[Christmas article: Can gin with herbs induce the vision of Christmas elves?]

INTRODUCTION: The Italian Medieval doctor Thaddeus Florentinus (AD 1210-1295) claimed that herbs could cure or relieve various symptoms such as obstipation, melancholia and nervousness. Additionally, certain herbs were proposed to be able to predict the weather and induce the vision of elves. Therefore, the aim of this study was to investigate whether herbs could have medical properties as claimed. METHODS: A randomized controlled trial with three arms was conducted: 1) Gin with St. John's wort, 2) Gin with angelica and 3) Gin with sweet woodruff. Participants were 21 anesthesia registrars. The primary outcome was visual induction of elves (yes/no) whereas secondary outcomes included melancholia (VAS 0-100), nervousness (VAS 0-100), weather prediction capabilities (yes/no) obstipation (Bristol Stool Chart 1-7) and others. Baseline recordings were obtained and hourly registrations of outcomes were undertaken. Confounding factors such as alcohol intoxication and vivid imagination was controlled by the means of alcohol breathalyzers and assessment of cerebral oxygenation by near infrared spectroscopy. RRESULTS: The vision of elves was induced in 10 out of 21 participants (48.6%) and was associated with male sex (p = 0.01), young age (p = 0.03) and increase in cerebral oxygenation (p = 0.04) but not with sweet woodruff (p = 0.83) or alcohol intoxication (p = 0.26). Participants were not capable of predicting the weather forecast (p = 0.55). Melancholia and nervousness were not relieved by St. John's wort, and obstipation could not be relieved by the intake of angelica. CONCLUSION: Sweet woodruff, St. John's wort and angelica were unable to relieve relevant Christmas symptoms as proposed by a medieval doctor. Alcohol ingestion might have influenced results, and data should be interpreted in the light of these precautions. FUNDING: none. TRIAL REGISTRATION: not applicable.

Opioids for Treatment of Pre-hospital Acute Pain: A Systematic Review.

INTRODUCTION: Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies. METHODS: The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method. RESULTS: A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine. CONCLUSIONS: Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.

Educational interventions to improve medical students' knowledge of acute pain management: a randomized study.

It has been consistently documented that the treatment of acute pain is inadequate. Education of medical students is an obvious strategy to improve this. We therefore conducted a study in which 217 medical students were randomized into one of three groups: a control group (no intervention) and two intervention groups (education with e-learning alone or e-learning combined with simulation-based training). We hypothesized that the combined intervention would be superior to no intervention and e-learning alone. All students completed the same multiple choice questionnaire twice with an interval of approximately 1 week. During this 1-week interval, students in the two intervention groups completed either an 45-min interactive case-based e-learning program, or the e-learning program and a simulation-based training. We showed that the theoretical knowledge about treatment of acute pain increased in both intervention groups but students who received the combined intervention felt more confident in the future handling of patients.

Acute pain in the emergency department: Effect of an educational intervention.

BACKGROUND AND AIMS: Pain management is often inadequate in emergency departments (ED) despite the availability of effective analgesics. Interventions to change professional behavior may therefore help to improve the management of pain within the ED. We hypothesized that a 2-h educational intervention combining e-learning and simulation would result in improved pain treatment of ED patients with pain. METHODS: Data were collected at the ED of Horsens Regional Hospital during a 3-week study period in March 2015. Pain intensity (NRS, 0-10) and analgesic administration were recorded 24h a day for all patients who were admitted to the ED during the first and third study weeks. Fifty-three ED nurses and 14 ED residents participated in the educational intervention, which took place in the second study week. RESULTS: In total, 247 of 796 patients had pain >3 on the NRS at the admission to the ED and were included in the data analysis. The theoretical knowledge of pain management among nurses and residents increased as assessed by a multiple choice test performed before and after the educational intervention (P=0.001), but no change in clinical practice could be observed: The administration for analgesics [OR: 1.79 (0.97-3.33)] and for opioids [2.02 (0.79-5.18)] were similar before and after the educational intervention, as was the rate of clinically meaningful pain reduction (NRS >2) during the ED stay [OR: 0.81 (CI 0.45-1.44)]. CONCLUSIONS: Conduction of a 2-h educational intervention combining interactive case-based e-learning with simulation-based training in an ED setting was feasible with a high participation rate of nurses and residents. Their knowledge of pain management increased after completion of the program, but transfer of the new knowledge into clinical practice could not be found. Future research should explore the effects of repeated education of healthcare providers on pain management. IMPLICATIONS: It is essential for nurses and residents in emergency departments to have the basic theoretical and practical skills to treat acute pain properly. A modern approach including e-learning and simulation lead to increased knowledge of acute pain management. Further studies are needed to show how this increased knowledge is transferred into clinical practice.