthopaedic surgery, 52.3% of participants viewed it as ‘completely’ or ‘mostly’ unethical. Participants were also asked to rank-order the value of (...) five different types of evidence supporting the efficacy of a surgery, ranging from RPCT to an anecdotal report. Responses regarding RPCTs were polarised with 26.4% viewing it as the least valuable (even less valuable than an anecdote) and 35.7.% viewing it as the most valuable. Where equipoise exists, if we want to subject orthopaedic surgeries to the highest standard of evidence (RPCTs) before they are implemented in clinical practice, it will be necessary to educate physicians on the value and ethics of placebo surgery control conditions. Otherwise, invasive procedures may be performed without any benefits beyond possible placebo effects. (shrink)

The COVID-19 pandemic has increased demand for physicians, leading to widespread redeployment of specialty physicians to care for patients with COVID-19. These redeployments highlight an important question: How do physicians balance competing obligations to their own health, their own patients, and society during a public health crisis? How can physicians, specifically subspecialists, navigate this tension? In this article, we analyse a clinical scenario in which an orthopaedic sports surgeon is redeployed to care for patients with COVID-19. This case raises questions (...) about physicians’ obligations to their own patients compared with society at large, the relative value of specialty physicians during a global pandemic, and the ethical permissibility of compulsory redeployment. Using the orthopaedic surgery specialty as a model, we build a redeployment framework for surgical specialists that is both ethical and equitable. We argue that although orthopaedic surgeons have a moral obligation to participate in physician redeployment schemes, the scope of this obligation is limited and contingent on the following conditions: (1) the number of local COVID-19 cases is high; (2) obligations to their own patients or orthopaedic patients requiring urgent or emergency care have been fulfilled; (3) their value as physicians exceeds their value as specialists because of the pandemic climate; (4) voluntary redeployments are exhausted before compulsory redeployments are implemented; and (5) redeployment would not put the physicians at unreasonable risk of harm. (shrink)

In this article I propose to reframe debates about ideals of emotion in medicine, abandoning the current binary setup of this debate as one between ‘clinical detachment’ and empathy. Inspired by observations from my own field work and drawing on Sky Gross’ anthropological work on rituals of practice as well as Henri Lefebvre’s notion of rhythm, I propose that the normative drive of clinical practice can be better understood through the notion of attunement. In this framework individual types of emotions (...) are not, as such, appropriate or inappropriate, but are evaluated depending on their synchronicity with the specific rhythms of the practice. To set up this proposal, I show how typical arguments about emotions in medicine—what I call emotion-entity focused frameworks—are insufficient. I then draw on ethnographic observations from two orthopaedic departments and interviews with medical practitioners to show (1) how clinical practice is driven by rhythmicity, shaped in the case of orthopaedic surgery by a clinical aim of efficient, controlled intervention, and (2) how clinicians continuously refer to this drive and the flow of rhythms when evaluating inappropriate or problematic emotion. I argue that the use of a rhythm framework rather than ideals of detachment or empathy allows for a sensitivity to the complexity and situation-dependent elements of emotional ideals in clinical practice; and I end by proposing the term ‘attuned concern’—which stresses the importance of regulation and adjustment to circumstances rather than of maintaining a constant distance/involvement—as a more fitting alternative to ‘clinical detachment’. (shrink)

