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PURPOSE: Episodic breathlessness is frequent in palliative cancer patients. Opioids are the only pharmacological agents with sufficient evidence in treatment. In Denmark, the main recommendation is red morphine drops (RMD), an off-label solution of morphine, ethanol, and red color (cochenille) described since 1893 (Pharmacopoea Danica). In 2015, the Danish Medicines Agency increased focus on off-label medicines and recommended registered morphine drops without ethanol instead. However, our palliative patients told us that RMD was better. For that reason, we conducted a clinical trial to clarify any perceived difference between the two types of drops. METHODS: We conducted a randomized, double blinded, crossover trial. Patients were asked to perform standardized activity (2-min walk) aiming to provoke breathlessness. Primary endpoint (breathlessness NRS) and secondary endpoints (saturation, pulse, respiratory frequency) were measured before (t = 0) and after test medicine at t = 1, t = 3, t = 5, t = 10, and t = 20 min. After 2-4 days (washout period), the patients repeated the test, receiving the alternative drops in a blinded setup (crossover). RESULTS: In the first 3 min, the relative drop in breathlessness for morphine drops with ethanol (RMD) was significant more than for morphine drops without ethanol. We found no significant difference in secondary endpoints. CONCLUSIONS: A conclusion could be that ethanol might facilitate morphine absorption in the mouth. Our results needs further research of opioid absorption in the mouth as well as trials, testing morphine vs. more lipophilic opioids. The RMD drops are cheap, easy to use, and noninvasive and keep the patient independent of health care professionals.
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Dispneia/tratamento farmacológico , Etanol/uso terapêutico , Morfina/uso terapêutico , Neoplasias/tratamento farmacológico , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Estudos Cross-Over , Método Duplo-Cego , Etanol/farmacologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Morfina/farmacologia , Neoplasias/complicaçõesRESUMO
BACKGROUND: The objective of this trial is to optimize the transmuscular quadratus lumborum (TQL) block, by investigating the minimal effective volume (MEV90 ) of ropivacaine 0.75% for single-shot TQL block in percutaneous nephrolithotomy (PNL) patients. METHODS: This double-blind, randomized and controlled dose-finding trial is based on a biased coin up-and-down sequential design, where the volume of local anaesthetic administered to each patient depends on the response from the previous one. Investigating the TQL block, the first patient recruited receives 20 ml ropivacaine 0.75% preoperatively. In case of block failure, the next patient will receive the same volume with an increment of 2 ml. Given a successful block for the first patient, the next patient will be randomized to either a lower volume (previous volume with a reduction of 2 ml), or the same volume as the previous patient. The respective probabilities being b = 0.11 for a reduced volume and 1-b = 0.89 for the same volume. Block success is defined as patient reported pain score numeric rated scale (NRS) ≤3 (0-10/10) 30 minutes after arrival in the post anaesthesia care unit (PACU). The NRS pain score is our primary and only outcome for block success. A minimum of 25 eligible patients are needed to achieve precise estimation of MEV90 with narrow 95% confidence intervals derived by bootstrapping. DISCUSSION: Recruiting will begin June 2020 and is expected to finish November 2020. Data analysis will be performed at interims during and after the study. Results will be published in an international peer-reviewed medical journal.
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Protocolos Clínicos , Nefrolitotomia Percutânea/métodos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/tratamento farmacológico , Projetos de Pesquisa , Ropivacaina/administração & dosagem , Músculos Abdominais , Adulto , Anestésicos Locais/administração & dosagem , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Humanos , Masculino , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: To investigate if early mobilization after open reduction internal fixation of distal radius fractures improved the functional outcome. We hypothesized that early mobilization would lead to improved patient-reported outcome. Second, we aimed to assess whether early mobilization increased the risk of postoperative implant loosening or breakage. METHODS: All included patients were treated with a volar locking plate. After surgery, patients were randomized to either early mobilization (E-MOB) with a removable orthosis (wrist lacer) and daily wrist exercises or to late mobilization (L-MOB) with a standard dorsal plaster cast for 2 weeks and, after that, a removable orthosis and exercises. We measured all patients at 4 weeks and at 3, 6, and 12 months after surgery. At each postoperative visit, we measured range of motion and grip strength and patients filled out the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Radiographic implant loosening or breakage was assessed 14 days after surgery. RESULTS: A total of 47 patients were allocated to E-MOB and 48 to L-MOB. The DASH score improved substantially throughout the follow-up period with no significant differences between the 2 groups at any time point. Implant loosening and fracture redisplacement was observed in 1 patient in the E-MOB group. Range of motion and grip strength were similar between the 2 groups at all time points. CONCLUSIONS: Early mobilization after surgical treatment of distal radius fractures does not lead to improved patient-reported outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.
