Indicators of pain in neonates at risk for neurological impairment

Title. 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.     

Determining behavioural and physiological responses to pain in infants at risk for neurological impairment

Multiple researchers have validated indicators and measures of infant pain. However, infants at risk for neurologic impairment (NI) have been under studied. Therefore, whether their pain responses are similar to those of other infants is unknown. Pain responses to heel lance from 149 neonates (GA>25-40 weeks) from 3 Canadian Neonatal Intensive Care units at high (Cohort A, n=54), moderate (Cohort B, n=45) and low (Cohort C, n=50) risk for NI were compared in a prospective observational cohort study. A significant Cohort by Phase interaction for total facial action (F(6,409)=3.50, p=0.0022) and 4 individual facial actions existed; with Cohort C demonstrating the most facial action. A significant Phase effect existed for increased maximum Heart Rate (F(3,431)=58.1, p=0.001), minimum Heart Rate (F(3,431)=78.7, p=0.001), maximum Oxygen saturation (F(3,425)=47.6, p=0.001), and minimum oxygen saturation (F(3,425)=12.2, p=0.001) with no Cohort differences. Cohort B had significantly higher minimum (F(2,79)=3.71, p=0.029), and mean (F(2,79)=4.04, p=0.021) fundamental cry frequencies. A significant Phase effect for low/high frequency Heart Rate Variability (HRV) ratio (F(2,216)=4.97, p=0.008) was found with the greatest decrease in Cohort A. Significant Cohort by Phase interactions existed for low and high frequency HRV. All infants responded to the most painful phase of the heel lance; however, infants at moderate and highest risk for NI exhibited decreased responses in some indicators.     

多发性硬化患者神经功能缺陷与康复干预治疗

目的:残留的神经功能缺陷是影响多发性硬化康复的主要因素,就多发性硬化康复治疗中的主要进展做了回顾和文献复习。资料来源:应用计算机检索Medline1990-01/2004-12期间与多发性硬化康复治疗相关的文章,检索词“multiplesclerosis,rehabilitation,physicatherapy”,并限定文章语言种类为English,同时经“中国生物医学数据库检索1990-01/2004-12期间的相关文章,限定文章语言为中文,检索词“多发性硬化、康复、物理治疗”。资料选择:选取与多发性硬化康复相关的临床随机对照试验(RCT)论文,内容主要包括改善神经功能新药的使用、物理作业疗法、肉毒毒素A的使用和医学康复教育等。资料提炼:对选入的64篇文章进行了筛选,其中39篇文章符合RCT要求,纳入23篇,排除的16篇文章为小样本和重复性研究文章,其余文章为相关的非康复主题的另类研究内容。资料综合:23篇研究论著中包含了神经功能缺陷的分类和康复干预两类主要内容。其中神经功能缺陷主要包括:精神行为障碍、多种运动损害、感觉障碍和膀胱直肠功能损害;康复干预的主要包括康复教育、非药物治疗措施和药物干预等。对近年来多发性硬化康复处理中在新药物的使用、物理作业的应用现状、医学康复教育的实施做了介绍;还就此类康复治疗中对患者的系统教育和医务人员的规范化训练等内容做了介绍。结论:多发性硬化治疗中应遵循对患者的医学教育-物理作业措施-药物治疗相结合的康复医学模式,要通过医院-社区-门诊-住院的链接来完成。     

