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Objective: Recent research has shown that the religious affiliation of both physicians and patients markedly influences end-of-life decisions in the intensive care unit in the Western world. The world's major religions' standings on withholding and withdrawing of therapy, on hastening of the death process when providing pain relief (double effect) and on euthanasia are described. This review also discusses whether nutrition should be provided to patients in a permanent vegetative state, and the issues of brain death and organ donation.Design: The review is based on literature research and a description of the legislature in countries where religious rulings do influence secular law.Results: Not all religions have distinct rulings on all the above-mentioned issues, but it is pointed out that all religions will probably have to develop rulings on these questions. The importance of patient autonomy in the Western (Christian) world is not necessarily an issue among other ethnic and religious groups, and guidelines are presented with methods to uncover and deal with different ethnic and religious views.Conclusion: Many religious groupings are now spread world-wide (most notably Muslims), and with increasing globalization it is important that health-care systems take into account the religious beliefs of a wide variety of ethnic and religious groups when contemplating end-of-life decisions. [ABSTRACT FROM AUTHOR]

Purpose: Religious beliefs affect end-of-life practices in intensive care units (ICUs). Changes over time in end-of-life practices were not investigated regarding religions., Methods: Twenty-two European ICUs (3 regions: Northern, Central, and Southern Europe) participated in both Ethicus-1 (years 1999-2000) and Ethicus-2 studies (years 2015-2016). Data of ICU patients who died or had limitations of life-sustaining therapy were analysed regarding changes in end-of-life practices and patient/physician religious affiliations. Frequencies, timing of decision-making, and religious affiliations of physicians/patients were compared using the same definitions., Results: In total, 4592 adult ICU patients (n = 2807 Ethicus-1, n = 1785 Ethicus-2) were analysed. In both studies, patient and physician religious affiliations were mostly Catholic, Greek Orthodox, Jewish, Protestant, or unknown. Treating physicians (but not patients) commonly reported no religious affiliation (18%). Distribution of end-of-life practices with respect to religion and geographical regions were comparable between the two studies. Withholding [n = 1143 (40.7%) Ethicus-1 and n = 892 (50%) Ethicus-2] and withdrawing [n = 695 (24.8%) Ethicus-1 and n = 692 (38.8%) Ethicus-2] were most commonly decided. No significant changes in end-of-life practices were observed for any religion over 16 years. The number of end-of-life discussions with patients/ families/ physicians increased, while mortality and time until first decision decreased., Conclusions: Changes in end-of-life practices observed over 16 years appear unrelated to religious affiliations of ICU patients or their treating physicians, but the effects of religiosity and/or culture could not be assessed. Shorter time until decision in the ICU and increased numbers of patient and family discussions may indicate increased awareness of the importance of end-of-life decision-making in the ICU., (© 2023. The Author(s).)

Objective: In 2019, the Danish parliament issued legislation requiring Danish physicians to clarify and honor seriously ill patients' treatment preferences. The American POLST (Physician Orders for Life-Sustaining Treatment) document could be a valuable model for this process. The aim of the study was to examine patients' preferences for life-sustaining treatment and participant assessment of a Danish POLST form., Methods: The study is a prospective intervention based on a pilot-tested Danish POLST form. Participant assessments were examined using questionnaire surveys. Patients with serious illness and/or frailty from seven hospital wards, two general practitioners, and four nursing homes were included. The patients and their physicians completed the POLST form based on a process of shared decision-making., Results: A total of 95 patients (aged 41-95) participated. Hereof, 88% declined cardiopulmonary resuscitation, 83% preferred limited medical interventions or comfort care, and 74% did not require artificial nutrition. The preferences were similar within age groups, genders, and locations, but with a tendency toward younger patients being more in favor of full treatment and nursing home residents being more in favor of cardiopulmonary resuscitation. Questionnaire response rates were 69% (66/95) for patients, 79% (22/28) for physicians, and 31% (9/29) for nurses. Hereof, the majority of patients, physicians, and nurses found that the POLST form was usable for conversations and decision-making about life-sustaining treatment to either a high or very high degree., Significance of Results: The majority of seriously ill patients did not want a resuscitation attempt and opted for selected treatments. The majority of participants found that the Danish POLST was usable for conversations and decisions about life-sustaining treatment to either a high or a very high degree, and that the POLST form facilitated an opportunity to openly discuss life-sustaining treatment.

Background: Prolonging life in the ICU increasingly is possible, so decisions to limit life-sustaining therapies frequently are made and communicated to patients and families or surrogates. Little is known about worldwide communication practices and influencing factors., Research Question: Are there regional differences in end-of-life communication practices in ICUs worldwide?, Study Design and Methods: This analysis of data from a prospective, international study specifically addressed end-of-life communications in consecutive patients who died or had limitation of life-sustaining therapy over 6 months in 199 ICUs in 36 countries, grouped regionally. End-of-life decisions were recorded for each patient and ethical practice was assessed retrospectively for each ICU using a 12-point questionnaire developed previously., Results: Of 87,951 patients admitted, 12,850 died or experienced a limitation of therapy (14.6%). Of these, 1,199 patients (9.3%) were known to have an advance directive, and wishes were elicited from 6,456 patients (50.2%). Limitations of life-sustaining therapy were implemented for 10,401 patients (80.9%), 1,970 (19.1%) of whom had mental capacity at the time, and were discussed with 1,507 patients (14.5%) and 8,461 families (81.3%). Where no discussions with patients occurred (n = 8,710), this primarily was because of a lack of mental capacity in 8,114 patients (93.2%), and where none occurred with families (n = 1,622), this primarily was because of unavailability (n = 720 [44.4%]). Regional variation was noted for all end points. In generalized estimating equation (GEE) analyses, the odds for discussions with the patient or family increased by 30% (OR, 1.30; 95% CI, 1.18-1.44; P < .001) for every one-point increase in the Ethical Practice Score and by 92% (OR, 1.92; 95% CI, 1.28-2.89; P = .002) in the presence of an advance directive., Interpretation: End-of-life communication with patients and families or surrogates varies markedly in different global regions. GEE analysis supports the hypothesis that communication may increase with ethical practice and an advance directive. Greater effort is needed to align treatment with patients' wishes., (Copyright © 2022 American College of Chest Physicians. All rights reserved.)