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Deambulação Precoce , Fraturas do Rádio , Idoso , Placas Ósseas , Fixação Interna de Fraturas , Força da Mão , Humanos , Fraturas do Rádio/cirurgia , Amplitude de Movimento Articular , Resultado do TratamentoRESUMO
BACKGROUND: Percutaneous nephrolithotomy (PNL) is associated with severe postoperative pain. The current study aimed to investigate the analgesic efficacy of transmuscular quadratus lumborum (TQL) block for patients undergoing PNL surgery. METHODS: Sixty patients were enrolled in this single centre study. The multimodal analgesic regime consisted of oral paracetamol 1 g and i.v. dexamethasone 4 mg before surgery and i.v. sufentanil 0.25 µg kg-1 30 min before emergence. After operation, patients received paracetamol 1 g regularly at 6 h intervals. Subjects were allocated to receive a preoperative TQL block with either ropivacaine 0.75%, 30 ml (intervention) or saline 30 ml (control). Primary outcome was oral morphine equivalent (OME) consumption 0-6 h after surgery. Secondary outcomes were OME consumption up to 24 h, pain scores, time to first opioid, time to first ambulation, and hospital length of stay. Results were reported as mean (standard deviation) or median (inter-quartile range). RESULTS: Morphine consumption was lower in the intervention group at 6 h after surgery (7.2 [8.7] vs 90.6 [69.9] mg OME, P<0.001) and at 24 h (54.0 [36.7] vs 126.2 [85.5] mg OME, P<0.001). Time to first opioid use was prolonged in the intervention group (678 [285-1020] vs 36 [19-55] min, P<0.0001). Both the time to ambulation (302 [238-475] vs 595 [345-925] min, P<0.004) and length of stay (2.0 [0.8] vs 3.0 [1.2] days, P≤0.001) were shorter in the intervention group. CONCLUSIONS: This is the first blinded, RCT that confirms that unilateral TQL block reduces postoperative opioid consumption and hospital length of stay. Further study is required for confirmation and dose optimisation. CLINICAL TRIAL REGISTRATION: NCT02818140.
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Músculos Abdominais/efeitos dos fármacos , Analgésicos Opioides/administração & dosagem , Deambulação Precoce/estatística & dados numéricos , Nefrolitotomia Percutânea , Bloqueio Nervoso/métodos , Dor Pós-Operatória/tratamento farmacológico , Alta do Paciente/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
BACKGROUND: Pediatric head and neck malignancies are rare and only a few descriptive epidemiological studies have been published. Using unique nationwide registries, we report age-specific incidence rates of head and neck cancer (HNC) among children during four decades. METHODS: Data were obtained from the Danish Cancer Registry. We included children aged 0-14 years diagnosed between January 1, 1978 and December 31, 2014 with extra-orbital, nonskin and nonbone HNC. Patients were divided into nine groups in regard to tumor location: oral cavity, oropharynx, nasopharynx, hypopharynx, thyroid, major salivary glands, larynx, and middle ear. Based on the World Health Organization standard population and Danish age-specific population counts, age-adjusted incidence rates (AAIR) and average annual percentage change (AAPC) were calculated and examined for trends. RESULTS: In total, 169 children (55.6% females) were registered with a malignant tumor in the head and neck region. The AAIR increased with an AAPC of 2.2% (95% CI, 0.8-3.7%). Females showed an AAIR of 0.54 per 100,000 person years compared to that of males, with 0.41 per 100,000 person years (P < 0.01). The AAIR was higher among children aged 10-14 years compared to 0-9-year-old children (P < 0.01). Based on morphology, a significant increase in AAIR was observed for sarcomas, with an increase of 0.16-0.27 per 100,000 person years (P < 0.05). CONCLUSIONS: The incidence rate of pediatric HNC was higher among females and evidence of increasing rates was observed during 1978-2014, explained by an increase mainly in sarcomas.
