Pain, PostoperativeNCT03080272
Do we Achieve the Goal of "No Worse Than Mild Pain" in Daily Clinical Practice?
An observational study of Pain, Postoperative, run by Zealand University Hospital at 1 site in Denmark.
Trial summary
With this study the investigators want to perform a prospective cross-sectional audit at Zealand University Hospital, Koege, Denmark. The aim is to investigate the actual pain treatment and outcomes from a representative number of surgical procedures from different surgical departments. Read more about this study
- Who is it for?
- Ages 18 to 120 years
- Conditions the study is for
- Pain, Postoperative
- How many people
- 190 participants
- Where
- 1 siteDenmark
- Study dates
- 3 Mar 2017to 8 Jan 2019
- Phase
- Observational
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 to 120 years
- All sexes
- No healthy volunteers
- Adult, Older adult
Study population: Patients undergoing a relevant surgical intervention at Zealand University Hospital, Koege and meeting the inclusion criteria
Who may be able to join
- Patients must meet all the following criteria to be suitable for inclusion in the study
- Age > 18 år
- Patients scheduled for relevant surgical procedure
- Patients who understand and speak Danish or English -
Who cannot join
- Patients who meet one or more of the following criteria are not suitable for inclusion in this study:
- Patients who cannot cooperate
- Alcohol and drug dependency as judged by the investigator
- Chronic opioid dependent patients
Trial locations and contacts
1 site in 1 country.
About this study
Official title: The Goal of "no Worse Than Mild Pain" in Daily Clinical Practice: Individual Responder Analysis - a Cross-sectional Prospective Cohort Study of Surgical Patients at Zealand University Hospital, Koege
With this study the investigators want to perform a prospective cross-sectional audit at Zealand University Hospital, Koege, Denmark. The aim is to investigate the actual pain treatment and outcomes from a representative number of surgical procedures from different surgical departments.
Read the detailed description
In contemporary postoperative pain management, patients are treated with combinations of non-opioid and opioid analgesics, and analgesic methods. The intention is to enhance pain relief from additive or synergistic effects of such combinations. However, the literature is complex and heterogenic and characterized by small sized studies investigating a diversity of analgesic combinations and methods. Consequently no well-documented "best current proven intervention" is definable
Efficacy of analgesics is most often based on results from randomized trials measuring differences between two groups based on the average pain level in each group, for example median or mean. This approach has weaknesses as individual patients vary in response, and the average pain level is actually only experienced by few patients. Also, it is well known that analgesics may only work in 30- 50% of the patients and it is not possible to predict who will experience excessive pain. Besides, data on pain score does not follow a normal distribution, but usually is either very good or very bad. Studies have demonstrated, that basically, patients want efficient pain treatment with large pain reductions (for example 50%) and/or pain levels corresponding to mild pain, Numeric Rating Scale ≤ 3. Pain treatment that does not include the achievement of adequate pain relief are likely to fail.
Consequently, a new and simple universal criterion for postoperative analgesic success has been suggested based on individual patient response analyses: Efficacy should be measured on the individual level, and patients should experience "no worse than mild pain"(Numeric Rating Scale ≤ 3). In a re-calculation of individual patient data from 16 randomized clinical trials, the investigators have recently documented that by using the success criteria that at least 80% of patients should achieve Visual Analogue Scale ≤ 30, only about 50% of the studies had achieved goal fulfillment.
A current review has further documented, that movement evoked pain is underreported. Only 39% of trials measured movement evoked pain even though trials measuring both movement evoked pain and pain at rest suggest that movement evoked pain is 95% - 226% more severe and intense for the patient than pain at rest. Therefore it is of great importance for the benefits and treatment of patients, that future trials not only record pain at rest but also movement evoked pain, and additionally supply relevant information about the actual physical maneuver used for assessment.
It is therefore essential, in the light of "no worse than mild pain", and based on individual responder analysis, to investigate current benefit and harm of postoperative pain treatment. Our goal is to highlight the need for an intensified focus on individual patient's pain and the investigators expect to shed a new and critical light on current clinical pain treatment.