Developments in biomedical science continue to transform our understanding of concepts such as health and disease. The creation of this expertise has also had a substantive role in changing the veterinary approach to animal diseases. Traditionally, companion animal veterinarians modelled their practices on developments in the diagnosis and treatment of human patients. As science and technology have realigned the boundaries between normalcy, intra-species variation and pathology in particular domains of expertise such as orthopaedic surgery, these patterns of knowledge translation have (...) changed. Not so long ago, treatments for the rupture of the cruciate ligament in human and canine patients were based on pathoanatomical comparison and designed to reestablish the stability of the joint by the functional restoration of ligament anatomy. Recently, a radically different characterization of the canine injury—with a corresponding alternative intervention—has been proposed within the field of veterinary orthopaedics. It views the normal anatomy of the canine knee as being in some way inherently pathogenic and proposes the surgical creation of an idealized structure as a remedy to dysfunction and disease. The veterinary focus on an ideal of patient performance, rather than a specific pathology, is now influencing how orthopaedists choose to approach analogous human injuries. In this article, I chart the history of canine ‘cruciate disease’ therapies as a means to map some of the epistemic assumptions, interplays of idealized and analogical reasoning and patterns of knowledge translation central to the biomedicalization of the science and practice of orthopaedic surgery. (shrink)

More than one single professional group deals with therapeutic manipulations of the spine and the joints. Osteopaths, Chiropractors, Naprapaths, Physical Therapists (and a contingent Physicians) all share this interest. Each profession is also very clear about where its bulk of knowledge stems from. The disciplines that are reckoned as the oldest are from the USA. A number of “inventors” are to be found, all without a formal university degree in Medicine. Andrew Taylor Still (1828–1917) came up with his system of (...) Osteopathy in 1874. Daniel D. Palmer (1845–1913), the man behind Chiropractic, founded his system in 1894, and Palmer’s colleague and former student, Oakley Smith (1880–1967), developed Naprapathy in 1906/1907. Physical Therapists working with what is called Orthopaedic Manual Physical Therapy are on the other hand not claiming American ancestry, nor do their body of knowledge and clinical skills originate from outside the medical profession. It is an offspring of Orthopaedic Medicine (OM) which was an invention by Physicians. Date and place of birth is said to be 1929 in England. This article turns the above-mentioned chronology on its head. It will show that Orthopaedic Medicine likely is the oldest system. It will also unearth OM’s sturdy roots in a strong but forgotten, and even hidden, discourse of Mechanical Medicine found in 19th century Europe, which was ruled by Physical Therapists. Why “we” do not know about this “history” is analysed and explained from a variety of perspectives. (shrink)

Advances in veterinary orthopaedics are assessed on their ability to improve the function and wellbeing of animal patients. And yet historically veterinarians have struggled to bridge the divide between an animal's physicality and its interior experience of its function in clinical settings. For much of the twentieth century, most practitioners were agnostic to the possibility of animal mentation and its implications for suffering. This attitude has changed as veterinarians adapted to technological innovations and the emergence of a clientele who (...) claimed to understand and relate to the subjective experiences of their animals. While visualising technologies and human analogies have shaped the nuts and bolts of veterinary orthopaedic practices, an emerging awareness of the inability of radiographic images to apprehend or correlate to a patient's experience of their function reliably has required veterinarians to place a greater emphasis on the owner's knowledge of the "selves" inhabiting their animals. Rather than simply basing clinical judgments on the "look" of their patients, the indeterminacy in the connection between form and function has compelled veterinarians to put questions regarding particular human-animal relationships near the centre of their practices, not least in orthopaedic surgery. (shrink)

Ransomware attacks on healthcare systems are becoming more prevalent globally. In May 2021, Waikato District Health Board in New Zealand was devastated by a major attack that crippled its information technology system. The Department of Orthopaedic Surgery faced a number of challenges to the way they delivered care including, patient assessment and investigations, the deferral of elective surgery, and communication and patient confidentiality. These issues are explored through the lens of the four key principles of medical ethics in the hope (...) that they will provide some guidance to future departments who may experience such attacks. (shrink)

