Validation of Two Pain Assessment Tools Using a Standardized Nociceptive Stimulation in Critically Ill Adults

CONTEXT

The Behavioral Pain Scale (BPS) or the Critical-Care Pain Observation Tool (CPOT) are recommended in practice guidelines for pain assessment in critically ill adults unable to self-report. However, their use in another language requires cultural adaptation and validation testing.

OBJECTIVES

Cross-cultural adaptation of the CPOT and BPS English versions into Brazilian Portuguese, and their validation by comparing behavioral scores during rest, standardized nociceptive stimulation by pressure algometry (SNSPA), and turning were completed. In addition, we explored clinical variables that could predict the CPOT and BPS scores.

METHODS

A prospective cohort study was conducted with 168 medical-surgical critically ill adults unable to self-report in the intensive care unit. Two nurses were trained to use the CPOT and BPS Brazilian Portuguese versions at the following assessments: 1) baseline at rest, 2) after SNSPA with a pressure of 14 kgf/cm², 3) during turning, and 4) 15 minutes after turning.

RESULTS

Inter-rater reliability of nurses' CPOT and BPS scores was supported by high weighted kappa >0.7. Discriminative validation was supported with higher CPOT and BPS scores during SNSPA or turning in comparison to baseline (P < 0.001). The Glasgow Coma Scale score was the only variable that predicted CPOT and BPS scores with explained variance of 44.5% and 55.2%, respectively.

CONCLUSION

The use of the Brazilian CPOT and BPS versions showed good reliability and validity in critically ill adults unable to self-report. A standardized procedure, the SNSPA, was used for the first time in the validation process of these tools and helped us improve the validation process.

Validation of The Critical-care Pain Observation Tool (CPOT) for the detection of oral-pharyngeal pain in critically ill adults

OBJECTIVE

Mechanically ventilated patients experience pain at rest and during daily care procedures. Our objective was to test the reliability and validity of the Critical-Care Pain Observation Tool (CPOT) to detect oral-pharyngeal pain in intubated and tracheostomised adults during routine oral care procedures.

MATERIALS AND METHODS

Two trained research team members independently observed patients during two non-painful (rest and gentle touch) and three potentially painful (oral suctioning, tooth brushing, and swabbing with a sponge toothette) procedures. Conscious patients were asked if they experienced pain during each procedure (yes/no) and to rate their pain intensity on a 0 to 10 numeric rating scale.

RESULTS

A total of 98 patients, primarily intubated (92.9%) and male (63.3%) participated. Criterion validation was supported by patient self-report of pain during tooth brushing (AUC=.80; P<0.5) and oral suction (AUC=.72; P<0.3) but not for oral swabbing (AUC=.68; P=0.16). Discriminative validation was demonstrated for all oral care procedures compared to rest (P<.001). Intra-class correlation coefficients between raters ranged from .78 to .91 (P<.001) for total CPOT scores, indicating excellent inter-rater reliability.

CONCLUSIONS

The CPOT is reliable and valid for the detection of oral-pharyngeal pain during oral care procedures indicated as painful by critically ill adults.

Development and Acceptability Assessment of a Self-Management Intervention to Prevent Acute to Chronic Pain Transition after Major Lower Extremity Trauma

PURPOSE

Transition from acute to chronic pain often occurs after major lower extremity trauma. Chronic pain has been found to negatively affect daily functioning, including the capacity to work and quality of life. Empirical data and an acceptability assessment were used to develop a self-management intervention aimed at preventing acute to chronic pain transition after major lower extremity trauma (i.e., iPACT-E-Trauma).

METHODS

Evidence from previous studies on preventive self-management interventions, combined with a biopsychosocial conceptual framework and clinical knowledge, helped define the key features of the preliminary version. Then a mixed-methods design was used to assess the acceptability of iPACT-E-Trauma by clinicians and patients.

RESULTS

The key features of the preliminary version of iPACT-E-Trauma were assessed as acceptable to very acceptable by clinicians and patients. After clinician assessment, intervention activities were simplified and session duration was reduced. Patient acceptability assessment of iPACT-E-Trauma led to the tailoring of key intervention features, based on determinants such as pain intensity and the implementation of self-management behaviors between intervention sessions. Web-based sessions were also developed to facilitate iPACT-E-Trauma delivery.

