Identification of pain indicators for infants at risk for neurological impairment: a Delphi consensus study

Diagnostic tests recommended for the clinical assessment of patients with wrist complaints, an e-Delphi study

BACKGROUND

Evidence-based practice for history-taking and physical examination in the evaluation of wrist complaints is limited.

PURPOSE

To create a set of recommended diagnostic tests for the clinical assessment of patients with undifferentiated wrist complaints.

STUDY DESIGN

An e-Delphi study, following the recommendations on conducting and reporting Delphi studies, was performed.

METHODS

In this e-Delphi study, a national multidisciplinary panel of experts was invited to inventory diagnostic tests, based on several case scenarios, for the probability diagnosis in patients (age ≥18 years) with undifferentiated wrist complaints. Four case scenarios were constructed and presented to the expert panel members, which differed in age of the patient (35 vs 65 years), location (radial vs ulnar), and duration (6 vs 10 weeks) of the complaints. In consecutive rounds, the experts were asked to rate the importance of the inventoried diagnostic tests. Finally, experts were asked to rank recommended diagnostic tests for each case scenario.

RESULTS

Merging all results, the following diagnostic tests were recommended for all case scenarios: ask whether a trauma has occurred, ask how the complaints can be provoked, ask about the localization of the complaints, assess active ranges of motion, assess the presence of swelling, assess the difference in swelling between the left and right, assess the deformities or changes in position of the wrist, and palpate at the point of greatest pain.

CONCLUSIONS

This is the first scientific study where experts clinicians recommended diagnostic tests when assessing patients with undifferentiated wrist complaints, varying in age of the patient (35 vs 65 years), location (radial vs ulnar), and duration (6 vs 10 weeks).

Evaluating user experience with immersive technology in simulation-based education: A modified Delphi study with qualitative analysis

BACKGROUND

Immersive technology is becoming more widespread in simulation-based medical education with applications that both supplement and replace traditional teaching methods. There is a lack of validated measures that capture user experience to inform of the technology utility. We aimed to establish a consensus of items and domains that different simulation experts would include in a measure for immersive technology use.

METHODS

A 3-stage modified Delphi using online software was conducted to support the conceptual framework for the proposed measure. The first round was informed by prior work on immersive technology in simulation. In the first round, participants were asked to describe what we could measure in simulation-based education and technology. Thematic analysis generated key themes that were presented to the participants in the second round. Ranking of importance in round 2 was determined by mean rank scores. The final round was an online meeting for final consensus discussion and most important domains by experts were considered.

RESULTS

A total of 16 simulation experts participated in the study. A consensus was reached on the ideal measure in immersive technology simulation that would be a user questionnaire and domains of interest would be: what was learnt, the degree of immersion experienced, fidelity provided, debrief, psychological safety and patient safety. No consensus was reached with the barriers that this technology introduces in education.

CONCLUSIONS

There is varied opinion on what we should prioritise in measuring the experience in simulation practice. Importantly, this study identified key areas that aids our understanding on how we can measure new technology in educational settings. Synthesising these results in to a multidomain instrument requires a systematic approach to testing in future research.

Home-based guided hypnotherapy for children with functional abdominal pain and irritable bowel syndrome in primary care: study protocol for a randomised controlled trial

INTRODUCTION

Children often present to primary care with functional abdominal pain (FAP) or irritable bowel syndrome (IBS), and around half still have abdominal complaints 1 year later. Hypnotherapy is an evidence-based treatment that is used in specialist care, but it lacks evidence in primary care. This study will investigate the (cost) effectiveness of home-based guided hypnotherapy for children with FAP or IBS in primary care.

METHODS AND ANALYSIS

We report the design of a pragmatic randomised controlled trial among children aged 7-17 years, diagnosed with FAP or IBS by their general practitioner (GP), with assessments over 12 months. The control group will receive care as usual (CAU) by their GP (eg, communication, education and reassurance), while the intervention group will receive CAU plus 3 months of home-based guided hypnotherapy via a website. The primary outcome will be the proportion of children with adequate relief from abdominal pain/discomfort at 12 months, analysed on an intention-to-treat basis. Secondary outcomes will include the adequacy of pain relief at 3 and 6 months, pain/discomfort severity, pain frequency and intensity, daily functioning and impact on function, anxiety and depression, pain beliefs, sleep disturbances, school absence, somatisation, and healthcare use and costs. We must include 200 children to determine a 20% difference in those with adequate relief (55% control vs 75% intervention).

