Units In Denmark Research Articles

The patient education — Learning and Coping Strategies — improves adherence in cardiac rehabilitation (LC-REHAB): A randomised controlled trial

BackgroundDespite proven benefits of cardiac rehabilitation (CR), adherence to CR remains suboptimal. This trial aimed to assess the impact of the patient education ‘Learning and Coping Strategies’ (LC) on patient adherence to an eight-week CR program. Methods825 patients with ischaemic heart disease or heart failure were open label randomised to either the LC arm (LC plus CR) or the control arm (CR alone) across three hospital units in Denmark. Both arms received same amount of training and education hours. LC consisted of individual clarifying interviews, participation of experienced patients as co-educators, situational, reflective and inductive teaching. The control arm received structured deductive teaching. The primary outcomes were patient adherence to at least 75% of the exercise training or education sessions. We tested for subgroup effects on the primary outcomes using interaction terms. The primary outcomes were compared across arms using logistic regression. ResultsMore patients in the LC arm adhered to at least 75% of the exercise training sessions than control (80% versus 73%, adjusted odds ratio (OR):1.48; 95% CI:1.07 to 2.05, P=0.018) and 75% of education sessions (79% versus 70%, adjusted OR:1.61, 1.17 to 2.22, P=0.003). Some evidence of larger effects of LC on adherence was seen for patients with heart failure, low education and household income. ConclusionsAddition of LC strategies improved adherence in rehabilitation both in terms of exercise training and education. Patients with heart failure, low levels of education and household income appear to benefit most from this adherence promoting intervention. Trial registrationwww.clinicaltrials.gov identifier NCT01668394

Surfactant Need by Gestation for Very Preterm Babies Initiated on Early Nasal CPAP: A Danish Observational Multicentre Study of 6,628 Infants Born 2000-2013

Background: In recent years, early nasal continuous positive airway pressure (nCPAP) as respiratory support for preterm infants is being advocated as an alternative to prophylactic surfactant and treatment with mechanical ventilation. A number of infants treated with early nCPAP do not need treatment with surfactant, but few studies provide data on this. Since the 1990s, the first approach to respiratory support to preterm infants in Denmark has been early nCPAP combined with surfactant administration by the INSURE method by which the infant is intubated and surfactant administration is followed by rapid extubation to nCPAP if possible. Objectives: To investigate how often surfactant was administered in preterm infants with a gestational age below 34 weeks treated with early nCPAP as a first approach to respiratory support. Methods: An observational multicentre study including all inborn infants with a gestational age below 34 weeks admitted to 1 of the 4 level 3 neonatal intensive care units in Denmark in the period from 2000 to 2013. Results: A total of 6,628 infants were included in this study. We found that surfactant was administered in 1,056 of 1,799 (59%; 95% CI: 57-61%), in 821 of 2,864 (29%; 95% CI: 27-31%), and in 132 of 1,796 (7%; 95% CI: 6-8%) of the infants with a gestational age from 24 to 27, 28 to 31, and 32 to 33 weeks and 6 days, respectively. Conclusions: A large proportion of preterm infants treated with early nCPAP as the first approach to respiratory support was never treated with surfactant.

Patient- and clinician- reported outcome in eating disorders

Patient-reported outcome is increasingly applied in health sciences. Patients with eating disorders (EDs) characteristically have a different opinion of their needs to that of the health professionals, which can lead to ambivalence towards treatment and immense compliance difficulties. This cross-sectional study compared data assessed by the clinician to patient-reported measures in patients with a history of EDs.We included data from a cohort of patients with EDs (n=544) referred to a specialized ED unit in Denmark. Patient-reported measures included the Eating Disorder Inventory-2 (EDI-2) and the Short Form 36 (SF-36), and clinical data included remission status and body mass index (BMI). We found a positive association between BMI and EDI-2 scores for anorexia nervosa (AN) and eating disorder not otherwise specified (EDNOS), reflecting increasing ED symptomatology with increasing BMI. This association was not observed in bulimia nervosa (BN). We did not find a correlation between SF-36 scores and BMI in any of the diagnostic groups.

