Björn Salomonsson

A review of national shoulder and elbow joint replacement registries.

BACKGROUND The aim was to review the funding, organization, data handling, outcome measurements, and findings from existing national shoulder and elbow joint replacement registries; to consider the possibility of pooling data between registries; and to consider wether a pan european registry might be feasible. MATERIALS AND METHODS Web sites, annual reports, and publications from ongoing national registries were searched using Google, PubMed, and links from other registries. Representatives from each registry were contacted. RESULTS Between 1994 and 2004, 6 shoulder registries and 5 elbow registries were established, and by the end of 2009, the shoulder registries included between 2498 and 7113 replacements and the elbow registries between 267 and 1457 replacements. The registries were initiated by orthopedic societies and funded by the government or by levies on implant manufacturers. In some countries, data reporting and patient consent are required. Completeness is assessed by comparing data with the national health authority. All registries use implant survival as the primary outcome. Some registries use patient-reported outcomes as a secondary outcome. CONCLUSIONS A registry offers many advantages; however, adequate long-term funding and completeness remain a challenge. It is unlikely that large-scale international registries can be implemented, but more countries should be encouraged to establish registries and, by adopting compatible processes, data could be pooled between national registries, adding considerably to their power and usefulness.

The Swedish Elbow Arthroplasty Register and The Swedish Shoulder Arthroplasty Register: Two new Swedish arthroplasty registers

Two new national orthopedic quality registers were started in Sweden in 1999, the Swedish Shoulder Arthroplasty Register and the Swedish Elbow Arthroplasty Register. Both are owned by the Swedish Shoulder and Elbow Section of the Swedish Orthopedic Association. The purpose of the registers is to improve surgical techniques and selection of implants and identify individual risk factors. Two of the main problems in starting a new national quality register involve inducing all centers in the country to participate and deciding on the data to register.

‘Talk to me baby, tell me what's the matter now’: Semiotic and developmental perspectives on communication in psychoanalytic infant treatment

Infants suffer to a considerable degree from disturbances in nursing, sleep, mood, and attachment. Psychotherapeutic methods are increasingly used to help them. According to case reports, psychoanalytic work with infants and mothers has shown deep‐reaching and often surprisingly rapid results, both in symptom reduction and in improved relations between mother and child. The clinical urgency of the method makes it important to study its results and theoretical underpinnings. Among the theoretical issues often raised in discussions on this modifi ed form of psychoanalysis, those addressing the nature of communication between analyst, baby, and the mother are the most frequent. For example, how and what does an infant understand when the analyst interprets to her? What does the analyst understand of the infants communication? These issues are addressed by investigating the infants tools for understanding linguistic and emotional communication, and by providing a semiotic framework for describing the communication between the three participants in the analytic setting. The paper also investigates problems with the traditional ways of using the concept of symbolization within psychoanalytic theory. The theoretical investigation is illustrated by two brief vignettes from psychoanalytic work with an 8 month‐old girl and her mother. demand for the breast. Like the two lovers in the blues, they seemed to be slaves to

Semiotic transformations in psychoanalysis with infants and adults.

The author addresses issues that emerge when we compare psychoanalytic experiences with adults and with infants. Two analyses‐one with a 35 year‐old woman and one with a 2 week‐old boy and his mother‐illustrate that infant psychoanalytic experiences help us understand and handle adult transference. However, we cannot extrapolate infant experiences to adult work. Truly, witnessing the babys communication widens our sensitivity to non‐verbal layers of the adults communication. Infant work also offers a direct encounter with the container and the contained personified by a mother with her baby. But we need to conceptualize carefully the links between clinical experiences with babies and adults. When we call an adult transference pattern ‘infantile’, we imply that primeval experience has been transformed into present behaviour. However, if we view the analytical situation as one in which infantile invariants have transformed into adult symptoms, we face the impossible task of indicating the roots of the present symptoms. The author rather suggests that what is transformed is not an invariant infantile essence but signs denoting the patients inner reality. He proposes we define transformation as a semiotic process instead of building it on an essentialist grounding. If we view the analytic situation as a map of signs that we translate during our psychoanalytic work, we can proceed into defining containment as a semiotic process. This idea will be linked with a conceptualization of the mother‐infant relation in semiotic terms.

