Odd Bjarte Nilsen

Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial

Objective To determine whether a systematic approach to the treatment of pain can reduce agitation in people with moderate to severe dementia living in nursing homes. Design Cluster randomised controlled trial. Setting 60 clusters (single independent nursing home units) in 18 nursing homes within five municipalities of western Norway. Participants 352 residents with moderate to severe dementia and clinically significant behavioural disturbances randomised to a stepwise protocol for the treatment of pain for eight weeks with additional follow-up four weeks after the end of treatment (33 clusters; n=175) or to usual treatment (control, 27 clusters; n=177). Intervention Participants in the intervention group received individual daily treatment of pain for eight weeks according to the stepwise protocol, with paracetamol (acetaminophen), morphine, buprenorphine transdermal patch, or pregabaline. The control group received usual treatment and care. Main outcome measures Primary outcome measure was agitation (scores on Cohen-Mansfield agitation inventory). Secondary outcome measures were aggression (scores on neuropsychiatric inventory-nursing home version), pain (scores on mobilisation-observation-behaviour-intensity-dementia-2), activities of daily living, and cognition (mini-mental state examination). Results Agitation was significantly reduced in the intervention group compared with control group after eight weeks (repeated measures analysis of covariance adjusting for baseline score, P<0.001): the average reduction in scores for agitation was 17% (treatment effect estimate −7.0, 95% confidence interval −3.7 to −10.3). Treatment of pain was also significantly beneficial for the overall severity of neuropsychiatric symptoms (−9.0, −5.5 to −12.6) and pain (−1.3, −0.8 to −1.7), but the groups did not differ significantly for activities of daily living or cognition. Conclusion A systematic approach to the management of pain significantly reduced agitation in residents of nursing homes with moderate to severe dementia. Effective management of pain can play an important part in the treatment of agitation and could reduce the number of unnecessary prescriptions for psychotropic drugs in this population. Trial registration ClinicalTrials.gov NCT01021696 and Norwegian Medicines Agency EudraCTnr 2008-007490-20.

Optimised anaesthesia to reduce post operative cognitive decline (POCD) in older patients undergoing elective surgery, a randomised controlled trial.

Background The study determined the one year incidence of post operative cognitive decline (POCD) and evaluated the effectiveness of an intra-operative anaesthetic intervention in reducing post-operative cognitive impairment in older adults (over 60 years of age) undergoing elective orthopaedic or abdominal surgery. Methods and Trial Design The design was a prospective cohort study with a nested randomised, controlled intervention trial, using intra-operative BiSpectral index and cerebral oxygen saturation monitoring to enable optimisation of anaesthesia depth and cerebral oxygen saturation in older adults undergoing surgery. Results In the 52 week prospective cohort study (192 surgical patients and 138 controls), mild (χ2 = 17.9 p<0.0001), moderate (χ2 = 7.8 p = 0.005) and severe (χ2 = 5.1 p = 0.02) POCD were all significantly higher after 52 weeks in the surgical patients than among the age matched controls. In the nested RCT, 81 patients were randomized, 73 contributing to the data analysis (34 intervention, 39 control). In the intervention group mild POCD was significantly reduced at 1, 12 and 52 weeks (Fisher’s Exact Test p = 0.018, χ2 = 5.1 p = 0.02 and χ2 = 5.9 p = 0.015), and moderate POCD was reduced at 1 and 52 weeks (χ2 = 4.4 p = 0·037 and χ2 = 5.4 p = 0.02). In addition there was significant improvement in reaction time at all time-points (Vigilance Reaction Time MWU Z =  −2.1 p = 0.03, MWU Z = −2.7 p = 0.004, MWU Z = −3.0 p = 0.005), in MMSE at one and 52 weeks (MWU Z = −2.9 p = 0.003, MWU Z = −3.3 p = 0.001), and in executive function at 12 and 52 weeks (Trail Making MWU Z = −2.4 p = .0.018, MWU Z = −2.4 p = 0.019). Conclusion POCD is common and persistent in older adults following surgery. The results of the nested RCT indicate the potential benefits of intra-operative monitoring of anaesthetic depth and cerebral oxygenation as a pragmatic intervention to reduce post-operative cognitive impairment. Trial Registration Controlled-Trials.com ISRCTN39503939

Good outcome in every fourth resuscitation attempt is achievable--an Utstein template report from the Stavanger region.