Coping with worry while waiting for diagnostic results: a qualitative study of the experiences of pregnant couples following a high-risk prenatal screening result.

BackgroundIt is well documented that pregnant women experience increased worry and uncertainty following a high-risk prenatal screening result. While waiting for diagnostic results this worry continues to linger. It has been suggested that high-risk women put the pregnancy mentally ‘on hold’ during this period, however, not enough is known about how high-risk women and their partners cope while waiting for diagnostic results. The aim of this study was to identify the strategies employed to cope with worry and uncertainty.MethodsQualitative, semi-structured interviews with 16 high-risk couples who underwent diagnostic testing. The couples were recruited at a university hospital fetal medicine unit in Denmark. Data were analysed using thematic analysis.ResultsAll couples reported feeling worried and sad upon receiving a high-risk screening result. While waiting for diagnostic results, the couples focused on coming to their own understanding of the situation and employed both social withdrawal and social engagement as strategies to prevent worry from escalating. Additionally, couples used gratitude, reassuring reasoning and selective memory as means to maintain hopes for a good outcome. Discussions about what to do in case of an abnormal test result were notably absent in the accounts of waiting. This bracketing of the potential abnormal result allowed the couples to hold on to a ‘normal’ pregnancy and to employ an ‘innocent-till-proven-guilty’ approach to their worries about the fetus’s health. None of the interviewed couples regretted having prenatal screening and all of them expected to have prenatal screening in a future pregnancy.ConclusionsThe couples in this study did not put the pregnancy mentally ‘on hold’. Worry and uncertainty must be understood as managed through a diverse range of practical and emotional strategies that change and overlap in the process of waiting. Clinicians may support appropriate ways of coping with worry and waiting through empathetic and empowering clinical communication. In addition to providing adequate information and presenting options available, clinicians may support high-risk women/couples by encouraging them to seek their own personal understandings and management strategies as a way to gain some control in an uncertain situation.

Combined use of the National Early Warning Score and D-dimer levels to predict 30-day and 365-day mortality in medical patients

AimTo investigate the combined use of NEWS and D-dimer levels to predict the 30-day and 365-day mortality rates of a cohort of Danish patients with complete follow-up. MethodsPost-hoc retrospective observational study of acutely admitted medical patients aged 18 years or older who had D-dimer measured within 6h after arrival to two medical admission units in Denmark. ResultsThe final study population consisted of 1201 patients with a median age of 65.0 years (range 18.0–107.0 years), and 44.7% were of male sex. Four patients (0.3%) died within 24h of admission, 69 (5.7%) within 30 days and 198 (16.5%) within 365 days. On admission, 576 (48%) patients had a NEWS≥3 – of these 441 had a D-dimer≥0.50mgL−1: 55 (12.5%) of these patients died within 30 days, compared with 5 (3.7%) of the 135 patients with a D-dimer<0.50mgL−1 (odds ratio 3.7, 95%CI 1.4–10.8). Nine of the 625 patients with a NEWS on admission <3 died within 30 days and all of these patients had a D-dimer≥0.50mgL−1. None of the 218 patients with a D-dimer<0.50mgL−1 died within 30 days of admission. ConclusionThe combination of NEWS score<3 and D-dimer levels below 0.50mgL−1 appears to identify patients of low risk of mortality within 30 days and, therefore, may prove to be a powerful risk assessment tool for acutely ill medical patients.

Epidemiologic characteristics of retinal detachment surgery at a specialized unit in Denmark.