多发性硬化患者神经功能缺陷与康复干预治疗

目的：残留的神经功能缺陷足影响多发性硬化康复的主要因素，就多发性硬化康复治疗中的主要进展做了同顾和献复习：资料来源：应用计算机检索Medjine 1990—01／2004—12期间与多发性硬化康复治疗相关的章，检索词“multiple sclerosis，rehabilitation，physical therapy”，并限定章语言种类为English，同时经“中国生物医学数据库”检索1990—01／2004—12期间的相关章，限定章语言为中，检索词“多发性硬化、康复、物理治疗”。资料选择：选取与多发性硬化康复相关的临床随机对照试验（RCT）论，内容主要包括改善神经功能新药的使用、物理作业疗法、肉毒毒素A的使用和医学康复教育等。资料提炼：对选人的64篇章进行了筛选，其中39篇章符合RCT要求，纳入23篇，排除的16篇章为小样本和重复性研究章，其余章为相关的非康复主题的另类研究内容。资料综合：23篇研究论中包含了神经功能缺陷的分类和康复干预两类主要内容。其中神经功能缺陷主要包括：精神行为障碍、多种运动损害、感觉障碍和膀胱直肠功能损害；康复干预的主要包括康复教育、非药物治疗措施和药物干预等。对近年来多发性硬化康复处理中在新药物的使用、物理作业的应用现状、医学康复教育的实施做了介绍；还就此类康复治疗中对患的系统教育和医务人员的规范化训练等内容做了介绍。结论：多发性硬化治疗中应遵循对患的医学教育-物理作业措施-药物治疗相结合的康复医学模式，要通过医院-社区-门诊-住院的链接来完成。     

Analysis of risk factors for multidrug-resistant pathogens and appropriate treatment indications for pneumonia in children with neurologic impairment

IntroductionThe features of pneumonia in children with neurologic impairment (NI) resemble those of healthcare-associated pneumonia is defined as pneumonia occurring in the community associated with healthcare risk factors. There are currently no guidelines for the treatment of pneumonia in children with NI. Here, we assessed whether the guidelines applicable for treating pneumonia in adults could be applied to children with NI.MethodsBetween 2008 and 2019, we enrolled children with NI who developed pneumonia and were treated in the pediatric ward of Kawasaki Medical School Hospital. We evaluated patient characteristics, the frequency of isolation of multidrug-resistant (MDR) pathogens, and clinical outcomes.ResultsMDR pathogens were more frequently isolated from patients receiving tube feeding (TF) and/or with tracheostomy than from patients without these risk factors. Other risk factors, including a history of antibiotic therapy and methicillin-resistant Staphylococcus aureus isolation, recent hospitalization, residence in a nursing home or extended care facility, and low-dose, long-term macrolide therapy, did not significantly affect the frequency of MDR pathogen isolation. In patients receiving TF and/or with tracheostomy, treatment success was achieved in all cases treated with broad-spectrum antibiotics and 72.2% of cases treated with non-broad-spectrum antibiotics (P = 0.007). Conversely, among patients without these risk factors, no such difference was observed.ConclusionsOur findings indicate that the guideline to select antibiotics for treating pneumonia in children with NI should be simpler and more useful than the current guidelines for adult pneumonia, based on risk factor assessment for MDR pathogens.     

Procedural pain management for children receiving physiotherapy

Purpose: This article provides an overview of literature relevant to the prevention and relief of pain and distress during physiotherapy procedures, with guidance for physiotherapists treating children.Summary of key points: Physiotherapists are generally well trained in assessing and managing pain as a symptom of injury or disease, but there is a need to improve the identification and management of pain produced by physiotherapy procedures such as stretching and splinting. In contrast to physiotherapy, other health care disciplines, such as dentistry, nursing, paediatrics, emergency medicine, and paediatric psychology, produce extensive literature on painful procedures. Procedural pain in children is particularly important because it can lead to later fear and avoidance of necessary medical care.Recommendations: We emphasize the need for physiotherapists to recognize procedural pain and fear in the course of treatment using verbal, nonverbal, and contextual cues. We present many methods that physiotherapists can use to prevent or relieve procedural pain and fear in paediatric patients and provide an example of a simple, integrated plan for prevention and relief of distress induced by painful procedures.     

Black and white men at risk for memory impairment

BACKGROUND: Blacks are under-represented in government-funded research. Epidemiological data indicate that morbidity and mortality in the United States are higher in Blacks than in Whites. OBJECTIVE: To examine memory performance in a sample of Black and White healthy men 70 years of age and older. METHOD: Sixty-nine (24 Black, 45 White) men participated in a study of memory performance. All individuals lived either in private homes or subsidized high-rise apartments. RESULTS: Black men had higher anxiety about their memories, used fewer internal and external memory strategies, and had less confidence and less understanding of their everyday memory than White men. Based on their depression scores, more Black men (35%) were at risk for depression than White men (10%). Even though there were no differences in the numbers of men who lived alone, White men were five times more likely to be married and live with a spouse (27 vs. 5). CONCLUSION: In this sample of Black and White men, there were no differences in actual memory performance, but significant differences were found in the subjective aspects of memory evaluation.     