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Neoplasias de Cabeça e Pescoço/epidemiologia , Sistema de Registros/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Dinamarca/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Prognóstico , Fatores de TempoRESUMO
BACKGROUND: The mortality following blood stream infection (BSI) and risk of subsequent BSI in relation to dialysis modality, vascular access, and other potential risk factors has received relatively little attention. Consequently, we assessed these matters in a retrospective cohort study, by use of the Danish nation-wide registries. METHODS: Patients more than 17 years of age, who initiated dialysis between 1.1.2010 and 1.1.2014, were grouped according to their dialysis modality and vascular access. Survival was modeled in time-dependent Cox proportional hazard analyses. Potential risk factors confined by a modified Charlson comorbidity index (MCCI), were subsequently assessed in stepwise selection models. RESULTS: At baseline, 764 patients received peritoneal dialysis (PD), and 434, 479, and 782 hemodialysis (HD) patients were dialyzed by use of arteriovenous fistulas (AVFs), tunneled catheters (TCs), and non-tunneled catheters (NTCs), respectively. We identified 1069 BSIs with an overall incidence rate of 17.7 episodes per 100 person years, and 216 BSIs occurred more than one time in the same patient. HRs of post BSI mortality relative to PD were 3.20 (95% CI 1.86-5.50; p < 0.001) with NTCs; whereas no associations were found for AVF and TC. The risk of subsequent BSIs was higher with NTCs [HR 2.29 (95% CI 1.09-4.82), p = 0.030], and no significant difference was found for AVF and TC, in relation to PD. There was an increased risk of both outcomes with TC relative to AVF [death: 1.57 (95% CI 1.07-2.29, P < 0.021); BSI: 1.78 (95% CI 1.13-2.83, P < 0.014], and risk of death was reduced in patients who changed to AVF after first-time BSI. The MCCI was significantly associated with the risk of subsequent BSI and post BSI death; however, only some of the variables contained in the index were found to be significant risk predictors when analyzed in the fitted model. CONCLUSIONS: While NTC was the most predominant risk factor for subsequent BSI and post BSI mortality, AVF appeared protective.
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Bacteriemia/mortalidade , Infecções Relacionadas a Cateter/mortalidade , Cateteres Venosos Centrais/microbiologia , Diálise Renal/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bacteriemia/epidemiologia , Bacteriemia/microbiologia , Infecções Relacionadas a Cateter/sangue , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/microbiologia , Causas de Morte , Cateteres Venosos Centrais/estatística & dados numéricos , Comorbidade , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Mortalidade , Diálise Peritoneal/efeitos adversos , Diálise Peritoneal/mortalidade , Diálise Peritoneal/estatística & dados numéricos , Diálise Renal/efeitos adversos , Diálise Renal/métodos , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
BACKGROUND: The association of increased cancer risk with glomerulonephritis (GN) is well known, but controversy exists concerning which types of GN are involved, and the size of the association. A national registry survey was performed to assess the size of this association, and the temporal relationship of cancer diagnosis to GN diagnosis. METHODS: All patients with biopsy-proven GN between 1985 and 2015 in Denmark were extracted from The Danish Renal Biopsy Registry and the National Pathology Data Bank. Incident cancer diagnoses between 10 years previous and 10 years subsequent to the GN diagnosis were extracted from the Danish Cancer Registry. Residence, birth and death data were obtained from the National Patient Register. Expected cancer incidence, classified according to cohort, age and sex were extracted from the Nordcan database. RESULTS: Nine hundred eleven cancers were diagnosed in 5594 patients. Thirty five percent were prevalent at renal biopsy. Prevalence at biopsy was 5.5% (expected 3.1%), but incidence was not increased < 1 year before