To examine the incidence of retinal detachments and to evaluate patient profiles and surgical characteristics. Retrospective review of patients operated for primary retinal detachment (RD) and redetachment between 2010 and 2012 at the Department of Ophthalmology, Odense University Hospital, Denmark. We included all RD such as rhegmatogenous retinal detachment (RRD), tractional retinal detachment (TRD) and exudative retinal detachment (ERD). In total, 779 RD surgeries were performed: 83.7% (n=652) primary operations and 16.3% (n=127) reoperation. For primary operation, pars plana vitrectomy (PPV), scleral buckling and combined operations were performed in 95.1% (n=620), 4.6% (n=30) and 0.3% (n=2) respectively. Over time there was less use of silicone oil and greater use of gas tamponade (p=<0.001), less simultaneous cataract operations (p=<0.001), less use of cryotherapy (p=0.045) and more use of peeling procedures (p =<0.001) in primary operations. The annual incidence of surgery for primary RD was 22.0 [95% confidence interval (CI) 20.4-23.8] per 100000 inhabitants aged >15years. Retinal detachment (RD) was more common in males than females (1.8:1), and mean age at presentation was 61.8 years (standard deviations±12.3). The annual incidence for RRD and TRD operation was 20.72 (95% CI 19.11-22.43) and 1.25 (95% CI 0.9-1.7) per 100000 inhabitants >15years. This study presents the first overall incidence for RD in Denmark. The highest incidence of RRD was among males aged 60 to 79years, whereas TRD was among females at same age. Pars plana vitrectomy (PPV) was the preferred surgical technique, and during 2012 all RD patients were treated with PPV, independent of lens status and age.

Patients’ views of the quality of Danish forensic psychiatric inpatient care

The present study describes the quality of psychiatric care among forensic inpatients in Denmark who answered the Danish version of the Quality in Psychiatric Care–Forensic In-Patient (QPC–FIP) instrument. A sample of 143 patients (response rate 53%) from 25 of the 27 specialized forensic units in Denmark participated in the study. The patients’ ratings of the quality of care were generally high. The highest rating was found for the quality of the secluded environment and the lowest for patient participation in the care. The results showed that several factors influenced the patients’ ratings. Women rated the quality of care lower in comparison to men. Patients living together with someone before admission, patients with a lower level of education, and patients who were better informed regarding their diagnosis, who was the responsible physician, and where to complain rated the quality of care higher. We can recommend the use of the Danish version of the QPC–FIP instrument for measuring and improving the quality of care in forensic inpatient care.

DEVELOPING LIFE SKILLS IN HAEMODIALYSIS USING THE GUIDED SELF‐DETERMINATION METHOD: A QUALITATIVE STUDY

Studies in patients with diabetes have shown that the guided self determination (GSD) method effectively improves patients' glycaemia control and life skills. As a pilot study in 2011 showed promising results of using parts of GSD adjusted to patients on haemodialysis (HD), we decided to develop and test a full-scale GSD for this patient group (GSD-HD). To study how a full-scale GSD-HD influenced the quality of relatedness between the patient and the GSD-HD nurse and the patients' ability to live well with end stage renal disease (ESRD). GSD-HD was developed through participatory research and evaluated qualitatively at five dialysis units in Denmark involving 31 patients and 16 nurses. The intervention lasted four months and comprised six sessions. Data consisting of semi-structured interviews with 13 patients were analysed using a mix of inductive and deductive thematic analysis. A process of developing life skills was clearly identified in the changes accomplished by all 13 participants going through the GSD-HD intervention. Six themes showed that the changes involved the patients personally, their relationships with healthcare professionals and relatives and their self-management of ESRD: Deeper and more meaningful relationships, self-exploration of self-selected challenges, self-understanding as a condition for meaningful knowledge, ability to act in a self-determined way, feedback from action that accords with daily life skills and decision-making from professional to share. The positive changes identified in this qualitative evaluation are promising and indicate that GSD-HD has a potential worthwhile to be tested further among patients with ESRD.

Enhanced recovery for gastrointestinal surgery

### Key points The perioperative care of patients undergoing elective inpatient surgery has undergone marked changes in the last 20 yr, resulting in significant reductions in length of hospital stay (LOS). Kehlet's unit in Denmark was the first to demonstrate very impressive reductions in LOS, and the process became known as fast-track surgery. From these concepts evolved the UK Enhanced Recovery (ER) Programme, which started in four specialities—colorectal, orthopaedics, urology, and gynaecology. In the last few years, there has been a wealth of data from nearly every major surgical speciality, although the majority of evidence comes from colorectal surgery. A major driver for ER has been the benefits not only for patients, but also clinicians and hospital managers. Patients not only leave hospital more quickly, but their subsequent return to normal activity is hastened. Other benefits are a reduction in the physiological stress response (see below), perioperative complications,1,2 and perhaps commencement of further therapy (e.g. chemotherapy) at an earlier stage. Clinicians and hospital managers are able to reduce LOS and either increase throughput or reduce the numbers of beds required accordingly, the latter with significant cost reductions. The individual steps for ER for colorectal surgery were described several years ago and still form the basis of modern ER for all GI surgery (Fig. 1). The adherence to these multimodal, evidenced-based …