Objective: To explore patients' and physicians' perspectives on a decision-making conversation for life-sustaining treatment, based on the Danish model of the American Physician Orders for Life Sustaining Treatment (POLST) form., Design: Semi-structured interviews following a conversation about preferences for life-sustaining treatment., Setting: Danish hospitals, nursing homes, and general practitioners' clinics., Subjects: Patients and physicians., Main Outcome Measures: Qualitative analyses of interview data., Findings: After participating in a conversation about life-sustaining treatment using the Danish POLST form, a total of six patients and five physicians representing different settings and age groups participated in an interview about their experience of the process. Within the main research questions, six subthemes were identified: Timing, relatives are key persons, clarifying treatment preferences, documentation across settings, strengthening patient autonomy, and structure influences conversations. Most patients and physicians found having a conversation about levels of life-sustaining treatment valuable but also complicated due to the different levels of knowledge and attending to individual patient needs and medical necessities. Relatives were considered as key persons to ensure the understanding of the treatment trajectory and the ability to advocate for the patient in case of a medical crisis. The majority of participants found that the conversation strengthened patient autonomy., Conclusion: Patients and physicians found having a conversation about levels of life-sustaining treatment valuable, especially for strengthening patient autonomy. Relatives were considered key persons. The timing of the conversation and securing sufficient knowledge for shared decision-making were the main perceived challenges.KEY POINTSConversations about preferences for life-sustaining treatment are important, but not performed systematically.When planning a conversation about preferences for life-sustaining treatment, the timing of the conversation and the inclusion of relatives are key elements.Decision-making conversations can help patients feel in charge and less alone, and make it easier for health professionals to provide goal-concordant care.Using a model like the Danish POLST form may help to initiate, conduct and structure conversations about preferences for life-sustaining treatment.

Background: Medically frail and/or chronically ill patients are often admitted to Danish hospitals without documentation of patient preferences. This may lead to inappropriate care. Modelled on the American Physician Orders for Life-Sustaining Treatment (POLST) form, the purpose of the study was to develop and pilot test a Danish POLST form to ensure that patients' preferences for levels of life-sustaining treatment are known and documented., Methods: The study was a mixed methods study. In the initial phase, a Danish POLST form was developed on the basis of literature and recommendations from the National POLST organisation in the US. A pilot test of the Danish POLST form was conducted in hospital wards, general practitioners' clinics, and nursing homes. Patients were eligible for inclusion if death was assessed as likely within 12 months. The patient and his/her physician engaged in a conversation where patient values, beliefs, goals for care, diagnosis, prognosis, and treatment alternatives were discussed. The POLST form was completed based on the patient's values and preferences. Family members and/or nursing staff could participate. Participants' assessments of the POLST form were evaluated using questionnaires, and in-depth interviews were conducted to explore experiences with the POLST form and the conversation., Results: In total, 25 patients participated, 45 questionnaires were completed and 14 interviews were conducted. Most participants found the POLST form readable and understandable, and 93% found the POLST form usable to a high or very high degree for discussing preferences regarding life-sustaining treatment. Three themes emerged from the interviews: (a) an understandable document is essential for the conversation, (b) handling and discussing wishes, and (c) significance for the future., Conclusion: The Danish version of the POLST form is assessed by patients, families, physicians, and nurses as a useful model for obtaining and documenting Danish patients' preferences for life-sustaining treatment. However, this needs to be confirmed in a larger-scale study., (© 2022. The Author(s).)

Background: End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices., Methods: In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision., Findings: Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation., Interpretation: Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide., Funding: None., Competing Interests: Declaration of interests AD reports grants, personal fees, and non-financial support from Philips, and Respinor; personal fees from Baxter, Getinge, Lowenstein, and Gilead; personal fees and non-financial support from Fisher & Paykel and Lungpacer; and grants from the French Ministry of Health, outside of the submitted work. JCS reports grants from Orion Pharma, Abbott Nutrition International, B Braun Medical AG, CSEM AG, Edwards Lifesciences Services GmbH, Kenta Biotech, Maquet Critical Care AB, Omnicare Clinical Research AG, Nestle, and Phagenesis, outside of the submitted work. Monies went into departmental funds directly. AG and and MP report grants from the Austrian Center for Documentation and Quality Assurance in Intensive Care during the conduct of the study. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: The "Paracetamol and Ibuprofen in Combination" (PANSAID) trial showed that combining paracetamol and ibuprofen resulted in lower opioid consumption than each drug alone and we did not find an increase in risk of harm when using ibuprofen vs paracetamol. The aim of this subgroup analysis was to investigate the differences in benefits and harms of the interventions in different subgroups. We hypothesized that the intervention effects would differ in subgroups with different risk of pain or adverse events., Methods: In these pre-planned subgroup analyses of the PANSAID trial population, we assessed subgroup heterogeneity in intervention effects between (a) subgroups (sex, age, use of analgesics, American Society of Anesthesiologists (ASA) score, and type of anesthesia) and morphine consumption, and (b) subgroups (sex, age, use of non-steroidal anti-inflammatory drugs (NSAIDs), and ASA score) and serious adverse events., Results: Test of interaction between age and the pairwise comparison between paracetamol 1 g vs paracetamol 0.5 g + ibuprofen 200 mg (P = .009) suggested lower morphine consumption in patients >65 years. However, post hoc analyses of related outcomes showed no interaction for this pairwise comparison. All other tests of interaction regarding both benefit and harm were not statistically significant., Conclusion: These pre-planned subgroup analyses did not suggest that patients in the investigated subgroups benefitted differently from a basic non-opioid analgesic regimen consisting of paracetamol and ibuprofen. Further, there was no evidence of subgroup heterogeneity regarding harm and use of ibuprofen. Because of reduced statistical power in subgroup analyses, we cannot exclude clinically relevant subgroup heterogeneity., (© 2019 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Importance: End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time., Objective: To determine the changes in end-of-life practices in European ICUs after 16 years., Design, Setting, and Participants: Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision., Exposures: Comparison between the 1999-2000 cohort vs 2015-2016 cohort., Main Outcomes and Measures: End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists., Results: Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001)., Conclusions and Relevance: Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.

