Parturients feel capable of giving informed consent for epidural analgesia: A qualitative and quantitative analysis.

INTRODUCTION: The patient's right to autonomy confirmed by informed consent is a cornerstone in modern medicine. Epidural analgesia is increasingly popular in obstetric analgesia, but physicians disagree whether labour pain impairs parturient decision-making. We investigated the fraction of parturients feeling capable of giving informed consent including their knowledge of risks. METHODS: Bedside survey postpartum women at the Herlev Hospital, Denmark. The inclusion criteria were recipient of epidural analgesia during labour. A power calculation based on the recognition of genuine and false side effects required the inclusion of 50 participants. RESULTS: Forty out of fifty (80%) of the participants felt they could make a judicious consent during labour and 46 out of 50 (92%) felt they knew enough about epidural analgesia to give consent to the procedure again if necessary. Participants spontaneously reported a median of two risks associated with epidural analgesia. Additionally, when prompted with a cued list of true and false risks from epidural analgesia, the participants reported on average 5.1 genuine risks compared with 0.4 made-up risks. The difference (4.7) suggests the included women could discern genuine risks from made-up risks. DISCUSSION: The majority of participants reported the capacity to give informed consent. Our quantitative results show the participants could clearly distinguish genuine risks of epidural labour analgesia from made-up risks. Our qualitative data likewise suggest that participants understood the information and consequently their informed consent was genuine. Accordingly, parturients are able to give informed consent. This is supported by parturients' ability to identify risks from epidural labour analgesia.

Training programmes for healthcare professionals in managing postoperative epidural analgesia: A scoping review protocol.

BACKGROUND: Epidural analgesia is an effective technique advocated worldwide for postoperative analgesia after a wide range of surgical procedures. Despite the benefits of epidural analgesia for pain management, systematic education of ward nurses in managing epidural analgesia appears to be lacking. METHODS: The aim of the proposed scoping review is to map the body of evidence and identify training programmes for healthcare professionals in the safe management of postoperative epidural analgesia. The methodology will follow the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). In addition, the five main steps set forth by Arksey and O'Malley and refined by Levac for guidance of the process will be used. The scoping review will include any study design of any date, design, setting and duration. RESULTS: We will present results descriptively, accompanied with visual presentations as tables and graphs. CONCLUSION: The outlined scoping review will provide an overview of existing training programmes for healthcare professionals in the safe management of postoperative epidural analgesia and map the body of available evidence on the topic. The study may support the development of a training programme for ward nurses caring for patients receiving postoperative epidural analgesia.

Perioperative management of patients declining transfusions of blood components-National survey of anaesthesiologists, abdominal surgeons and obstetricians in Denmark.

Perioperative management of patients declining transfusions of blood products can be challenging both ethically and clinically. Jehovah's Witnesses (JW) decline treatment with blood products and have published a list of interventions they might accept as substitutes. No detailed documentation of available substitute interventions at Danish hospitals exists. Likewise, no national guidelines exist on how to optimise patients who refuse to receive treatment with blood products. The primary aim was to investigate which treatments are currently available to healthcare professionals in Denmark when treating patients who refuse transfusion of blood components. Additionally, we wanted to investigate how many departments have local guidelines for treatment for this group of patients. Based on our findings we would suggest potential improvements in the treatment of patients declining transfusion of blood components. Consultants from Danish departments of anaesthesiology, abdominal surgery and obstetrics were invited to participate in a nationwide cross-sectional online survey. The questionnaire explored available interventions offered perioperatively. Respondents were all on-call consultants. The questionnaire underwent content, face and technical validation during pilot testing. Ninety-six of 108 (89%) respondents from 55 departments completed the questionnaire. Thirty-five (36%) respondents reported having a departmental guideline mostly dealing with judicial aspects regarding patients declining transfusions with blood, and 34 (35%) would in collaboration with other professionals make an interdisciplinary strategy for patients declining transfusions with blood. For patients declining treatment with blood products in anticoagulant treatment, and hence with a greater risk of bleeding, reverting treatment is essential. Depending on the type of anticoagulant, between 31 (32%) and 59 (60%) of respondents reported locally available guidelines for reverting anticoagulant treatments. We found a considerable variation and limited availability of interventions to minimise blood loss in patients declining transfusion of blood components. This scarcity of local guidelines together with the considerable variation of available treatment documented in our survey could possibly be enhanced by a lack of national guidelines.