- Conditions
- Pain, Postoperative
- Being tested
- no intervention will take place
- Keywords
- individual patient
- Medical subject headings
- Pain, Postoperative
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
no intervention will take placeOther
Only registration and data collection of patients' care and treatment will take place. There will be no changes in patients' treatment. No intervention will take place
| Study group | Role | What they receive |
|---|---|---|
| Spinal Surgery | No intervention will take place. Recruiting Autumn 2017 until spring 2018 Receives: Other: no intervention will take place | |
| Gastric sleeve | No intervention will take place. Recruiting Autumn 2017 until spring 2018 Receives: Other: no intervention will take place | |
| Total knee arthroplasty | No intervention will take place. Recruiting Spring 2018 until Summer 2018 Receives: Other: no intervention will take place | |
| Shoulder arthroplasty | No intervention will take place. Recruiting Winter 2017 until Summer 2018 Receives: Other: no intervention will take place | |
| Maxillofacial surgery | No intervention will take place. Recruiting 6 march 2017 until Autumn 2017 Receives: Other: no intervention will take place |
What is being measured
The primary outcome is the main question the study is designed to answer.
Pain during mobilisation late
Proportions achieving "no worse than mild pain" (Numeric Rating Scale ≤ 3) for pain during mobilisation at 24 hours (±2h) postoperatively
Measured: Outcome measure will be assessed and data will be presented in june 2018
Secondary outcomes (13)
Pain during mobilisation early
Proportions achieving "no worse than mild pain" (Numeric Rating Scale ≤ 3) during mobilisation at 6 hours (±2h) postoperatively
Measured: Outcome measure will be assessed and data will be presented in june 2018
Pain at rest early
Proportions achieving "no worse than mild pain" (Numeric Rating Scale ≤ 3) at rest at 6h (±2h) and 24h (±2h) postoperatively
Measured: Outcome measure will be assessed and data will be presented in june 2018
Numeric Rating Scale pain levels
Numeric Rating Scale pain levels at rest and during mobilisation at 6h (±2h) and 24h (±2h) after completed surgery 6 and 24 hours
Measured: Outcome measure will be assessed and data will be presented in june 2018
Patient satisfaction
Patients' experience of pain treatment and their contentment hereof using a questionnaire based on "PAIN OUT" at 24h (±2h) postoperatively
Measured: Outcome measure will be assessed and data will be presented in june 2018
Morphine consumption
Morphine i.v. equivalent consumption (mg) the first 24h postoperatively (including opioids given as pre-medication
Measured: Outcome measure will be assessed and data will be presented in june 2018
Non opioid use
Non-opioid analgesic usage the first 24h postoperatively (including non-opioids given as pre-medication)
Measured: Outcome measure will be assessed and data will be presented in june 2018
Nausea
Nausea measured by Verbal Rating Scale at T6 og T24 hours postoperatively
Measured: Outcome measure will be assessed and data will be presented in june 2018
Vomiting
Vomiting (number of episodes 0-24 hours) postoperatively
Measured: Outcome measure will be assessed and data will be presented in june 2018
Dizziness
Dizziness measured by Verbal Rating Scale at T6 and T24 hours
Measured: Outcome measure will be assessed and data will be presented in june 2018
Sedation
Sedation measured by Verbal Rating Scale at T6 og T24 hours postoperatively
Measured: Outcome measure will be assessed and data will be presented in june 2018
LOS
Length of postoperative hospital stay measured in days
Measured: Outcome measure will be assessed and data will be presented in june 2018
Readmission
Re-admission within 90 days postoperatively
Measured: Outcome measure will be assessed and data will be presented in june 2018
Mortality
Mortality within the first 90 days
Measured: Outcome measure will be assessed and data will be presented in june 2018
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted15 Mar 2017
- Study start3 Mar 2017
- Primary completion8 Jan 2019
- Study completion8 Jan 2019
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (11)Papers the sponsor has linked to this study.
- Other trials for Pain, PostoperativeStudies of the same condition, open and under way.
- More trials run by Zealand University HospitalThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Observational
- Observational model
- Cohort
- Time perspective
- Prospective
- Enrolment
- 190 participants (actual)
Sponsor and investigators
- Lead sponsor
- Zealand University Hospital
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Anja Geisler, Zealand University Hospital
- Investigators
- Ole Mathiesen, MD.PhD, Study director, Zealand University Hospital, Koege
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT03080272
- Sponsor's protocol ID
- SM3-AG-2017
- Status last verified
- Jan 2019
- First submitted
- 27 Feb 2017
- Last updated
- 9 Jan 2019
- Results posted
- No
- Data monitoring committee
- Yes
- Individual data sharing
- Undecided: no plan
Publications
Kehlet H. Fast-track surgery-an update on physiological care principles to enhance recovery. Langenbecks Arch Surg. 2011 Jun;396(5):585-90. doi: 10.1007/s00423-011-0790-y. Epub 2011 Apr 6.
