[Anterior shoulder dislocation: revised Dutch Clinical Guideline in practice]. / Primaire anterieure schouderluxatie.

Shoulder dislocations remain the most frequent of joint dislocations, with anterior displacement of the humeral head being the direction of dislocation seen most often (97%). Recently, the Dutch clinical guideline on shoulder dislocations has been revised on the basis of predetermined bottlenecks in clinical practice. In this paper, the guideline is translated to clinical practice by means of two fictional cases, in which the novel recommendations are incorporated. The following topics were systematically assessed based on the best available scientific evidence: primary diagnostics, reduction techniques, painmedication/ sedation surrounding reduction and the need for physiotherapy, stabilization surgery and immobilization. Also, a best practice care pathway is advocated. Since scientific evidence is often inconclusive to provide undebatable therapeutic rules, the committee graded the available evidence and additionally used expert opinion to carefully draft recommendations. The paper concludes with an overview of all the recommendations stated in the updated multidisciplinary guideline.

A modified Delphi study to identify which items should be evaluated in shoulder instability research: a first step in developing a core outcome set.

Background: The aim of this study was to identify items that healthcare providers and/or patients consider important to include in a questionnaire for clinical trials and cohort studies in shoulder instability research. This could serve as a basis to develop a core outcome set for shoulder instability research. Methods: Healthcare providers and patients were included in a panel for a modified Delphi consensus study. The study consisted of three rounds, comprising (1) identifying items, (2) rating the importance of the items, and (3) rating the importance again after seeing a summary of the results of round two. Importance was rated on a 9-point Likert scale. Consensus was defined as ≥ 80% of the panel giving a score of 7 or higher. Results: In total, 44 healthcare providers and 30 patients completed all three rounds. Round one identified 54 items. After round three, the panel reached a consensus on 11 items that should be included in a questionnaire, comprising re-dislocation (99%), instable feeling of the shoulder (96%), limitations during sport (93%), patient satisfaction with the shoulder (93%), fear/anxiety for re-dislocation (91%), range of motion (88%), return to old level of functioning (85%), performing daily activities (85%), return to sport (82%), return to work (82%), and trusting the shoulder (81%). Conclusion: Healthcare providers and patients reached a consensus on 11 items that should be included in a questionnaire for shoulder instability research. These items can facilitate design and development of future clinical trials and form the basis for the development of a core outcome set.

[Suicidal behavior in emergency care: 10 tips for an active, empathetic and preventative approach]. / Suïcidaal gedrag op de SEH.

Patients with suicidal behaviour are frequently seen in A&E departments. Providing care for this patient group can be challenging and medical staff have often not received specialized training to improve their knowledge and skills. An empathetic approach combined with brief interventions such as safety planning, collaborating with carers and partnership with local organizations can help A&E professionals to optimize care for these patients and contribute to the prevention of future suicide attempts.

BRASD trial: biomechanical reposition techniques in anterior shoulder dislocation-a randomized multicenter clinical trial.

BACKGROUND: Biomechanical reduction techniques for shoulder dislocations have demonstrated high reduction success rates with a limited pain experience for the patient. We postulated that the combination of biomechanical reduction techniques with the shortest length of stay would also have the lowest pain experience and the highest first reduction success rate. METHODS: A randomized multicenter clinical trial was performed to compare different biomechanical reduction techniques in treating anterior shoulder dislocations without the use of invasive pain relief. Patients who were able to perform adduction of the arm were randomly assigned to Cunningham, the modified Milch, and the scapular manipulation technique. Those who were not able to do so were randomly assigned to modified Milch and the scapular manipulation technique. Primary outcomes were emergency department length of stay and pain experienced during the reduction process, measured by the numeric pain rating scale. Secondary outcomes were reduction time, reduction success, use of analgesics or sedatives, and complications. RESULTS: Three hundred eight patients were included, of whom 134 were in the adduction group. In both groups, no differences in emergency department length of stay and experienced pain were observed between the treatment arms. In the adduction group, the modified Milch technique had the highest first reduction success rates 52% (p = 0.016), within protocol 61% (p = 0.94), and with sedation in the ED 100% ( -). In the no-adduction group, the modified Milch was also the most successful primary reduction technique with 51% success (p = 0.040), within protocol 66% (p = 0.90), and with sedation in the ED 98% (p = 0.93). No complications were recorded in any of the techniques. CONCLUSION: A combination of biomechanical techniques resulted in a similar length of stay in the emergency department and showed similar pain scores with an overall high success rate of reduction. In both groups, the modified Milch had the highest first-reduction success rate. TRIAL REGISTRATION: Netherlands Trial Register NTR5839-1 April 2016. Ethical committee Noord-Holland with the CCMO-number NL54173.094.15.