Investigating the use of physical restraint of children in emergency departments: A Scandinavian survey.

AIM: The aim of the study is to describe the current frequency of physical restraint and the use of analgesics and sedatives for treating pediatric pain in emergency departments (EDs) in Scandinavia. METHODS: We performed a nation-wide electronic survey asking nurses in the emergency departments in Denmark, Norway, and Sweden about their experience treating children in pain. RESULTS: Responses from 103 Danish, Norwegian and Swedish nurses were included (79% response rate). Physical restraint was reported used at 79% [70.0-85.9] (N = 78) of the surveyed departments (DK: 96%, NO: 67%, SE: 77%) with two participants reporting daily use of physical restraint. Paracetamol was available at all departments and used most frequently. Sedation was available at 88% [78.8-92.0] of the departments with midazolam as the most recurrent sedative (83%, [74.8-89.4]). Seventy-three percent of respondents reported a need for better treatments. Lack of education was the most frequently reported obstacle for providing both pain treatment (29%) and sedation (43%) followed by lack of guidelines. CONCLUSION: Physical restraint of children during painful procedures is used in the majority of Scandinavian emergency departments (79%). There appears to be a lack of local guidelines for both pain treatment and sedation.

Clinical considerations for reposition of a dislocated hip: A qualitative study.

BACKGROUND: A well-known complication of having hip alloplasty surgery is dislocation of the prothesis. This affects 2%-4% of the patients, and 75% of the dislocations occur within the first year after surgery. The aim of our study was to gain knowledge about the clinical considerations underlying the choice of anaesthesia for, and treatment of, patients with dislocated hips by specialists in anaesthesiology and orthopaedic surgery. METHODS: We used semi-structured group interviews of specialists in anaesthesiology and orthopaedic surgery. An interview guide was developed and pilot tested before the group interviews. In total, 25 specialists participated, recruited from two university hospitals in Denmark. Data saturation was reached after seven group interviews. Inductive content analysis was used in the data analysis. RESULTS: We identified four overall themes, describing essential considerations made by the specialists: "Adhering to the principle of minimal intervention", "Ensuring patient safety through optimal working conditions", "Organisational considerations" and "Pain induced gastric retention". CONCLUSION: Our study illustrates different clinical considerations made by specialists in anaesthesiology and orthopaedic surgery in relation to the treatment of patients with dislocated hips. Our results hope to promote mutual understanding in joint clinical decision-making in relation to patients with dislocated hips as well as to inspire less-experienced anaesthesiologists and orthopaedic surgeons. Additionally, our results suggest a set of "rules of thumb" for how jointly to decide on the repositioning site of the patient during the procedure.

Developing Core Competency-Based Learning Objectives for Postgraduate Curricula for Postanesthesia Nurses-A Delphi Study.