Sweet pain management in newborns

Gradin et al.'s (2002) study supported the use of oral glucose to help relieve pain in neonates. The results of this study could be used to support a research utilization project to promote the use of oral glucose in nursing practice. Feasibility issues would include the need to educate nurses on how to incorporate this research in practice. Future research could be done to determine if glucose loses its effectiveness with increasing age or at what age would a different form of analgesic be more effective.     

Intraoperative care of patients at risk of neurologic injury

The pathophysiology of disease states that place the patient at risk are reviewed and specific management schemes are developed. Additionally, anesthetic drugs and adjuvants are discussed with regard to their use in patients at risk of neurologic injury.     

Judgments of pain in the neonatal intensive care setting: a survey of direct care staffs' perceptions of pain in infants at risk for neurological impairment

OBJECTIVE: To determine whether healthcare professionals believe the pain of infants at risk for neurologic impairment differs from that of typical infants. SETTING: Neonatal intensive care units at 2 tertiary pediatric centers in Canada. PARTICIPANTS: Ninety-nine healthcare professionals who practice in the neonatal intensive care unit (51 nurses, 19 physicians, 18 respiratory therapists, 11 other). MAJOR MEASURES: Participants completed the Pain Opinion Questionnaire. It elicits beliefs regarding the similarity of the pain experienced by infants at mild, moderate, and severe risk for neurologic impairment relative to those without risk for neurologic impairment along 5 pain facets (ie, sensation, emotional reaction, behavioral reaction, communication, incidence). RESULTS: Pain Opinion Questionnaire scores varied by level of risk of neurologic impairment (mild, moderate, severe) and pain facet. Respondents believed infants with risk were overall less likely to experience pain similar to infants without risk as the level of risk increased [F(2,97) = 66.0, P < 0.001] and were more likely to have a reduced pain experience relative to infants without risk as the level of risk increased [F(2,97) = 62.2, P < 0.001]. Pain Opinion Questionnaire scores did not vary due to profession, experience, gender, or age. CONCLUSION: Professionals expressed the belief that neurologically impaired infants' pain experience is reduced, relative to infants without impairment, as their level of risk for neurologic impairment increases. This belief did not vary due to professional experience or personal factors. Future studies should investigate the source of these beliefs and their impact on the pain management provided to infants with risk for neurologic impairment.     

Older adults in the SeniorWISE study at risk for mild cognitive impairment

As part of a larger clinical trial, SeniorWISE (Wisdom Is Simply Exploration), this study provides baseline affective, cognitive, and functional ability data and reports on the likely incidence of mild cognitive impairment (MCI) in a tri-ethnic community sample of older adults (N = 265). Seventy-eight individuals had memory complaints, whereas 105 had none. Of the complainants, 32 had normal memory function and 46 had poor memory performance. Among those without memory complaints, 42 had no memory impairment and 63 had poor memory performance. Forty-six individuals (17%) met the criteria of poor everyday memory functioning and memory complaints whereas 81 (31%) would be considered to be at risk based on other MCI criteria. This pattern of results suggests that those with declining memory are less aware of their deficits in activities of daily living that their actual performance would suggest are occurring.     

