Efficacy of intergrating vestibular rehabilitation and cognitive behaviour therapy in persons with persistent dizziness in primary care- a study protocol for a randomised controlled trial.

BACKGROUND: Dizziness is a common complaint, and the symptom often persists, together with additional complaints. A treatment combining Vestibular Rehabilitation (VR) and Cognitive Behaviour Therapy (CBT) is suggested. However, further research is necessary to evaluate the efficacy of such an intervention. The objective of this paper is to present the design of a randomised controlled trial aiming at evaluating the efficacy of an integrated treatment of VR and CBT on dizziness, physical function, psychological complaints and quality of life in persons with persistent dizziness. METHODS/DESIGN: The randomised controlled trial is an assessor-blinded, block-randomised, parallel-group design, with a 6- and 12-month follow-up. The study includes 125 participants from Bergen (Norway) and surrounding areas. Included participants present with persistent dizziness lasting for at least 3 months, triggered or exacerbated by movement. All participants receive a one-session treatment (Brief Intervention Vestibular Rehabilitation; BI-VR) with VR before being randomised into a control group or an intervention group. The intervention group will further be offered an eight-session treatment integrating VR and CBT. The primary outcomes in the study are the Dizziness Handicap Inventory and preferred gait velocity. DISCUSSION: Previous studies combining these treatments have been of varying methodological quality, with small samples, and long-term effects have not been maintained. In addition, only the CBT has been administered in supervised sessions, with VR offered as home exercises. The current study focusses on the integrated treatment, a sufficiently powered sample size, and a standardised treatment programme evaluated by validated outcomes using a standardised assessment protocol. TRIAL REGISTRATION: www.clinicaltrials.gov, ID: NCT02655575 . Registered on 14 January 2016.

Feasibility of integrating vestibular rehabilitation and cognitive behaviour therapy for people with persistent dizziness.

PURPOSE: To evaluate the feasibility of integrating vestibular rehabilitation and cognitive behaviour therapy (VR-CBT) for people with persistent dizziness in primary care. DESIGN: Prospective single-group pre- and post-test study. PARTICIPANTS: Adults (aged 18-70) with acute onset of dizziness and symptoms lasting a minimum 3 months, recruited from Bergen municipality. METHODS: Participants attended eight weekly group sessions of VR-CBT intervention. Feasibility outcomes consisted of recruitment and testing procedures, intervention adherence, and participant feedback, besides change in primary outcomes. The primary outcomes were Dizziness Handicap Inventory (DHI) and preferred gait velocity. RESULTS: Seven participants were recruited for the study. All participants completed the pre-treatment tests, five participants completed the intervention and answered post-treatment questionnaires, and three completed post-treatment testing. Of the five participants, three attended at least 75% of the VR-CBT sessions, and two 50% of the sessions. Participants reported that the VR-CBT was relevant and led to improvement in function. DHI scores improved beyond minimal important change in two out of five participants, and preferred gait velocity increased beyond minimal important change in two out of three participants. CONCLUSION: The current tests and VR-CBT treatment protocols were feasible. Some changes are suggested to optimise the protocols, before conducting a randomised controlled trial. TRIAL REGISTRATION: NCT02655575. Registered 14 January 2016-retrospectively registered.

Short-term information pattern in optokinetic nystagmus amplitude time series.

In this paper we analyzed optokinetic nystagmus (OKN) signals for underlying information patterns. Fourteen OKN signals were recorded in five healthy subjects. First, we tested the correlation between nystagmus slow and fast phases. Previously, it has been suggested that the correlation is higher between the amplitude of the slow phase and the following fast phase, compared to the correlation between the fast phase and the following slow phase. However, we found no such difference. This is in agreement with the view that the saccade performed by the eye is not determined by the previous slow phase, but is free to move voluntarily in order to focus on an object of interest. Second, we analyzed the information entropy contained in the sequence of optokinetic nystagmus amplitudes, and found a short-term information pattern. Further analysis of these patterns could eventually lead to more knowledge about the vestibular and oculomotor systems.

Postural control in a simulated saturation dive to 240 msw.