CONCLUSION

This study outlines the process involved in the development of an intervention to prevent chronic pain in patients with lower extremity trauma. Relevant information is provided to nurses and interdisciplinary teams on a self-management intervention to prevent the transition from acute to chronic pain in the trauma population.

A Hybrid Web-Based and In-Person Self-Management Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma: Feasibility and Acceptability of iPACT-E-Trauma

Background

A transition from acute to chronic pain frequently occurs after major lower extremity trauma. While the risk factors for developing chronic pain in this population have been extensively studied, research findings on interventions aiming to prevent chronic pain in the trauma context are scarce. Therefore, we developed a hybrid, Web-based and in-person, self-management intervention to prevent acute to chronic pain transition after major lower extremity trauma (iPACT-E-Trauma).

Objective

This study aimed to assess the feasibility and acceptability of iPACT-E-Trauma.

Methods

Using a descriptive design, the intervention was initiated at a supra-regional level-1 trauma center. Twenty-eight patients ≥18 years old with major lower extremity trauma, presenting with moderate to high pain intensity 24 hours post-injury were recruited. Feasibility assessment was two-fold: 1) whether the intervention components could be provided as planned to ≥80% of participants and 2) whether ≥80% of participants could complete the intervention. The rates for both these variables were calculated. The E-Health Acceptability Questionnaire and the Treatment Acceptability and Preference Questionnaire were used to assess acceptability. Mean scores were computed to determine the intervention’s acceptability.

Results

More than 80% of participants received the session components relevant to their condition. However, the Web pages for session 2, on the analgesics prescribed, were accessed by 71% of participants. Most sessions were delivered according to the established timeline for ≥80% of participants. Session 3 and in-person coaching meetings had to be provider earlier for ≥35% of participants. Session duration was 30 minutes or less on average, as initially planned. More than 80% of participants attended sessions and <20% did not apply self-management behaviors relevant to their condition, with the exception of deep breathing relaxation exercises which was not applied by 40% of them. Web and in-person sessions were assessed as very acceptable (mean scores ≥3 on a 0 to 4 descriptive scale) across nearly all acceptability attributes.

Conclusions

Findings showed that the iPACT-E-Trauma intervention is feasible and was perceived as highly acceptable by participants. Further tailoring iPACT-E-Trauma to patient needs, providing more training time for relaxation techniques, and modifying the Web platform to improve its convenience could enhance the feasibility and acceptability of the intervention.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 91987302; http://www.controlled-trials.com/ISRCTN91987302 (Archived by WebCite at http://www.webcitation.org/6ynibjPHa)

Delirium Assessment Tools for Use in Critically Ill Adults: A Psychometric Analysis and Systematic Review

BACKGROUND

Delirium is highly prevalent in critically ill patients. Its detection with valid tools is crucial.

OBJECTIVE

To analyze the development and psychometric properties of delirium assessment tools for critically ill adults.

METHODS

Databases were searched to identify relevant studies. Inclusion criteria were English language, publication before January 2015, 30 or more patients, and patient population of critically ill adults (>18 years old). Search terms were delirium, scales, critically ill patients, adult, validity, and reliability. Thirty-six manuscripts were identified, encompassing 5 delirium assessment tools (Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Cognitive Test for Delirium, Delirium Detection Score, Intensive Care Delirium Screening Checklist (ICDSC), and Nursing Delirium Screening Scale). Two independent reviewers analyzed the psychometric properties of these tools by using a standardized scoring system (range, 0-20) to assess the tool development process, reliability, validity, feasibility, and implementation of each tool.

RESULTS

Psychometric properties were very good for the CAM-ICU (19.6) and the ICDSC (19.2), moderate for the Nursing Delirium Screening Scale (13.6), low for the Delirium Detection Score (11.2), and very low for the Cognitive Test for Delirium (8.2).

CONCLUSIONS

The results indicate that the CAM-ICU and the ICDSC are the most valid and reliable delirium assessment tools for critically ill adults. Additional studies are needed to further validate these tools in critically ill patients with neurological disorders and those at various levels of sedation or consciousness.