PubMed 21468643Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet. 2003 Dec 6;362(9399):1921-8. doi: 10.1016/S0140-6736(03)14966-5.
PubMed 14667752Dahl JB, Mathiesen O, Kehlet H. An expert opinion on postoperative pain management, with special reference to new developments. Expert Opin Pharmacother. 2010 Oct;11(15):2459-70. doi: 10.1517/14656566.2010.499124.
PubMed 20586709Rathmell JP, Wu CL, Sinatra RS, Ballantyne JC, Ginsberg B, Gordon DB, Liu SS, Perkins FM, Reuben SS, Rosenquist RW, Viscusi ER. Acute post-surgical pain management: a critical appraisal of current practice, December 2-4, 2005. Reg Anesth Pain Med. 2006 Jul-Aug;31(4 Suppl 1):1-42. doi: 10.1016/j.rapm.2006.05.002.
PubMed 16849098Gurusamy KS, Vaughan J, Toon CD, Davidson BR. Pharmacological interventions for prevention or treatment of postoperative pain in people undergoing laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2014 Mar 28;2014(3):CD008261. doi: 10.1002/14651858.CD008261.pub2.
PubMed 24683057Hojer Karlsen AP, Geisler A, Petersen PL, Mathiesen O, Dahl JB. Postoperative pain treatment after total hip arthroplasty: a systematic review. Pain. 2015 Jan;156(1):8-30. doi: 10.1016/j.pain.0000000000000003.
PubMed 25599296Moore A, Derry S, Eccleston C, Kalso E. Expect analgesic failure; pursue analgesic success. BMJ. 2013 May 3;346:f2690. doi: 10.1136/bmj.f2690. No abstract available.
PubMed 23645858Moore RA, Straube S, Aldington D. Pain measures and cut-offs - 'no worse than mild pain' as a simple, universal outcome. Anaesthesia. 2013 Apr;68(4):400-12. doi: 10.1111/anae.12148. Epub 2013 Jan 24. No abstract available.
PubMed 23347230Geisler A, Dahl JB, Karlsen AP, Persson E, Mathiesen O. Low degree of satisfactory individual pain relief in post-operative pain trials. Acta Anaesthesiol Scand. 2017 Jan;61(1):83-90. doi: 10.1111/aas.12815. Epub 2016 Oct 3.
PubMed 27696343Srikandarajah S, Gilron I. Systematic review of movement-evoked pain versus pain at rest in postsurgical clinical trials and meta-analyses: a fundamental distinction requiring standardized measurement. Pain. 2011 Aug;152(8):1734-1739. doi: 10.1016/j.pain.2011.02.008. Epub 2011 Mar 12.
PubMed 21402445Geisler A, Zachodnik J, Nersesjan M, Persson E, Mathiesen O. Postoperative Pain Management and Patient Evaluations After Five Different Surgical Procedures. A Prospective Cohort Study. Pain Manag Nurs. 2022 Dec;23(6):791-799. doi: 10.1016/j.pmn.2022.06.006. Epub 2022 Aug 6.
PubMed 35941015
Study at a glance
From the registry record, last updated by the sponsor on 9 Jan 2019. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- The Goal of "no Worse Than Mild Pain" in Daily Clinical Practice: Individual Responder Analysis - a Cross-sectional Prospective Cohort Study of Surgical Patients at Zealand University Hospital, Koege
- ClinicalTrials.gov ID
- NCT03080272
- Acronym / sponsor ID
- SM3-AG-2017
- Conditions
- Pain, Postoperative
- Keywords
- individual patient
- Study type
- Observational
- Recruitment status
- Completed
- Enrolment
- 190 participants (actual)
- Lead sponsor
- Zealand University HospitalUniversity, hospital or other
- Study start
- 3 Mar 2017 (actual)
- Primary completion
- 8 Jan 2019 (actual)
- Study completion
- 8 Jan 2019 (actual)
- First posted
- 15 Mar 2017 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
With this study the investigators want to perform a prospective cross-sectional audit at Zealand University Hospital, Koege, Denmark. The aim is to investigate the actual pain treatment and outcomes from a representative number of surgical procedures from different surgical departments.