biopsy. Increased cancer rates were seen for GN forms: minimal change, endocapillary, focal segmental glomerulosclerosis, mesangioproliferative, membranous, focal segmental, membranoproliferative, proliferative, ANCA-associated vasculitis, lupus nephritis and unclassified. Increased cancer rates were seen for lung, prostate, renal, non-Hodgkin lymphoma, myeloma, leukaemia and skin. The increased incidence was mainly limited to - 1 to 1 year after biopsy, but skin cancer showed an increased risk over time. Some diagnoses showed an increase 5-10 years after biopsy. Incidence was raised for patients with uraemia and nephrosis, but less for proteinuria or haematuria. Cancers in patients < 45 years were rare. The risk of developing cancer 0-3 years after biopsy for patients 45-64 years varied from 7.3% (minimal change) to 15.8% (unclassified GN); > 64 years from 11.8 (endocapillary GN) to 20.3% (unclassified). The diagnosis with the highest risk was membranoproliferative GN (8.6 & 19.6%). CONCLUSIONS: Cancer rates are increased for many cancer and most GN diagnoses. Cancer screening for patients < 45 years and for patients without nephrosis or uraemia may not be necessary. The findings suggest that screening programs for specific GN diagnoses can be extended to other GN forms.
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Bases de Dados Factuais/tendências , Glomerulonefrite/diagnóstico , Glomerulonefrite/epidemiologia , Neoplasias/diagnóstico , Neoplasias/epidemiologia , Adulto , Idoso , Dinamarca/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Risco , Adulto JovemRESUMO
BACKGROUND: To prevent occupational skin cancer, it is essential that the sun-protective behavior of outdoor workers is adequate. The aim is to study the sun-protective behavior of Danish outdoor workers at work, at leisure, and on sun holiday and compare it to that of indoor workers. METHODS: This is a cross-sectional study, based on a 53-item survey completed by Danish outdoor (n = 380) and indoor workers (n = 119) in 2016-2017. Status as outdoor or indoor worker was decided based on self-report and behavioral differences were tested using (paired) t tests and multiple regression adjusted for age, sex, educational level, history of smoking, and skin type. RESULTS: Danish outdoor workers at work use sun protection less than they do at leisure and on sun holiday (α < .05) where their sun protection behavior is similar to that of indoor workers. The proportion of Danish outdoor workers that always/often use sun protection at work is for shade seeking around noon 4.2%, sunscreen 34.5%, wide-brimmed hat 25.3%, and long trousers and shirt with sleeves 42.4%. Of Danish outdoor workers, 49.5% do not think about the risk of occupational skin cancer and 11.8% think the risk is insignificant, 32.4% think that the use of sun protection is of low or no importance, 84.2% consider sunburn important as skin cancer risk factor still 88.9% have a history of sunburn at work, > 80.0% agree that risk of skin cancer is reduced by the use of sun protection, and only 4.0% dismiss the possibility of sun protection use at work. CONCLUSIONS: Skin cancer risk and use of sun protection at work are largely neglected in Danish outdoor workers, more so than at leisure and on sun holiday where their risk behavior resembles that of indoor workers. This indicates an untapped workplace preventive potential.
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Conhecimentos, Atitudes e Prática em Saúde , Doenças Profissionais/prevenção & controle , Exposição Ocupacional/prevenção & controle , Comportamento de Redução do Risco , Neoplasias Cutâneas/prevenção & controle , Estudos Transversais , Dinamarca , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Exposição Ocupacional/estatística & dados numéricos , Saúde Ocupacional/estatística & dados numéricos , Queimadura Solar/prevenção & controle , Inquéritos e Questionários , Local de Trabalho/classificação , Local de Trabalho/psicologia , Local de Trabalho/estatística & dados numéricosRESUMO
Following publication of the original article [1], it was highlighted that Table 3 contained an error.