ETHICS AND DISSEMINATION

The Medical Ethics Review Committee of the University Medical Center Groningen, the Netherlands, approved this study (METc2020/237). The results will be disseminated to patients, GPs and other stakeholders via email, a dedicated website, peer-reviewed publications and presentations at national and international conferences. We plan to collaborate with the Dutch Society of GPs to implement the results in clinical practice.

TRIAL REGISTRATION NUMBER

NCT05636358.

Attitudes of mothers attending public hospitals in Addis Ababa, Ethiopia, to neonatal sunlight exposure: a cross-sectional study

BACKGROUND

Sunlight exposure helps the body produce vitamin D, prevents rickets and is used for neonatal jaundice treatment. Good neonatal sunlight exposure is exposing the neonate to sunlight in the morning, 8:00 to 10:00, for 30 to 60 min. However, little is known about the practice of neonatal sunlight exposure among mothers in Ethiopia. This study aimed to assess the practices and factors associated with neonatal sunlight exposure among mothers attending public hospitals in Addis Ababa, Ethiopia.

METHODS

An institution-based cross-sectional study was conducted among 420 mothers attending public hospitals in Addis Ababa. Study participants were selected using a systematic random sampling method. The collected data were entered into Epi-data V.4.6 and exported to SPSS V.26 for analysis. Descriptive and logistic regression analyses were conducted.

RESULTS

The practice of neonatal sunlight exposure among mothers was 27.1%. Neonatal age of 16-28 days (adjusted OR (aOR) 1.99, 95% CI 1.15 to 3.44), family members of 4-6 (aOR 1.86, 95% CI 1.08 to 3.21) and ≥7 (aOR 4.43, 95% CI 1.54 to 12.78), living in compound/villa houses (aOR 2.59, 95% CI 1.26 to 5.33), complete antenatal care (ANC) follow-up (aOR 2.79, 95% CI 1.49 to 5.22), delivery at term (aOR 2.54, 95% CI 1.06 to 6.07), poor knowledge of sunlight exposure (aOR 0.40, 95% CI 0.23 to 0.71) and no fear of sunlight exposure (aOR 1.83, 95% CI 1.08 to 3.12) were factors associated with the practice of neonatal sunlight exposure.

CONCLUSION

This study revealed that 27.1% of mothers had good sunlight exposure. Advanced neonatal age, larger family, living in compound/villa houses, complete ANC visits and term delivery were associated with good practices, whereas poor knowledge and fear of sunlight exposure were associated with poor practices. Therefore, interventions focusing on these findings are required to improve the practice of neonatal sunlight exposure.

Prevalence and psychosocial factors associated with serious injuries among in-school adolescents in eight sub-Saharan African countries

Background

Injury is one of the major causes of death and illness among children and adolescents worldwide. We sought to investigate the prevalence of serious injury and its associated factors among in-school adolescents in eight countries in sub-Saharan Africa.

Methods

A sample of 14,967 in-school adolescents was drawn from the Global School-based Student Health Surveys conducted from 2012 to 2017 in eight sub-Saharan African countries. Data were collected using self-administered structured questionnaires. The prevalence of serious injuries was calculated using proportions while multivariable binary logistic regression analysis was carried out to determine the factors associated with serious injuries.

Results

Approximately 45% of in-school adolescents had experienced serious injuries during the past 12 months to the survey in the eight sub-Saharan African countries, with variations from 32.3% in Mauritius to 68.2% in Liberia. Adolescents who experienced bullying [aOR = 2.37, CI = 2.10, 2.68], those who engaged in physical fight [aOR = 2.14, CI = [1.87, 2.44], those who experienced an attack [aOR = 1.96, CI = [1.73, 2.22], those who felt anxious [aOR = 1.47, CI = 1.22,1.77], those who attempted suicide [aOR = 1.38, CI = 1.14, 1.65], truants [aOR = 1.33, CI = [1.17,1.51], current tobacco users [aOR = 1.42, CI = [1.01, 2.01] and current marijuana users [aOR = 1.78, CI = 1.08, 2.93] had higher odds of experiencing serious injuries. However, those whose parents or guardians respected their privacy had lower odds of experiencing serious injuries [aOR =0.78, CI = [0.68, 0.88] compared to those whose parents or guardians did not respect their privacy.

Conclusion

A relatively high prevalence of serious injuries among in-school adolescents was identified in the eight sub-Saharan African countries studied. Programs and interventions that target the reduction of injuries in educational institutions should take a keen interest in the factors identified in this study. To deal with injury victims, first aid services should be provided in school settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13198-6.