Tailored Web-Based Interventions for Pain: Systematic Review and Meta-Analysis

BACKGROUND

Efforts have multiplied in the past decade to underline the importance of pain management. For both acute and chronic pain management, various barriers generate considerable treatment accessibility issues, thereby providing an opportunity for alternative intervention formats to be implemented. Several systematic reviews on Web-based interventions with a large emphasis on chronic pain and cognitive behavioral therapy have been recently conducted to explore the influence of these interventions on pain management However, to our knowledge, the specific contribution of tailored Web-based interventions for pain management has not been described and their effect on pain has not been evaluated.

OBJECTIVE

The primary aim of this systematic review was to answer the following research question: What is the effect of tailored Web-based pain management interventions for adults on pain intensity compared with usual care, face-to-face interventions, and standardized Web-based interventions? A secondary aim was to examine the effects of these interventions on physical and psychological functions.

METHODS

We conducted a systematic review of articles published from January 2000 to December 2015. We used the DerSimonian-Laird random effects models with 95% confidence intervals to calculate effect estimates for all analyses. We calculated standardized mean differences from extracted means and standard deviations, as outcome variables were measured on different continuous scales. We evaluated 5 different outcomes: pain intensity (primary outcome), pain-related disability, anxiety, depression, and pain catastrophizing. We assessed effects according to 3 time intervals: short term (<1 month), medium term (1-6 months), and long term (6-12 months).

RESULTS

After full-text review, we excluded 31 articles, resulting in 17 eligible studies. Only 1 study concerned acute pain and was removed from the meta-analysis, resulting in 16 studies available for quantitative assessment. Compared with standard care or a waiting list, tailored Web-based intervention showed benefits immediately after, with small effect sizes (<0.40) for pain intensity (10 randomized controlled trials [RCTs], n=1310, P=.003) and pain-related disability (6 RCTs, n=953, P<.001). No other improvements were observed at follow-up in the medium and long terms. Compared with the active control group, no improvements were found for the primary outcome (pain intensity) or any of the outcomes except for a small effect size on pain catastrophizing (2 RCTs, n=333, P<.001) immediately after the intervention.

CONCLUSIONS

Tailored Web-based interventions did not prove to be more efficacious than standardized Web-based interventions in terms of pain intensity, pain-related disability, anxiety, and depression. An interesting finding was that some efficacy was shown on pain catastrophizing compared with active control interventions. Considering the diversity of approaches used in tailored Web-based interventions for chronic pain management, their efficacy is yet to be explored. Moreover, their contribution to acute pain management is embryonic.

TRIAL REGISTRATION

International prospective register of systematic reviews (PROSPERO): CRD42015027669; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42015027669 (Archived by WebCite at http://www. webcitation.org/6uneWAuyR).

The effect of psychological interventions on the prevention of chronic pain in adults: a systematic review protocol

BACKGROUND

Numerous psychological risk and protective factors have been identified as contributing to or preventing the development of the prevalent issue of chronic pain. Systematic reviews of studies on psychological interventions that tackle these factors have shown limited effects on chronic pain. Therefore, implementing psychological interventions before pain becomes chronic has been put forward. However, the efficacy of such interventions in preventing the transition from acute to chronic pain has not yet been systematically assessed.

METHODS

The aims of this systematic review are to assess the effects of psychological interventions applied in the acute pain phase on pain severity as well as on physical, psychological, and social functions at 3 months and beyond. Randomized controlled trials including psychological intervention as a treatment of primary interest and participants with pain of less than 3 months duration will be considered. The following comparisons will be undertaken: psychological interventions with (1) standard treatment, (2) information, (3) waiting-list, and (4) active treatment. The primary outcome will be pain severity using indicators such the presence or absence of pain and self-report measures such as the numeric pain intensity rating scale. Secondary outcomes will include pain-related disability, mood, coping with pain, quality of life, health care utilization, and work capability. A systematic review of English and French articles in MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials will be conducted without date restriction. Extracted data will include demographics and clinical characteristics, sample size, intervention and control group types, assessment tools used, time interval of measurement, fidelity of the intervention, and attrition rate. Standardized mean differences (SMD) and risk ratios with 95% confidence intervals (CI) will be used to assess treatment effects.

DISCUSSION

This systematic review is the first in examining the effects of psychological interventions implemented in the acute pain phase with the objective of preventing chronic pain. Results of this systematic review could provide information on psychological intervention characteristics that are most helpful for individuals with pain and guidance as to when such interventions should be applied in the continuum of care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016049312.