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BACKGROUND: Psychological distress is a trans-diagnostic feature of mental suffering closely associated with mental disorders. Kessler's 10-item Psychological Distress Scale (K10), a scale with sound psychometric properties, is widely used in epidemiological studies. AIM: To translate and investigate whether K10 is a reliable and valid rating scale for the measurement of psychological distress in a Danish population. METHODS: The translation was carried out according to official WHO translation guidelines. A sample of 100 subjects was included, 54 patients from the regional Mental Health Service (MHS) and 46 subjects with no psychiatric history. All participants were assessed with a psychiatric diagnostic interview (MINI) and handed out K10. Concurrent validity was assessed by WHO Well-being Index (WHO-5). Correlation matrix analysis was conducted for the full sample and receiver operating characteristic (ROC) curves for discriminating mental health service affiliation. RESULTS: Mean K10 scores differed, with decreasing levels, between inpatients and outpatient in MHS and the subjects with no psychiatric history. Factor analysis confirmed a unidimensional structure, and Cronbach's alpha and Omega showed excellent internal reliability. AUC for the K10 ROC curves showed excellent sensitivity (0.947 [0.900-0.995]), accurately differentiating mental health from non-mental health patients. CONCLUSION: The Danish K10 has the same strong internal reliability as the original English version, and scores differ between psychiatric patients in outpatient and emergency ward settings. CLINICAL IMPLICATIONS: The Danish K10 translation is authorized and freely available for download at https://www.hcp.med.harvard.edu/ncs/k6_scales.php . The utility as an instrument for clinical screening in a mental healthcare setting is supported.
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Testes Neuropsicológicos/normas , Estresse Psicológico/diagnóstico , Estresse Psicológico/psicologia , Traduções , Adolescente , Adulto , Idoso , Estudos Transversais , Dinamarca/epidemiologia , Feminino , Humanos , Masculino , Transtornos Mentais/diagnóstico , Transtornos Mentais/epidemiologia , Transtornos Mentais/psicologia , Pessoa de Meia-Idade , Curva ROC , Reprodutibilidade dos Testes , Estresse Psicológico/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Robotic and hand-assisted laparoscopic nephrectomies are often associated with moderate to severe postoperative pain. The aim of the current study was to investigate the analgesic efficacy of the transmuscular quadratus lumborum (TQL) block for patients undergoing robotic or hand-assisted laparoscopic nephrectomy. METHODS: Fifty patients were included in this single-center study. All patients were scheduled for elective hand-assisted or robotic laparoscopic nephrectomy under general anesthesia. Preoperatively, patients were randomly allocated to TQL block bilaterally with ropivacaine 60 mL 0.375% or 60 mL saline and all patients received standard multimodal analgesia and intravenous patient-controlled analgesia. Primary outcome was postoperative oral morphine equivalent (OME) consumption 0-12 hours. Secondary outcomes were postoperative OME consumption up to 24 hours, pain scores, time to first opioid, nausea/vomiting, time to first ambulation and hospital length of stay (LOS). RESULTS: Mean (95% CI) OME consumption was significantly lower in the intervention group at 12 hours after surgery 50 (28.5 to 71.5) mg versus control 87.5 (62.7 to 112.3) mg, p=0.02. At 24 hours, 69.4 (43.2 to 95.5) mg versus 127 (96.7 to 158.6) mg, p<0.01. Time to first opioid was significantly prolonged in the intervention group median (IQR) 4.4 (2.8-17.6) hours compared with 0.3 (0.1-1.0) hours in the control group, p<0.001. No significant intergroup differences were recorded for time to first ambulation, pain scores, nausea/vomiting nor for LOS. CONCLUSION: Preoperative bilateral TQL block significantly reduced postoperative opioid consumption by 43% and significantly prolonged time to first opioid. TRIAL REGISTRATION NUMBER: NCT03571490.