PURPOSE: Postanesthesia care unit (PACU) nurse competencies involve the ability to care for patients receiving complex treatment. Well-educated PACU nurses are required to provide safe patient care, and accordingly, they require investment in their education. However, core competencies for PACU nurses that are based on systematic methods for curriculum development and consensus have not been established. The purpose of this study was to develop a nationwide consensus on core competency-based learning objectives for a postgraduate PACU nursing curriculum. DESIGN: Nationwide Delphi Study using Kern's six steps of curriculum development as a framework. METHODS: Forty-one anesthesiologists and 38 PACU nurses from 37 Danish departments of anesthesiology were invited to participate. In Delphi round 1, the participants listed core competencies for PACU nurses within 12 predefined categories. We analyzed the responses using an inductive and manifest approach to content analysis and developed learning objectives in accordance with the Structure of Observed Learning Outcomes and Simpson taxonomies. In Delphi round 2 and 3, the participants rated and rerated the learning objectives on a 7-point Likert scale, measuring statements of agreement. Consensus was predefined as a median score of 6 and or greater. The main outcome was a prioritized list of competency-based learning objectives for a postgraduate PACU nurse curriculum. FINDINGS: Twenty-six nurses and 14 anesthesiologists (51%) completed all Delphi rounds, representing 22 (60%) departments of anesthesiology. Consensus was reached on 180 learning objectives. The learning objectives described competencies ranging from basic to complex nursing tasks and emphasized the knowledge and skills needed to identify and initiate treatment of postoperative complications. CONCLUSIONS: Nationwide consensus on core competencies for postgraduate curricula for PACU nurses was achieved through the Delphi method. Our study exemplifies the range of complex knowledge and skills needed to work as a PACU nurse. The learning objectives are applicable in postgraduate curricula designed for PACU nurses.

Freeze-dried plasma in major haemorrhage: a systematic review.

BACKGROUND AND OBJECTIVES: Freeze-dried plasma (FDP) has logistical advantages in terms of storage and reconstitution time compared to fresh-frozen plasma. In vitro studies show FDP to be equivalent to fresh-frozen plasma regarding coagulation and clotting capacities. FDP is used in an increasing number of countries. We wanted to evaluate the clinical effects of FDP in major haemorrhage compared to standard care. METHODS: MEDLINE, Embase, Central, Biosis Previews, WHO ICTRP, Clinical Trials and Open Grey were systematically searched from inception until September 2018, without language restriction. Studies were eligible if they examined haemorrhagic adult patients transfused with FDP. Our primary outcome was mortality. Two reviewers independently assessed studies for eligibility, extracted data and assessed bias. RESULTS: Nine studies were eligible for inclusion. Three studies had a comparison group: one was a randomized controlled trial and two were before and after comparisons. Six studies were uncontrolled. A total of 606 patients received FDP, while 72 patients received non-FDP transfusion. In total, five minor adverse effects were documented. Two studies compared FDP to fresh-frozen plasma and found no difference in 30-day mortality between the groups. The included studies were heterogenous and had several methodological weaknesses, such as no control group, missing data or no protocol. CONCLUSIONS: The available research does not document the clinical effects of FDP. We cannot recommend or discourage use of FDP in major haemorrhage on base of available research.

Permanent catheters for recurrent ascites-a critical and systematic review of study methodology.

PURPOSE: Management of refractory ascites traditionally includes medical treatment with diuretics or intermittent paracentesis. Patients with recurrent ascites may benefit from the use of permanent intra-abdominal catheters with more frequent drainage without hospitalization. The objective was to systematically asses the methodology of factors and endpoints reported in studies investigating permanent catheters for recurrent ascites treatment. METHODS: Using a systematic search strategy, we critically assessed the methodology when treating refractory ascites using a permanent catheter. Studies critically assessed included both retro- and prospective studies. RESULTS: A total of 715 unique articles were found via PubMed, The Cochrane Library and Embase. Twenty-nine studies (tunnelled catheter = 12, peritoneal ports = 6 and peritoneovenous shunts = 11) with three distinct types of permanent catheters fulfilled the inclusion criteria. Only three studies reported technical success less than 100 %. Data on complications and treatment were not available in all papers; peritonitis (48 %), cellulitis (41 %), prophylactic antibiotics (48 %) and complications to catheter insertion were difficult to distinguish from advanced co-morbidity of patients. Thirteen studies (45 %) reported some type of evaluating patient experience or functional outcome, but only three studies used validated reproducible scales when assessing outcomes. Fifteen of the 29 studies included 30 patients or less. CONCLUSION: Knowledge is limited because complications and outcomes are poorly defined. The expected increase in catheter treatment of refractory ascites necessitates comparative studies, using validated patient-related outcomes, and the reporting of unambiguous complications. A proposal of variables to include in future studies is presented.

