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Seyfried S, Herrle F, Schröter M, Hardt J, Betzler A, Rahbari NN, Reißfelder C. [Initial experiences with the implementation of the enhanced recovery after surgery (ERAS®) protocol]. Chirurg 2021; 92:428-433. [PMID: 33471183 DOI: 10.1007/s00104-020-01341-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND To further improve treatment quality and patient orientation, a multiprofessional enhanced recovery after surgery (ERAS®) transformation program was initiated in our clinic in January 2020. The ERAS® treatment pathway for colorectal surgery was established in October 2020. OBJECTIVE The aim of the study was to show that the perioperative treatment quality can be increased by implementing a certified ERAS® program in the setting of a fast-track pathway that has been established since 2008. MATERIAL AND METHODS The first ERAS® patients from October/November 2020 (ERAS®) were compared with those of a representative consecutive control cohort (pre-ERAS®) who had undergone interventions from August to December 2019. Patient care and data collection of the ERAS® patients were ensured by an ERAS® nurse in daily visits. For the comparison cohorts, the electronic patient files were analyzed and historical colon pathway data from our clinic from 2008 were used. RESULTS AND CONCLUSION A total of 10 ERAS® and 50 pre-ERAS® patients were included. After the ERAS® transformation, an increase in overall compliance with ERAS® guideline recommendations from 45% (pre-ERAS®) to 75% (ERAS®) was achieved. The number of days to tolerance of solid food decreased from 2 days (pre-ERAS®) to 1 day (ERAS®). The general postoperative complication rate was comparable (22% pre-ERAS® vs. 20% ERAS®). Most noticeable was the reduction of the median hospital stay of 9 days in the historical cohort to 3 days after ERAS® implementation. We attribute the necessary high ERAS® pathway compliance of 75% to a successful combination of process standards and multiprofessional ERAS® teams.
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Affiliation(s)
- Steffen Seyfried
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Florian Herrle
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Michele Schröter
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Julia Hardt
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Alexander Betzler
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Nuh N Rahbari
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Christoph Reißfelder
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
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Iftimie S, Escribano A, Díez-Sans A, Albiciuc I, Hernández-Aguilera A, Fort-Gallifa I, López-Azcona AF, Camps J, Joven J, Castro A. Influence of Surgical Procedures on Serum Paraoxonase-1-Related Variables and Markers of Inflammation in Hospitalized Patients. J INVEST SURG 2019; 34:216-224. [PMID: 30947571 DOI: 10.1080/08941939.2019.1597223] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose: Surgical stress is a phenomenon not completely understood from the biochemical point of view, although it produces alterations in the oxidative balance and inflammatory status. The present study aimed to investigate the alterations of the circulating levels of paraoxonase-1 (PON1)-related variables and markers of inflammation in hospitalized patients who underwent surgery. Methods: We recruited 285 hospitalized patients. Of those, 115 were hospitalized due to a surgical intervention and 170 for reasons other than surgery. The control group consisted of 128 healthy volunteers. A blood sample was obtained for the measurement of serum PON1-related variables, and C-reactive protein (CRP), chemokine (C-C motif) ligand 2 (CCL2), and procalcitonin concentrations. Results: Hospitalized patients had lower serum PON1 activities [paraoxonase: 215.6 (168.6 - 277.8) vs. 298.7 (229.7 - 382.6) U/L, p < 0.001; lactonase: 3.0 (2.3 - 3.7) vs. 5.7 (4.6 - 6.5) U/L, p < 0.001], and higher CCL2, CRP and procalcitonin concentrations than the healthy individuals. The days elapsed following surgery and the duration of the procedure itself inversely correlated with PON1-related variables, and directly correlated with CRP concentrations. Patients that were operated on by laparotomy had higher PON1 activity than patients operated on by laparoscopy. Local and regional anesthesia was associated with higher PON1 activities and lower CRP concentrations. Conclusion: These results show a decrease in PON1 activities and an increase in acute phase response in hospitalized patients undergoing surgery and support the hypothesis that these phenomena are related to post-surgical metabolic alterations.