AIM OF THE STUDY Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the western world. We wanted to study changes in survival over time and factors linked to this in a region which have already reported high survival rates. METHODS We used a prospectively collected Utstein template database to identify all resuscitation attempts in adult patients with OHCA of presumed cardiac origin. We included 846 resuscitation attempts and compared survival to discharge with good outcome in two time periods (2001-2005 vs. 2006-2008). RESULTS We found no significant differences between the two time periods for mean age (71 and 70 years (p=0.309)), sex distribution (males 70% and 71% (p=0.708)), location of the OHCA (home 64% and 63% (p=0.732)), proportion of shockable rhythms (44% and 47% (p=0.261)) and rate of return of spontaneous circulation (38% and 43% (p=0.136)), respectively. Bystander cardiopulmonary resuscitation (CPR), however, increased significantly from 60% to 73% (p<0.0001), as did the overall rate of survival to discharge from 18% to 25% (p=0.018). In patients with a shockable first rhythm, rate of survival to discharge increased significantly from 37% to 48% (p=0.036). In witnessed arrest with shockable rhythm survival to discharge increased from 37% to 52% (p=0.0105). CONCLUSION Overall, good outcome is now achievable in every fourth resuscitation attempt and in every second resuscitation attempt when patients have a shockable rhythm. The reason for the better outcomes is most likely multi-factorial and linked to improvements in the local chain of survival.

Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions?

Objective. To analyze changes in postpartum hemorrhage over a 10‐year period from 1998 to 2007, and to explore factors associated with severe hemorrhage. Design. Retrospective cohort study, prospectively collected information. Setting. Stavanger University Hospital, a secondary referral center, Norway. Population. An unselected population of 41,365 women giving birth at the hospital. Methods. We analyzed changes over time in mean postpartum hemorrhage, severe postpartum hemorrhage and associated factors. Estimated blood loss >1,000 ml was defined as severe hemorrhage. Data were collected from the hospitals database. Main outcome measures. Severe postpartum hemorrhage and obstetric interventions. Results. We observed an increase in severe hemorrhage during the study period. After cesarean sections, the risk of severe hemorrhage was twice the risk of severe hemorrhage after vaginal deliveries (5.9%; 95% CI 5.3–6.6 vs. 2.8%; 95% CI 2.6–2.9). The most important factors associated with severe hemorrhage following vaginal deliveries were twin deliveries (OR 6.8), retained placenta (OR 3.9) and inductions of labor (OR 2.2). For cesarean sections, twin deliveries had the strongest association with severe hemorrhage (OR 3.7) followed by general anesthesia (OR 3.0). Obstetric interventions became more frequent; elective cesarean sections increased from 2.4 to 4.9%, acute cesarean sections from 5.5 to 8.9%, operative vaginal deliveries from 9.3 to 12.5%, inductions of labor from 14.3 to 15.8% and augmentations of labor from 5.8 to 29.3%. Conclusions. The incidence of severe postpartum hemorrhage increased, and this may be related to more frequent use of obstetric interventions.

Quality of chest compressions during 10 min of single-rescuer basic life support with different compression: ventilation ratios in a manikin model

INTRODUCTION Good quality basic life support (BLS) improves outcome during cardiac arrest. As fatigue may reduce BLS performance over time we wanted to examine the quality of chest compressions in a single-rescuer scenario during prolonged BLS with different compression:ventilation ratios (C:V ratios). MATERIAL AND METHODS Professional paramedics were asked to perform single-rescuer BLS with C:V ratios of 15:2, 30:2 and 50:2 for 10 min each in random order. A Laerdal Medical Resusci Anne Simulator with PC Skillreporting System was used for BLS quality analysis. Total number of chest compressions, compression depth and compression rate were measured and the differences between the C:V ratios were analysed with repeated measures ANOVA. For analysis of fatigue, chest compression variables for each 2-min period were analysed and compared with the first 2-min period using repeated measures ANOVA. RESULTS Altogether 50 paramedics completed the study. The mean number of chest compressions increased significantly from 604 to 770 and 862 with C:V ratios of 15:2, 30:2 and 50:2, respectively. Chest compression rate was significantly higher with C:V ratio of 15:2 compared to 30:2 and 50:2 but was above 100 per minute for all three ratios. However, the mean chest compression depth did not change significantly between the different C:V ratios. The number of chest compressions did not change significantly with time for any of the three C:V ratios. Compression depth did decline after the first 2-min period for 30:2 and 50:2 as did compression rate for all three ratios. However all were above the guideline limits for the entire test period. CONCLUSION Increasing the C:V ratio increases the number of chest compressions during 10 min of BLS. Compression depth and compression rate were within guideline recommendations for all three ratios. We found no decline in chest compression quality below guideline recommendations during 10 min of BLS with any of the three different C:V ratios.

