Appropriate medication use in Dutch terminal care: study protocol of a multicentre stepped-wedge cluster randomized controlled trial (the AMUSE study).

BACKGROUND: Polypharmacy is common among patients with a limited life expectancy, even shortly before death. This is partly inevitable, because these patients often have multiple symptoms which need to be alleviated. However, the use of potentially inappropriate medications (PIMs) in these patients is also common. Although patients and relatives are often willing to deprescribe medication, physicians are sometimes reluctant due to the lack of evidence on appropriate medication management for patients in the last phase of life. The aim of the AMUSE study is to investigate whether the use of CDSS-OPTIMED, a software program that gives weekly personalized medication recommendations to attending physicians of patients with a limited life expectancy, improves patients' quality of life. METHODS: A multicentre stepped-wedge cluster randomized controlled trial will be conducted among patients with a life expectancy of three months or less. The stepped-wedge cluster design, where the clusters are the different study sites, involves sequential crossover of clusters from control to intervention until all clusters are exposed. In total, seven sites (4 hospitals, 2 general practices and 1 hospice from the Netherlands) will participate in this study. During the control period, patients will receive 'care as usual'. During the intervention period, CDSS-OPTIMED will be activated. CDSS-OPTIMED is a validated software program that analyses the use of medication based on a specific set of clinical rules for patients with a limited life expectancy. The software program will provide the attending physicians with weekly personalized medication recommendations. The primary outcome of this study is patients' quality of life two weeks after baseline assessment as measured by the EORTC QLQ-C15-PAL questionnaire, quality of life question. DISCUSSION: This will be the first study investigating the effect of weekly personalized medication recommendations to attending physicians on the quality of life of patients with a limited life expectancy. We hypothesize that the CDSS-OPTIMED intervention could lead to improved quality of life in patients with a life expectancy of three months or less. TRIAL REGISTRATION: This trial is registered at ClinicalTrials.gov (NCT05351281, Registration Date: April 11, 2022).

Effects of reduction technique for acute anterior shoulder dislocation without sedation or intra-articular pain management: a systematic review and meta-analysis.

INTRODUCTION: Anterior shoulder dislocations are commonly seen in the emergency department for which several closed reduction techniques exist. The aim of this systematic review is to identify the most successful principle of closed reduction techniques for an acute anterior shoulder dislocation in the emergency department without the use of sedation or intra-articular lidocaine injection. METHODS: A literature search was conducted up to 15-08-2022 in the electronic databases of PubMed, Embase and CENTRAL for randomized and observational studies comparing two or more closed reduction techniques for anterior shoulder dislocations. Included techniques were grouped based on their main operating mechanism resulting in a traction-countertraction (TCT), leverage and biomechanical reduction technique (BRT) group. The primary outcome was success rate and secondary outcomes were reduction time and endured pain scores. Meta-analyses were conducted between reduction groups and for the primary outcome a network meta-analysis was performed. RESULTS: A total of 3118 articles were screened on title and abstract, of which 9 were included, with a total of 987 patients. Success rates were 0.80 (95% CI 0.74; 0.85), 0.81 (95% CI 0.63; 0.92) and 0.80 (95% CI 0.56; 0.93) for BRT, leverage and TCT, respectively. No differences in success rates were observed between the three separate reduction groups. In the network meta-analysis, similar yet more precise effect estimates were found. However, in a post hoc analysis the BRT group was more successful than the combined leverage and TCT group with a relative risk of 1.33 (95% CI 1.19, 1.48). CONCLUSION: All included techniques showed good results with regard to success of reduction. The BRT might be the preferred technique for the reduction of an anterior shoulder dislocation, as patients experience the least pain and it results in the fastest reduction.

Hypocalcaemic laryngospasm in the emergency department.

A 51-year-old African male presented to the emergency department with a sore throat, a productive cough and a striking pinched voice. Investigation revealed severe hypocalcaemia (0.97 mmol/l) with a prolonged QT interval on ECG. The authors administered intravenous calcium in the emergency department, which instantly improved the quality of the patient's voice. He was eventually diagnosed with primary hypoparathyroidism and an upper airway infection. Severe hypocalcaemia is a life-threatening condition. Identifying laryngospasm as an atypical presentation in the presence of a concomitant airway infection and prompt treatment in the emergency department are critical.

Antioxidant effect on urinary excretion of malondialdehyde in non-athletes during aerobic training.

Conditions in the body during aerobic exercise increase the level of lipid peroxidation (LP). LP is associated with elevated concentration of modified low-density lipoproteins that are implicated in development of cardiovascular disease. Supplementation with antioxidant vitamin E to athletes at 267 mg (400 IUs) or greater has been reported to reduce levels of LP associated with exercise. Little is currently known about the effects of modest supplementation of vitamin E on previously sedentary adults who initiate an aerobic fitness program. In the present study, sedentary subjects (n = 14) kept 24-hour diet records to establish antioxidant intake of vitamins E and C and collected 24-hour urine samples that were used to determine baseline urinary malondialdehyde (MDA) concentrations, one measure of in vivo LP. No significant differences were noted in the parameters between groups. Seven subjects were randomly selected and supplemented daily with 133 mg (200 IUs) of vitamin E. All subjects participated in moderate-intensity aerobic training for 8 weeks. Post-training, non-supplemented subjects excreted significantly more MDA (p<0.05) and consumed significantly fewer antioxidants than the supplemented group. Vitamin E supplementation appears to suppress elevated LP associated with beginning an aerobic exercise regimen in previously sedentary subjects.

Is topical local anaesthesia necessary when performing paediatric flexible nasendoscopy? A double-blind randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of lignocain 2% and oxymetazoline 0.025% compared to oxymetazoline 0.025% alone when administered prior to fibreoptic nasendoscopy in paediatric patients. STUDY DESIGN: Prospective, randomized controlled, double-blind study. A group of 56 children, undergoing nasendoscopy to determine adenoidal size, were randomized into two groups and received either lignocain 2% and oxymetazoline 0.025% or oxymetazoline 0.025% alone prior to fibreoptic nasendoscopy. SETTING: A tertiary care Paediatric Hospital. METHOD: The endoscopist recorded the ease of performance of the procedure, cooperation of patient and quality of the view achieved using a visual analogue scale (VAS). The pain and anxiety levels of the child were recorded before, during and immediately after the procedure, using a VAS. The duration of performing the procedure was recorded from insertion of the endoscope into the nostril until removal. RESULTS: All 56 children were able to undergo the endoscopy and the full anxiety and pain assessment was done. Three children were excluded because they have undergone nasendoscopies before. Of the 53 patients included, 27 children received solution A (oxymetazoline 0.025%) and 26 children received solution B (oxymetazoline 0.025% and lignocain 2%). There was no statistical difference between the two groups regarding the duration of the endoscopy, quality of view, ease of performance and cooperation of the patients. The median pain and anxiety scores were not significantly different between the two groups. CONCLUSIONS: This study concludes that the use of a decongestant (oxymetazoline) for paediatric nasendoscopy is just as effective as the use of oxymetazoline with lignocain. Pain and anxiety is not increased in the absence of lignocain.