Is intravenous magnesium sulphate a suitable adjuvant in postoperative pain management? - A critical and systematic review of methodology in randomized controlled trials.

A growing worldwide focus on opioid-free anaesthesia entails multimodal analgesic strategies involving non-opioids such as magnesium sulphate (MgSO4). Several systematic reviews have concluded there is beneficial analgesic effect of MgSO4 administration but do not take considerable heterogeneity among the studies into consideration. Medical literature published until June 2021 was searched in PubMed/Medline, Embase, Central and Web of Science: The final search yielded a total of 5,672 articles. We included only randomised controlled trials assessing the effect of intravenous MgSO4 on opioid consumption and acute postoperative pain when compared to either placebo or standardized analgesic treatment. The primary aim was to compare the homogeneity of essential variables and confounders. A post-hoc meta-analysis demonstrated a reduction in both postoperative morphine consumption (-6.12 mg) and pain score (-12.32 VAS points) in favour of the MgSO4-groups. Data for meta-analysis was missing from 19 studies (45%) on morphine consumption and 29 studies (69%) for pain score, the majority of which reports no effect for either morphine consumption or pain score. The calculated heterogeneity among the included studies was considerable for both outcomes; I 2=91% for morphine consumption and I 2=96% for pain score. Although we found a per se reduction in opioid consumption and pain score, methodological heterogeneity and clinical shortcomings of pre-, intra-, and post anaesthetic data precludes conclusions on clinical importance of intraoperative intravenous MgSO4. In addition, the reduction is likely less than what can be gained from using standardized analgesic treatment.

Preoperative intervention to prevent delirium in patients with hip fracture - a systematic review.

INTRODUCTION: Delirium is a syndrome characterised by disturbance of consciousness and is a common complication to hip fractures. This systematic review was conducted to investigate the effect of simple preoperative interventions for the prevention of delirium in patients with hip fractures. The aim was to establish an easily implementable and resource-sparring treatment for the initial admission phase of hip fracture patients aimed at reducing the incidence of delirium. MEHODS: Five databases were searched to identify randomised controlled trials comparing preoperative interventions other than geriatric assessment to placebo or usual care. Our primary outcome was incidence of delirium using a well-defined delirium-screening tool. Secondary outcomes included need for pharmacological treatment, duration of delirium and mortality. RESULTS: A total of 13 RCTs provided data on 2,222 patients who had been exposed to 11 different interventions. Four interventions significantly reduced of the incidence of delirium: methylprednisolone (odds ratio (OR) = 0.42; 95% confidence interval (CI): 0.17-1.00; p = 0.048), fascia iliaca block (OR = 0.39; 95% CI: 0.18-0.84; p = 0.02), hypertonic saline (OR = 0.21; 95% CI: 0.08-0.55; p = 0.001) and rivastigmine patches (OR = 0.23; 95% CI: 0.07-0.77; p = 0.013). All studies were rated as having a high risk of overall bias. CONCLUSIONS: Robust conclusions are precluded by study heterogeneity and high risk of bias in the included studies. However, this systematic review provides an indication of treatments that should be investigated further to establish any effect on delirium in the preoperative setting in hip fracture patients.

Use of Medical Supplies at the Roskilde Festival 2016: A Prospective Observational Study.