Development of a valid and reliable software customization model for SaaS quality through iterative method: perspectives from academia

Despite the benefits of standardization, the customization of Software as a Service (SaaS) application is also essential because of the many unique requirements of customers. This study, therefore, focuses on the development of a valid and reliable software customization model for SaaS quality that consists of (1) generic software customization types and a list of common practices for each customization type in the SaaS multi-tenant context, and (2) key quality attributes of SaaS applications associated with customization. The study was divided into three phases: the conceptualization of the model, analysis of its validity using SaaS academic-derived expertise, and evaluation of its reliability by submitting it to an internal consistency reliability test conducted by software-engineer researchers. The model was initially devised based on six customization approaches, 46 customization practices, and 13 quality attributes in the SaaS multi-tenant context. Subsequently, its content was validated over two rounds of testing after which one approach and 14 practices were removed and 20 practices were reformulated. The internal consistency reliability study was thereafter conducted by 34 software engineer researchers. All constructs of the content-validated model were found to be reliable in this study. The final version of the model consists of 6 constructs and 44 items. These six constructs and their associated items are as follows: (1) Configuration (eight items), (2) Composition (four items), (3) Extension (six items), 4) Integration (eight items), (5) Modification (five items), and (6) SaaS quality (13 items). The results of the study may contribute to enhancing the capability of empirically analyzing the impact of software customization on SaaS quality by benefiting from all resultant constructs and items.

Opioid and benzodiazepine use during therapeutic hypothermia in encephalopathic neonates

OBJECTIVES

To evaluate the use of sedatives and analgesics during therapeutic hypothermia in encephalopathic neonates and assess associations between medication exposure and hospital outcomes.

STUDY DESIGN

We identified neonates ≥35 weeks gestational age treated with therapeutic hypothermia at 125 neonatal intensive care units between 2007 and 2015. We compared characteristics and hospital outcomes between unexposed neonates and neonates exposed to opioids and/or benzodiazepines.

RESULTS

Opioids were administered to 1 677/2 621 (64%) neonates, and exposure increased from 38% in 2008 to 68% in 2015. Sedation/analgesia varied widely between centers. Opioid-exposed neonates experienced greater durations of respiratory support and were more likely to receive inotropes and inhaled nitric oxide. Mortality during postnatal days 0-3 was lower among opioid-exposed neonates (31/625 [5%]) than unexposed neonates (64/714 [9%]).

CONCLUSIONS

Sedation/analgesia during therapeutic hypothermia is prevalent but not uniform across centers. Prospective studies are needed to assess if exposure independently predicts intensity and duration of physiologic support.

Preliminary Aquatic Physical Therapy Core Sets for Children and Youth With Neurological Disorders: A Consensus Process

PURPOSE

To report on the preliminary aquatic physical therapy core sets for children and youth with neurological disorders using the International Classification of Functioning, Disability and Health-children and youth version.

METHODS

A formal and structured consensus process was developed, integrating the findings of preparatory studies: a systematic literature review, expert survey with 69 participants, and a qualitative study with 43 participants.

RESULTS

Five preliminary aquatic physical therapy core sets were described: a Comprehensive Core Set (64 categories); a Common Brief (13 categories); and 3 age-specific Core Sets: infant (below 6 years, 18 categories), school-age (from 6 to <14 years, 22 categories), and youth (from 14 to 18 years, 19 categories).

CONCLUSIONS

Consensus among aquatic physical therapists' expert opinions identified the relevant intervention categories available when treating children and youth with neurological disorders. This list of intervention categories can be used in practice, research, education, and health administration.

Development of Self-Management Indicators for Chronic Hepatitis B Patients on Antiviral Therapy: Results of a Chinese Delphi Panel Survey

Objective

This study aimed to develop a set of indicators that could be used to measure and monitor the self-management performance for chronic hepatitis B (CHB) patients on antiviral therapy in China.

Methods

A two-round Delphi study via e-mail correspondence was conducted, with a group of 30 Chinese experts. The Delphi questionnaire consisted of 53 indicators identified from a literature review. Experts rated and scored the importance of indicators on a five-point Likert scale. Consensus was considered to be reached if a median score in the top tertile (4-5) and ≥80% of panel ratings in the top tertile (4-5) after Round 2. The included indicators were validated with a group of 106 CHB patients.

