Efficacy of intergrating vestibular rehabilitation and cognitive behaviour therapy in persons with persistent dizziness in primary care- a study protocol for a randomised controlled trial.

BACKGROUND: Dizziness is a common complaint, and the symptom often persists, together with additional complaints. A treatment combining Vestibular Rehabilitation (VR) and Cognitive Behaviour Therapy (CBT) is suggested. However, further research is necessary to evaluate the efficacy of such an intervention. The objective of this paper is to present the design of a randomised controlled trial aiming at evaluating the efficacy of an integrated treatment of VR and CBT on dizziness, physical function, psychological complaints and quality of life in persons with persistent dizziness. METHODS/DESIGN: The randomised controlled trial is an assessor-blinded, block-randomised, parallel-group design, with a 6- and 12-month follow-up. The study includes 125 participants from Bergen (Norway) and surrounding areas. Included participants present with persistent dizziness lasting for at least 3 months, triggered or exacerbated by movement. All participants receive a one-session treatment (Brief Intervention Vestibular Rehabilitation; BI-VR) with VR before being randomised into a control group or an intervention group. The intervention group will further be offered an eight-session treatment integrating VR and CBT. The primary outcomes in the study are the Dizziness Handicap Inventory and preferred gait velocity. DISCUSSION: Previous studies combining these treatments have been of varying methodological quality, with small samples, and long-term effects have not been maintained. In addition, only the CBT has been administered in supervised sessions, with VR offered as home exercises. The current study focusses on the integrated treatment, a sufficiently powered sample size, and a standardised treatment programme evaluated by validated outcomes using a standardised assessment protocol. TRIAL REGISTRATION: www.clinicaltrials.gov, ID: NCT02655575 . Registered on 14 January 2016.

Feasibility of integrating vestibular rehabilitation and cognitive behaviour therapy for people with persistent dizziness.

PURPOSE: To evaluate the feasibility of integrating vestibular rehabilitation and cognitive behaviour therapy (VR-CBT) for people with persistent dizziness in primary care. DESIGN: Prospective single-group pre- and post-test study. PARTICIPANTS: Adults (aged 18-70) with acute onset of dizziness and symptoms lasting a minimum 3 months, recruited from Bergen municipality. METHODS: Participants attended eight weekly group sessions of VR-CBT intervention. Feasibility outcomes consisted of recruitment and testing procedures, intervention adherence, and participant feedback, besides change in primary outcomes. The primary outcomes were Dizziness Handicap Inventory (DHI) and preferred gait velocity. RESULTS: Seven participants were recruited for the study. All participants completed the pre-treatment tests, five participants completed the intervention and answered post-treatment questionnaires, and three completed post-treatment testing. Of the five participants, three attended at least 75% of the VR-CBT sessions, and two 50% of the sessions. Participants reported that the VR-CBT was relevant and led to improvement in function. DHI scores improved beyond minimal important change in two out of five participants, and preferred gait velocity increased beyond minimal important change in two out of three participants. CONCLUSION: The current tests and VR-CBT treatment protocols were feasible. Some changes are suggested to optimise the protocols, before conducting a randomised controlled trial. TRIAL REGISTRATION: NCT02655575. Registered 14 January 2016-retrospectively registered.

Short-term information pattern in optokinetic nystagmus amplitude time series.

In this paper we analyzed optokinetic nystagmus (OKN) signals for underlying information patterns. Fourteen OKN signals were recorded in five healthy subjects. First, we tested the correlation between nystagmus slow and fast phases. Previously, it has been suggested that the correlation is higher between the amplitude of the slow phase and the following fast phase, compared to the correlation between the fast phase and the following slow phase. However, we found no such difference. This is in agreement with the view that the saccade performed by the eye is not determined by the previous slow phase, but is free to move voluntarily in order to focus on an object of interest. Second, we analyzed the information entropy contained in the sequence of optokinetic nystagmus amplitudes, and found a short-term information pattern. Further analysis of these patterns could eventually lead to more knowledge about the vestibular and oculomotor systems.

Postural control in a simulated saturation dive to 240 msw.

INTRODUCTION: There is evidence that increased ambient pressure causes an increase in postural sway. This article documents postural sway at pressures not previously studied and discusses possible mechanisms. METHODS: Eight subjects participated in a dry chamber dive to 240 msw (2.5 MPa) saturation pressure. Two subjects were excluded due to unilateral caloric weakness before the dive. Postural sway was measured on a force platform. The path length described by the center of pressure while standing quietly for 60 seconds was used as test variable. Tests were repeated 38 times in four conditions: with eyes open or closed, while standing on bare platform or on a foam rubber mat. RESULTS: Upon reaching 240 msw, one subject reported vertigo, disequilibrium and nausea, and in all subjects, mean postural sway increased 26% on bare platform with eyes open (p < 0.05) compared to predive values. There was no significant improvement in postural sway during the bottom phase, but a trend was seen toward improvement when the subjects were standing with eyes closed on foam rubber (p = 0.1). Postural sway returned to predive values during the decompression phase. DISCUSSION: Postural imbalance during deep diving has been explained previously as HPNS possibly including a specific effect on the vestibulo-ocular reflex. Although vertigo and imbalance are known to be related to compression rate, this study shows that there remains a measurable increase in postural sway throughout the bottom phase at 240 msw, which seems to be related to absolute pressure.