INTRODUCTION: Music festivals are popular events often including camping at the festival site. A mix of music, alcohol, drugs, and limited hygiene increases health risks. This study aimed to assess the use of medical supplies at a major music festival, thereby aiding planning at similar events in the future. METHOD: The Medical Health Care Organization (MHCO) at Roskilde Festival 2016 (Denmark) collected prospective data on disposable medical supply use and injuries and illnesses presenting to the MHCO. RESULTS: A total of 12,830 patient presentations were registered by the MHCO and a total of 104 different types of disposable medical supplies were used by the MHCO from June 25, 2016 through July 3, 2016. Out of 12,830 cases, 594 individuals (4.6%) had a potential or manifest medical emergency, 6,670 (52.0%) presented with minor injuries, and 5,566 (43.4%) presented with minor illnesses. The overall patient presentation rate (PPR) was 99.0/1,000 attendees and the transport-to-hospital rate (TTHR) was 2.1/1,000 attendees. For medical emergencies, the most frequently used supplies were aluminum rescue blankets (n = 627), non-rebreather masks (n = 121), and suction catheters for an automatic suction unit (ASU) for airway management (n = 83). Most used diagnostic equipment were blood glucose test strips (n = 1,155), electrocardiogram electrodes (n = 960), and urinary test strips (n = 400). The most frequently used personal protection equipment were non-sterile gloves (n = 1,185 pairs) and sterile gloves (n = 189). CONCLUSION: This study demonstrates a substantial use of disposable medical supplies at a major music festival. The results provide aid for planning similar mass-gathering (MG) events.

Use of Medication at the Roskilde (Denmark) Music Festival 2015 - A Prospective Observational Study of 15,133 Treated Attendees.

BACKGROUND: Outdoor music festivals (OMFs) attract large numbers of guests and benefit from the help of large numbers of volunteers. Studies have previously described the injury patterns at OMFs, but no studies have described the use of medication and sales from on-site pharmacies at a large OMF. METHOD: The usage of medication and prescriptions in the Medical Health Care Organization (MHCO), including sales from the on-site pharmacy, at the Roskilde (Denmark) Festival 2015 were prospectively recorded. RESULTS: In excess of 130,000 attendees (guests and volunteers) participated in the Roskilde Festival 2015. The number of attendees contacting the MHCO was 15,133, of which 3,723 (25%) had a consultation with a doctor. Of all attendees evaluated by a doctor, 669 attendees received some form of medication in relation to the consultation. The MHCO administered and/or handed out a total of 6,494 units of prescription and over-the-counter medication, of which analgesics represented nearly 51%. Asthma was the condition with the highest proportion of attendees requiring pharmaceutical treatment, as 28 out of 48 (58%) received medication during the consultation. Sixty-five attendees received both medicine and a prescription. The MHCO handed out 562 prescriptions. In total, 609 prescriptions were redeemed at the on-site pharmacy. Antibiotics represented more than 78% of all redeemed prescriptions at the on-site pharmacy. CONCLUSION: The most utilized medications were analgesics and antibiotics. The data indicate a need for on-site prophylaxis using tetanus toxoid in combination with diphtheria toxoid vaccine and an on-site pharmacy. The content of the formulary at a mass-gathering event should be based on: evacuation time by ambulance/helicopter to hospitals with the level of competence needed; types of conditions to be treated on-site; level of competencies of festival medical staff; expected incidence and type of illness and injuries; and treatment of acute, life-threatening illnesses and or injuries.

[Information specialists improve the quality of systematic reviews].

Systematic reviews (SR) are a recognised standard for synthesising clinical data in order to support evidence-based clinical decisions. A robust search strategy is the core of an SR, requiring theoretical and methodological considerations in the pre-, intra- and post-search stage. This review discusses the competencies necessary to design a search including the necessary symbiosis between medical knowledge and detailed knowledge of database architecture and corresponding semantics. Information specialists play an important role in high-quality SR.

Obstetric early warning score in Scandinavia. A survey of midwives' use of systematic monitoring in parturients.