Opioid-associated iatrogenic withdrawal in critically ill adult patients: a multicenter prospective observational study

Background

Opioids and benzodiazepines are frequently used in the intensive care unit (ICU). Regular use and prolonged exposure to opioids in ICU patients followed by abrupt tapering or cessation may lead to iatrogenic withdrawal syndrome (IWS). IWS is well described in pediatrics, but no prospective study has evaluated this syndrome in adult ICU patients. The objective of this study was to determine the incidence of IWS caused by opioids in a critically ill adult population. This multicenter prospective cohort study was conducted at two level-1 trauma ICUs between February 2015 and September 2015 and included 54 critically ill patients. Participants were eligible if they were 18 years and older, mechanically ventilated and had received more than 72 h of regular intermittent or continuous intravenous infusion of opioids. For each enrolled patient and per each opioid weaning episode, presence of IWS was assessed by a qualified ICU physician or senior resident according to the 5th edition of Diagnostic and Statistical Manual of Mental Disorders criteria for opioid withdrawal.

Results

The population consisted mostly of males (74.1%) with a median age of 50 years (25th–75th percentile 38.2–64.5). The median ICU admission APACHE II score was 22 (25th–75th percentile 12.0–28.2). The overall incidence of IWS was 16.7% (95% CI 6–27). The median cumulative opioid dose prior to weaning was higher in patients with IWS (245.7 vs. 169.4 mcg/kg, fentanyl equivalent). Patients with IWS were also exposed to opioids for a longer period of time as compared to patients without IWS (median 151 vs. 125 h). However, these results were not statistically significant.

Conclusions

IWS was occasionally observed in this very specific population of mechanically ventilated, critically ill ICU patients. Further studies are needed to confirm these preliminary results and identify risk factors.

A Hybrid Web-Based and In-Person Self-Management Intervention to Prevent Acute to Chronic Pain Transition After Major Lower Extremity Trauma (iPACT-E-Trauma): Protocol for a Pilot Single-Blind Randomized Controlled Trial

Background

Acute pain frequently transitions to chronic pain after major lower extremity trauma (ET). Several modifiable psychological risk and protective factors have been found to contribute to, or prevent, chronic pain development. Some empirical evidence has shown that interventions, including cognitive and behavioral strategies that promote pain self-management, could prevent chronic pain. However, the efficacy of such interventions has never been demonstrated in ET patients. We have designed a self-management intervention to prevent acute to chronic pain transition after major lower extremity trauma (iPACT-E-Trauma).

Objective

This pilot randomized controlled trial (RCT) aims to evaluate the feasibility and research methods of the intervention, as well as the potential effects of iPACT-E-Trauma, on pain intensity and pain interference with daily activities.

Methods

A 2-arm single-blind pilot RCT will be conducted. Participants will receive the iPACT-E-Trauma intervention (experimental group) or an educational pamphlet (control group) combined with usual care. Data will be collected at baseline, during iPACT-E-Trauma delivery, as well as at 3 and 6 months post-injury. Primary outcomes are pain intensity and pain interference with daily living activities at 6 months post-injury. Secondary outcomes are pain self-efficacy, pain acceptance, pain catastrophizing, pain-related fear, anxiety and depression symptoms, health care service utilization, and return to work.

Results

Fifty-three patients were recruited at the time of manuscript preparation. Comprehensive data analyses will be initiated in July 2017. Study results are expected to be available in 2018.

Conclusions

Chronic pain is an important problem after major lower ET. However, no preventive intervention has yet been successfully proven in these patients. This study will focus on developing a feasible intervention to prevent acute to chronic pain transition in the context of ET. Findings will allow for the refinement of iPACT-E-Trauma and methodological parameters in prevision of a full-scale multi-site RCT.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 91987302; http://www.controlled-trials.com/ISRCTN91987302 (Archived by WebCite at http://www.webcitation.org/6rR8G2vMs)

Symptom assessment in non-vocal or cognitively impaired ICU patients: Implications for practice and future research

BACKGROUND

Symptom assessment in critically ill patients is challenging because many cannot provide a self-report.

OBJECTIVES

To describe the state of the science on symptom communication and the assessment of selected physical symptoms in non-vocal ICU patients.