Results

The response rates for the first and second rounds were 90.9% (n=30) and 86.7% (n=26), respectively. Three new indicators were suggested in the first round. 55 indicators were included in the second round after modified. 45 (81.8%) indicators achieved on the level of consensus, all of which had an inter-quartile range of 1 or below. The final set included 4 domains and 45 indicators which were well accepted and understandable by CHB patients.

Conclusion

This Delphi study produced a set of 45 self-management indicators for CHB patients on antiviral therapy in China. These indicators could be used to measure and monitor the patients’ self-management performance, with the goal of improving the quality of life in this population.

Effect of repeated Kangaroo Mother Care on repeated procedural pain in preterm infants: A randomized controlled trial

BACKGROUND

Preterm infants' repeated exposure to painful procedures may lead to negative consequences. Thus, non-pharmacological pain management is essential due to medication side effects. Kangaroo Mother Care, which aims at offering human care to neonates, has been established for the treatment of a single painful procedure, but the effectiveness of Kangaroo Mother Care across repeated painful procedures is unknown.

OBJECTIVE

To test the effectiveness of repeated Kangaroo Mother Care on repeated heel-stick pain in preterm neonates.

DESIGN

Randomized controlled trial.

SETTING

Level III Neonatal Intensive Care Unit at a large teaching hospital in northeast China.

METHOD

Preterm infants (gestational age less than 37 weeks) (n=80) were recruited and randomly assigned using a random table format to either an incubator group (n=40) or Kangaroo Mother Care group (n=40). Pain assessments were carried out during four routine heel stick procedures. For the first heel stick, preterm infants in each group received no intervention (routinely stayed in incubator). During the next three heel sticks, the infants in Kangaroo Mother Care group received heel sticks during Kangaroo Mother Care, while infants in the incubator group received heel sticks in incubator. The procedure of each heel stick included 3 phases: baseline, blood collection and recovery. Crying, grimacing and heart rate in response to pain were evaluated at each phase across four heel sticks by three trained independent observers who were blinded to the purpose of the study. Data were analyzed by analysis of variance (ANOVA), with repeated measures at different evaluation phases of heel stick.

RESULTS

75 preterm infants completed the protocol. Between-group comparison revealed that preterm infants' heart rate was significantly lower, and the duration of crying and facial grimacing were both significantly shorter in the Kangaroo Mother Care group (n=38) than the incubator group (n=37) from the blood collection phase to recovery phase during repeated heel sticks. No significant within-group difference was found in heart rate between the baseline phase and recovery phase through repeated heel sticks for Kangaroo Mother Care group. In contrast, the incubator group experienced significant within group differences in heart rate between baseline and recovery through repeated heel sticks.

CONCLUSION

The effect of repeated Kangaroo Mother Care analgesia remains stable in preterm infants over repeated painful procedures. Given the many invasive procedures that are part of clinical care in preterm infants and most mothers preferred to provide comfort for their infants during painful procedures, Kangaroo Mother Care may be a safe analgesic alternative in preterm infants in whom it is feasible.

Outcomes of primary ligation of patent ductus arteriosus compared with secondary ligation after pharmacologic failure in very-low-birth-weight infants

This study aimed to determine whether primary surgical closure of patent ductus arteriosus (PDA) is a risk factor for morbidity and mortality compared with secondary surgical ligation. The study enrolled 178 very-low-birth-weight infants. The surgical group included 34 patients who did not respond to pharmacologic intervention and eventually required ligation of their PDA as well as 35 patients who underwent direct ligation because of contraindications to the use of oral ibuprofen. The overall outcomes for the primary and secondary ligation groups were compared. The outcome during hospitalization showed no statistically significant difference in terms of morbidity and mortality between the two groups. The group that had primary ligation for PDA experienced more complications associated with premature birth such as lower gestational age and birth weight. The two groups did not differ significantly in terms of overall outcomes.