Procedural pain and oxidative stress in premature neonates

Preterm neonates exposed to painful procedures in the neonatal intensive care unit exhibit increased pain scores and alterations in oxygenation and heart rate. It is unclear whether these physiological responses increase the risk of oxidative stress. Using a prospective study design, we examined the relationship between a tissue-damaging procedure (TDP; tape removal during discontinuation of an indwelling central arterial or venous catheter) and oxidative stress in 80 preterm neonates. Oxidative stress was quantified by measuring uric acid (UA) and malondialdehyde (MDA) concentration in plasma before and after neonates (n = 38) experienced a TDP compared to those not experiencing any TDP (control group, n = 42). Pain was measured before and during the TDP using the Premature Infant Pain Profile (PIPP). We found that pain scores were higher in the TDP group compared to the control group (median scores, 11 and 5, respectively; P < .001). UA significantly decreased over time in control neonates but remained stable in TDP neonates (132.76 to 123.23 μM versus 140.50 to 138.9 μM; P = .002). MDA levels decreased over time in control neonates but increased in TDP neonates (2.07 to 1.81 μM versus 2.07 to 2.21 μM, P = .01). We found significant positive correlations between PIPP scores and MDA. Our data suggest a significant relationship between procedural pain and oxidative stress in preterm neonates. PERSPECTIVE: This article presents data describing a significant relationship between physiological markers of neonatal pain and oxidative stress. The method described in this paper can potentially be used to assess the direct cellular effects of procedural pain as well the effectiveness of interventions performed to decrease pain.     

A sugar-coated pacifier reduces procedural pain in newborns

PURPOSE: To examine the efficacy of pacifiers and sugar, alone and in combination, for pain management in neonates. METHODS: An experimental design examined pain responses of 84 newborns undergoing heelstick. They were randomly assigned to one of four groups: (a) water-moistened pacifier, (b) sugar-coated pacifier, (c) 2 cc of a 12% oral sucrose solution, or (d) control. Pain measures were duration of cry, vagal tone, and salivary cortisol. RESULTS: Multivariate analysis of variance (MANOVA) revealed that the sugar-coated pacifier group cried significantly less than the water-moistened pacifier and control groups. Repeated measures analysis of variance (ANOVA) revealed that the sugar-coated pacifier group demonstrated significantly lower vagal tone during heelstick than the oral sucrose solution and control groups. This difference between the sugar-coated pacifier and control groups persevered for 15 minutes after heelstick. CONCLUSIONS: Offering a sugar coated pacifier during heelstick in healthy neonates reduces pain behaviors more effectively than a water-moistened pacifier, 2 cc of a 12% sucrose solution, or no intervention.     

低频重复经颅磁刺激对脑卒中后抑郁状态和神经功能缺损的治疗效应

目的:探讨低频重复经颅磁刺激对脑卒中后抑郁患者抑郁状态和神经功能缺损的治疗效应。方法:脑卒中后抑郁患者32例为2002-01/2004-09华中科技大学同济医学院附属协和医院神经内科收治,所有患者脑卒中病程均>2个月,汉密顿抑郁量表(17项版本)评分均>17分,并排除既往有精神异常史者。32例患者随机抽签分为重复经颅磁刺激治疗组和对照组各16例,对照组仅给予常规治疗,重复经颅磁刺激治疗组在此基础上予以低频重复经颅磁刺激治疗,以60%最大刺激强度刺激双侧额叶,每侧刺激30次,频率0.5Hz,每日一序列,连续治疗7d。两组治疗期间均停用抗抑郁药物。于治疗前、后观察两组汉密顿抑郁量表评分及临床神经功能缺损程度评分的变化,以及两组患者抑郁症状改善率。结果:按意向处理分析,32例患者均完成了治疗,治疗期间无显著不适应现象。①重复经颅磁刺激治疗组平均汉密顿抑郁量表评分治疗后较治疗前明显降低(25.9±5.2,15.4±6.7),较对照组治疗后评分也明显降低(22.4±7.1),治疗组自身前后比较及治疗组与对照组治疗后比较差异均有显著性意义(t=4.97,3.43,P<0.01)。②重复经颅磁刺激治疗组临床神经功能缺损程度评分评分治疗后(12.6±4.6)较治疗前评分(18.3±4.8)明显降低(t=3.43,P<0.01),较对照组治疗后评分(16.6±4.7)也有所降低(t=2.43,P<0.05)。③重复经颅磁刺激治疗组治疗后抑郁症状改善有效率88%(14/16),对照组为12%(2/16)。两组有效率比较差异意义明显(χ2=31.64,P<0.01)。结论:0.5Hz低频重复经颅磁刺激可改善脑卒中后抑郁患者的抑郁症状,减轻患者的神经功能缺损程度,且患者无特殊不适应现象。