Consent plays a vital role in every aspect of medicine and surgery, facilitating the patient in making informed decisions about their treatment. The recently published Reference Guide to Consent, by the Department of Health (DH), notes that, although not a legal requirement, the completion of consent forms is good practice, particularly in interventions such as surgery. In addition, the Parliamentary and Health Service Ombudsman noted that a significant number of complaints about consent involved the complainant feeling that they did not (...) fully understand what was going to happen. It was often found that there was no documentation to clarify what the patient was told, when and by whom. We have performed an audit of 71 randomly selected consent forms, elective and trauma cases within our district general hospital orthopaedics department. Our data demonstrate that a significant number of consent forms were incorrectly or insufficiently completed. This could not only leave the patient confused about their procedure but also leaves the doctor open to litigation, with little in the way of documentation support. Minor changes in consenting methods and more precise documentation could significantly improve patient experience and satisfaction. (shrink)

1894 erwarb das Germanische Nationalmuseum in Nürnberg ein Instrument, welches einem Beinharnisch ähnlich sieht. Über seitliche Gewinde konnten damit steife Beine gebeugt oder gestreckt werden. Dem Ätzdekor nach zu urteilen stammt es aus der Kunstkammer Kurfürst Augusts von Sachsen (1526–1586). Ein Vergleich mit zeitgenössischen Beinharnischen legt nahe, dass die Beinschiene bereits ursprünglich als orthopädisches Instrument hergestellt wurde. Sie komplettierte die Sammlung chirurgischer Instrumente des sächsischen Regenten in Dresden. Vermutlich war der Plattenharnisch in vielen Eigenschaften eine technologische Bedingung für derartige Orthesen (...) und Prothesen. (shrink)

This study elucidates the nursing of undernourished patients as experienced by eight registered clinical nurses and five nursing assistants by using content analysis. The participants' narratives describe the inner perspective of caring for undernourished patients, known in Sweden as `the thin ones'. Categories identified were: frustration in nursing, joy in nursing and that undernourishment is taboo. The taboo was narrated as feelings of guilt and shame. Frustration in nursing could be seen as feeling stressed, exposed, lonely, powerless, helpless, and being (...) torn between demands and needs. Joy in nursing was experienced when creating a trusting relationship, promoting pleasure in the meal situation and working with respect for each individual's life-style and context of life. Understanding staff members' views is important when implementing guidelines as well as in the teaching situation in order to identify where staff stand with regard to knowledge and attitudes. (shrink)

In many countries, there are health care initiatives to make smokers give up smoking in the peri-operative setting. There is empirical evidence that this may improve some, but not all, operative outcomes. However, it may be feared that some support for such policies stems from ethically questionable opinions, such as paternalism or anti-smoker sentiments. This study aimed at investigating the support for a policy of smoking cessation prior to surgery among Swedish physicians and members of the general public, as well (...) as the reasons provided for this. A random sample of general practitioners and orthopaedic surgeons as well as members of the general public received a mail questionnaire. It contained a vignette case with a smoking 57-year old male farmer with hip osteoarthritis. The patient had been recommended hip replacement therapy, but told that in order to qualify for surgery he needed to give up smoking four weeks prior to and after surgery. The respondents were asked whether making such qualifying demands is acceptable, and asked to rate their agreement with pre-set arguments for and against this policy. Response rates were 58.2% among physicians and 53.8% among the general public. Of these, 83.9% and 86.6%, respectively, agreed that surgery should be made conditional upon smoking cessation. Reference to the peri-operative risks associated with smoking was the most common argument given. However, there was also strong support for the argument that such a policy is mandated in order to achieve long term health gains. There is strong support for a policy of smoking cessation prior to surgery in Sweden. This support is based on considerations of peri-operative risks as well as the general long term risks of smoking. This study indicates that paternalistic attitudes may inform some of the support for peri-operative smoking cessation policies and that at least some respondents seem to favour a “recommendation strategy” vis-à-vis smoking cessation prior to surgery rather than a “requirement strategy”. The normative reasons speak in favour of the “recommendation strategy”. (shrink)