Background: Oxygen is liberally administered in intensive care units (ICUs). Nevertheless, ICU doctors' preferences for supplementing oxygen are inadequately described. The aim was to identify ICU doctors' preferences for arterial oxygenation levels in mechanically ventilated adult ICU patients., Methods: In April to August 2016, an online multiple-choice 17-part-questionnaire was distributed to 1080 ICU doctors in seven Northern European countries. Repeated reminder e-mails were sent. The study ended in October 2016., Results: The response rate was 63%. When evaluating oxygenation 52% of respondents rated arterial oxygen tension (PaO 2 ) the most important parameter; 24% a combination of PaO 2 and arterial oxygen saturation (SaO 2 ); and 23% preferred SaO 2 . Increasing, decreasing or not changing a default fraction of inspired oxygen of 0.50 showed preferences for a PaO 2 around 8 kPa in patients with chronic obstructive pulmonary disease, a PaO 2 around 10 kPa in patients with healthy lungs, acute respiratory distress syndrome or sepsis, and a PaO 2 around 12 kPa in patients with cardiac or cerebral ischaemia. Eighty per cent would accept a PaO 2 of 8 kPa or lower and 77% would accept a PaO 2 of 12 kPa or higher in a clinical trial of oxygenation targets., Conclusion: Intensive care unit doctors preferred PaO 2 to SaO 2 in monitoring oxygen treatment when peripheral oxygen saturation was not included in the question. The identification of PaO 2 as the preferred target and the thorough clarification of preferences are important when ascertaining optimal oxygenation targets. In particular when designing future clinical trials of higher vs lower oxygenation targets in ICU patients., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Effective postoperative pain management is essential for the rehabilitation of the surgical patient. The PANSAID trial evaluates the analgesic effects and safety of the combination of paracetamol and ibuprofen. This paper describes in detail the statistical analysis plan for the primary publication to prevent outcome reporting bias and data-driven analysis results., Methods/design: The PANSAID trial is a multicentre, randomised, controlled, parallel, four-group clinical trial comparing the beneficial and harmful effects of different doses and combinations of paracetamol and ibuprofen in patients having total hip arthroplastic surgery. Patients, caregivers, physicians, investigators, and statisticians are blinded to the intervention. The two co-primary outcomes are 24-h consumption of morphine and proportion of patients with one or more serious adverse events within 90 days after surgery. Secondary outcomes are pain scores during mobilisation and at rest at 6 and 24 h postoperatively, and the proportion of patients with one or more adverse events within 24 h postoperatively., Discussion: PANSAID will provide a large trial with low risk of bias regarding benefits and harms of the combination of paracetamol and ibuprofen used in a perioperative setting., Trial Registration: ClinicalTrials.org identifier: NCT02571361 . Registered on 7 October 2015.

Purpose: To analyze the relationship between hypercapnia developing within the first 48 h after the start of mechanical ventilation and outcome in patients with acute respiratory distress syndrome (ARDS)., Patients and Methods: We performed a secondary analysis of three prospective non-interventional cohort studies focusing on ARDS patients from 927 intensive care units (ICUs) in 40 countries. These patients received mechanical ventilation for more than 12 h during 1-month periods in 1998, 2004, and 2010. We used multivariable logistic regression and a propensity score analysis to examine the association between hypercapnia and ICU mortality., Main Outcomes: We included 1899 patients with ARDS in this study. The relationship between maximum PaCO 2 in the first 48 h and mortality suggests higher mortality at or above PaCO 2 of ≥50 mmHg. Patients with severe hypercapnia (PaCO 2 ≥50 mmHg) had higher complication rates, more organ failures, and worse outcomes. After adjusting for age, SAPS II score, respiratory rate, positive end-expiratory pressure, PaO 2 /FiO 2 ratio, driving pressure, pressure/volume limitation strategy (PLS), corrected minute ventilation, and presence of acidosis, severe hypercapnia was associated with increased risk of ICU mortality [odds ratio (OR) 1.93, 95% confidence interval (CI) 1.32 to 2.81; p = 0.001]. In patients with severe hypercapnia matched for all other variables, ventilation with PLS was associated with higher ICU mortality (OR 1.58, CI 95% 1.04-2.41; p = 0.032)., Conclusions: Severe hypercapnia appears to be independently associated with higher ICU mortality in patients with ARDS., Trial Registration: Clinicaltrials.gov identifier, NCT01093482.