INTRODUCTION: There is evidence that increased ambient pressure causes an increase in postural sway. This article documents postural sway at pressures not previously studied and discusses possible mechanisms. METHODS: Eight subjects participated in a dry chamber dive to 240 msw (2.5 MPa) saturation pressure. Two subjects were excluded due to unilateral caloric weakness before the dive. Postural sway was measured on a force platform. The path length described by the center of pressure while standing quietly for 60 seconds was used as test variable. Tests were repeated 38 times in four conditions: with eyes open or closed, while standing on bare platform or on a foam rubber mat. RESULTS: Upon reaching 240 msw, one subject reported vertigo, disequilibrium and nausea, and in all subjects, mean postural sway increased 26% on bare platform with eyes open (p < 0.05) compared to predive values. There was no significant improvement in postural sway during the bottom phase, but a trend was seen toward improvement when the subjects were standing with eyes closed on foam rubber (p = 0.1). Postural sway returned to predive values during the decompression phase. DISCUSSION: Postural imbalance during deep diving has been explained previously as HPNS possibly including a specific effect on the vestibulo-ocular reflex. Although vertigo and imbalance are known to be related to compression rate, this study shows that there remains a measurable increase in postural sway throughout the bottom phase at 240 msw, which seems to be related to absolute pressure.

Interleukin-1beta influences the effect of infliximab on temporomandibular joint pain in rheumatoid arthritis.

OBJECTIVES: The aim of this study was to investigate the influence of plasma and synovial fluid tumour necrosis factor alpha (TNFalpha), interleukin-1beta (IL-1beta), IL-6, soluble TNF receptor II (TNF-sRII), IL-1 receptor antagonist (IL-1ra), soluble IL-1 receptor II (IL-1sRII) and IL-10 on the effect of the TNFalpha antibody infliximab on temporomandibular joint (TMJ) pain in patients with active rheumatoid arthritis (RA). METHODS: Fifteen patients with TMJ pain taking methotrexate were included in the study. The effect of intravenous infusions of infliximab was assessed after 14 or 22 weeks. TMJ resting and movement pain was assessed by a visual analogue scale (VAS) (0-100 mm) and samples of venous blood and TMJ synovial fluid were collected before and after treatment. RESULTS: The effect of infliximab on TMJ pain was influenced by pretreatment plasma levels of IL-1beta, IL-1ra, and IL-10 as well as pretreatment levels of TMJ synovial fluid IL-1sRII. High pretreatment levels of these cytokines and receptors as well as the presence of rheumatoid factor (RF) were associated with no or minor reduction in TMJ pain after treatment. CONCLUSIONS: Systemic treatment of RA with a combination of infliximab and methotrexate seems to be insufficient to alleviate TMJ pain in patients with RF or high pretreatment plasma levels of IL-1beta.

Radiographic signs of bone destruction in the arthritic temporomandibular joint with special reference to markers of disease activity. A longitudinal study.

OBJECTIVE: To investigate the progression of radiographic changes of the temporomandibular joint (TMJ) with reference to plasma levels of interleukin-1beta (IL-1beta), C-reactive protein (CRP) and disease duration. METHODS: Twenty-one patients with chronic inflammatory joint disease and TMJ involvement were included. Individualized tomography of the TMJ was performed twice with an interval of at least 12 months. Blood samples were analysed for IL-1beta and CRP. RESULTS: Significant progression of the overall grade of radiographic changes occurred during the observation period, whereas erosions showed great interindividual variability. Progression of TMJ bone loss was correlated to raised levels of CRP and, in patients with a diagnosis of rheumatoid arthritis, or with shorter duration, also to plasma IL-1beta. CONCLUSION: Progression of overall grade of radiographic changes in the TMJ occurs in patients with chronic inflammatory joint disease. Raised levels of serum CRP are associated with progression of TMJ bone loss.

Static stabilometry and repeated testing in a normal population.

BACKGROUND: The purpose of the present study was to see if there is a learning effect of repeated static stabilometric testing, using a protocol suitable for testing postural control in narrow spaces, like hypo- and hyperbaric chambers. HYPOTHESIS: Static stabilometry testing under normobaric conditions is objective and reproducible. With repeated testing, a learning effect may be observed. METHODS: Four groups of healthy individuals were tested ten times under the same four acoustically and visually standardized and normobaric normoxic test conditions on a static balance platform. First, the subjects were asked to stand on a bare platform with the eyes open, thereafter with the eyes closed. This was repeated with a foam rubber mat placed on top of the balance platform. The time interval between the first and the last test sequence was 11 (10-13) days for the test subjects in group I (n = 22), 17 d for group II (n = 13), 31(28-36) days for group III (n = 15) and 115 (49-193) days for group IV (n = 10). RESULTS: Static stabilometry tests in a normal population are objective and reproducible. With repeated tests, a learning effect was observed. The learning effect was largest when standing on a foam rubber mat with eyes closed and when the time intervals between the tests were shortest. There was no difference in sway pattern or learning ability between tall and short test subjects, between subjects with heavy and light body weight or between the sexes.