Biomechanical reposition techniques in anterior shoulder dislocation: a randomised multicentre clinical trial- the BRASD-trial protocol.

INTRODUCTION: Glenohumeral (shoulder) dislocations are the most common large joint dislocations seen in the emergency department (ED). They cause pain, often severe, and require timely interventions to minimise discomfort and tissue damage. Commonly used reposition or relocation techniques often involve traction and/or leverage. These techniques have high success rates but may be painful and time consuming. They may also cause complications. Recently, other techniques-the biomechanical reposition techniques (BRTs)-have become more popular since they may cause less pain, require less time and cause fewer complications. To our knowledge, no research exists comparing the various BRTs. Our objective is to establish which BRT or BRT combination is fastest, least painful and associated with the lowest complication rate for adult ED patients with anterior glenohumeral dislocations (AGDs). METHODS AND ANALYSIS: Adults presenting to the participating EDs with isolated AGDs, as determined by radiographs, will be randomised to one of three BRTs: Cunningham, modified Milch or scapular manipulation. Main study parameters/endpoints are ED length of stay and patients' self-report of pain. Secondary study parameters/endpoints are procedure times, need for analgesic and/or sedative medications, iatrogenic complications and rates of successful reduction. ETHICS AND DISSEMINATION: Non-biomechanical AGD repositioning techniques based on traction and/or leverage are inherently painful and potentially harmful. We believe that the three BRTs used in this study are more physiological, more patient friendly, less likely to cause pain, more time efficient and less likely to produce complications. By comparing these three techniques, we hope to improve the care provided to adults with acute AGDs by reducing their ED length of stay and minimising pain and procedure-related complications. We also hope to define which of the three BRTs is quickest, most likely to be successful and least likely to require sedative or analgesic medications to achieve reduction. TRIAL REGISTRATION NUMBER: NTR5839.

Endometriosis with an acute colon obstruction: a case report.

INTRODUCTION: The presentation of an acute bowel obstruction caused by endometriosis in an emergency department setting is rare, as it usually presents through years of complaints in the absence of a distinct acute onset. In this report, we present a case of a patient who was familiar with abdominal complaints and eventually required emergency surgery to treat an acute bowel obstruction caused by endometriosis. Endometrioses present infrequently in the acute phase, and only a few cases in which emergency surgery was required have been described in the literature. CASE PRESENTATION: A 31-year-old Caucasian woman presented to the emergency room of our hospital with a distended abdomen, pain and nausea accompanied by a history of 14 years of chronic abdominal pain and constipation. An abdominal X-ray and subsequent computed tomographic scan showed a severely distended cecum of 9cm with stenosis in the sigmoid. Cecal blow-out was considered highly likely, and, during an emergency laparotomy, an obstructing process was found in the sigmoid. An oncologic resection of the sigmoid was performed with a primary anastomosis and loop ileostomy. A pathological examination revealed a tumor of 4cm in the sigmoid, which contained a tubelike structure with cytogenic stroma and the remains of focal bleeding. These are typical aspects of endometriosis. CONCLUSIONS: Infiltrating endometriosis is an invalidating disease that can be misdiagnosed for a wide range of other diseases. Emergency room physicians and surgeons should be aware that it can present as an acute obstruction and should be considered in diagnosing women of childbearing age. After initial colonoscopy, emergency surgery is the best therapeutic approach if there is a complete obstruction.

[A newborn with an ovarian cyst]. / Een pasgeborene met een ovariumcyste.

BACKGROUND: An ovarian cyst is one of the most common types of cysts found in neonates. As a result of the introduction of the 20-week screening ultrasound, the detection of ovarian cysts will likely increase. CASE DESCRIPTION: An abdominal cyst was detected by ultrasound in a female foetus in her 20th gestational week. This simple cyst remained smaller than 5 cm in diameter so an expectative course was opted for. Six months after her birth, however, the cyst's echographic appearance changed. A necrotic left ovary was resected during a diagnostic laparoscopy. CONCLUSION: We recommend taking an expectative approach to asymptomatic simple or complex ovarian cysts, because they usually regress spontaneously in the first year of life. It is important to monitor the cyst by ultrasound and to repeatedly measure tumour marker concentrations as necessary.