Detailed description
In contemporary postoperative pain management, patients are treated with combinations of non-opioid and opioid analgesics, and analgesic methods. The intention is to enhance pain relief from additive or synergistic effects of such combinations. However, the literature is complex and heterogenic and characterized by small sized studies investigating a diversity of analgesic combinations and methods. Consequently no well-documented "best current proven intervention" is definable
Efficacy of analgesics is most often based on results from randomized trials measuring differences between two groups based on the average pain level in each group, for example median or mean. This approach has weaknesses as individual patients vary in response, and the average pain level is actually only experienced by few patients. Also, it is well known that analgesics may only work in 30- 50% of the patients and it is not possible to predict who will experience excessive pain. Besides, data on pain score does not follow a normal distribution, but usually is either very good or very bad. Studies have demonstrated, that basically, patients want efficient pain treatment with large pain reductions (for example 50%) and/or pain levels corresponding to mild pain, Numeric Rating Scale ≤ 3. Pain treatment that does not include the achievement of adequate pain relief are likely to fail.
Consequently, a new and simple universal criterion for postoperative analgesic success has been suggested based on individual patient response analyses: Efficacy should be measured on the individual level, and patients should experience "no worse than mild pain"(Numeric Rating Scale ≤ 3). In a re-calculation of individual patient data from 16 randomized clinical trials, the investigators have recently documented that by using the success criteria that at least 80% of patients should achieve Visual Analogue Scale ≤ 30, only about 50% of the studies had achieved goal fulfillment.
A current review has further documented, that movement evoked pain is underreported. Only 39% of trials measured movement evoked pain even though trials measuring both movement evoked pain and pain at rest suggest that movement evoked pain is 95% - 226% more severe and intense for the patient than pain at rest. Therefore it is of great importance for the benefits and treatment of patients, that future trials not only record pain at rest but also movement evoked pain, and additionally supply relevant information about the actual physical maneuver used for assessment.
It is therefore essential, in the light of "no worse than mild pain", and based on individual responder analysis, to investigate current benefit and harm of postoperative pain treatment. Our goal is to highlight the need for an intensified focus on individual patient's pain and the investigators expect to shed a new and critical light on current clinical pain treatment.
Study design
- Observational model
- Cohort
- Time perspective
- Prospective
- Number of arms
- 5
| Arm | Type | Receives |
|---|---|---|
| Spinal Surgery | – | Other: no intervention will take placeNo intervention will take place. Recruiting Autumn 2017 until spring 2018 |
| Gastric sleeve | – | Other: no intervention will take placeNo intervention will take place. Recruiting Autumn 2017 until spring 2018 |
| Total knee arthroplasty | – | Other: no intervention will take placeNo intervention will take place. Recruiting Spring 2018 until Summer 2018 |
| Shoulder arthroplasty | – | Other: no intervention will take placeNo intervention will take place. Recruiting Winter 2017 until Summer 2018 |
| Maxillofacial surgery | – | Other: no intervention will take placeNo intervention will take place. Recruiting 6 march 2017 until Autumn 2017 |
Who may qualify
- Ages
- 18 to 120 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
- Study population
- Patients undergoing a relevant surgical intervention at Zealand University Hospital, Koege and meeting the inclusion criteria
Key inclusion criteria (4 listed)
- Patients must meet all the following criteria to be suitable for inclusion in the study
- Age > 18 år
- Patients scheduled for relevant surgical procedure
- Patients who understand and speak Danish or English -
Key exclusion criteria (4 listed)
- Patients who meet one or more of the following criteria are not suitable for inclusion in this study:
- Patients who cannot cooperate
- Alcohol and drug dependency as judged by the investigator
- Chronic opioid dependent patients
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| no intervention will take placeOnly registration and data collection of patients' care and treatment will take place. There will be no changes in patients' treatment. No intervention will take place | Other | Gastric sleeve, Maxillofacial surgery, Shoulder arthroplasty, Spinal Surgery, Total knee arthroplasty |
Primary outcome
Pain during mobilisation late
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Proportions achieving "no worse than mild pain" (Numeric Rating Scale ≤ 3) for pain during mobilisation at 24 hours (±2h) postoperatively
13 secondary outcomes
Pain during mobilisation early
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Pain at rest early
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Numeric Rating Scale pain levels
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Patient satisfaction
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Morphine consumption
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Non opioid use
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Nausea
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Vomiting
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Dizziness
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Sedation
Time frame: Outcome measure will be assessed and data will be presented in june 2018
LOS
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Readmission
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Mortality
Time frame: Outcome measure will be assessed and data will be presented in june 2018
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 9 Jan 2019.