Tumor necrosis factor-alpha in synovial fluid and plasma from patients with chronic connective tissue disease and its relation to temporomandibular joint pain.

PURPOSE: The purpose of this study was to determine the level of tumor necrosis factor-alpha (TNF-alpha) in the temporomandibular joint (TMJ) synovial fluid (SF-TNF-alpha) and blood plasma (P-TNF-alpha) of patients with chronic inflammatory connective tissue disease and investigate its relation to TMJ pain, hyperalgesia, and allodynia. PATIENTS AND METHODS: Twenty-four patients with a diagnosis of chronic inflammatory connective tissue disease and TMJ pain were included in the study. Visual analog scale, tenderness of the TMJ, and pain at mandibular movements were registered, and the pressure pain threshold and pressure pain tolerance levels were measured. TMJ synovial fluid samples and blood plasma were analyzed for TNF-alpha and the levels related to TMJ pain, hyperalgesia, and allodynia. RESULTS: TNF-alpha was present in the TMJ synovial fluid of 8 of 24 patients at levels significantly exceeding those in plasma at the same visit. The presence of SF-TNF-alpha showed a significant positive correlation to TMJ pain at maximum voluntary mouth opening and tenderness to posterior palpation of the TMJ. CONCLUSION: Local production of TNF-alpha occurs in the TMJ synovium of patients with chronic inflammatory connective tissue disease. Pain on mandibular movement and tenderness on posterior palpation (allodynia) of the TMJ is related to the level of SF-TNF-alpha.

Effect of bupivacaine on pain after tonsillectomy: a randomized clinical trial.

Several authors have found that pre-incisional injection of local anaesthetics reduces postoperative pain. In the present double-blind study, comprising 126 inpatients aged 6-42 (mean 19) years, we investigated whether pre-incisional injection of bupivacaine during general anaesthesia reduces the pain experienced after tonsillectomy. The patients were randomized into three treatment groups: 43 patients were injected with 5 ml of bupivacaine (2.5 mg/ml)+ epinephrine (5 microg/ml) solution in both tonsillar fossa, 41 had epinephrine (5 microg/ml) + saline (9 mg/ml) and 42 patients received saline (9 mg/ml) only. Self-assessment of pain during the first postoperative week (repeated measures) was recorded. Use of analgetics, experience of the surgeons, peroperative bleeding and several other clinical parameters were assessed. Analyses of covariance with repeated measures was carried out for each pain score. In general there was no statistical significant difference in pain scores, represented by a visual analogue scale (VAS) between the three treatment groups. However, injection of bupivacaine into the tonsillar fossa seemed to reduce pain shortly after the operation in the age group 19-24 years. Further, females and older patients reported more pain and used more analgetics than males and younger patients. Increasing experience of the surgeon was related to a lower score for baseline pain shortly after the operation. Epinephrine in bupivacaine or saline reduced peroperative bleeding. We conclude that bupivacaine does not provide significant postoperative analgesia after tonsillectomy in an unselected group of patients.

Effects of hypobaric hypoxia on postural control.

BACKGROUND: While the effects of accelerative forces on the vestibular system have been thoroughly investigated, the effects of hypobaric conditions on the postural system have attracted less attention. The purpose of the study was to investigate if postural control is affected by hypobaric hypoxia. HYPOTHESIS: Moderate hypobaric hypoxia may reduce postural control. METHODS: Subjective and multiple objective measurements of postural control with open and closed eyes were made in 16 military aircrew standing on a static balance platform before, during, and after exposure to an altitude chamber training profile with a maximum altitude of 25,000 ft. RESULTS: No subjective dizziness and no clinical unsteadiness were noted. However, significant changes in body sway were found at the balance platform during hypobaric exposure at 18,000, 14,000 and 8000 ft compared with the baseline registrations. The relative increase in sway movements was greater in the eyes open condition compared with the eyes closed condition, and significant for movements in the anteroposterior plane but not in the lateral plane. Most sway parameters returned to pre-exposure values on return to ground level. CONCLUSIONS: Acute hypobaric hypoxia, corresponding to the tested altitudes, influenced postural control primarily in the anteroposterior plane with eyes open. This is in agreement with other studies showing that vision is the first of the special senses to be altered by lack of oxygen.