Background: Effective postoperative pain management is essential for the rehabilitation of the surgical patient. No 'gold standard' exists after total hip arthroplasty (THA) and combinations of different nonopioid medications are used with virtually no evidence for additional analgesic efficacy compared to monotherapy. The objective of this trial is to investigate the analgesic effects and safety of paracetamol and ibuprofen alone and in combination in different dosages after THA., Methods: PANSAID is a placebo-controlled, parallel four-group, multicentre trial with centralised computer-generated allocation sequence and allocation concealment and with varying block size and stratification by site. Blinding of assessor, investigator, caregivers, patients and statisticians. Patients are randomised to four groups: (A) paracetamol 1 g × 4 and ibuprofen 400 mg × 4, (B) paracetamol 1 g × 4 and placebo, (C) placebo and ibuprofen 400 mg × 4 and (D) paracetamol 0.5 g × 4 and ibuprofen 200 mg. The two co-primary outcomes are 24-h consumption of morphine and number of patients with one or more serious adverse events within 90 days after surgery. Secondary outcomes are pain scores during mobilisation and at rest at 6 and 24 h postoperatively, and number of patients with one or more adverse events within 24 h postoperatively. Inclusion criteria are patients scheduled for unilateral, primary THA; age above 18 years; ASA status 1-3; BMI >18 and <40 kg/m 2 ; women must not be pregnant; and provision of informed consent. Exclusion criteria are patients who cannot cooperate with the trial; participation in another trial; patients who cannot understand/speak Danish; daily use of strong opioids; allergy against trial medication; contraindications against ibuprofen; alcohol and/or drug abuse. A total of 556 eligible patients are needed to detect a difference of 10 mg morphine i.v. the first 24 h postoperatively with a standard deviation of 20 mg and a family wise type 1 error rate of 0.025 (two-sided) and a type 2 error rate of 0.10 for the six possible comparisons of the four intervention groups., Discussion: We started recruiting patients in December 2015 and expect to finish in September 2017. Data analysis will be from September 2017 to October 2017 and manuscript submission ultimo 2017., Trial Registration: EudraCT: 2015-002239-16 (12/8-15); ClinicalTrials.gov: NCT02571361 . Registered on 7 October 2015.

Introduction: In 2002, two landmark studies concluded that therapeutic hypothermia (TH) improves survival and neurologic outcome in patients with shockable rhythms and out-of-hospital cardiac arrest (OHCA). However, the evidence on whether TH also improves the prognosis in patients with non-shockable rhythms or in-hospital cardiac arrest (IHCA) is sparse. The aim of this study was to assess the prevalence and prognosis of patients with non-shockable rhythms or IHCA after implementation of TH in a real-life setting., Methods: The study included 72 consecutive, unconscious patients that were admitted to Holbaek Hospital after cardiac arrest and successful resuscitation. Patients were included regardless of initial cardiac rhythms and location of the cardiac arrest. All patients were cooled to a temperature of 32-34 °C. The primary outcome was survival with a favourable neurologic outcome within six months., Results: Almost two thirds (63%) of the included patients had non-shockable rhythms or IHCA and only 8.7% of these patients survived with a favourable neurologic outcome. Nearly a third (29%) of the included patients had OHCA with an initial non-shockable rhythm and none (0%) of these patients survived with a favourable neurologic outcome., Conclusions: In a real-life setting, the majority of resuscitated patients receiving TH do not fulfil the criteria of the original studies upon which the current guidelines are based. Furthermore, these patients have a poor outcome, indicating that not all patients may benefit from TH., Funding: none., Trial Registration: not relevant.

Purpose: There are limited data available about the role of sedation and analgesia during noninvasive positive pressure ventilation (NPPV). The objective of study was to estimate the effect of analgesic or sedative drugs on the failure of NPPV., Methods: We studied patients who received at least 2 h of NPPV as first-line therapy in a prospective observational study carried out in 322 intensive care units from 30 countries. A marginal structural model (MSM) was used to analyze the association between the use of analgesic or sedative drugs and NPPV failure (defined as need for invasive mechanical ventilation)., Results: 842 patients were included in the analysis. Of these, 165 patients (19.6%) received analgesic or sedative drugs at some time during NPPV; 33 of them received both. In the adjusted analysis, the use of analgesics (odds ratio 1.8, 95% confidence interval 0.6-5.4) or sedatives (odds ratio 2.8, 95% CI 0.85-9.4) alone was not associated with NPPV failure, but their combined use was associated with failure (odds ratio 5.7, 95% CI 1.8-18.4)., Conclusions: Slightly less than 20% of patients received analgesic or sedative drugs during NPPV, with no apparent effect on outcome when used alone. However, the simultaneous use of analgesics and sedatives may be associated with failure of NPPV.

The impedance threshold device (ITD) works by increasing negative intrathoracic pressure, venous return and cardiac output during cardiopulmonary resuscitation. Although animal studies have shown promising results on haemodynamics, randomized studies and metaanalyses in humans have not shown better long-term survival or neurologic outcome. No studies have been done on the use of the ITD during in-hospital cardiac arrest. The ITD combined with active compression-decompression cardiopulmonary resuscitation may result in a better outcome.

Introduction: The aim of this study was to describe and compare the changes in ventilator management and complications over time, as well as variables associated with 28-day hospital mortality in patients receiving mechanical ventilation (MV) after cardiac arrest., Methods: We performed a secondary analysis of three prospective, observational multicenter studies conducted in 1998, 2004 and 2010 in 927 ICUs from 40 countries. We screened 18,302 patients receiving MV for more than 12 hours during a one-month-period. We included 812 patients receiving MV after cardiac arrest. We collected data on demographics, daily ventilator settings, complications during ventilation and outcomes. Multivariate logistic regression analysis was performed to calculate odds ratios, determining which variables within 24 hours of hospital admission were associated with 28-day hospital mortality and occurrence of acute respiratory distress syndrome (ARDS) and pneumonia acquired during ICU stay at 48 hours after admission., Results: Among 812 patients, 100 were included from 1998, 239 from 2004 and 473 from 2010. Ventilatory management changed over time, with decreased tidal volumes (VT) (1998: mean 8.9 (standard deviation (SD) 2) ml/kg actual body weight (ABW), 2010: 6.7 (SD 2) ml/kg ABW; 2004: 9 (SD 2.3) ml/kg predicted body weight (PBW), 2010: 7.95 (SD 1.7) ml/kg PBW) and increased positive end-expiratory pressure (PEEP) (1998: mean 3.5 (SD 3), 2010: 6.5 (SD 3); P <0.001). Patients included from 2010 had more sepsis, cardiovascular dysfunction and neurological failure, but 28-day hospital mortality was similar over time (52% in 1998, 57% in 2004 and 52% in 2010). Variables independently associated with 28-day hospital mortality were: older age, PaO2 <60 mmHg, cardiovascular dysfunction and less use of sedative agents. Higher VT, and plateau pressure with lower PEEP were associated with occurrence of ARDS and pneumonia acquired during ICU stay., Conclusions: Protective mechanical ventilation with lower VT and higher PEEP is more commonly used after cardiac arrest. The incidence of pulmonary complications decreased, while other non-respiratory organ failures increased with time. The application of protective mechanical ventilation and the prevention of single and multiple organ failure may be considered to improve outcome in patients after cardiac arrest.