- Background: PubMed 21468643Kehlet H. Fast-track surgery-an update on physiological care principles to enhance recovery. Langenbecks Arch Surg. 2011 Jun;396(5):585-90. doi: 10.1007/s00423-011-0790-y. Epub 2011 Apr 6.
- Background: PubMed 14667752Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet. 2003 Dec 6;362(9399):1921-8. doi: 10.1016/S0140-6736(03)14966-5.
- Background: PubMed 20586709Dahl JB, Mathiesen O, Kehlet H. An expert opinion on postoperative pain management, with special reference to new developments. Expert Opin Pharmacother. 2010 Oct;11(15):2459-70. doi: 10.1517/14656566.2010.499124.
- Background: PubMed 16849098Rathmell JP, Wu CL, Sinatra RS, Ballantyne JC, Ginsberg B, Gordon DB, Liu SS, Perkins FM, Reuben SS, Rosenquist RW, Viscusi ER. Acute post-surgical pain management: a critical appraisal of current practice, December 2-4, 2005. Reg Anesth Pain Med. 2006 Jul-Aug;31(4 Suppl 1):1-42. doi: 10.1016/j.rapm.2006.05.002.
- Background: PubMed 24683057Gurusamy KS, Vaughan J, Toon CD, Davidson BR. Pharmacological interventions for prevention or treatment of postoperative pain in people undergoing laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2014 Mar 28;2014(3):CD008261. doi: 10.1002/14651858.CD008261.pub2.
- Background: PubMed 25599296Hojer Karlsen AP, Geisler A, Petersen PL, Mathiesen O, Dahl JB. Postoperative pain treatment after total hip arthroplasty: a systematic review. Pain. 2015 Jan;156(1):8-30. doi: 10.1016/j.pain.0000000000000003.
- Background: PubMed 23645858Moore A, Derry S, Eccleston C, Kalso E. Expect analgesic failure; pursue analgesic success. BMJ. 2013 May 3;346:f2690. doi: 10.1136/bmj.f2690. No abstract available.
- Background: PubMed 23347230Moore RA, Straube S, Aldington D. Pain measures and cut-offs - 'no worse than mild pain' as a simple, universal outcome. Anaesthesia. 2013 Apr;68(4):400-12. doi: 10.1111/anae.12148. Epub 2013 Jan 24. No abstract available.
- Background: PubMed 27696343Geisler A, Dahl JB, Karlsen AP, Persson E, Mathiesen O. Low degree of satisfactory individual pain relief in post-operative pain trials. Acta Anaesthesiol Scand. 2017 Jan;61(1):83-90. doi: 10.1111/aas.12815. Epub 2016 Oct 3.
- Background: PubMed 21402445Srikandarajah S, Gilron I. Systematic review of movement-evoked pain versus pain at rest in postsurgical clinical trials and meta-analyses: a fundamental distinction requiring standardized measurement. Pain. 2011 Aug;152(8):1734-1739. doi: 10.1016/j.pain.2011.02.008. Epub 2011 Mar 12.
- Derived from this study: PubMed 35941015Geisler A, Zachodnik J, Nersesjan M, Persson E, Mathiesen O. Postoperative Pain Management and Patient Evaluations After Five Different Surgical Procedures. A Prospective Cohort Study. Pain Manag Nurs. 2022 Dec;23(6):791-799. doi: 10.1016/j.pmn.2022.06.006. Epub 2022 Aug 6.
- Individual participant dataSharing planned: Undecided. no plan
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Ole Mathiesen, MD.PhD study director
Zealand University Hospital, Koege
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
An observational study of Pain, Postoperative, run by Zealand University Hospital at 1 site in Denmark.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 4 inclusion and 4 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 9 Jan 2019. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Denmark. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Pain during mobilisation late (time frame: Outcome measure will be assessed and data will be presented in june 2018). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT03080272, which also lists 11 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 9 Jan 2019.