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Laparoscopia , Bloqueio Nervoso , Analgésicos Opioides , Anestésicos Locais , Humanos , Laparoscopia/efeitos adversos , Nefrectomia/efeitos adversos , Bloqueio Nervoso/efeitos adversos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , RopivacainaRESUMO
OBJECTIVE: To report the incidence of venous thromboembolism (VTE) after nephrectomy in Denmark and explore associated risk factors. MATERIALS AND METHODS: A nationwide population-based retrospective cohort study was performed. All nephrectomies from January 2010 to August 2018 were assessed for postoperative VTE events. Univariable and multivariable analyses were used to evaluate the odds ratio (OR) of clinical variables' effect on postoperative VTEs, within 4 weeks and 4 months after nephrectomy. RESULTS: In 5213 nephrectomized patients, postoperative VTE incidence was 1% and 2% within 4 weeks and 4 months, respectively. Multivariable analyses revealed that predictors of postoperative VTE within 4 months were: open nephrectomy (OR 2.5, P = .001), history of VTE (OR 13.3, P <.001), length of hospital stay (OR 0.98, P = .02), and lymph node dissection (OR 2.0, P = .04). Limitations included the retrospective and registry-based study design and absence of individual patient data on patient body mass index and length of surgery. CONCLUSION: For nephrectomy, postoperative VTE is rare. Open nephrectomy, history of VTE, length of hospital stay, and lymph node dissection are important risk factors which should be evaluated when tailoring VTE prophylaxis regimens.
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Anticoagulantes/administração & dosagem , Laparoscopia/efeitos adversos , Nefrectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Tromboembolia Venosa/epidemiologia , Idoso , Dinamarca/epidemiologia , Feminino , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Nefrectomia/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controleRESUMO
Previous studies suggest an increased cancer risk in hypertension. Patients with hypertensive nephropathy have not been studied. A national registry study was performed to assess the presence and size of this association. Clinical data and cancer diagnoses for all patients with biopsy-proven hypertensive nephropathy between 1985 and 2015 in Denmark were extracted from four national registries and compared with age- and sex-adjusted national cancer rates. The risk of cancer was twice the background population. It was raised for renal cancer (odds ratio 10.4), myeloma (13.2), skin cancer (7.9), and other/unspecified (1.8). No increase in incidence was seen until 1 year before renal biopsy and then rose rapidly. It was again normal 5 years after biopsy. Hypertensive nephropathy is associated with an increased risk of myeloma, skin, renal, and other cancers. Screening of patients with hypertensive nephropathy, in the presence of reduced renal function or significant proteinuria, may be indicated.
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Hipertensão Renal/complicações , Neoplasias Renais/etiologia , Mieloma Múltiplo/etiologia , Nefrite/complicações , Neoplasias Cutâneas/etiologia , Adulto , Idoso , Biópsia , Estudos de Casos e Controles , Dinamarca/epidemiologia , Humanos , Hipertensão/complicações , Hipertensão Renal/epidemiologia , Hipertensão Renal/mortalidade , Hipertensão Renal/patologia , Incidência , Neoplasias Renais/epidemiologia , Pessoa de Meia-Idade , Mieloma Múltiplo/epidemiologia , Nefrite/epidemiologia , Nefrite/mortalidade , Nefrite/patologia , Prevalência , Proteinúria/diagnóstico , Sistema de Registros , Insuficiência Renal/complicações , Insuficiência Renal/fisiopatologia , Fatores de Risco , Neoplasias Cutâneas/epidemiologia , Análise de SobrevidaRESUMO
INTRODUCTION: Greenland has one of the highest prevalences of otitis media in the world. However, access to ear specialists throughout Greenland is limited and currently there are no national guidelines for treatment or prevention. Tele-otoscopy may be beneficial in optimizing diagnosis and treatment. The smartphone otoscopy device, Cupris®, has previously been validated when used by medical doctors on a population primarily consisting of adults. In this study we evaluated the usability of the Cupris® otoscope when used by local health care workers with different levels of training and education, examining children aged 1-6 years. METHODS: We conducted a cross-sectional study in three Greenlandic towns. Health care personnel were asked to perform video-otoscopy on children contacting the health clinic for any reason. The videos were sent for remote evaluation by three ear specialists who rated the videos on a five-point Likert scale and provided information on challenges with the videos. The dichotomous outcome "not useful/useful" was defined as 1-3 and 4-5 on the Likert scale, respectively. RESULTS: In total, 142 videos were recorded on 84 patients. Mean proportion of useful videos was 18.1%, with a modified Fleiss' Kappa interrater agreement coefficient of 0.67 95% CI [0.57-0.76] corresponding to substantial agreement among the three raters. CONCLUSIONS: In this study the usefulness of the Cupris® TYM otoscope did not prove to be sufficient with the presented instruction in the hands of local health care workers when examining Greenlandic children. Focus on training and education of local health personnel is crucial and warranted before advantageous implementation for non-specialist health care workers can be expected.