Russia did not participate in the bourgeois revolution, the revolution occurred in Russia after the Tsar absolute doctrine, dictatorship, terrorism, superstition and personal police state. Stalinist Marxism beyond recognition, damaged Marx's own image. Impoverishment of the proletariat of Marx and Engels theory, crisis theory has been declared invalid, the Marxist dialectics is still valid is that the theory of contradiction. Contradictions of capitalism can be accurately understood as the general alienation, self-alienation. Inherited estate will determine the natural rights of free (...) face of communism. Straight orthopedic surgery is the most urgent task of socialism, and humane socialism contains the highest human rights as straight. Marxism is not is not a utopia, but a concrete utopia. Russia did not join in the bourgeois revolution, and there appeared absolutely Tsarism, autarchy, terror, individual superstition and police country after its revolution. Stalinism made the Marxism distorted beyond recognition and destroyed the figures of Marx himself. The theory of Proletarian poverty and the theory of crisis of Marx and Engles' were declared invalid, while its dialectic, that is Contradiction, is still valid. The contradiction of Capital can be understood precisely as Total-alienation and Self-alienation. Inheriting natural rights will decide the freedom face of Communism. Orthopaedic surgery of upright way is the most urgent mission of Socialism, and human Socialism contains the upright way as the highest human rights. Marxism is not non-Utopia, but concrete Utopia. (shrink)

ObjectiveTo evaluate the knowledge and performance of surgical residents regarding the person from whom informed consent should be taken for surgery and from whom the consent is taken in practice.Materials and methodsThis study was done in 2013. The population of this study was all residents of urology, surgery, orthopaedic surgery and gynaecology of Tehran and Iran University of Medical Sciences. The study tool was a self-administered questionnaire, containing questions on their knowledge and performance regarding informed consent acquisition from patients with (...) different conditions in terms of age, sex, marital status and their capacity to make treatment decisions.ResultsA total of 213 residents participated in the study. The mean score of the participants’ knowledge was 72.95 out of 100. There was no significant correlation between the residents’ knowledge and performance. Regarding a competent married male patient, 98.2% of the residents knew that the person’s consent was enough, but only 63.6% obtained informed consent only from the patient. These percentages were 69% and 19.7% for a competent married female patient, respectively. For a competent single male patient, 90.9% of the residents were aware that the patient’s consent was enough, while only 40% of the residents obtained informed consent only from the patient. These percentages were 65.3% and 16% for a competent single female patient, respectively.ConclusionDespite the residents’ average knowledge of patient autonomy, this right is not observed for female patients, and their treatment is subject to consent acquisition from other family members. (shrink)