Pain in hospitalized children: Effect of a multidimensional knowledge translation strategy on pain process and clinical outcomes

Hospitalized children frequently receive inadequate pain assessment and management despite substantial evidence to support effective pediatric pain practices. The objective of this study was to determine the effect of a multidimensional knowledge translation intervention, Evidence-based Practice for Improving Quality (EPIQ), on procedural pain practices and clinical outcomes for children hospitalized in medical, surgical and critical care units. A prospective cohort study compared 16 interventions using EPIQ and 16 standard care (SC) units in 8 Canadian pediatric hospitals. Chart reviews at baseline (time 1) and intervention completion (time 2) determined the nature and frequency of painful procedures and of pain assessment and pain management practices. Trained pain experts evaluated pain intensity 6 months post-intervention (time 3) during routine, scheduled painful procedures. Generalized estimating equation models compared changes in outcomes between EPIQ and SC units over time. EPIQ units used significantly more validated pain assessment tools (P<0.001) and had a greater proportion of patients who received analgesics (P=0.03) and physical pain management strategies (P=0.02). Mean pain intensity scores were significantly lower in the EPIQ group (P=0.03). Comparisons of moderate (4-6/10) and severe (7-10/10) pain, controlling for child and unit level factors, indicated that the odds of having severe pain were 51% less for children in the EPIQ group (adjusted OR: 0.49, 95% CI: 0.26-0.83; P=0.009). EPIQ was effective in improving practice and clinical outcomes for hospitalized children. Additional exploration of the influence of contextual factors on research use in hospital settings is required to explain the variability in pain processes and clinical outcomes.

Health care professionals' pain narratives in hospitalized children's medical records. Part 1: pain descriptors

BACKGROUND

Although documentation of children's pain by health care professionals is frequently undertaken, few studies have explored the nature of the language used to describe pain in the medical records of hospitalized children.

OBJECTIVES

To describe health care professionals' use of written language related to the quality and quantity of pain experienced by hospitalized children.

METHODS

Free-text pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized on 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was used.

RESULTS

Pain narratives were documented a total of 5390 times in 1518 of the 3822 children's medical records (40%). Overall, word choices represented objective and subjective descriptors. Two major categories were identified, with their respective subcategories of word indicators and associated cues: indicators of pain, including behavioural (e.g., vocal, motor, facial and activities cues), affective and physiological cues, and children's descriptors; and word qualifiers, including intensity, comparator and temporal qualifiers.

CONCLUSIONS

The richness and complexity of vocabulary used by clinicians to document children's pain lend support to the concept that the word 'pain' is a label that represents a myriad of different experiences. There is potential to refine pediatric pain assessment measures to be inclusive of other cues used to identify children's pain. The results enhance the discussion concerning the development of standardized nomenclature. Further research is warranted to determine whether there is congruence in interpretation across time, place and individuals.

Physician variability in treating pain and irritability of unknown origin in children with severe neurological impairment

BACKGROUND

Pain and irritability of unknown origin (PIUO) is a challenging problem for nonverbal children with severe neurological impairments. PIUO is not associated with an identifiable source of nociceptive-inflammatory or neuropathic pain.

OBJECTIVE

To assess how physicians use pharmacotherapy to treat PIUO, and to report a pilot study of a standardized approach to investigating and treating PIUO.

METHOD

Part 1 of the present study involved independently presenting a case vignette of a patient with PIUO to six experienced physicians who care for children with neurological impairments. They were asked for medication choices and sequences to empirically treat PIUO. Part 2 was a pilot study of a PIUO protocol. Patients followed a standard pathway for PIUO, referred to as the pathway for unknown pain (PUP). The initial drug sequence for the PUP was based on Part 1.

RESULTS

In Part 1, physicians responding to the case vignette listed eight medications (atypical antipsychotics, benzodiazepines, gabapentin, methadone, opioids, selective serotonin reuptake inhibitors, tramadol and tricylic antidepressants) and eight empiric drug sequences. In Part 2, eight children with PIUO (six to 17 years of age; five females, three males) were enrolled in a pilot clinic. Only two had been fully evaluated for nociceptive-inflammatory pain sources before enrollment. At the end of the pilot study, four patients were clinically improved and only three required a study medication.

DISCUSSION AND CONCLUSION

Even experienced physicians do not agree on a common approach for medical treatment of PIUO. A standardized pathway is feasible and readily implemented. The proposed PUP has the potential to address PIUO and be the basis for future intervention studies.

Consensus building in palliative care: a Europe-wide delphi study on common understandings and conceptual differences

CONTEXT

Throughout Europe, there are major differences in the stages of development and in the types of service delivery of palliative care. Consensus on standards and norms for palliative care in Europe is needed for advocacy and health policy decision making.

OBJECTIVES

To provide an empirical basis for a common understanding of palliative care delivery in Europe.

METHODS

A two-round, online consensus Delphi study was undertaken with a multiprofessional expert panel of board members of national hospice and palliative care associations in Europe.