‘What do you think?’ the collaborative practices of choice and care in a Danish obstetric ultrasound unit

ABSTRACTThis paper is based on ethnographic fieldwork at an obstetric ultrasound unit in Denmark and explores the few, intense minutes of clinical interaction following a high-risk screening result for Down's syndrome. The category of high-risk transforms the routine ultrasound into a situation of inescapable choice, where the health of the foetus is questioned and decisions must be made. The clinical interactions following a high-risk result are investigated as processes of production, and the concepts of logic of choice and the logic of care are employed as analytical tools for identifying different rationales at play in the situation. The analysis shows that sonographers and women/couples collaboratively engage in logics of choice and care. Their mutual aim is to make the high-risk results meaningful and manageable so that a decision can be made. In this process initiative is shifted back and forth. Through a logic of care, complexity is reduced and statistics transformed by emphasising certain interpretations and leaving others unspoken. However, the logic of choice is also collectively maintained by positioning the women/couples as decision-makers. It is argued that in the obstetric ultrasound unit, the logic of choice provides a powerful frame, with the logic of care filling in the gaps and discontinuities to facilitate decisions. In this context, the logics are complementary rather than competing, and thus the analysis add new perspectives to the original concepts. In sum, the logics of choice and care provide a valuable analytical tool for interpreting and understanding the complex and collaborative practices of clinical interaction.

Economic valuation of heat pumps and electric boilers in the Danish energy system

Heat pumps (HP) and electric immersion boilers (EB) have great potential to increase flexibility in energy systems. In parallel, decreasing taxes on electricity-based heat production are creating a more favorable economic environment for the deployment of these units in Denmark. In this paper, the economic value of heat pumps and electric boilers is assessed by simulating their day-to-day market performance using a novel operational strategy based on two-stage stochastic programming. This stochastic model is employed to optimize jointly the daily operation of HPs and EBs along with the Combined Heat and Power (CHP) units in the system. Uncertainty in the heat demand and power price is modeled via scenarios representing different plausible paths for their future evolution. A series of case-studies are performed using real-world data for the heat and power systems in the Copenhagen area during four representative weeks of 2013. We show that the use of stochastic operational models is critical, as standard deterministic models provide an overestimation of the added benefits from the installation of HPs and EBs, thus leading to over-investment in capacity. Furthermore, we perform sensitivity studies to investigate the effect on market performance of varying capacity and efficiency for these units, as well as of different levels of prices in the electricity market. We find that these parameters substantially affect the profitability of heat pumps and electric boilers, hence, they must be carefully assessed by potential investors.

Intensive care unit patients' experience of being conscious during endotracheal intubation and mechanical ventilation.

There is a change in paradigm in intensive care units with trends towards lighter sedation. Light or no sedation protocols are, however, a radical change for clinical practice and can cause challenges for the patients. Undergoing mechanical ventilation when conscious can be a distressing experience for the patients. Receiving a tracheostomy increases patient comfort, but some patients still undergo prolonged endotracheal intubation during mechanical ventilation. The experience of being conscious during endotracheal intubation and mechanical ventilation in the intensive care unit has not previously been described. The aim of the study was to explore adult intensive care unit patients' experience of being conscious during endotracheal intubation and mechanical ventilation. Data collection was performed through semi-structured interviews and four patients were enrolled. Data were collected at two multidisciplinary intensive care units in Denmark. Data were analysed using Ricoeur's theory of interpretation, using the method described by Dreyer and Pedersen. The scientific tradition was phenomenological-hermeneutic. During the analysis, three themes emerged: (1) The tube in the throat. (2) To be conscious but feeling doped. (3) When passing of time is dragging on. The findings shed a light over the experience of being conscious during endotracheal intubation and mechanical ventilation in the intensive care unit. A no-sedation protocol may cause problems for the patients both of a physical and an existential character, but despite this, patients seem positive towards being conscious. The study suggests that clinical nursing practice may have to be further developed to accommodate the patients' needs, e.g. communicating and participating as well as optimizing nursing interventions towards thirst, pain and tube management. Furthermore, the intensive care unit setting may need revision, providing space for the patient and sensory meaningful inputs in the technologically intense environment.