Static stabilometry and repeated testing in a normal population.

BACKGROUND: The purpose of the present study was to see if there is a learning effect of repeated static stabilometric testing, using a protocol suitable for testing postural control in narrow spaces, like hypo- and hyperbaric chambers. HYPOTHESIS: Static stabilometry testing under normobaric conditions is objective and reproducible. With repeated testing, a learning effect may be observed. METHODS: Four groups of healthy individuals were tested ten times under the same four acoustically and visually standardized and normobaric normoxic test conditions on a static balance platform. First, the subjects were asked to stand on a bare platform with the eyes open, thereafter with the eyes closed. This was repeated with a foam rubber mat placed on top of the balance platform. The time interval between the first and the last test sequence was 11 (10-13) days for the test subjects in group I (n = 22), 17 d for group II (n = 13), 31(28-36) days for group III (n = 15) and 115 (49-193) days for group IV (n = 10). RESULTS: Static stabilometry tests in a normal population are objective and reproducible. With repeated tests, a learning effect was observed. The learning effect was largest when standing on a foam rubber mat with eyes closed and when the time intervals between the tests were shortest. There was no difference in sway pattern or learning ability between tall and short test subjects, between subjects with heavy and light body weight or between the sexes.

Effect of bupivacaine on pain after tonsillectomy: a randomized clinical trial.

Several authors have found that pre-incisional injection of local anaesthetics reduces postoperative pain. In the present double-blind study, comprising 126 inpatients aged 6-42 (mean 19) years, we investigated whether pre-incisional injection of bupivacaine during general anaesthesia reduces the pain experienced after tonsillectomy. The patients were randomized into three treatment groups: 43 patients were injected with 5 ml of bupivacaine (2.5 mg/ml)+ epinephrine (5 microg/ml) solution in both tonsillar fossa, 41 had epinephrine (5 microg/ml) + saline (9 mg/ml) and 42 patients received saline (9 mg/ml) only. Self-assessment of pain during the first postoperative week (repeated measures) was recorded. Use of analgetics, experience of the surgeons, peroperative bleeding and several other clinical parameters were assessed. Analyses of covariance with repeated measures was carried out for each pain score. In general there was no statistical significant difference in pain scores, represented by a visual analogue scale (VAS) between the three treatment groups. However, injection of bupivacaine into the tonsillar fossa seemed to reduce pain shortly after the operation in the age group 19-24 years. Further, females and older patients reported more pain and used more analgetics than males and younger patients. Increasing experience of the surgeon was related to a lower score for baseline pain shortly after the operation. Epinephrine in bupivacaine or saline reduced peroperative bleeding. We conclude that bupivacaine does not provide significant postoperative analgesia after tonsillectomy in an unselected group of patients.

Effects of hypobaric hypoxia on postural control.

BACKGROUND: While the effects of accelerative forces on the vestibular system have been thoroughly investigated, the effects of hypobaric conditions on the postural system have attracted less attention. The purpose of the study was to investigate if postural control is affected by hypobaric hypoxia. HYPOTHESIS: Moderate hypobaric hypoxia may reduce postural control. METHODS: Subjective and multiple objective measurements of postural control with open and closed eyes were made in 16 military aircrew standing on a static balance platform before, during, and after exposure to an altitude chamber training profile with a maximum altitude of 25,000 ft. RESULTS: No subjective dizziness and no clinical unsteadiness were noted. However, significant changes in body sway were found at the balance platform during hypobaric exposure at 18,000, 14,000 and 8000 ft compared with the baseline registrations. The relative increase in sway movements was greater in the eyes open condition compared with the eyes closed condition, and significant for movements in the anteroposterior plane but not in the lateral plane. Most sway parameters returned to pre-exposure values on return to ground level. CONCLUSIONS: Acute hypobaric hypoxia, corresponding to the tested altitudes, influenced postural control primarily in the anteroposterior plane with eyes open. This is in agreement with other studies showing that vision is the first of the special senses to be altered by lack of oxygen.

[Chaos theory and otoneurologic diagnosis]. / Kaosteori i otonevrologisk diagnostikk.

Current interpretation of signals obtained from ENG (electronystagmography) of patients suffering from vertigo is based on methods developed before computers became standard laboratory equipment. New signal processing methods, based on the use of fast computers, can increase our knowledge of the mechanisms involved in the regulation of the vestibular system. Preliminary results suggests that new analyzing tools from the field of chaos theory may yield information of clinical relevance. At present this would appear to be a promising approach to research in this field.