RESULTS

Respondents represented 80% of the member associations of the European Association for Palliative Care, comprising 96 experts and 35 national hospice and palliative care associations from 22 countries. High to very high consensus was found for common values and principles of palliative care (e.g., autonomy, dignity) and the provision of different levels of palliative care. Lower consensus emerged for concepts such as end-of-life care or terminal care, the demand of services and the composition of palliative care teams. The role of social workers was emphasized, but there was ambiguity about the contribution of psychologists. The need for health professionals without specialist palliative care skills to strengthen their contribution to palliative care provision was emphasized.

CONCLUSION

Overall, this study contributed to a higher level of consensus toward the proposed recommendations. Expert comments underlined the need for clearer definitions and specifications of terms and indicated important topics where cultural issues, geographical aspects, and the local health care setting have to be considered in palliative care.

Kangaroo care and behavioral and physiologic pain responses in very-low-birth-weight twins: a case study

The purpose of this case study was to describe pain responses in three study conditions: longer (30 minutes) kangaroo care (KC) before and throughout heel stick (KC30), shorter (15 minutes) KC before and throughout heel stick (KC15), and incubator care throughout heel stick (IC) in 28-week gestational age twins. Pain responses were measured by crying time, Preterm Infant Pain Profile (PIPP), and heart rate variability indexes, including low-frequency power (LF, representing sympathetic activity), high-frequency power (HF, parasympathetic activity), and LF/HF ratio (sympathetic-parasympathetic balance). Both twins cried more and had higher PIPP pain scores and tachycardia during heel stick in the IC condition. Infant B had an incident of apnea and tachycardia by the end of the heel stick and a bradycardia episode during recovery in the IC condition. The twins had lower LF/HF ratios (better autonomic nervous system balance) during recovery in both longer and shorter KC conditions compared with the IC condition. Infant B had difficulty returning to LF/HF ratio baseline level after the painful procedure in the IC condition. These data suggest that both longer and shorter KC before and throughout painful procedures can be helpful in reducing behavioral and physiologic pain responses in preterm infants.

Can parents assess dental pain in children with cognitive impairment?

It is often said that the "gold standard" for pain assessment in both children and adults is verbal report. This means that the individual is best at describing his or her pain experience. This however does not take into account individuals who lack the ability to communicate their feelings including those with cognitive immaturity such as infants and very young children, people with cognitive impairment and adults with dementia. This is even complicated by the fact that children who experience the most pain are those who are least able to verbally describe it; those with greater physical and cognitive disability. This paper reviews past and current beliefs on the experience and expression of pain in children with cognitive impairment and how parents can be used as useful tools in diagnosing their pain.

Content validation of the infant malnutrition and feeding checklist for congenital heart disease: a tool to identify risk of malnutrition and feeding difficulties in infants with congenital heart disease

Infants with congenital heart disease (CHD) have a high prevalence of feeding difficulties and malnutrition. Early intervention decreases morbidity and long-term developmental deficits. The purpose of this study was to develop and establish the content validity of a screening checklist to identify infants with CHD at risk of feeding difficulties or inadequate nutritional intake for timely referral to a feeding specialist or dietitian. The Delphi method was used, and expert participants reached consensus on 24 risk indicators. This study is the first step in establishing the validity and reliability of a screening tool for early intervention of feeding difficulties and inadequate nutritional intake in infants with CHD.

Measuring preterm cumulative stressors within the NICU: the Neonatal Infant Stressor Scale

BACKGROUND

Stress experiences, while pervasive, are less likely than painful experiences to be managed in still-hospitalised preterm infants.

AIM

We aimed to quantify the severity of common stressors for preterm infants with a view to providing a tool to manage presumed accumulated infant stress.

METHODS AND SUBJECTS

Seventeen doctors and 130 nurses who work in Neonatal Intensive and Special Care Nurseries rated the perceived stress severity of 44 acute events and 24 chronic living conditions for preterm infants at three ages (<28 weeks, 28-32 weeks, >32 weeks post-conceptional age) and for themselves. Acute items (such as heel lance) were organised into nursing, peripheral venous access, peripheral arterial access, central vascular access, ventilation, nutrition, medical procedures, surgery, radiology and miscellaneous categories. Chronic living conditions included items such as receiving intranasal oxygen and having a systemic infection.

RESULTS

Doctors and nurses perceived nearly all items to be stressful to infants to some degree and to be equally stressful across ages. The degree of stress experienced by clinicians themselves was generally low and moderately correlated with presumed infant stress for the same items. Presumed infant stress was inversely related to clinician age.