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Otite Média/diagnóstico , Otoscopia , Consulta Remota , População Rural , Smartphone , Gravação em Vídeo , Criança , Pré-Escolar , Estudos Transversais , Feminino , Groenlândia/epidemiologia , Acessibilidade aos Serviços de Saúde , Humanos , Lactente , Masculino , Otite Média/epidemiologia , Serviços de Saúde RuralRESUMO
BACKGROUND: We tested the joint hypotheses that both perineural and systemic dexmedetomidine prolong the duration of an ulnar nerve block (UNB) compared with ropivacaine alone and that systemic dexmedetomidine is noninferior compared with perineural dexmedetomidine in block prolongation. METHODS: We performed bilateral UNBs in 22 healthy volunteers on two separate days. On the first day, each arm was randomized to either 4 mL ropivacaine 5 mg/mL+1 mL dexmedetomidine 100 µg/mL (Perineural) or 4 mL ropivacaine 5 mg/mL+1 mL saline (Systemic). On the subsequent treatment day, each arm was randomized to 1 mL of saline plus 4 mL of ropivacaine at either 7.5 mg/mL(HiRopi) or 5 mg/mL (NoDex). The primary outcome measure was the duration of sensory block assessed by mechanical discrimination. RESULTS: Mean sensory block duration was longer in both the Perineural (14.4 hours, 95% CI 13.1 to 15.6) and Systemic treatments (9.2 hours, 95% CI 8.6 to 9.8) compared with the NoDex treatment (7.1 hours, 95% CI 6.6 to 7.6) (p<0.0001 for both). Systemic dexmedetomidine was inferior (not noninferior) compared with perineural dexmedetomidine, as the 95% CI of the difference (mean difference 5.2 hour, 95% CI 4.2 to 6.1) exceeded the noninferiority limit of 3.6 hour. Onset time did not differ among the groups. The other test modalities demonstrated similar block durations as the primary outcome. CONCLUSIONS: Adding dexmedetomidine perineurally to ropivacaine doubles the duration of an UNB. Systemic dexmedetomidine also prolongs the duration of UNB, but has less of an effect compared with the perineural route. TRIAL REGISTRATION NUMBER: NCT03222323.
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BACKGROUND: Elective cesarean section (ECS) can cause moderate to severe pain that often requires opioid administration. To enhance maternal recovery, and promote mother and baby interaction, it is important to reduce postoperative pain and opioid consumption. Various regional anesthesia techniques have been implemented to improve postoperative pain management following ECS. This study aimed to investigate the efficacy of bilateral ultrasound-guided transmuscular quadratus lumborum (TQL) block on reducing postoperative opioid consumption following ECS. METHODS: A randomized double-blind trial with concealed allocation was conducted in 72 parturients who received bilateral TQL block with either 30 mL ropivacaine 0.375% or saline. TQL block injectate was deposited in the interfascial plane between the quadratus lumborum and psoas major muscles, posterior to the transversalis fascia. Primary outcome was opioid consumption, which was recorded electronically. Pain scores and time to first opioid request were also evaluated. RESULTS: Opioid consumption (oral morphine equivalents, OME) was significantly reduced in group ropivacaine (GRO) in the first 24 hours compared with group saline (65 mg OME vs 94 mg OME) with a mean difference of 29 mg OME; 95% CI 3 to 55, p<0.03. Time to first opioid request was significantly prolonged in GRO, p<0.003. Numerical rating scale pain scores were significantly lower in GRO in the first 6 hours after surgery, p<0.03. CONCLUSIONS: Bilateral TQL block significantly reduced 24 hours' opioid consumption. Further, we observed significant prolongation in time to first opioid, and significant reduction of pain during the first 6 postoperative hours.