Balance testing in saturation diving.

UNLABELLED: The literature is sparse and equivocal concerning the possible influence of hyperbaric exposure on postural control and the vestibular system. HYPOTHESIS: Deep heliox diving may influence postural control and the vestibular system. METHOD: Multiple objective measurements of postural control were made in four divers by means of a static balance platform before, during and after an onshore experimental saturation heliox chamber dive of 32 d duration. Saturation pressure was 4.6 MPa, corresponding to a depth of 450 m of seawater (msw). Downward excursions to 470 msw were also performed. Clinical ENT and otoneurological examination, including bithermal caloric vestibular testing with electronystagmography (ENG) was performed before and after the dive. RESULTS: Reduced postural control was detected by the balance platform test in all four divers from approximately 200 msw and deeper. Body sway showed a distinct increase during compression, reaching a maximum value during the bottom phase. The Romberg index was not suitable for describing shifts in postural stability. All sway parameters returned to pre-dive values after surfacing. Immediately post-dive, most caloric responses were reduced, compared to the pre-dive results. CONCLUSION: We conclude that deep heliox diving influences postural control and the vestibular system. Computerized stabilometry is a convenient and sensitive method of monitoring postural control during saturation diving. The path length of the center of pressure (COP) seems to be suitable as a monitoring parameter.

Home application of EMLA cream prior to venipuncture. Is it feasible in pediatric ENT day care surgery?

EMLA (Eutectic Mixture of Local Anaesthetics) cream is an emulsion made from lidocaine and prilocaine. The cream is well known among parents in Scandinavia, and it has become most popular in preventing pain during venipuncture in children. To be fully effective the cream must be applied at least 60 min before the painful stimulus, which is a major drawback in outpatient practice. Could this problem be eliminated by home application of EMLA cream? To answer this we performed a study comprising 228 consecutive patients (1-15 years of age) planned for outpatient surgery. All parents received a letter with detailed information about the procedure and a prescription of EMLA cream. Parents and anaesthesiology nurses answered questionnaires after the operation. Twenty-three children were excluded from the study due to failure in registration or they were called in to fill vacancies. One hundred and eighty out of 205 children had EMLA cream applied. Home application of EMLA cream reduced the waiting time at the ENT outpatient clinic by at least 60 min, and the study showed that home application of EMLA cream is safe, easy to perform and a well-tolerated procedure.

Tularemia: a differential diagnosis in oto-rhino-laryngology.

Tularemia can present as an oto-rhino-laryngological disease. The clinical and radiological (CT) manifestations, diagnosis and treatment are discussed based on a case report where a patient with tonsillitis and enlarged cervical lymph nodes was admitted to the department of oto-rhino-laryngology of a hospital in Northern Norway. Francisella tularensis was isolated from the blood and there was a high titre of agglutinating serum antibodies to F. tularensis. The patient's contaminated drinking water well is the suspect source of infection.

[Minitracheotomy]. / Minitrakeotomi.

Minitracheotomy is used most often in intensive care units for tracheobronchial suctioning, especially after major abdominal and thoracic surgery. In addition, minitracheotomy is used in emergency situations involving obstruction of upper airways. Percutaneous minitracheotomy means a coniotomy that should be performed under safe conditions. The Seldinger technique may facilitate insertion of the tube. The position of the tube has to be checked by aspiration of air. We describe a case with bleeding and intralaryngeal haematoma. Usually, however, minitracheotomy seems to be a valuable and safe therapeutic asset provided that the necessary precautions are taken.

Water- and airborne Francisella tularensis biovar palaearctica isolated from human blood.

The isolation of Francisella tularensis from human blood is extremely rare in Europe. We here describe two cases of septicemia caused by F. tularensis biovar palaearctica, where the causative bacterium was isolated from blood. One of our patients had ingested contaminated water; the other was probably infected by inhalation of contaminated dust. The isolation of the causative organism was essential for initiating the appropriate antibiotic treatment, which led to a rapid improvement. Since the responsive agent rarely is isolated from tularemia patients, blood cultures should be drawn more often in order to improve the diagnostic procedures.

[Schistosomiasis]. / Schistosomiasis.

Schistosomiasis ranks among the major public health problems in the tropics and subtropics. The disease is caused by the parasite Schistosoma, a flatworm with a life cyclus including man as the definitive host and a freshwater snail as the intermediate host. During the last ten years one hundred cases of this disease have been reported in Norway. We report two cases of schistosomiasis, one patient infected with Schistosoma japonicum, the first reported case in Norway, the other with Schistosoma mansoni and Schistosoma haematobium. We discuss the disease, including the clinical picture and treatment.