Interleukin-1beta in plasma and synovial fluid in relation to radiographic changes in arthritic temporomandibular joints.

The aim of this study was to investigate the level of the cytokine IL-1beta in plasma and temporomandibular joint (TMJ) synovial fluid of patients with arthropathies, and to study the relation between IL-1beta levels of synovial fluid and plasma as well as radiographic changes of the TMJ. 31 patients with general disease, 14 with rheumatoid arthritis (RA) and 17 with various arthritides were included in the study. Synovial fluid and blood samples were collected, and an individualized tomography of the TMJ was performed. Detectable levels of IL-1beta were found in 5 out of 39 synovial fluids and in 10 out of 27 plasma samples. The presence of IL-1beta in both plasma and synovial fluid was more frequent in RA patients than in the non-RA group. The extension of radiographic erosion was significantly greater in joints with IL-1beta than in those without. Both the extension of erosion and grade of radiographic changes of the TMJ were greater in patients with detectable IL-1beta level of plasma than in patients without. Our study indicates that presence of IL-1beta in plasma and synovial fluid is related to radiographic changes of the TMJ.

Pain, tenderness, mandibular mobility, and anterior open bite in relation to radiographic erosions in temporomandibular joint disease.

The relationship between radiographic changes and clinical signs and symptoms of the temporomandibular joint (TMJ) was investigated in 39 patients with joint diseases. Radiographic erosions were found in 33% of the TMJ joints, and overall frequency of radiographic changes including remodeling was 47%. Fifty-four percent of the patients had an anterior open bite (AOB). The AOB showed statistically significant correlation to the extension of erosion of the TMJ. Pain expressed by means of a visual analog scale, tenderness to palpation of the TMJ, and pressure pain threshold showed no significant correlation to erosion, but mandibular mobility showed significant negative correlation to erosive changes. In conclusion, AOB is correlated with erosive radiographic changes in this patient group. However, the degree of local pain and tenderness showed no correlation to radiographic changes.

[Chaos theory and otoneurologic diagnosis]. / Kaosteori i otonevrologisk diagnostikk.

Current interpretation of signals obtained from ENG (electronystagmography) of patients suffering from vertigo is based on methods developed before computers became standard laboratory equipment. New signal processing methods, based on the use of fast computers, can increase our knowledge of the mechanisms involved in the regulation of the vestibular system. Preliminary results suggests that new analyzing tools from the field of chaos theory may yield information of clinical relevance. At present this would appear to be a promising approach to research in this field.

Measurement of joint aspirate dilution by a spectrophotometer capillary tube system.

The amount of synovial fluid in small joints which is available for analysis of endogenous compounds is usually very limited and saline washings are therefore commonly required. However, since the washing fluid is not fully recovered and, furthermore, dilutes the synovial fluid in the joint aspirate, the true synovial fluid concentration of a particular substance is unknown. In the present study we validate the use of vitamin B12 (hydroxocobalamin, 1 mg ml-1) as an internal standard to determine this dilution, since its strong red colour lends itself to spectroscopic measurement by a capillary tube system requiring only 3 microliter per sample. The absorbance of different dilutions of the stock solutions (25, 33 and 50% vitamin B12 in saline) by saline, plasma and hyaluronan was measured in order to establish the optimal wavelength, the lower limit of detection and the interference by plasma or hyaluronan in the absorbance. Furthermore, the interaction of vitamin B12 in the analyses of interleukin-1 beta, serotonin and glucose was investigated. The optimal wavelength was found to be 350 nm and the limit of detection 0.5-0.9% dilution of the vitamin B12 solution. Hyaluronan or plasma did not influence the absorbance measurements and the minute interaction of vitamin B12 in the photometric measurements could be compensated for.

Balance testing in saturation diving.