There is a male dominance among patients in intensive care units (ICUs). Potentially, this will increase the risk of a skewed male/female distribution in randomised, controlled trials (RCTs). We have evaluated if this has in fact happened when randomising and whether the authors have been aware of that. We performed a systematic search on PubMed from 1 January 2011 to 31 May 2012 using the mesh terms 'randomized controlled trial' and 'intensive care unit'. Twenty-five RCTs with a total of 12,788 patients met the inclusion criteria, with an overall male dominance of 63.6% (P < 0.0001). Eighteen of the 25 papers had an individually statistically significant gender difference in their total trial population. None of the 18 trials with a significant gender difference in their overall trial population had calculated the P-value for this overall difference. In the randomised groups, there was a significant gender difference in five papers. Seventeen had no significant gender difference in the randomised groups, and three papers did not state gender in the randomised groups. This study show that there is a marked male dominance in RCTs conducted in ICUs. We recommend that when planning future RCTs, the authors contemplate if their results can be used indiscriminately among ICU patients if the distribution of males and females is much skewed. It is relevant to determine if ones endpoint can be influenced by gender differences and if there is a risk of gender influence on data, proportional allocation or stratification should be considered., (© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Survival after in-hospital cardiac arrest (CA) has been reported to be surprisingly low without any major improvement during the last decade. Cardiopulmonary resuscitation (CPR) quality affects survival after CA, and specific education is necessary for health care professionals participating in CPR. Decisions regarding CPR and do not attempt resuscitation (DNAR) orders remain demanding, as does including patients in the process. Addressed training regarding CPR/DNAR orders is necessary to improve the CPR/DNAR decision process used by physicians. The aim of this retrospective study is to evaluate the clinical impact (return of spontaneous circulation and 21-day survival after CA) of an intervention within one single hospital, including a systematic education of all health care professionals in CPR. In total, there were 33 in-hospital CAs before (12 months) and 176 after (36 months) the intervention. No significant difference was found between the 2 calendar periods., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Rationale: Baseline characteristics and management have changed over time in patients requiring mechanical ventilation; however, the impact of these changes on patient outcomes is unclear., Objectives: To estimate whether mortality in mechanically ventilated patients has changed over time., Methods: Prospective cohort studies conducted in 1998, 2004, and 2010, including patients receiving mechanical ventilation for more than 12 hours in a 1-month period, from 927 units in 40 countries. To examine effects over time on mortality in intensive care units, we performed generalized estimating equation models., Measurements and Main Results: We included 18,302 patients. The reasons for initiating mechanical ventilation varied significantly among cohorts. Ventilatory management changed over time (P < 0.001), with increased use of noninvasive positive-pressure ventilation (5% in 1998 to 14% in 2010), a decrease in tidal volume (mean 8.8 ml/kg actual body weight [SD = 2.1] in 1998 to 6.9 ml/kg [SD = 1.9] in 2010), and an increase in applied positive end-expiratory pressure (mean 4.2 cm H2O [SD = 3.8] in 1998 to 7.0 cm of H2O [SD = 3.0] in 2010). Crude mortality in the intensive care unit decreased in 2010 compared with 1998 (28 versus 31%; odds ratio, 0.87; 95% confidence interval, 0.80-0.94), despite a similar complication rate. Hospital mortality decreased similarly. After adjusting for baseline and management variables, this difference remained significant (odds ratio, 0.78; 95% confidence interval, 0.67-0.92)., Conclusions: Patient characteristics and ventilation practices have changed over time, and outcomes of mechanically ventilated patients have improved. Clinical trials registered with www.clinicaltrials.gov (NCT01093482).

Background: Transfusion of red blood cells (RBC) is recommended in septic shock and the majority of these patients receive RBC transfusion in the intensive care unit (ICU). However, benefit and harm of RBCs have not been established in this group of high-risk patients., Methods/design: The Transfusion Requirements in Septic Shock (TRISS) trial is a multicenter trial with assessor-blinded outcome assessment, randomising 1,000 patients with septic shock in 30 Scandinavian ICUs to receive transfusion with pre-storage leuko-depleted RBC suspended in saline-adenine-glucose and mannitol (SAGM) at haemoglobin level (Hb) of 7 g/dl or 9 g/dl, stratified by the presence of haematological malignancy and centre. The primary outcome measure is 90-day mortality. Secondary outcome measures are organ failure, ischaemic events, severe adverse reactions (SARs: anaphylactic reaction, acute haemolytic reaction and transfusion-related circulatory overload, and acute lung injury) and mortality at 28 days, 6 months and 1 year.The sample size will enable us to detect a 9% absolute difference in 90-day mortality assuming a 45% event rate with a type 1 error rate of 5% and power of 80%. An interim analysis will be performed after 500 patients, and the Data Monitoring and Safety Committee will recommend the trial be stopped if a group difference in 90-day mortality with P ≤0.001 is present at this point., Discussion: The TRISS trial may bridge the gap between clinical practice and the lack of efficacy and safety data on RBC transfusion in septic shock patients. The effect of restrictive versus liberal RBC transfusion strategy on mortality, organ failure, ischaemic events and SARs will be evaluated.