CONCLUSION

Based on these results we developed the Neonatal Infant Stressor Scale to help track, measure and manage presumed accumulated stress in preterm neonates.

Development of a diagnostic protocol for dizziness in elderly patients in general practice: a Delphi procedure

Background

Dizziness in general practice is very common, especially in elderly patients. The empirical evidence for diagnostic tests in the evaluation of dizziness is scarce. Aim of our study was to determine which set of diagnostic tests should be part of a diagnostic protocol for evaluating dizziness in elderly patients in general practice.

Methods

We conducted a Delphi procedure with a panel of 16 national and international experts of all relevant medical specialities in the field of dizziness. A selection of 36 diagnostic tests, based on a systematic review and practice guidelines, was presented to the panel. Each test was described extensively, and data on test characteristics and methodological quality (assessed with the Quality Assessment of Diagnostic Accuracy Studies, QUADAS) were presented. The threshold for in- or exclusion of a diagnostic test was set at an agreement of 70%.

Results

During three rounds 21 diagnostic tests were selected, concerning patient history (4 items), physical examination (11 items), and additional tests (6 items). Five tests were excluded, although they are recommended by existing practice guidelines on dizziness. Two tests were included, although several practice guidelines question their diagnostic value. Two more tests were included that have never been recommended by practice guidelines on dizziness.

Conclusion

In this study we successfully combined empirical evidence with expert opinion for the development of a set of diagnostic tests for evaluating dizziness in elderly patients. This comprehensive set of tests will be evaluated in a cross-sectional diagnostic study.

Indicators of pain in neonates at risk for neurological impairment

AIM

This paper is a report of a study to compare the importance and usefulness ratings of physiological and behavioural indicators of pain in neonates at risk for neurological impairment by nurse clinicians and pain researchers.

BACKGROUND

Neonates at risk for neurological impairment have not been systematically included in neonatal pain measure development and how clinicians and researchers view pain indicators in these infants is unknown.

METHODS

Data triangulation was undertaken in three Canadian Neonatal Intensive Care Units using data from: (a) 149 neonates at high, moderate and low risk for neurological impairment, (b) 95 nurse clinicians from the three units where infant data were collected and (c) 14 international pain researchers. Thirteen indicators were assessed following heel lance in neonates and 39 indicators generated from nurse clinicians and pain researchers were assessed for importance and accuracy. Data were collected between 2004 and 2005.

RESULTS

Across risk groups, indicators with the highest accuracy for discriminating 'pain' among neonates were: brow bulge (77-83%), eye squeeze (75-84%), nasolabial furrow (79-81%), and total facial expression (78-83%). Correlations between nurse ratings and neonatal accuracy scores ranged from moderate to none (mild risk r = 0.52, P = 0.07; moderate r = 0.43, P = 0.15; high r = -0.12, P = 0.69). Researchers demonstrated a better understanding of the importance of pain indicators (mild risk, r = 0.91, P < 0.001; moderate 0.85, P < 0.001; 0.0002; high r = 0.64, P = 0.019) than nurse clinicians.

CONCLUSION/DISCUSSION

Facial actions were rated as the most important indicators of neonatal pain. However, as neurological impairment risk increased, physiological indicators were rated more important by nurse clinicians and pain researchers, opposite to pain indicators demonstrated by neonates.

Kangaroo Care (skin contact) reduces crying response to pain in preterm neonates: pilot results

Crying commonly occurs in response to heel stick and adversely affects the infant's physiologic stability. Minimal crying in response to pain is desired. "Kangaroo Care," skin contact between mother and infant, reduces pain and may reduce crying in response to pain. The purpose of this pilot study was to test Kangaroo Care's effect on the preterm infant's audible and inaudible crying response to heel stick. Inaudible crying has not been previously studied. A prospective randomized cross-over study with 10 preterm infants 2-9 days old (30-32 weeks' postmenstrual age) was conducted. Infants were randomly assigned to two sequences (sequence A: day 1 heel stick in Kangaroo Care [after 30 min of prone skin contact upright between maternal breasts] and day 2 heel stick in incubator [inclined, nested and prone]; or sequence B: opposite of sequence A) was conducted. Videotapes of baseline, heel warming, heel stick, and recovery phases were scored for audible and inaudible crying times. Audible and inaudible crying times for each subject in each phase were summed and analyzed by repeated-measures analysis of variance. Subject characteristics did not differ between those in the two sequences. Crying time differed between the study phases on both days (p <or= .001). When in Kangaroo Care compared with the incubator, crying time was less during the heel stick (p = .001) and recovery (p = .01) phases, regardless of sequence. Because Kangaroo Care reduced crying in response to heel stick in medically stable preterm infants, a definitive study is merited before making recommendations.