METHODS

This paper summarizes a 2014 American Thoracic Society Annual International Conference symposium presenting current evidence on symptom communication, delirium, and the assessment of common physical symptoms (i.e., dyspnea, pain, weakness, and fatigue) experienced by non-vocal ICU patients.

RESULTS

Symptom assessment begins with accurate assessment, which includes an evaluation of delirium, and assistance in symptom communication. Simple self-report measures (e.g., 0-10 numeric rating scale), observational measures (e.g., Respiratory Distress Observation Scale and Critical-Care Pain Observation Tool), or objective measures (e.g., manual muscle testing and hand dynamometry) have demonstrated utility among this population.

CONCLUSION

Optimizing symptom assessment with valid and reliable instruments with minimum patient burden is necessary to advance clinical practice and research in this field.

Histone deacetylase inhibitors containing a benzamide functional group and a pyridyl cap are preferentially effective human immunodeficiency virus-1 latency-reversing agents in primary resting CD4+ T cells

Antiretroviral therapy (ART) can control human immunodeficiency virus-1 (HIV-1) replication in infected individuals. Unfortunately, patients remain persistently infected owing to the establishment of latent infection requiring that ART be maintained indefinitely. One strategy being pursued involves the development of latency-reversing agents (LRAs) to eliminate the latent arm of the infection. One class of molecules that has been tested for LRA activity is the epigenetic modulating compounds histone deacetylases inhibitors (HDACis). Previously, initial screening of these molecules typically commenced using established cell models of viral latency, and although certain drugs such as the HDACi suberoylanilide hydroxamic acid demonstrated strong activity in these models, it did not translate to comparable activity with patient samples. Here we developed a primary cell model of viral latency using primary resting CD4+ T cells infected with Vpx-complemented HIV-1 and found that the activation profile using previously described LRAs mimicked that obtained with patient samples. This primary cell model was used to evaluate 94 epigenetic compounds. Not surprisingly, HDACis were found to be the strongest activators. However, within the HDACi class, the most active LRAs with the least pronounced toxicity contained a benzamide functional moiety with a pyridyl cap group, as exemplified by the HDACi chidamide. The results indicate that HDACis with a benzamide moiety and pyridyl cap group should be considered for further drug development in the pursuit of a successful viral clearance strategy.

Pain, agitation, and delirium guidelines: nurses' involvement in development and implementation

The 2013 American College of Critical Care Medicine/Society of Critical Care Medicine clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit serves as a living example of nurses' involvement in the development and implementation of professional guidelines. Nurses who served on this guideline-writing panel describe their experiences. Specific examples from the pain, agitation, and delirium guidelines for care are used to explore the roles of the nurse leader, nurse informaticist, staff nurse, and nurse researcher in relationship to guideline implementation.

Evaluation of the preliminary effectiveness of hand massage therapy on postoperative pain of adults in the intensive care unit after cardiac surgery: a pilot randomized controlled trial

Although many intensive care unit patients experience significant pain, very few studies explored massage to maximize their pain relief. This study aimed to evaluate the preliminary effects of hand massage on pain after cardiac surgery in the adult intensive care unit. A pilot randomized controlled trial was used for this study. The study was conducted in a Canadian medical-surgical intensive care unit. Forty adults who were admitted to the intensive care unit after undergoing elective cardiac surgery in the previous 24 hours participated in the study. They were randomly assigned to the experimental (n = 21) or control (n = 19) group. The experimental group received a 15-minute hand massage, and the control group received a 15-minute hand-holding without massage. In both groups the intervention was followed by a 30-minute rest period. The interventions were offered on 2-3 occasions within 24 hours after surgery. Pain, muscle tension, and vital signs were assessed. Pain intensity and behavioral scores were decreased for the experimental group. Although hand massage decreased muscle tension, fluctuations in vital signs were not significant. This study supports potential benefits of hand massage for intensive care unit postoperative pain management. Although larger randomized controlled trials are necessary, this low-cost nonpharmacologic intervention can be safely administered.

The Effectiveness of Hand Massage on Pain in Critically Ill Patients After Cardiac Surgery: A Randomized Controlled Trial Protocol

Background

Postoperative pain is common in the intensive care unit despite the administration of analgesia. Some trials suggest that massage can be effective at reducing postoperative pain in acute care units; however, its effects on pain relief in the intensive care unit and when pain severity is highest remain unknown.