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Affiliation(s)
- Simona Iftimie
- Hospital Universitari de Sant Joan, Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Reus, Spain
| | - Ana Escribano
- Hospital Universitari de Sant Joan, Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Reus, Spain
| | - Ariadna Díez-Sans
- Hospital Universitari de Sant Joan, Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Reus, Spain
| | - Isabela Albiciuc
- Hospital Universitari de Sant Joan, Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Reus, Spain
| | | | | | - Ana Felisa López-Azcona
- Hospital Universitari de Sant Joan, Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Reus, Spain
| | | | | | - Antoni Castro
- Hospital Universitari de Sant Joan, Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Reus, Spain
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Preoperative Preparations for Enhanced Recovery After Surgery Programs: A Role for Prehabilitation. Surg Clin North Am 2018; 98:1149-1169. [PMID: 30390849 DOI: 10.1016/j.suc.2018.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Preoperative risk assessment is valuable only if subsequent targeted optimization of patient care is allowed. Early assessment of high-risk surgical patients is essential to facilitate appropriate optimization. Preoperative assessment and optimization should not be exclusively focused on patients' comorbidities, but also include nutritional assessment, functional capacity, and promote healthy life style habits that affect surgical outcomes (eg, smoking cessation); it requires a multidisciplinary approach.
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Enhanced Recovery after Cardiac Surgery: An Update on Clinical Implications. Int Anesthesiol Clin 2017; 55:148-162. [DOI: 10.1097/aia.0000000000000168] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Preoperative risk factors related to bladder cancer rehabilitation: a registry study. Eur J Clin Nutr 2013; 67:917-21. [PMID: 23839668 DOI: 10.1038/ejcn.2013.120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 05/10/2013] [Accepted: 05/17/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Patients diagnosed with (muscle-) invasive bladder cancer (IBC) are more likely to harbour comorbidities due to their advanced age at diagnosis. Under-nutrition is a predictor for postoperative morbidity and mortality in cancer patients, but under-reported in urology. Understanding the IBC patient profile before major surgery could facilitate and optimise outcome of the surgical patient. BACKGROUND/OBJECTIVES To identify preoperative risk factors for early rehabilitation before radical cystectomy (RC). SUBJECTS/METHODS A historical registry-based study of 76 patients referred for RC at Aarhus University Hospital, Denmark (DK) in 2009. Early rehabilitation was defined by length of stay (LOS) postoperatively with a cutoff ≥11 days. High comorbidity was expressed by the charlson comorbidity index score (CCI) ≥3. LOS was calculated by linking the unique Civil Registration Number with the National Patient Registry. Preoperative nutritional risk was identified using the screening tool, nutritional risk score 2002 (NRS) of the European Society of Clinical Nutrition and Metabolism. Multivariate analysis was used to identify risk factors for early rehabilitation. RESULTS The proportion of patients at preoperative nutritional risk was 26% (95% confidence interval (CI): (95% CI: 17; 37) and 43% of patients held a high CCI (95% CI: 33; 55). Prolonged LOS was independently associated with female gender (P=0.02) and age ≥70 years (P=0.04). NRS and CCI were not associated with LOS. CONCLUSIONS Attention should be focused on women and elderly patients undergoing RC to optimise early rehabilitation and reduce LOS. It is still unknown whether preoperative nutritional risk and comorbidity are obstacles in early rehabilitation of RC patients.
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Srinivasa S, Kahokehr A, Soop M, Taylor M, Hill AG. Goal-directed fluid therapy- a survey of anaesthetists in the UK, USA, Australia and New Zealand. BMC Anesthesiol 2013; 13:5. [PMID: 23433064 PMCID: PMC3598228 DOI: 10.1186/1471-2253-13-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 02/07/2013] [Indexed: 12/03/2022] Open
Abstract
Background Goal-directed fluid therapy (GDFT) has been shown to reduce complications and hospital length of stay following major surgery. However, there has been no assessment regarding its use in clinical practice. Methods An electronic survey was administered to randomly selected anaesthetists from the United Kingdom (UK, n = 2000) and the United States of America (USA, n = 2000), and 500 anaesthetists from Australia/New Zealand (AUS/NZ). Preferences, clinical use and attitudes towards GDFT were investigated. Results were collated to examine regional differences. Results The response rates from the UK (n = 708) and AUS/NZ (n = 180) were 35%, and 36% respectively. The response rate from the USA was very low (n = 178; 9%). GDFT use was significantly more common in the UK than in AUS/NZ (p < 0.01). The Oesophageal Doppler Monitor was the most preferred instrument in the UK (n = 362; h76%) with no clear preferences in other regions. GDFT was most commonly utilised in major abdominal surgery and for patients with significant comorbidities. The commonest reasons stated for not using GDFT were either lack of availability of monitoring tools (AUS/NZ: 57 (70%); UK: 94 (64%)) or a lack of experience with instruments (AUS/NZ: 43 (53%); UK: 51 (35%)). A subset of respondents (AUS/NZ: 22(27%); UK: 45 (30%)) felt GDFT provided no perceived benefit. Enthusiasm towards the use of GDFT in the absence of existing barriers was high. Conclusion Several hypotheses were generated regarding important differences in the use of GDFT between anaesthetists from the UK and AUS/NZ. There is significant interest in utilising GDFT in clinical practice and existing barriers should be addressed.