OBJECTIVE: systematic monitoring has recently been implemented widely in non-obstetric departments. In the UK, Early Warning Score (EWS) systems specifically designed for the obstetric population (OEWS) are used. No information on the use of OEWS in Scandinavia has been reported. Consequently, we wanted to investigate the use of vital signs and attitude towards systematic monitoring of parturients in Denmark, Norway and Sweden. DESIGN: electronic questionnaires sent to heads of midwifery. The heads of midwifery referred two clinically active midwives. All in-hospital obstetric departments in Scandinavia were invited to participate. FINDINGS: heads of midwifery from 76 departments (68%), and 125 clinical midwives (82%) responded. Ten per cent of midwives reported use of OEWS. Reported implementation barriers to OEWS included lack of evidence and suspected impact on the parturient due to frequent interruptions. fifty-four per cent of clinical midwives reported a systolic blood pressure threshold of 90-139mmHg, while 33% reported a threshold of>160mmHg. Ninety-three per cent stated a low threshold for maternal heart rate<60 bpm whereas 10% reported an upper threshold heart rate ≥ 150 bpm. Forty-seven per cent reported call for assistance thresholds for maternal heart rate at 60-110 bpm. KEY CONCLUSIONS: OEWS is not implemented in Scandinavian obstetric departments and reported thresholds of vital signs varied considerably. Major barriers for implementation in Scandinavia include midwives' concern of interruptions for the parturient and increased workload, and unclear benefit from use of OEWS. Local departments should provide midwives with unambiguous thresholds for vital signs in parturients either through local guidelines or via OEWS.

[Medical doctors' surgical abilities measured by means of a surgical simulator].

INTRODUCTION: The aim of the study was to test the surgical abilities between orthopaedic surgeons and anaesthetists on a surgical simulator intended for children. METHODS: The study was a prospective comparative study with 31 consultant or specialist grade medical doctors: 15 orthopaedic surgeons and 16 anaesthetists. The speed and failure rate when removing foreign bodies on a surgical simulator was measured. RESULTS: There was no statistically significant difference in speed and failure rate between orthopaedic surgeons and anaesthetists, when they were working on the simulator. Anaesthetists demonstrated statistically significant more body movement and more use of foul language doing the simulation, and they were more willing to read the written instruction but less likely to follow it. CONCLUSION: Anaesthetists may be just as handy as orthopaedic surgeons but should be given more physical and verbal space in the operation room. FUNDING: none. TRIAL REGISTRATION: not relevant.

[Metabolic myopathy causing rhabdomyolysis]. / Metabolisk myopati som årsag til rabdomyolyse.

Rhabdomyolysis is a potential life-threatening condition characterized by a rapid destruction of striated muscle cells. Causes include trauma, muscle hypoxia, drugs, malignant hyperthermia, infections, toxins and metabolic myopathies. We report a case of a 52-year-old man with hereditary myoglobi-n-uria and gastroenteritis-induced rhabdomyolysis. Metabolic myopathy as a cause of rhabdomyolysis is rare but potential life-threatening if not diagnosed and treated promptly.

Regional analgesia for video-assisted thoracic surgery: a systematic review.

Video-assisted thoracic surgery (VATS) is emerging as the standard surgical procedure for both minor and major oncological lung surgery. Thoracic epidural analgesia (TEA) and paravertebral block (PVB) are established analgesic golden standards for open surgery such as thoracotomy; however, there is no gold standard for regional analgesia for VATS. This systematic review aimed to assess different regional techniques with regard to effect on acute postoperative pain following VATS, with emphasis on VATS lobectomy. The systematic review of PubMed, The Cochrane Library and Embase databases yielded 1542 unique abstracts; 17 articles were included for qualitative assessment, of which three were studies on VATS lobectomy. The analgesic techniques included TEA, multilevel and single PVB, paravertebral catheter, intercostal catheter, interpleural infusion and long thoracic nerve block. Overall, the studies were heterogeneous with small numbers of participants. In comparative studies, TEA and especially PVB showed some effect on pain scores, but were often compared with an inferior analgesic treatment. Other techniques showed no unequivocal results. No clear gold standard for regional analgesia for VATS could be demonstrated, but a guide of factors to include in future studies on regional analgesia for VATS is presented.

Use of professional profiles in applications for specialist training positions.