Objective

The objective is to evaluate the effectiveness of hand massage on the pain intensity (primary outcome), unpleasantness and interference, muscle tension, anxiety, and vital signs of critically ill patients after cardiac surgery.

Methods

A 3-arm randomized controlled trial will be conducted. A total of 79 patients who are 18 years or older, able to speak French or English and self-report symptoms, have undergone elective cardiac surgery, and do not have a high risk of postoperative complications and contraindications to hand massage will be recruited. They will be randomly allocated (1:1:1) to standard care plus either 3 20-minute hand massages (experimental), 3 20-minute hand holdings (active control), or 3 20-minute rest periods (passive control). Pain intensity, unpleasantness, anxiety, muscle tension, and vital signs will be evaluated before, immediately after, and 30 minutes later for each intervention administered within 24 hours postoperatively. Peer-reviewed competitive funding was received from the Quebec Nursing Intervention Research Network and McGill University in December 2015, and research ethics approval was obtained February 2016.

Results

Recruitment started in April 2016, and data collection is expected to be complete by January 2017. To date, 24 patients were randomized and had data collection done.

Conclusions

This study will be one of the first randomized controlled trials to examine the effect of hand massage on the pain levels of critically ill patients after cardiac surgery and to provide empirical evidence for the use of massage among this population.

ClinicalTrial

ClinicalTrials.gov NCT02679534; https://clinicaltrials.gov/ct2/show/NCT02679534 (Archived by WebCite at http://www.webcitation.org/6l8Ly5eHS)

Acute to chronic pain transition in extremity trauma: A narrative review for future preventive interventions (part 2)

BACKGROUND

The first part of this series of 2 articles revealed that chronic pain is an important issue post extremity trauma (ET) involving permanent biological transformations. Interventions aimed at preventing chronic pain in ET patients are therefore required.

OBJECTIVE

To conduct a comprehensive analysis of literature on risk and protective factors for chronic pain post-ET to guide the development of relevant preventive interventions.

METHODS

A narrative review of the literature was undertaken. Databases were searched to identify studies on chronic pain prognostic factors in ET patients.

RESULTS

Demographic, injury-related and psychological factors were shown to either contribute to or limit acute to chronic pain transition. High-intensity acute pain hasconsistently been identified as an important chronic pain risk factor. Other significant documented risk factors include: female gender, older age, less than college education, lower limb injury, symptoms of anxiety and depression and pain catastrophizing. Pain self-efficacy and pain acceptance have been shown to protect individuals against chronic pain.

CONCLUSIONS

This narrative review highlights factors placing ET patients at higher risk of chronic pain or protecting them against this problem. Determining how these factors could be addressed in preventive interventions is the next step before undertaking their development.

The effect of tailored Web-based interventions on pain in adults: a systematic review protocol

BACKGROUND

Information technologies can facilitate the implementation of health interventions, especially in the case of widespread conditions such as pain. Tailored Web-based interventions have been recognized for health behavior change among diverse populations. However, none of the systematic reviews looking at Web-based interventions for pain management has specifically addressed the contribution of tailoring.

METHODS

The aims of this systematic review are to assess the effect of tailored Web-based pain management interventions on pain intensity and physical and psychological functions. Randomized controlled trials including adults suffering from any type of pain and involving Web-based interventions for pain management, using at least one of the three tailoring strategies (personalization, feedback, or adaptation), will be considered. The following types of comparisons will be carried out: tailored Web-based intervention with (1) usual care (passive control group), (2) face-to-face intervention, and (3) standardized Web-based intervention. The primary outcome will be pain intensity measured using a self-report measure such as the numeric rating scale (e.g., 0-10) or visual analog scale (e.g., 0-100). Secondary outcomes will include pain interference with activities and psychological well-being. A systematic review of English and French articles using MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library will be conducted from January 2000 to December 2015. Eligibility assessment will be performed independently in an unblinded standardized manner by two reviewers. Extracted data will include the following: sample size, demographics, dropout rate, number and type of study groups, type of pain, inclusion and exclusion criteria, study setting, type of Web-based intervention, tailoring strategy, comparator, type of pain intensity measure, pain-related disability and psychological well-being outcomes, and times of measurement. Disagreements between reviewers at the full-text level will be resolved by consulting a third reviewer, a senior researcher.