The development of Environmental Productivity: the Case of Danish Energy Plants

The Danish “Klima 2020” plan sets an ambitious target for the complete phasingout of fossil fuels by 2050. The Danish energy sector currently accounts for 40% of national CO2 emissions. Based on an extended Farrell input distance function that accounts for CO2 as an undesirable output, we estimate the environmental productivity of individual generator units based on a panel data set for the period 1998 to 2011 that includes virtually all fuel-fired generator units in Denmark. We further decompose total productivity into technical eciency, best practice ratio, and scale eciency and use a global Malmquist index to calculate the yearly changes. By applying time series clustering, we can identify high, middle, and low performance groups of generator units in a dynamic setting. Our results indicate that the sectoral productivity only slightly increased over the fourteen years. Furthermore, we find that there is no overall high achiever group, but that the ranking, although time consistent, varies between the dierent productivity measures. However, we identify steam turbines and combustion engines for combined heat and power production as potential high performers, while combustion engines that only produce electricity are clearly low performers.

Curriculum development for a national cardiotocography education program: a Delphi survey to obtain consensus on learning objectives.

To define learning objectives for a national cardiotocography (CTG) education program based on expert consensus. A three-round Delphi survey. One midwife and one obstetrician from each maternity unit in Denmark were appointed based on CTG teaching experience and clinical obstetric experience. Following national and international guidelines, the research group determined six topics as important when using CTG: fetal physiology, equipment, indication, interpretation, clinical management, and communication/responsibility. In the first Delphi round, participants listed one to five learning objectives within the predefined topics. Responses were analyzed by a directed approach to content analysis. Phrasing was modified in accordance with Bloom's taxonomy. In the second and third Delphi rounds, participants rated each objective on a five-point relevance scale. Consensus was predefined as objectives with a mean rating value of ≥ 3. A prioritized list of CTG learning objectives. A total of 42 midwives and obstetricians from 21 maternity units were invited to participate, of whom 26 completed all three Delphi rounds, representing 18 maternity units. The final prioritized list included 40 objectives. The highest ranked objectives emphasized CTG interpretation and clinical management. The lowest ranked objectives emphasized fetal physiology. Mean ratings of relevance ranged from 3.15 to 5.00. National consensus on CTG learning objectives was achieved using the Delphi methodology. This was an initial step in developing a valid CTG education program. A prioritized list of objectives will clarify which topics to emphasize in a CTG education program.

Nurses’ experiences of caring for critically ill, non-sedated, mechanically ventilated patients in the Intensive Care Unit: A qualitative study

The objective was to explore nurses' experiences of caring for non-sedated, critically ill patients requiring mechanical ventilation. The study had a qualitative explorative design and was based on 13 months of fieldwork in two intensive care units in Denmark where a protocol of no sedation is implemented. Data were generated during participant observation in practice and by interviews with 16 nurses. Data were analysed using thematic interpretive description. An overall theme emerged: "Demanding, yet rewarding". The demanding aspects of caring for more awake intubated patients included unpredictability, ambiguous needs and complex actions, while the rewarding aspects included personal interaction. Three sub-themes were identified: (i) caring for and with the patient, (ii) negotiating relational and instrumental care and (iii) managing physical and emotional closeness. Despite the complexity of care, nurses preferred to care for more awake rather than sedated patients and appreciated caring for just one patient at a time. The importance of close collaboration between nurses and doctors to ensure patient comfort during mechanical ventilation was valued. Caring for more awake non-sedated patients required the nurses to act at the interface between ambiguous possibilities and needs, which was perceived as both demanding and rewarding.