Health Care Centres are institutions which, because of their specificity and character, are particularly exposed to various kinds of risk. One of the most important and most frequently used methods of risk management is the black spots method. The research material collected for the study comes from one of the hospitals in Wrocław. All hospital stays of the C22 (Face and Jaw Surgery Ward) and H05 (Injury and Orthopaedics Surgery Ward) settlement groups (DRG) were analysed - a total of (...) 178 hospitalisations. The black spots method was used in the study, which consisted of risk identification, the ordering of threats and proposals for remedial actions. Using the black spots method, it was possible to identify adverse events that occurred during the hospitalisation of patients with H05 and C22 DRGs in the Injury and Orthopaedics Surgery Ward and Facial and Jaw Surgery Ward. In both cases, the treatment costs for patients with complications were higher than for the stays without complications. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:I Am Not Sure?Paul E. LevinIt was a beautiful Friday morning, a few weeks into the summer. My schedule appeared lighter than usual and I even envisioned leaving work a bit early. Maybe a challenging bike ride before dinner. I was sitting in the chairman’s office having our weekly meeting. One of our junior faculty members called... he needed help. He was on call and a 32–year–old pregnant woman (...) with a displaced femoral neck fracture had just been transferred to our emergency department (ED). Ms. B tripped in her kitchen last evening. She was unable to stand and was brought to the local ED by ambulance.My colleague was concerned that he wouldn’t be able to successfully reduce the fracture. The long–term prognosis of the hip joint depended on a successful reduction of the femoral neck fracture. In addition, there was an ongoing debate in the orthopaedic literature related to the urgency of operative care to prevent osteonecrosis of the femoral head. I reviewed the x–rays, didn’t anticipate a problem and let him know that I would come to the operating room (OR) to assist. “No”, he responded, “I am not comfortable caring for this patient”. I immediately left the office, went to the hospital and assumed care of the patient. Clearly, my plans for a bike ride were gone, but I had the opportunity to help a woman in need of expert orthopaedic care.Ms. B had been admitted to the obstetrical service. She was a 32–year–old woman of Haitian descent who had recently immigrated to the United States. She had very limited English comprehension and her primary spoken languages were French and Creole. She was alone, in a hospital in a foreign country. She was 24 weeks pregnant with her first child and had no other co–morbidities. Her pregnancy had ben progressing uneventfully.When I first met Ms. B she was lying on a stretcher in an observation unit on the obstetrical floor. She appeared frightened. Two orthopaedic residents were present and obtaining consent for surgical repair of the hip. In their minds there was nothing to discuss, the patient had a displaced femoral neck fracture and needed to have surgery immediately. In their minds, no other options were available and obtaining consent would be straightforward. I introduced myself, sat down on a lab stool by the bed and began a conversation. I needed to meet the patient, understand who she was and discuss treatment. I am not sure that obtaining an informed consent is ever “straightforward” when [End Page 14] a doctor is explaining to a patient that they require emergency surgery. This discussion surely would not be easy or straightforward.We utilized a telephone interpretation service. Every question and response required the transfer of the handset between the patient and physician. Ms. B was in pain and frightened. She immediately expressed concern about her pregnancy and her baby. I arranged for her to meet all of the physicians who would possibly be involved in her care and the care of her baby. Each consultant could explain their area of expertise and potential involvement in the care of Ms. B and her child. She met and had an opportunity to talk with the obstetrician on call, a maternal fetal medicine (MFM) fellow and a neonatologist. I supplied the orthopaedic information. I explained the severity of the injury, the risks of osteonecrosis either with or without surgery as well as concerns over non–union and traumatic arthritis of the hip. Undoubtedly, in a healthy 32–year–old woman who wasn’t pregnant, early surgical intervention would be the most appropriate management in hopes of preserving a normal hip joint. We also discussed the possibility of treating her without surgery. She would be administered pain medication, which were known to be safe during pregnancy, and allowed to begin to ambulate with a walker or crutches. I explained potential problems without surgery and what options would be available to treat any problems that developed with her hip after the child was born. Of course, hip fractures in pregnant woman are very rare, and as a result treating a... (shrink)

RATIONALE AND AIMS: Total hip and knee replacements, usually, have long waiting lists. There are several prioritization tools for these kind of patients. A new tool should undergo a standardized validation process. The aim of the present study was to validate a new prioritization tool for primary hip and knee replacements. METHODS: We carried out a prospective study. Consecutive patients placed on the waiting list were eligible for the study. Patients included were mailed a questionnaire which included, among other questions, (...) the seven items of the priority tool and the Western Ontario and McMasters Universities Arthritis Index (WOMAC) specific questionnaire. The priority tool gives a score from 0 to 100 points, and three categories (urgent, preferent and ordinary). We studied the content and construct validity. We used Student's t-test or one-way analysis of variance. Correlational analysis was used to evaluate convergent and discriminate validity. RESULTS: The sample consisted of 838 patients (62.3% were female), with mean age of 70.2 years (SD 8.4). A total of 55.5% patients underwent knee replacement. Given that the tool was elaborated by patients and orthopaedic surgeons, it shows a good content validity. The priority score was statistically different (P < 0.001) among the three urgency categories created. The scores of the three WOMAC dimensions showed differences (P < 0.001) by the three urgency categories created. The correlations between the priority score and WOMAC dimensions were 0.79 (function), 0.69 (pain) and 0.51 (stiffness). The correlations between WOMAC items and items from priority tool were greater (0.47-0.69) between items measuring similar constructs than those measuring different constructs (0.27-0.49). These data are similar in both joints. CONCLUSIONS: Results support the validity of the prioritization tool to be used with patients waiting for hip or knee replacement. (shrink)