Some psychoanalytic viewpoints on neuropsychiatric disorders in children.

The author addresses issues interfacing neuropsychiatry and psychoanalysis. He recommends psychoanalysis for children with Attention Deficit, Hyperactivity Disorder (ADHD) and Dysfunction in Attention and activity control, Motility control and Perception (DAMP). He attributes its low status in neuropsychiatric treatment recommendations partly to the fact that psychoanalysts do not always declare their specific field of investigation. The scientific community then assumes that psychoanalysis aims to comment on issues outside its field of investigation, e.g. on neurobiological aetiology. The community therefore fails to discern the psychoanalysts specific task, to help the child express and work through his conscious and unconscious experiences. Clarity on the analysts part will improve relations with the scientific community and facilitate a relevant comparison of treatment methods. Another reason for neuropsychiatrys negative attitude towards analysis is its unwillingness to accept that unconscious conflict influences behaviour. With theoretical and clinical arguments, the author argues that unconscious factors must be taken in to understand and to treat the child. Countertransference, often cumbersome with neuropsychiatric children, becomes easier to handle if the analyst is clear about his field of investigation. If he sees through simplistic formulations on aetiology, countertransference gets even more manageable. Psychoanalysis can result in considerable intellectual and emotional development, as illustrated by work with a latency boy with DAMP, autism and slight mental retardation. In his psychoanalytic theoretical framework of the case, the author unites ego‐psychological formulations with a Bionian conceptualisation of the thought disturbance.

The impact of words on children with ADHD and DAMP : Consequences for psychoanalytic technique

Children with attention‐defi cit/hyperactivity disorder (ADHD) and disorder of attention, motility control, and perception (DAMP) are often sensitive to the analysts interventions. This is not always due to the literal import of the intervention. The children sometimes react as if the words were dangerous concrete objects, which they must physically fend off. The author traces this phenomenon to the childs unstable internal situation. A bad, un‐containing internal object is easily awakened and threatens to expel the analysts words independently of their content. This results in violent clinical situations. Infant research and psychoanalytic work with infants and mothers evince how a complex semiotic process develops between mother and baby. The prerequisite for this process to get started and maintained is a secure external object, which gradually is internalized. Findings from developmental research and clinical infant work are used to illuminate analytic work with children with ADHD and DAMP. Vignettes demonstrate how important it is for the analyst to phrase interpretations after having gauged the state of the analysands internal object as well as his/her own countertransference. If this is overlooked, the psychoanalytic dialogue easily capsizes. The author provides some technical recommendations on the psychoanalysis of these children. As part of the theoretical discussion he raises the general question of how the representations, which the baby forms in interaction with the mother, and the analysand forms in interaction with the analyst, should be classifi ed. Rather than dividing them into bipartite thing‐ or word‐presentations (Freud), the author suggests C. S. Peirces tripartite semiotic classifi cation in that the baby forms representations of icons, indices, and symbols.

Is it feasible to merge data from national shoulder registries? A new collaboration within the Nordic Arthroplasty Register Association

BACKGROUND The Nordic Arthroplasty Register Association was initiated in 2007, and several papers about hip and knee arthroplasty have been published. Inspired by this, we aimed to examine the feasibility of merging data from the Nordic national shoulder arthroplasty registries by defining a common minimal data set. METHODS A group of surgeons met in 2014 to discuss the feasibility of merging data from the national shoulder registries in Denmark, Norway, and Sweden. Differences in organization, definitions, variables, and outcome measures were discussed. A common minimal data set was defined as a set of variables containing only data that all registries could deliver and where consensus according to definition of the variables could be made. RESULTS We agreed on a data set containing patient-related data (age, gender, and diagnosis), operative data (date, arthroplasty type and brand), and data in case of revision (date, reason for revision, and new arthroplasty brand). From 2004 to 2013, there were 19,857 primary arthroplasties reported. The most common indications were osteoarthritis (35%) and acute fracture (34%). The number of arthroplasties and especially the number of arthroplasties for osteoarthritis have increased in the study period. The most common arthroplasty type was total shoulder arthroplasty (34%) for osteoarthritis and stemmed hemiarthroplasty (90%) for acute fractures. CONCLUSION We were able to merge data from the Nordic national registries into 1 common data set; however, the set of details was reduced. We found considerable differences between the 3 countries regarding incidence of shoulder arthroplasty, age, diagnoses, and choice of arthroplasty type and brand.