INTRODUCTION: The seven roles of the CanMEDS system have been implemented in Danish postgraduate medical training. For each medical specialty, a professional profile describes which elements of the seven roles the specialty deems important for applicants for a specialist training position. We investigated use of professional profiles among the 38 Danish specialty societies in order to ascertain the use of the seven roles. MATERIAL AND METHODS: We used information from the websites of the Postgraduate Medical Training Secretariats in March 2012. For each profile, we extracted information on how the seven roles were described, how the roles were ranked by importance, whether a score sheet was used by the appointment committee and whether the profile had been updated. RESULTS: Twenty-four (63%) of the 38 profiles described the contents for all of the seven roles and four (11%) described the contents only for some of the roles. Nine specialties (24%) described a clear ranking of the seven roles with the medical expert and scholar roles generally ranked as most important. Seven specialties (18%) used standardised score sheets as part of the application process. Four (11%) specialties had updated their professional profiles. CONCLUSION: The majority of specialties described the seven roles in their professional profiles, but the level of detail varied substantially. Few specialties described whether the roles were ranked by importance or provided specific guidelines for appointment committees on how the contents of the profiles should be interpreted. We suggest that specialties seek inspiration for updating their profiles, and that they use the contents from all specialties provided at a website. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Pain-related impairment of daily activities after thoracic surgery: a questionnaire validation.

OBJECTIVE: Persistent postoperative pain is an acknowledged entity that reduces daily activities. Evaluation of the post-thoracotomy pain syndrome (PTPS) is often measured using traditional pain scales without in-depth questions on pain impairment. Thus, the purpose was to create a procedure-specific questionnaire for assessment of functional impairment due to PTPS. METHODS: Activities were obtained from the literature supplemented by interviews with patients and surgeons. The questionnaire was validated using the Rasch model in order to describe an underlying pain impairment scale. RESULTS: Four of 17 questions were redundant. The remaining 13 questions from low to intensive activity described functional impairment following persistent pain from thoracotomy and video-assisted thoracic surgery (VATS). No evidence for differential item functioning for gender, age or differences between open or VATS, were found. A generalized log-linear Rasch model including local dependence was constructed. Though local dependence influenced reliability, the test-retest reliability estimated under the log-linear Rasch model was high (0.88-0.96). Correlation with items from the Disability of the Arm, Shoulder and Hand (quick) questionnaire supported validity (γ = 0.46, P < 0.0001), and procedure specificity. The analysis also procured evidence that the pain impairment questionnaire measured 2 qualitatively different pain dimensions although highly correlated (γ = 0.76). CONCLUSIONS: This study presents method, results and validation of a new unidimensional scale measuring procedure specific functional impairment due to PTPS following open surgery and VATS. Procedure specific tools such as this could provide important outcomes measures for future trials on persistent postsurgical pain states allowing better assessment of interventions (250).

Sensory testing in patients with postthoracotomy pain syndrome: Part 1: mirror-image sensory dysfunction.

OBJECTIVES: Mirror-image sensory dysfunction (MISD) has not been systematically characterized in persistent postoperative pain. METHODS: The presence of MISD was evaluated with standardized stimuli, in preoperative patients scheduled for a thoracotomy (n = 14) and in patients with postthoracotomy pain syndrome [PTPS (n = 14)]. The primary outcome was investigation of the areas of sensory dysfunction, evaluated twice by dynamic sensory mapping with metal rollers and a brush. RESULTS: In PTPS patients, sensory dysfunction was present on the surgical side, and in 12 of 14 patients MISD was demonstrated. The total areas of sensory dysfunction [median (interquartile range)] were: day 1, 500 (289 to 636) cm and 60 (0 to 379) cm on the surgical and nonsurgical side (P < 0.005), respectively; and day 2, 355 (266 to 697) cm and 81 (0 to 202) cm on the surgical and nonsurgical side (P < 0.0002), respectively. Magnitudes of areas on the surgical side, respective of the nonsurgical side, did not significantly differ between the 2 days of investigation (P > 0.5). The agreement between test-retest assessments was fair to excellent on the surgical side but poor on the nonsurgical side. None of the PTPS patients experienced mirror pain. DISCUSSION: MISD is a common finding in PTPS patients and deserves further study involving mechanism and clinical implications.