DISCUSSION

This systematic review is the first one looking at the specific ingredients and effects of tailored and Web-based interventions for pain management. Results of this systematic review could contribute to a better understanding of the mechanisms by which Web-based interventions could be helpful for people facing pain problems.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015027669.

Methods for assessing the in vitro transforming activity of NF-κB transcription factor c-Rel and related proteins

Among NF-κB transcription factors, c-Rel and c-Rel-derived proteins, including v-Rel, are the only ones that have shown consistent and frank transforming activity in cell culture. In particular, viral, chicken, mouse, and human Rel proteins can rapidly transform primary chicken spleen and bone marrow cells. Overexpression of a human Rel protein missing a C-terminal transactivation domain can also enhance the transformed state of the human B-lymphoma cell line BJAB. As described in this chapter, these in vitro assays can be used to quantitatively assess the transforming activity of Rel proteins.

Acceptability of a web-based and tailored intervention for the self-management of pain after cardiac surgery: the perception of women and men

Background

Approximately two thirds of adults undergoing cardiac surgery suffer from moderate to severe postoperative pain. Assisting patients with pain management is therefore critical to prevent its negative consequences. Information technologies have become part of our lifestyle and can facilitate the implementation of interventions to manage pain in a busy care setting. A computer-tailored and Web-based intervention—referred to as SOUtien à L’AutoGEstion-Traitement-Assistance Virtuelle Infirmière-Enseignement (SOULAGE-TAVIE)—for the self-management of pain was developed. Findings from a previous pilot randomized controlled trial (RCT) provided some evidence of the feasibility and preliminary effectiveness of this intervention in decreasing pain interference with a few postoperative activities and by modulating pain beliefs and analgesic intake. However, its acceptability from the patient’s perspective remains unclear. Moreover, the proportion of women is much lower in the cardiac surgical population, making it difficult to detect differences in experiences between men and women.

Objective

The objectives were (1) to describe SOULAGE-TAVIE’s acceptability from the perspective of adults experiencing pain after cardiac surgery and (2) to compare the perceptions of men and women.

Methods

A mixed-method approach was used to capture the various attributes of patients’ perceptions of the intervention’s acceptability and to compare the perceptions of men and women. Quota samples of men (n=10; mean age 62.5 years, SD 7.3) and women (n=10; mean age 64.3 years, SD 10.7) who had cardiac surgery in the past month were invited to view the intervention, complete a brief questionnaire rating its acceptability, and then to discuss each component in a 60-minute, semistructured interview. Mann-Whitney U tests were used to compare groups. The transcripts were content analyzed to generate themes based on patients’ experiences with the intervention and reports of acceptability. The content of each category and subcategory were compared between men and women. Frequency counts were also done to validate the emergence of a difference between the 2 subgroups.

Results

Participants perceived the intervention to be very acceptable in terms of content and format, and tended to describe awareness-raising and convenient support experiences. Women scored higher than men in terms of the intervention’s appropriateness (U=13.5, P=.008). They were willing to adhere to the intervention based on the importance and relevance of the advice provided, whereas men were more focused on the delivery mode and its flexibility.

Conclusions

This study underlined the acceptability of computer tailoring and persuasive communication to modulate pain beliefs and attitudes in an acute care context. Both men and women appreciated the Web-based interface and general self-guided approach of the intervention. The delivery of SOULAGE-TAVIE across the continuum of care seems to be an interesting avenue to influence the transition from acute to chronic postoperative pain.

Measuring pain in non-verbal critically ill patients: which pain instrument?

Pain is experienced by many critically ill patients. Although the patient’s self-report represents the gold-standard measure for pain, many patients are unable to communicate in the ICU. In this commentary, we discuss the study findings comparing three objective scales for the assessment of pain in non-verbal patients and the importance of the tool selection process.

Nurses' evaluations of the CPOT use at 12-month post-implementation in the intensive care unit

BACKGROUND

Performing routine pain assessments with all intensive care unit (ICU) patients is strongly recommended in clinical practice guidelines. As many ICU patients are unable to self-report, the Critical-Care Pain Observation Tool (CPOT) is one of the two behavioural pain scales suggested for clinical use. Still, no study has described the evaluations of its use in ICU daily practice.