Has infantile sexuality anything to do with infants

Classical psychoanalytic theory draws many concepts from mental processes that are assumed to arise in the infant and influence the adult mind. Still, psychoanalytic practice with mothers and infants has been integrated but little within general psychoanalytic theory. One reason is that only few analysts have utilized such practice to further theory. Another reason is that infant therapists tend to abandon classical psychoanalytic concepts in favour of attachment concepts. As a result the concept of infantile sexuality, so central to classical theory, plays an unobtrusive role in clinical discussions on infant therapy. The author argues that infantile sexuality plays an important role in many mother–infant disturbances. To function as a clinical concept, it needs to be delineated from attachment and be understood in the context of mother–infant interaction. Two examples are provided; one where the analyst’s infantile sexuality emerged in a comment to the infant. Another is a case of breast‐feeding problems with a little boy fretting at the breast. This is interpreted as reflecting the mother’s infantile sexual conflicts as well as the boy’s emerging internalization of them. Thus, to conceptualize such disorders we need to take into account the infantile sexuality in both mother and baby.

‘Weaving thoughts’ A method for presenting and commenting psychoanalytic case material in a peer group

The authors argue that there are good reasons for seriously considering the dynamics of the peer group when discussing psychoanalytical case material. The setting and procedure have to protect and facilitate for the presenter and the group members to work together. The aim of this paper is to discuss the problems connected with presenting and discussing clinical psychoanalytical material in a peer group and to describe one such specifi c method, which the authors call the ‘weaving thoughts’ method. The design is primarily inspired by Bions formulation ‘thoughts in search of a thinker’. The group participants refl ect on the presented clinical material in a way that the authors metaphorically describe as creating a weave of thoughts that emerges from the material. The aim of the method is to facilitate a work‐group climate that allows thoughts to wander about, and to avert group members from debating and compromising the integrity of its members by letting basic assumptions come into power. The method is described from theoretical and practical points of view, with two illustrations of seminars according to this design and fi nally a discussion of the advantages and drawbacks of the method.

Establishing an international shoulder arthroplasty consortium

Shoulder replacement surgery has evolved dramatically since first attempted by P ean and Gluck and modernized by Neer. Interest in shoulder replacement surgery is growing globally and, in many countries, is the fastest growing market in joint arthroplasty surgery. In the coming year, over 57,000 replacements will be undertaken in the United States and over 4,000 in Australia. To a large extent, this growth is based on successful outcomes with patients benefiting from carefully executed surgery, using implants with established track records. However, with arthroplasty surgery of any joint, problems may be slow to become clinically apparent and long follow-up is required. Inevitably, with increases in shoulder replacement rates, the future revision burden will increase as well. In addition, often large patient volumes are needed to detect differences in outcomes, which may be beyond the scope of clinical trials. Internationally, joint arthroplasty registries are becoming increasingly recognized as important mechanisms for monitoring patient and prosthesis outcomes, providing large data sets that give an early indication when patient groups or implants are not functioning as expected. The ability to provide guidance and reduce revision burden in this current climate of increased scrutiny on health care expenditure has significant attraction. This level of monitoring requires informed clinician oversight to be relevant and interpreted appropriately. International interest in collaborative arrangements among joint registries already exists in the sphere of hip and knee arthroplasty with the formation of the International Society of Arthroplasty Registries (ISAR) and a collaborative data-sharing arrangement sponsored by the Food and Drug Administration with the International Consortium of Outcome Registries (ICOR). This environment of high-level data sharing greatly increases the potential insights and level of understanding into causes for revision. There are already a small number of national-level shoulder registries internationally, with the longest