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Affiliation(s)
- Sanket Srinivasa
- Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland, Auckland, New Zealand.
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Kehlet H, Harling H. Length of stay after laparoscopic colonic surgery - an 11-year nationwide Danish survey. Colorectal Dis 2012; 14:1118-20. [PMID: 22181974 DOI: 10.1111/j.1463-1318.2011.02922.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The use of laparoscopic colonic surgery in Denmark was analysed with particular reference to the length of stay. METHOD Data were obtained from the Danish National Patient Registry to assess duration of hospital stay after laparoscopic colonic surgery in Denmark within the 11-year period from 2000 to 2010. RESULTS There were 4582 laparoscopic colonic resections performed, reaching about 1000 operations/year in the last 2 years (2009-2010). Length of stay decreased from a median of 7 to 4 days, while mean length of stay only decreased from 9 to 7 days. CONCLUSION The use of laparoscopic colonic resection has increased in Denmark over the last 11 years and with a concomitant decrease in postoperative length of stay. However, there is a need for further improvement by combining the laparoscopic technique with fast-track recovery.
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Affiliation(s)
- H Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet Copenhagen University, Copenhagen, Denmark.
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Affiliation(s)
- Karem Slim
- Department of Digestive Surgery, CHU Estaing, Clermont-Ferrand, France.
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Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Reg Anesth Pain Med 2012; 36:63-72. [PMID: 22002193 DOI: 10.1097/aap.0b013e31820307f7] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Fast-track programs have been developed with the aim to reduce perioperative surgical stress and facilitate patient's recovery after surgery. Potentially, regional anesthesia and analgesia techniques may offer physiological advantages to support fast-track methodologies in different type of surgeries. The aim of this article was to identify and discuss potential advantages offerred by regional anesthesia and analgesia techniques to fast-track programs.In the first section, the impact of regional anesthesia on the main elements of fast-track surgery is addressed. In the second section, procedure-specific fast-track programs for colorectal, hernia, esophageal, cardiac, vascular, and orthopedic surgeries are presented. For each, regional anesthesia and analgesia techniques more frequently used are discussed. Furthermore, clinical studies, which included regional techniques as elements of fast-track methodologies, were identified. The impact of epidural and paravertebral blockade, spinal analgesia, peripheral nerve blocks, and new regional anesthesia techniques on main procedure-specific postoperative outcomes is discussed. Finally, in the last section, implementations required to improve the role of regional anesthesia in the context of fast-track programs are suggested, and issues not yet addressed are presented.
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NIELSEN PR, CHRISTENSEN PA, MEYHOFF CS, WERNER MU. Post-operative pain treatment in Denmark from 2000 to 2009: a nationwide sequential survey on organizational aspects. Acta Anaesthesiol Scand 2012; 56:686-94. [PMID: 22385392 DOI: 10.1111/j.1399-6576.2012.02662.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND In Denmark, the first acute pain service (APS) was introduced in 1993. An important objective became to facilitate implementation of accelerated post-operative rehabilitation programmes (ACC) in selected procedures in abdominal, gynaecological and orthopaedic surgery. Therefore, it is of considerable interest to study the association between the developments of post-operative pain management and the ACC by sequential analyses from 2000 to 2009. METHODS In 2000, 2003, 2006 and 2009, a questionnaire was mailed to all Danish anaesthesiology departments. The headings of the questionnaire were demographics of responder departments, resources allocated to pain management methods, quality assessment methods, research activities and implementation of ACC. RESULTS The responder rates varied between 80% and 94% (mean 88%) representing a mean number of anaesthetics of 340.000 per year. The number of APSs in the study period varied in university hospitals between 52% and 71% (P = 0.01), regional hospitals between 8% and 40% (P < 0.01), and local hospitals between 0% and 47% (P < 0.01). The prevalences of departments actively engaged in ACC were 40% in 2000, 54% in 2003, 73% in 2006 and 80% in 2009 (P < 0.01). CONCLUSIONS The study, spanning nearly a decade, illustrates that following an increase in number of APSs from 2000 to 2006, followed by a significant decline, a steadily increasing number of departments implemented ACC.