OBJECTIVE

To describe the nurses' evaluation of the feasibility, clinical relevance and satisfaction with the CPOT use 12 months after its implementation in the ICU.

METHOD

A descriptive design was used. It was conducted in the medical-surgical ICU of a university affiliated setting at Greenfield Park (Québec, Canada). A self-administered evaluation questionnaire including four sections (i.e. feasibility, clinical relevance, satisfaction and socio-demographic information) was completed by ICU nurses who were all trained to use the CPOT. The questionnaires were completed anonymously.

RESULTS

A total of 38 ICU nurses returned their completed questionnaire (63% participation rate). Regarding its feasibility, the majority rated the CPOT as quick to use, simple to understand and easy to complete (92-100%). According to clinical relevance, close to 70% of ICU nurses acknowledged that the CPOT had influenced their practice, but lower results (<50%) were found for effective communication of pain assessment findings with the physicians and other health professionals. More than 80% of ICU nurses were satisfied with its daily use.

CONCLUSION

The CPOT use was deemed feasible and relevant in daily practice as per the nurses' evaluations but did not allow an effective communication with other ICU care team members.

RELEVANCE TO CLINICAL PRACTICE

Training should be offered to all members of the ICU care team, and other implementation strategies should be explored as well to ensure optimal uptake of a pain assessment approach which impacts on their decision-making process for pain management.

Fluctuations in vital signs and behavioural responses of brain surgery patients in the Intensive Care Unit: are they valid indicators of pain?

AIM

To examine the validity of behaviours and fluctuations in vital signs for pain assessment of postbrain surgery adults in the neurosurgical intensive care unit.

BACKGROUND

Many patients in an intensive care unit may be unable to self-report their pain. In such cases, the use of observable indicators is recommended. Very little research has explored the validity of the use of behaviours and vital signs for pain assessment of neurocritically ill patients.

DESIGN

Prospective repeated-measure within-subject observational design.

METHODS

A total of 43 postbrain surgery patients were video recorded before, during and 15 minutes after a non-nociceptive (non-invasive blood pressure cuff inflation) and a nociceptive (turning) procedures. Their behaviours and vital signs were collected with a pre-tested behavioural checklist and a data collection computer connected to the bedside monitor. The patients' self-report of pain was obtained whenever possible. Data were collected between June-December in 2011.

RESULTS

A larger number of pain-related behaviours were exhibited by participants during the nociceptive procedure compared with the non-nociceptive procedure supporting discriminant validation. Among vital signs, only respiratory rate differed significantly between the two procedures. Regarding criterion validation, only behaviours were positively correlated with self-reports of pain.

CONCLUSION

Behaviours were found valid indicators of pain in neurocritically ill patients after elective brain surgery. Fluctuations in vital signs may suggest the presence of pain, but their validity for such use is not supported. They should only be used in combination with other validated pain assessment methods.

Can fluctuations in vital signs be used for pain assessment in critically ill patients with a traumatic brain injury?

Background. Many critically ill patients with a traumatic brain injury (TBI) are unable to communicate. While observation of behaviors is recommended for pain assessment in nonverbal populations, they are undetectable in TBI patients who are under the effects of neuroblocking agents. Aim. This study aimed to validate the use of vital signs for pain detection in critically ill TBI patients. Methods. Using a repeated measure within subject design, participants (N = 45) were observed for 1 minute before (baseline), during, and 15 minutes after two procedures: noninvasive blood pressure: NIBP (nonnociceptive) and turning (nociceptive). At each assessment, vital signs (e.g., systolic, diastolic, mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), capillary saturation (SpO2), end-tidal CO2, and intracranial pressure (ICP)) were recorded. Results. Significant fluctuations (P < 0.05) in diastolic (F = 6.087), HR (F = 3.566), SpO2 (F = 5.740), and ICP (F = 3.776) were found across assessments, but they were similar during both procedures. In contrast, RR was found to increase exclusively during turning (t = 3.933; P < 0.001) and was correlated to participants' self-report. Conclusions. Findings from this study support previous ones that vital signs are not specific for pain detection. While RR could be a potential pain indicator in critical care, further research is warranted to support its validity in TBI patients with different LOC.