UNLABELLED: The literature is sparse and equivocal concerning the possible influence of hyperbaric exposure on postural control and the vestibular system. HYPOTHESIS: Deep heliox diving may influence postural control and the vestibular system. METHOD: Multiple objective measurements of postural control were made in four divers by means of a static balance platform before, during and after an onshore experimental saturation heliox chamber dive of 32 d duration. Saturation pressure was 4.6 MPa, corresponding to a depth of 450 m of seawater (msw). Downward excursions to 470 msw were also performed. Clinical ENT and otoneurological examination, including bithermal caloric vestibular testing with electronystagmography (ENG) was performed before and after the dive. RESULTS: Reduced postural control was detected by the balance platform test in all four divers from approximately 200 msw and deeper. Body sway showed a distinct increase during compression, reaching a maximum value during the bottom phase. The Romberg index was not suitable for describing shifts in postural stability. All sway parameters returned to pre-dive values after surfacing. Immediately post-dive, most caloric responses were reduced, compared to the pre-dive results. CONCLUSION: We conclude that deep heliox diving influences postural control and the vestibular system. Computerized stabilometry is a convenient and sensitive method of monitoring postural control during saturation diving. The path length of the center of pressure (COP) seems to be suitable as a monitoring parameter.

Home application of EMLA cream prior to venipuncture. Is it feasible in pediatric ENT day care surgery?

EMLA (Eutectic Mixture of Local Anaesthetics) cream is an emulsion made from lidocaine and prilocaine. The cream is well known among parents in Scandinavia, and it has become most popular in preventing pain during venipuncture in children. To be fully effective the cream must be applied at least 60 min before the painful stimulus, which is a major drawback in outpatient practice. Could this problem be eliminated by home application of EMLA cream? To answer this we performed a study comprising 228 consecutive patients (1-15 years of age) planned for outpatient surgery. All parents received a letter with detailed information about the procedure and a prescription of EMLA cream. Parents and anaesthesiology nurses answered questionnaires after the operation. Twenty-three children were excluded from the study due to failure in registration or they were called in to fill vacancies. One hundred and eighty out of 205 children had EMLA cream applied. Home application of EMLA cream reduced the waiting time at the ENT outpatient clinic by at least 60 min, and the study showed that home application of EMLA cream is safe, easy to perform and a well-tolerated procedure.

Tularemia: a differential diagnosis in oto-rhino-laryngology.

Tularemia can present as an oto-rhino-laryngological disease. The clinical and radiological (CT) manifestations, diagnosis and treatment are discussed based on a case report where a patient with tonsillitis and enlarged cervical lymph nodes was admitted to the department of oto-rhino-laryngology of a hospital in Northern Norway. Francisella tularensis was isolated from the blood and there was a high titre of agglutinating serum antibodies to F. tularensis. The patient's contaminated drinking water well is the suspect source of infection.

[Minitracheotomy]. / Minitrakeotomi.

Minitracheotomy is used most often in intensive care units for tracheobronchial suctioning, especially after major abdominal and thoracic surgery. In addition, minitracheotomy is used in emergency situations involving obstruction of upper airways. Percutaneous minitracheotomy means a coniotomy that should be performed under safe conditions. The Seldinger technique may facilitate insertion of the tube. The position of the tube has to be checked by aspiration of air. We describe a case with bleeding and intralaryngeal haematoma. Usually, however, minitracheotomy seems to be a valuable and safe therapeutic asset provided that the necessary precautions are taken.

Delivery of oral health care to the elderly patient.

This paper, delivered at the 1990 FDI Singapore Congress, reports the results of studies performed by a Working Group, appointed by the Commission on Dental Education and Practice, to study the delivery of oral health care to the elderly patient. The teaching of gerodontology was also included in the group's remit. The problems of the widely differing oral health care needs of the elderly in different societies around the world are considered and recommendations made.

Water- and airborne Francisella tularensis biovar palaearctica isolated from human blood.

The isolation of Francisella tularensis from human blood is extremely rare in Europe. We here describe two cases of septicemia caused by F. tularensis biovar palaearctica, where the causative bacterium was isolated from blood. One of our patients had ingested contaminated water; the other was probably infected by inhalation of contaminated dust. The isolation of the causative organism was essential for initiating the appropriate antibiotic treatment, which led to a rapid improvement. Since the responsive agent rarely is isolated from tularemia patients, blood cultures should be drawn more often in order to improve the diagnostic procedures.