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Affiliation(s)
| | | | - C. S. MEYHOFF
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
| | - M. U. WERNER
- Multidisciplinary Pain Centre 7612, Neuroscience Centre; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
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Beaussier M, Bouaziz H, Aubrun F, Belbachir A, Binhas M, Bloc S, Fuzier R, Jochum D, Nouette-Gaulain K, Paqueron X. [Wound infiltration with local anesthetics for postoperative analgesia. Results of a national survey about its practice in France]. ACTA ACUST UNITED AC 2011; 31:120-5. [PMID: 22209702 DOI: 10.1016/j.annfar.2011.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 10/04/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Local wound infiltration is a component of multimodal postoperative (p.o.) analgesia. Its implementation in current clinical practice remains unknown. Pain and Regional Anesthesia Committee of the French Anaesthesia and Intensive Care Society (Sfar) aimed to appraise its practice. METHOD Postal sample survey based on representative sample of national activity were sent to heads of anaesthesiology departments. The questionnaires included 36 items on single-shot and continuous wound infiltrations (CWI) with considerations about modality of administration, drugs and development limitations. Results in mean [CI95 %]. RESULTS Response rate was 32 % (n=120). Sample was in accordance with national representation of health institutions. Local infiltration was included in 85 % [79-91] of the p.o. analgesia protocols. Regardless of the surgery, single-shot wound infiltration and CWI were used in more than 50 % of the patients by respectively 58 % [49-67] and 18 % [11-25] of the responders. However, a significant part of the surgeons remained reluctant to CWI. Lack of information and fear of septic complications were the most reported barriers. Peritoneal instillation after laparoscopy was rarely performed, in contrast with intra-articular infiltration after knee arthroscopy, performed systematically or very frequently by 60 % [50-70] of the responders. CONCLUSION The practice of local wound infiltration for p.o. analgesia seems presently well established, especially for single-shot injections. CWI is less commonly performed. Several surgical reluctances remain to be overcome. Better information about effectiveness and safety are likely to still improve their practices.
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Affiliation(s)
- M Beaussier
- Département d'anesthésie-réanimation chirurgicale, hôpital Saint-Antoine, université Pierre-et-Marie-Curie, Paris-6, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75571 Paris cedex 12, France.
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Jensen BT, Kristensen SA, Christensen SV, Borre M. Efficacy of tele-nursing consultations in rehabilitation after radical prostatectomy: a randomised controlled trial study. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2011. [DOI: 10.1111/j.1749-771x.2011.01130.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Donohoe CL, Nguyen M, Cook J, Murray SG, Chen N, Zaki F, Mehigan BJ, McCormick PH, Reynolds JV. Fast-track protocols in colorectal surgery. Surgeon 2011; 9:95-103. [PMID: 21342674 DOI: 10.1016/j.surge.2010.07.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 07/26/2010] [Accepted: 07/27/2010] [Indexed: 01/22/2023]
Abstract
Fast-track surgery (FTS) is a set of protocols aimed to reduce the physiological burden of surgery thus improving outcomes. FTS aims to use evidence-based practice to reduce complications, improve post-operative quality of life and decrease hospital length of stay. This review seeks to examine the evidence base for protocols employed in colorectal surgery in the areas of pre-operative preparation, anaesthetic management, intraoperative and surgical factors and post-operative care. Despite the evidence that recovery after colorectal surgery can be enhanced by using these approaches, implementation of FTS protocols has been slow. Acceptance of FTS protocols by all members of the multi-disciplinary team and a change in organisational structure to accommodate structured peri-operative care, are imperative to implementation.
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Affiliation(s)
- Claire L Donohoe
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin/St James' Hospital, Dublin 8, Ireland.
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Kehlet H. Fast-track surgery—an update on physiological care principles to enhance recovery. Langenbecks Arch Surg 2011; 396:585-90. [DOI: 10.1007/s00423-011-0790-y] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 03/13/2011] [Indexed: 12/14/2022]
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Werner MU. Trismus-An important issue in pain and palliative care. Scand J Pain 2010; 1:82-83. [PMID: 29913941 DOI: 10.1016/j.sjpain.2010.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Mads U Werner
- Multidisciplinary Pain Center 7612, Neuroscience Center, Rigshospitalet, Copenhagen University Hospitals, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
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