Preoperative informed consent is a legal and ethical requirement that ensures patients understand a procedure, its associated risks and benefits, alternative treatment options, and potential complications to make an informed decision about their care. This cross‐sectional study evaluated the informed consent process for major orthopaedic surgeries at a tertiary hospital in Nigeria. A self‐administered questionnaire was used to collect data from 120 adult participants. Results showed that many patients do not read the consent form before signing it, and surgeons do (...) not adequately explain the alternatives to surgery, potential risks, and available anaesthetic options. Higher‐educated patients are more likely to read the consent form. Surgeons performed well in explaining the nature of the condition and prognosis, the procedure's potential benefits, and answering patients' questions. The study emphasises the need to improve the informed consent process to ensure patients understand and can make rational decisions about their healthcare. (shrink)

Stroke survivors undergo a thorough cognitive diagnosis that often involves administration of multiple standardized tests. However, patient’s narrative discourse can provide clinicians with additional knowledge on patient’s subjective experience of illness, attitude toward current situation, and motivation for treatment. We evaluated the methods of analyzing thematic content and story types in relationship to cognitive impairment in stroke survivors with no aphasia. Cognitive impairment was evaluated in comparison to a group of 25 patients with orthopaedic injury not involving the brain. Our (...) findings primarily show that higher elaboration on own cognitive problems, physical ailments or coping strategies in LHD patients and cognitive problems, emotional issues and circumstances of illness onset in RHD patients is related to deficits in executive functions and retrieval of information from memory. Furthermore, RHD patients who use more chaos story type show lower executive functioning. However, these results did not survive the significance threshold of p < 0.05 after Bonferroni adjustment for multiple comparisons. In conclusion, this study provides preliminary evidence that stroke survivor’s narrative can constitute an additional source of clinically-relevant information regarding patient’s experience of illness and attitude toward recovery. This knowledge can aid clinicians and nurses in everyday interactions with the patients and support individualized strategy to treatment. Still, the current results need be confirmed with future studies in a larger cohort of stroke patients. (shrink)

Ojectives Low energy hip fractures are one of the greatest causes of morbidity and mortality in orthopaedics. This study aims to evaluate written consent forms with respect to basic standards as set out in the Good Practice in Consent Initiative. In particular the stated risks and benefits of each procedure were assessed. Methods 100 consecutive consent forms were reviewed prospectively. The stated procedure, side and complications were recorded. Appropriate signature and legibility was assessed. 13 consultant orthopaedic surgeons were surveyed (...) to identify what risks and benefits they thought should be stated. Results Of 100 consent forms, 31 were for patients who are unable to consent. All 100 consent forms were correctly filled in with patient details and signed. 98% were legible. All stated the side of the operation. The number of complications listed per form ranged from 4 to 11. Infection, bleeding and thromboembolic complications were stated in the majority of consent forms. In total, 30 different complications were recorded; some were only stated once. Discussion and Conclusions This work suggests consent forms are completed well with respect to patient identifiers, legibility and procedure. The variability of complications stated is vast. We suggest standard pre-printed consent forms containing risks and benefits should be used as this may improve standards of informed consent. This has also been recently supported by the British Orthopaedic Association. (shrink)