Two nomograms for determining extended-dosing intervals for gentamicin in neonates

PURPOSE

The development of two nomograms to predict dosing intervals for gentamicin in neonates based on one gentamicin concentration is described.

METHODS

Pooled data from three retrospective studies on neonates age seven days or younger were used to create nomograms that would predict dosing intervals for gentamicin. The population volume of distribution (0.45 L/kg) and a determined half-life were used to create nomogram cutoff concentrations that could select a dosing interval for neonates to achieve steady-state trough concentrations of < or =0.5 or < or =1 mg/L. A dose of 4 mg/kg was used to simulate concentration-versus-time profiles for included neonates based on their individual pharmacokinetic data. Predicted concentrations from hours 6 to 22, at one-hour intervals, for each neonate were compared against the nomograms and evaluated for the number of correct interval predictions. The nomograms were considered to have failed at any time point where they indicated an interval that would not have achieved the desired trough concentration of < or =0.5 or < or =1 mg/L or if the interval chosen was longer than necessary.

RESULTS

The 0.5- and 1-mg/L nomograms predicted correct dosing intervals for 81-92% of neonates for postinfusion hours between 15 to 21 and 86-93% for postinfusion hours of 13 and 21, respectively. Accuracy of the nomograms to predict correct dosing intervals improved as the postinfusion time before the next concentration measurement increased.

CONCLUSION

Using the two nomograms may help predict the correct extended-dosing intervals of gentamicin administration for neonates. Prospective evaluation and validation of the nomograms may be necessary for their wider use as a clinical tool.

Predictive factors of chronic pediatric pain and disability: a Delphi poll

The purpose of this study was to establish consensus on the factors that predict chronic pediatric pain and pain-related disability. A Delphi poll involving 2 rounds of data collection was used as a way to reach consensus among professionals with a specific interest in chronic pain in children and adolescents. Factors that had the greatest influence on long-term maintenance of pediatric pain included: Excessive use of heath care services; a tendency to somatize; and children's catastrophizing. Factors that had the greatest influence on long-term disability included: Children's self-concept as being disabled; a hesitance to perform exercise because of fear of a potential injury; and children's catastrophizing. These findings may help identify the specific items to be assessed in studies designed to predict which children are at risk to develop chronic pain and disability. If supported by further research, these results may ultimately help develop intervention programs that could prevent long-term pain in disability in children and adolescents.

PERSPECTIVE

A Delphi poll was conducted to reach consensus among professionals with a specific interest in chronic pain among children and adolescents, regarding the factors associated with the development of chronic pediatric pain and disability. This study could serve as the basis for (1) prospective studies to validate the predictive utility of the variables; and (2) the design of secondary prevention programs.

Potentially inappropriate medications in the elderly: a French consensus panel list

OBJECTIVE

To evaluate drug-related problems in the elderly, various lists of potentially inappropriate medications have been published in North America. Unfortunately, these lists are hardly applicable in France. The purpose of this study was to establish a list of inappropriate medications for French elderly using the Delphi method.

METHOD

A two-round Delphi method was used to converge to an agreement between a pool of 15 experts from various parts of France and from different backgrounds (five geriatricians, five pharmacologists, two pharmacists, two general practitioners, one pharmacoepidemiologist). In round one, they were sent a questionnaire based on a literature review listing medications and clinical situations. They were asked to comment on the potential inappropriateness of the criteria proposed using a 5-point Likert scale (from strong agreement to strong disagreement) and to suggest therapeutic alternatives and new criteria. In round two, the experts confirmed or cancelled their previous answers from the synthesis of the responses of round one. After round two, a final list of potentially inappropriate drugs was established.

RESULTS

The final list proposed 36 criteria applicable to people >/=75 years of age. Twenty-nine medications or medication classes applied to all patients, and five criteria involved medications that should be avoided in specific medical conditions. Twenty-five medications or medication classes were considered with an unfavourable benefit/risk ratio, one with a questionable efficacy and eight with both unfavourable benefit/risk ratio and questionable efficacy.

CONCLUSION

This expert consensus should provide prescribers with an epidemiological tool, a guideline and a list of alternative therapies.