This article presents a mini medical technology evaluation of three less invasive monitoring techniques for monitoring cardiac output, CardioQ, ECOM and PiCCO, with focus on validation, usability and costs in intensive care. In conclusion, when identifying patients with low cardiac output, we suggest starting with simple screening tools (e.g. CardioQ or central venous O2 saturation), and when in doubt, upgrade to better validated, yet more time-consuming techniques (e.g. PiCCO using thermodilution). Also consults should be made to other intensive care units in terms of the practical implementation of the monitors.

Purpose: This study explored differences in end-of-life (EOL) decisions and respect for patient autonomy of religious members versus those only affiliated to that particular religion (affiliated is a member without strong religious feelings)., Methods: In 2005 structured questionnaires regarding EOL decisions were distributed in six European countries to ICUs in 142 hospital ICUs. This sub-study of the original data analyzed answers from Protestants, Catholics and Jews., Results: A total of 304 physicians, 386 nurses, 248 patients and 330 family members were included in the study. Professionals wanted less treatment (ICU admission, CPR, ventilator treatment) than patients and family members. Religious respondents wanted more treatment and were more in favor of life prolongation, and they were less likely to want active euthanasia than those affiliated. Southern nurses and doctors favored euthanasia more than their Northern colleagues. Three quarters of doctors and nurses would respect a competent patient's refusal of a potentially life-saving treatment. No differences were found between religious and affiliated professionals regarding patient's autonomy. Inter-religious differences were detected, with Protestants most likely to follow competent patients' wishes and the Jewish respondents least likely to do so, and Jewish professionals more frequently accepting patients' wishes for futile treatment. However, these findings on autonomy were due to regional differences, not religious ones., Conclusions: Health-care professionals, families and patients who are religious will frequently want more extensive treatment than affiliated individuals. Views on active euthanasia are influenced by both religion and region, whereas views on patient autonomy are apparently more influenced by region.

Metformin (MET) is the first-line agent in treatment of type 2 diabetes. However, MET has been associated with lactic acidosis (MALA), a potential but rare complication which has influenced treatment strategies in decades. Recently, guidelines have been changed in regards of age and heart failure and the contradiction of chronic renal impairment has been debated. This article identifies potential risk groups and situations that would benefit from a temporary interruption in the MET treatment.

Background: By tradition colloid solutions have been used to obtain fast circulatory stabilisation in shock, but high molecular weight hydroxyethyl starch (HES) may cause acute kidney failure in patients with severe sepsis. Now lower molecular weight HES 130/0.4 is the preferred colloid in Scandinavian intensive care units (ICUs) and 1st choice fluid for patients with severe sepsis. However, HES 130/0.4 is largely unstudied in patients with severe sepsis., Methods/design: The 6S trial will randomize 800 patients with severe sepsis in 30 Scandinavian ICUs to masked fluid resuscitation using either 6% HES 130/0.4 in Ringer's acetate or Ringer's acetate alone. The composite endpoint of 90-day mortality or end-stage kidney failure is the primary outcome measure. The secondary outcome measures are severe bleeding or allergic reactions, organ failure, acute kidney failure, days alive without renal replacement therapy or ventilator support and 28-day and 1/2- and one-year mortality. The sample size will allow the detection of a 10% absolute difference between the two groups in the composite endpoint with a power of 80%., Discussion: The 6S trial will provide important safety and efficacy data on the use of HES 130/0.4 in patients with severe sepsis. The effects on mortality, dialysis-dependency, time on ventilator, bleeding and markers of resuscitation, metabolism, kidney failure, and coagulation will be assessed., Trial Registration: ClinicalTrials.gov: NCT00962156.

Background: End-of-life decisions are common in intensive care units (ICUs), and increasingly, non-invasive ventilation (NIV) is used as a ceiling of ventilatory care. However, little is known about the outcome following that decision., Methods: An observational, single-center, retrospective, follow-up study with no interventions, on ICU patients treated with NIV and a do-not-intubate (DNI) order. The patients were followed until a 5-year survival rate could be calculated., Results: One hundred and fifty-seven patients were treated with NIV during 2002 and 2003, and among 38 a DNI order was in effect. Of the 38 DNI patients, 11 died in the ICU, 16 died on the ward and 11 survived the hospital stay. Five of these 11 survivors died within 6 months, two died after 2.7 and 3.3 years, respectively, but four were still alive after 5 years. The long-term (>6 months) survivors have, surprisingly only been admitted to the hospital 0-2 times a year - and seldom with the need for ICU treatment., Conclusions: According to this study, and previous ones, it seems worthwhile treating DNI patients with NIV. Twenty-five to 35% leave the hospital alive, every 6th patient lives for at least 1 year, and this paper shows that 10% may survive for 5 years or more. However, only chronic obstructive pulmonary disease and chronic heart failure patients (both with a concomitant low APACHE score) seem to have a reasonable outcome, and patients should be informed about this. So far, no study has investigated the quality of life of these survivors.

It is now documented that intensive care units do consider whether treatments promote "the good" and serve patients best. Uncritical use of technology to prolong the dying process must be avoided, and palliative principles worked out. Decisions to withhold or withdraw treatment are among the toughest for both patients and physicians. Legislation covering the area is sufficient, both with regard to competent as well as incompetent patients. However, there are major differences as to how the law is acted upon. Guidelines for futile intensive care treatment should therefore be worked out, and uncritical referral of patients to the ICU avoided.