Background: Informed consent in the modern era is a common and important topic both for the well-informed patient and to prevent unnecessary litigation. However, the effectiveness of informed consent in trauma patients is an under-researched area. This paper aims to assess the differences in patient recall of the consent process and desire for information by performing a comparative analysis between orthopaedic trauma and elective patients. Methods: Information from 41 consecutive elective operations and 40 consecutive trauma operations was collected on the (...) first post-operative day. Results: 100% of elective patients and 90% of trauma patients knew what operation they had received (p = 0.06). Overall recall of complications was poor, but was significantly lower in trauma patients compared with elective patients (62% vs 22%, p<0.001). 30% of trauma patients desired more information about their operation compared to 12% of elective patients (p = 0.049), although only 35% of trauma patients wanted written as well as verbal explanations, compared to 85% of elective patients p<0.001). Overall 100% of elective and 90% of trauma patients were happy with the consent process (p = 0.06). Subset analysis of neck of femur compared to other trauma patients showed that the above factors were not significantly different between the two groups. Conclusions: Recall of complications in the trauma patients is significantly lower than in elective patients, although both groups scored poorly overall. Repeated verbal explanations should be reinforced with the option of additional information leaflets for trauma operations. Further research into the usefulness of DVDs for commonly performed operations is warranted, although official internet resources may be more cost-effective. (shrink)

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments (n=98; proportion of participation was (...) 99%) conducted in 2015 across publicly funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector. (shrink)

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments conducted in 2015 across publicly (...) funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector. (shrink)

Health workers and support staff at Malawi’s major referral hospital, the Queen Elizabeth Central Hospital, Blantyre, were on strike between 5th and 19th October 2001. The health workers’ grievances included: lack of risk allowances; poor professional allowances; low salaries; and low housing allowances. The strike resulted in almost total closure of the 1500-bed hospital; only the burns and orthopaedic wards continued to serve patients. Volunteer staff, comprising the Red Cross, and nursing and medical students provided services. Verbal and written threats (...) by the authorities had minimal effect on terminating the strike; rather, they encouraged the resolve to continue with the industrial action. We report aspects of the genesis, progress and resolution of the strike. Although not much seems to have been achieved, both the employer and the workers need to draw lessons from the experience. (shrink)

Despite decades of research, remaining safety concerns regarding disease transmission, heterotopic tissue formation, and tumorigenicity have kept stem cell‐based therapies largely outside the standard‐of‐care for musculoskeletal medicine. Recent insights into trophic and immune regulatory activities of mesenchymal stem cells (MSCs), although incomplete, have stimulated a plethora of new clinical trials for indications far beyond simply supplying progenitors to replenish or re‐build lost/damaged tissues. Cell banks are being established and cell‐based products are in active clinical trials. Moreover, significant advances have also (...) been made in the field of pluripotent stem cells, in particular the recent development of induced pluripotent stem cells. Their indefinite proliferation potential promises to overcome the limited supply of tissue‐specific cells and adult stem cells. However, substantial hurdles related to their safety must be overcome for these cells to be clinically applicable. (shrink)

Qual è lo statuto libidico dello schermo? In che modo gli schermi coinvolgono le pulsioni dello spettatore, facendo appello alla sua percezione e ai suoi desideri? Nel suo Acinema, Lyotard risponde a tali questioni, affermando che lo schermo cinematografico articola due operazioni opposte. La prima, seguendo un modello rappresentativo, trasforma lo schermo in uno specchio ortopedico – come quello descritto da Jacques Lacan – così producendo il riconoscimento del soggetto nell’immagine proiettata sullo schermo e un conseguente piacere illusorio. La seconda, (...) seguendo invece un principio anti-rappresentativo o de-rappresentativo, impedisce alle pulsioni sparse di riunirsi nell’immagine organica di un soggetto, mostrando così lo schermo stesso, come compimento del desiderio di essere delusi. Lo schermo e lo specchio risultano dunque come opposti in questa relazione dialettica? Come tenterò di mostrare in questo articolo, attraverso la riflessione di Lacan e di Merleau-Ponty, il rapporto tra schermo e specchio può essere concepito a partire dalla figura dell’intreccio ovvero del chiasma. (shrink)