Severe and fatal obstetric injury claims in relation to labor unit volume.

To assess possible association between the incidence of approved claims for severe and fatal obstetric injuries and delivery volume in Denmark. A nationwide panel study of labor units. Claimants seeking financial compensation due to injuries occurring in labor units in 1995-2012. Exposure information regarding the annual number of deliveries per labor unit was retrieved from the Danish National Birth Register. Outcome information was retrieved from the Danish Patient Compensation Association. Exposure was categorized in delivery volume quintiles as annual volume per labor unit: (10-1377), (1378-2016), (2017-2801), (2802-3861), (3862-6659). Five primary measures of outcome were used. Incidence rate ratios of (A) Submitted claims, (B) Approved claims, (C) Approved severe injury claims (120% degree of disability), (D) Approved fatal injury claims, and (C+D) Combined. 1 151 734 deliveries in 51 labor units and 1872 submitted claims were included. The incidence rate ratios of approved claims overall, of approved fatal injury claims, and of approved severe and fatal injuries combined increased significantly with decreasing annual delivery volume. Face value incidence rate ratios of approved severe injuries increased with decreasing labor unit volume, but the association did not reach statistical significance. High volume labor units appear associated with fewer approved and fewer fatal injury claims compared with units with less volume. The findings support the development towards consolidation of units in Denmark. A suggested option would be to tailor obstetric patient safety initiatives according to the delivery volume of individual labor units.

Comparing the effect of non-medical mechanical restraint preventive factors between psychiatric units in Denmark and Norway

Background: The use of mechanical restraint (MR) is controversial, and large differences regarding the use of MR are often found among countries. In an earlier study, we observed that MR was used twice as frequently in Denmark than Norway. Aims: To examine how presumed MR preventive factors of non-medical origin may explain the differing number of MR episodes between Denmark and Norway. Methods: This study is a cross-sectional survey of psychiatric units. Linear regression was used to assess the confounding effects of the MR preventive factors, i.e. whether a difference in the impact of these factors is evident between Denmark and Norway. Results: Six MR preventive factors confounded [∆exp(B)> 10%] the difference in MR use between Denmark and Norway, including staff education (− 51%), substitute staff (− 17%), acceptable work environment (− 15%), separation of acutely disturbed patients (13%), patient–staff ratio (− 11%), and the identification of the patient's crisis triggers (− 10%). Conclusions: These six MR preventive factors might partially explain the difference in the frequency of MR episodes observed in the two countries, i.e. higher numbers in Denmark than Norway. One MR preventive factor was not supported by earlier research, the identification of the patient's crisis triggers; therefore, more research on the mechanisms involved is needed. Clinical implications: None of the six MR preventive factors presents any adverse effects; therefore, units in Denmark and Norway may consider investigating the effect of implementing, the identification of the patient's crisis triggers, an increased number of staff per patient, increased staff education, a better work environment and reduced use of substitute staff in practice.

LC-REHAB: randomised trial assessing the effect of a new patient education method - learning and coping strategies – in cardiac rehabilitation