Objective: To describe 2 years of experience and staff learning curves after the introduction of non-invasive ventilation (NIV)., Methods: A prospective, consecutive, strictly observational, 2-year cohort study of all patients treated with NIV in a county general hospital intensive care unit (ICU), with no interventions, was performed., Results: One hundred and fifty-seven patients with 15 different diagnoses were treated with NIV. An increasing number of patients were treated in the second year and, probably as a result of increased staff experience, the NIV treatment time and overall time spent in the ICU were less in the second year of the study period (30 h vs. 19 h and 55 h vs. 34 h, respectively; P < 0.05). Patients were also intubated earlier if NIV failed during the second year. Of the 157 patients, 119 had a full treatment option (i.e. including the possibility of invasive mechanical ventilation) and 26% died; their Acute Physiology and Chronic Health Evaluation II (APACHE II)- and Simplified Acute Physiology II (SAPS II)-predicted death rates were 31% and 32% respectively (not significant, NS). The overall mortality rate in all NIV patients was 38%, compared with predicted death rates of 36% and 33%, respectively (NS). 'Do-not-intubate' orders were issued for 38 of the 157 patients, and 11 of these (29%) left the hospital alive. Patients treated successfully with NIV had significantly lower APACHE II scores than those in whom it failed (18.8 vs. 22, P= 0.01)., Conclusion: With increasing staff experience, more patients may be treated with NIV and the treatment period decreases significantly. Weaning from NIV has almost exclusively been taken over by nurses. Unselected cohorts of patients with chronic obstructive pulmonary disease can be treated successfully with NIV, and NIV offers a treatment option even for some patients with a 'do-not-intubate' order.

Lactic acidosis is a common cause of metabolic acidosis and is usually connected with high mortality. However, changes in the level of lactate and pH can also be seen after generalized epileptic attacks, due to local muscle hypoxia during the seizures. Although these changes can be quite marked, the condition is self-limiting and usually does not call for any specific treatment. We report five cases of lactic acidosis following convulsions from our centre.

Background: In 1989 a study had shown that the quality of postoperative pain treatment (PPT) in a district general hospital was not satisfactory. Therefore, new instructions for PPT were issued, intra-venous medication with morphine was introduced on the wards, and the staff was educated in PPT. The purpose of this study was to investigate the quality of PPT in 1992 compared to the quality in 1989., Methods: Using identical questionnaires, 191 patients in 1989 and 126 patients in 1992 were interviewed before and 2-5 days after surgery regarding postoperative pain. At the postoperative interview patients in pain also filled out the McGill Pain Questionnaire. A questionnaire was also answered by the nurses regarding PPT in 1989 and in 1992., Results: 1992 compared to 1989 (1992/1989): all patients were now medicated (100%/93%), most of them regularly (79%/ 4%) and the majority (94%/15%) also received non-opioid analgesic. Fewer patients (65%/80%) experienced postoperative pain lasting more than one day following surgery. Analgesic prescription was more standardized. In 1992 the nurses were more satisfied than in 1989 with the PPT and the physicians' prescribing patterns. All the above-mentioned parameters were significantly improved from 1989 to 1992. All the different pain-scores showed a reduction (8-30%) but did not reach statistical significance (P = 0.2)., Conclusions: Our two investigations show that it is possible to improve the quality of pain management with rather simple reforms.

This study made a longterm (72 hours) evaluation of the efficacy and possible side-effects of transdermal delivery of fentanyl (TTS-system) for post-operative pain relief. The study was double-blind, placebo-controlled with either a TTS-system delivering fentanyl 100 micrograms.h-1 and rescue analgesic on demand or a placebo system and analgesic on demand. Analgesic consumption, pain, general satisfaction, respiratory rate, and levels of SpO2 and tcCO2 (pulse oximetry and transcutaneous CO2 measuring) were evaluated. Recruitment was stopped after enrolment of 24 patients, on safety grounds. The Fentanyl group was more satisfied with postoperative pain relief (P = 0.008); they had a lower analgesic demand (P < 0.05) but also a lower respiratory rate (P < 0.05) and a higher level of tcCO2 23 hours after application (P < 0.05). There were three cases (25%) of increased PaCO2 (> 6.5 kPa) in the Placebo group but without low PaO2 levels, sedation or bradypnoea. Conversely, there were three cases (33%) in the Fentanyl group with bradypnoea (< 10 breaths/minute), two without influence on PaO2 or PaCO2, but one (no. 24) with bradypnoea, heavy sedation, a marked decrease in PaO2 (5.8 kPa) and increased PaCO2 (7.5 kPa). These findings terminated the study. The 100 micrograms transdermal fentanyl system is agreeable to the patients, but apparently too potent for routine postoperative pain relief due to a risk of respiratory depression. Respiratory frequency can not be relied upon as sole indicator of insufficient respiration.

One hundred and ninety-one patients were interviewed before and after surgery about their attitude toward and the quality of received pain relief. The nurses working in the same surgical units answered a questionnaire covering attitudes to postoperative pain and pain treatment. Forty-seven percent of the patients were in pain at the time of the postsurgical interview, 10% had not any analgesic prescribed at all, and 15% had received less than prescribed. Fifty-one nurses (71% of the total nursing staff) answered the questionnaire. Of these, 63% were sometimes in doubt about the physicians' prescriptions, 55% would occasionally refuse to give analgesics for various reasons, and 37% were not satisfied with the routines of pain control in their ward. Knowledge of pain treatment and communication between surgeons, anaesthesiologists, nurses and patients must be improved to make postsurgical pain relief adequate.

The purpose of this study was to examine acupuncture treatment of patients with osteoarthrosis of the knee. Twenty-nine patients with a total of 42 osteoarthritic knees were randomized to two groups. Group A was treated while group B served as a no treatment control group for nine weeks. Analgesic consumption, pain and objective measurements were registered. In the second part of the study 17 patients (26 knees) continued with treatments once a months. Registrations were continued for a total study period of 49 weeks. Comparing group A with B, there was a significant reduction in pain, analgesic consumption and in most objective measures. In group A + B combined there was an 80% subjective improvement, and a significantly increased range of movement of the knee. Results were significantly better in those who had not been ill for a long time. The second part of the study showed that it was possible to maintain the improvements.