Low levels of cellular omega-3 increase the risk of ventricular fibrillation during the acute ischaemic phase of a myocardial infarction

AIM OF THE STUDY Animal studies have demonstrated evidence of an anti-arrhythmic effect of marine n-3 fatty acids (FAs). In humans the same mechanism may explain the observed reduction in sudden cardiac death (SCD) associated with intake of fish. Whether high levels of n-3 FAs could protect against ventricular fibrillation (VF) during the acute ischaemic phase of a myocardial infarction (MI) is, however, not known. MATERIALS AND METHODS We measured red blood cell content of eicosapentaenoic acid (EPA)+docosahexaenoic acid (DHA) expressed as a percentage of total FAs (the omega-3 index) at admission in 460 patients hospitalised with an acute coronary syndrome. Out of 265 patients suffering their first MI, 10 (cases) experienced an episode of VF during the initial 6h of symptom onset. The omega-3 index of these patients was compared to that of 185 first-MI patients (controls) free of VF for at least 30 days post-admission. RESULTS The median value of the omega-3 index in the VF cases was 4.88% as compared to 6.08% in the controls (p=0.013). After adjustment for age, sex, ejection fraction, high-sensitivity C-reactive protein, use of beta-blocker, differences of infarct characteristics and previous angina pectoris, a 1% increase of the omega-3 index was associated with a 48% reduction in risk of VF (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.28-0.96; p=0.037). CONCLUSION Our study supports an anti-arrhythmic effect of n-3 FAs through their incorporation into myocardial cell membranes, reducing the risk of VF during ischaemia.

APOE Alleles in Parkinson Disease and Their Relationship to Cognitive Decline: A Population-based, Longitudinal Study

Apolipoprotein E gene alleles have been linked to various cardiovascular and neurodegenerative disorders. There have been conflicting reports of associations between Apolipoprotein E alleles and Parkinson disease and Parkinson disease dementia. To investigate the role of Apolipoprotein E alleles in Parkinson disease and Parkinson disease dementia, we have determined Apolipoprotein E genotypes in a group of patients with Parkinson disease (n = 95) and compared them with those of healthy control participants (n = 73). Additionally, in 64 longitudinally followed patients with Parkinson disease, the allele types were correlated to development and progression of dementia and to time from onset of Parkinson disease to dementia using multivariate and survival analyses. The Apolipoprotein E e4e4 genotype was more common in patients with Parkinson disease (7.4%) than in healthy controls (1.4%; P = .03). No significant associations between the Apolipoprotein E genotype and development and progression of dementia or time to dementia were found. More studies with larger Parkinson disease samples are warranted.

Parkinson’s disease and nursing home placement: the economic impact of the need for care

Background and Purpose:  To examine the relative risk (RR) for living in nursing homes for patients with Parkinson’s disease (PD) compared with the general population and to ascertain society’s costs related to nursing home placement for this patient group.

Parkinson's disease and hospital admissions: frequencies, diagnoses and costs.

Objective –  To evaluate the frequencies, causes and costs related to hospital admissions for patients with Parkinson’s disease (PD) and controls.

Risk factors of post‐operative urinary retention in hospitalised patients

Background: Post‐operative urinary retention (POUR) is most accurately determined by using ultrasound to measure bladder volume. The aim of this study was to define the risk factors of POUR in the recovery room in hospitalised patients.