BackgroundDue to improved treatments and ageing population, many countries now report increasing prevalence in rates of ischemic heart disease and heart failure. Cardiac rehabilitation has potential to reduce morbidity and mortality, but not all patients complete. In light of favourable effects of cardiac rehabilitation it is important to develop patient education methods which can enhance adherence to this effective program. The LC-REHAB study aims to compare the effect of a new patient education strategy in cardiac rehabilitation called ‘learning and coping’ to that of standard care. Further, this paper aims to describe the theoretical basis and details of this intervention.Methods/designOpen parallel randomised controlled trial conducted in three hospital units in Denmark among patients recently discharged with ischemic heart disease or heart failure. Patients are allocated to either the intervention group with learning and coping strategies incorporated into standard care in cardiac rehabilitation or the control group who receive the usual cardiac rehabilitation program. Learning and coping consists of two individual clarifying interviews, participation of experienced patients as educators together with health professionals and theory based, situated and inductive teaching. Usual care in cardiac rehabilitation is characterised by a structured deductive teaching style with use of identical pre-written slides in all hospital units. In both groups, cardiac rehabilitation consists of training three times a week and education once a week over eight weeks. The primary outcomes are adherence to cardiac rehabilitation, morbidity and mortality, while secondary outcomes are quality of life (SF-12, Health education impact questionnaire and Major Depression Inventory) and lifestyle and risk factors (Body Mass Index, waist circumference, blood pressure, exercise work capacity, lipid profile and DXA-scan). Data collection occurs four times; at baseline, at immediate completion of cardiac rehabilitation, and at three months and three years after the finished program.DiscussionIt is expected that learning and coping incorporated in cardiac rehabilitation will improve adherence in cardiac rehabilitation and may decrease morbidity and mortality. By describing learning and coping strategies the study aims to provide knowledge that can contribute to an increased transparency in patient education in cardiac rehabilitation.Trial registrationIdentifier NCT01668394.

Acute pain management in burn patients: Appraisal and thematic analysis of four clinical guidelines

ObjectiveBurn patients suffer excruciating pain due to their injuries and procedures related to surgery, wound care, and mobilization. Acute Stress Disorder, Post-Traumatic Stress Disorder, chronic pain and depression are highly prevalent among survivors of severe burns. Evidence-based pain management addresses and alleviates these complications. The aim of our study was to compare clinical guidelines for pain management in burn patients in selected European and non-European countries. We included pediatric guidelines due to the high rate of children in burn units. MethodThe study had a comparative retrospective design using combined methodology of instrument appraisal and thematic analysis. Three investigators appraised guidelines from burn units in Denmark (DK), Sweden (SE), New Zealand (NZ), and USA using the AGREE Instrument (Appraisal of Guidelines for Research & Evaluation), version II, and identified core themes in the guidelines. ResultsThe overall scores expressing quality in six domains of the AGREE instrument were variable at 22% (DK), 44% (SE), 100% (NZ), and 78% (USA). The guidelines from NZ and USA were highly recommended, the Swedish was recommended, whereas the Danish was not recommended. The identified core themes were: continuous pain, procedural pain, postoperative pain, pain assessment, anxiety, and non-pharmacological interventions. ConclusionThe study demonstrated variability in quality, transparency, and core content in clinical guidelines on pain management in burn patients. The most highly recommended guidelines provided clear and accurate recommendations for the nursing and medical staff on pain management in burn patients. We recommend the use of a validated appraisal tool such as the AGREE instrument to provide more consistent and evidence-based care to burn patients in the clinic, to unify guideline construction, and to enable interdepartmental comparison of treatment and outcomes.

The combined diagnosis of allergic and irritant contact dermatitis in a retrospective cohort of 1000 consecutive patients with occupational contact dermatitis.

The diagnosis of combined allergic and irritant contact dermatitis is an accepted subdiagnosis for hand dermatitis, and it is often considered in a patient with contact dermatitis, a positive and relevant patch test result, and wet work exposure. We therefore hypothesize that it is arbitrary for wet work exposure to be taken into consideration in a patient with newly diagnosed relevant contact allergy. Furthermore, an overestimation of the diagnosis will probably occur if the criteria for wet work exposure are applied correctly, as many occupations have an element of wet work. To find the statistically expected number of combined allergic and irritant contact dermatitis cases in 1000 patients, and to evaluate the diagnostic criteria for the diagnosis. One thousand consecutive patients with occupational contact dermatitis from a hospital unit in Denmark were assessed. The expected number of cases with the diagnosis of combined allergic and irritant contact dermatitis was 0.33%, as compared with the observed number of 6.4%. Females occupied in wet occupations were often diagnosed with combined allergic and irritant contact dermatitis (p < 0.005). The diagnosis of combined allergic and irritant contact dermatitis should be used critically to avoid misclassification, and possible criteria for the diagnosis are proposed.