RESUMO
BACKGROUND: Meta-analyses of studies on psychological treatment of refugees describe highly varying outcomes, and research on multi-facetted and personalized treatment of refugees with post-traumatic stress disorder (PTSD) is needed. Music therapy has been found to affect arousal regulation and emotional processing, and a pilot study on the music therapy method Trauma-focused Music and Imagery (TMI) with traumatized refugees resulted in significant changes of trauma symptoms, well-being and sleep quality. The aim of the trial is to test the efficacy of TMI compared to verbal psychotherapy. METHODS: A randomized controlled study with a non-inferiority design is carried out in three locations of a regional outpatient psychiatric clinic for refugees. Seventy Arabic-, English- or Danish-speaking adult refugees (aged 18-67 years) diagnosed with PTSD are randomized to 16 sessions of either music therapy or verbal therapy (standard treatment). All participants are offered medical treatment, psychoeducation by nurses, physiotherapy or body therapy and social counseling as needed. Outcome measures are performed at baseline, post therapy and at 6 months' follow-up. A blind assessor measures outcomes post treatment and at follow-up. Questionnaires measuring trauma symptoms (HTQ), quality of life (WHO-5), dissociative symptoms (SDQ-20, DSS-20) and adult attachment (RAAS) are applied, as well as physiological measures (salivary oxytocin, beta-endorphin and substance P) and participant evaluation of each session. DISCUSSION: The effect of music therapy can be explained by theories on affect regulation and social engagement, and the impact of music on brain regions affected by PTSD. The study will shed light on the role of therapy for the attainment of a safe attachment style, which recently has been shown to be impaired in traumatized refugees. The inclusion of music and imagery in the treatment of traumatized refugees hopefully will inform the choice of treatment method and expand the possibilities for improving refugee health and integration. TRIAL REGISTRATION: ClinicalTrials.gov ID number NCT03574228, registered retrospectively on 28 June 2016.
Assuntos
Imagens, Psicoterapia , Musicoterapia , Refugiados/psicologia , Transtornos de Estresse Pós-Traumáticos/terapia , Adaptação Psicológica , Adolescente , Adulto , Idoso , Dinamarca , Estudos de Equivalência como Asunto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Ocitocina/metabolismo , Qualidade de Vida , Saliva/metabolismo , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/metabolismo , Transtornos de Estresse Pós-Traumáticos/psicologia , Substância P/metabolismo , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem , beta-Endorfina/metabolismoRESUMO
BACKGROUND: The European Resuscitation Council Guidelines 2015 recommend bystanders to activate their mobile phone speaker function, if possible, in case of suspected cardiac arrest. This is to facilitate continuous dialogue with the dispatcher including (if required) cardiopulmonary resuscitation instructions. The aim of this study was to measure the bystander capability to activate speaker function in case of suspected cardiac arrest. METHOD: In 87days, a systematic prospective registration of bystander capability to activate the speaker function, when cardiac arrest was suspected, was performed. For those asked, "can you activate your mobile phone's speaker function", audio recordings were examined and categorized into groups according to the bystanders capability to activate speaker function on their own initiative, without instructions, or with instructions from the emergency medical dispatcher. Time delay was measured, in seconds, for the bystanders without pre-activated speaker function. RESULTS: 42.0% (58) was able to activate the speaker function without instructions, 2.9% (4) with instructions, 18.1% (25) on own initiative and 37.0% (51) were unable to activate the speaker function. The median time to activate speaker function was 19s and 8s, with and without instructions, respectively. CONCLUSION: Dispatcher assisted cardiopulmonary resuscitation with activated speaker function, in cases of suspected cardiac arrest, allows for continuous dialogue between the emergency medical dispatcher and the bystander. In this study, we found a 63.0% success rate of activating the speaker function in such situations.