Unlabelled: The pharmacodynamics and -kinetics as well as rational pharmacotherapy of furosemide and bumetanide is reviewed. In renal insufficiency, a reduced response to diuretics is due to altered pharmacokinetics. The optimum dose can be determined within three to four hours by titration and the effect is measured by the amount of excreted sodium. In nephrotic syndrome, both pharmaco-kinetics and--dynamics are altered. The optimum dose is established as above. Starting and ceiling doses are given in tables for both drugs in renal insufficiency and nephrotic syndrome. In congestive heart failure, the difference is greater between oral and intravenous doses than apparent from the bioavailability of the drugs. If potent diuretics are without effect, the heart failure must be treated more vigorously or a combination with thiazides tried out. Potent diuretics are seldom used in the treatment of liver cirrhosis, but, if used, large doses are necessary. Non-steroidal antiinflammatory drugs are usually considered contra-indicated in patients with severe renal insufficiency, since the pharmacodynamics of the diuretics are altered., Conclusion: The general strategy when using potent diuretics is titration to an effective dose and then using this dose as frequently as needed in order to obtain the desired response.

Three cases of iatrogenic infection following the insertion and subsequent use of an epidural catheter are described. The development, symptoms, diagnostic possibilities and treatment of epidural abscess are described. It is stressed that patients with decreased immunological defences are more prone to infection. Two patients with epidural abscesses are described. In both cases there was a "doctors-delay" before diagnosis was reached. Despite neurosurgical intervention both patients developed paralysis of the lower extremities, bladder and intestinal function, in one of them irreversibly. We also describe one patient who developed meningitis following eight attempts to insert an epidural catheter. The importance of quick diagnosis and intervention is stressed as well as the importance of strict sterility while inserting and using epidural catheters.

Unlabelled: A 50 year old man was treated in the intensive care unit. Due to a prolonged catabolic state with a loss of 35 kg of body weight, he was practically paralyzed following 70 days of treatment. After 200 days of intensive physical training, he had recuperated remarkably. CT-scans before and after the physical training revealed 90-180% increase in the muscles examined. At the femoral level the muscle/fat ratio increased from 40% to 70%, indicating less atrophy. MR-imaging of the crural muscles showed a substantial increase in the muscle mass after training. MR-fat/water proton spectra showed a decrease in the relative fat content from 0.31 to 0.13 during training, objectively measuring the remission of the severe atrophy., Conclusion: CT- and MR-techniques can be used for objective, non-invasive, evaluations of muscle condition, and MR-proton spektroscopy can probably be used for following the remission of muscle atrophy during physical training.

Unlabelled: In this prospective, consecutive study, 191 patients were interviewed before and after surgery (orthopaedic, gynaecological, abdominal and urological operations) about their attitude to and the quality of received pain relief, respectively. In addition, nurses working in the surgical units involved in the study were asked to answer a questionnaire covering attitudes to postoperative pain and pain treatment. Of the patients, 47% were in pain at the time of the postsurgical interview, 10% had not any analgesic prescribed at all and 15% had received less than prescribed. In 36% of the cases there was a discrepancy between the amount of analgesic prescribed by the surgeon and the amount prescribed by the anaesthetist. In 80% of the patients the pain outlasted the first postoperative day, but only 64% would always tell the staff if they had pain. Seventeen per cent of the patients had never been asked about their postoperative pain status. Preoperative pain had a significant correlation to postoperative pain. Although the results are not impressive, they do constitute some improvement compared to previously published studies. Fifty-one nurses (71% of the total nursing staff) answered the questionnaire. Of these, 63% were sometimes in doubt about the physicians' prescriptions, 55% would occasionally refuse to give analgesics for various reasons, and 37% were not satisfied with the routines of pain control in their ward., Conclusion: Knowledge of pain treatment and communication between surgeons, anaesthesiologists, nurses and patients must be improved to make postsurgical pain relief adequate.

Purpose: Acupuncture treatment of patients waiting for arthroplasty surgery., Methods: 29 patients with a total of 42 osteoarthritic knees were randomized to two groups. Group A was treated while Group B served as a no-treatment control group. After 9 weeks Group B was treated too. Analgesic consumption, pain and objective measurements were registered. All objective measures were done by investigators who were "blinded" as to Group A & B. In the second part of the study 17 patients (26 knees) continued with treatments once a month. Registration of analgesic consumption, pain and objective measurements continued. Total study period 49 weeks., Results: Comparing Group A to B there was a significant reduction in pain, analgesic consumption and in most objective measures. In Group A + B combined there was an 80% subjective improvement, and a significantly increased knee range movement - an increase mainly in the worst knees. Results were significantly better in those who had not been ill for a long time. In the second part of the study, it was shown that it was possible to maintain the improvements., Conclusions: Acupuncture can ease the discomfort while waiting for an operation and perhaps even serve as an alternative to surgery. Seven patients have responded so well that at present they do not want an operation. (USD 9000 saved per operation).

To evaluate if it is possible to predict the outcome of acupuncture treatment in patients with knee osteoarthrosis, six treatments were given during a 3 week period. Follow-up time was 9-17 weeks. Seven parameters were evaluated to examine if they had any influence on the outcome of treatment: Age, duration of disease, pain, range of knee movement, analgesic consumption, knee score (an objective and subjective evaluation of the knees) and x-ray changes. Twenty-nine patients were included with a total of 42 osteoarthritic knees waiting for a total knee replacement. The median age was 69.2 years, and median duration of disease was 4.2 years. 85% of the participants reported a subjective effect, and in 88% an objective effect was found. Although there were some significant differences when you looked at the 7 parameters above, the pattern was not a consistent one. Follow up results also indicated that those with the best immediate results, not necessarily were the ones with the best long-term effect. It is not possible to predict the outcome of acupuncture treatment of osteoarthritic knees. Immediate results are not a guide-line for long-term results, which indicate that acupuncture research must include a follow-up period.