Faces scales for the measurement of postoperative pain intensity in children following minor surgery

OBJECTIVES: Faces scales are commonly used to obtain self-reports of pain intensity from children. Previous research using hypothetical vignettes and pain following venepuncture has found differences in children's pain ratings as a function of the type of faces scale used. The purpose of the present study was to determine whether scales beginning with a smiling rather than neutral "no pain" face would produce higher ratings in the assessment of postoperative pain intensity in children and to compare ratings using different faces scales to those reported with an additional independent measure of pain intensity. METHODS: Participants were 78 children between the ages of 5 and 13 years undergoing surgery, one of their parents, and their postoperative care nurse. Following surgery, children were asked to provide a rating of their current pain intensity using a set of 5 successively administered faces scales and the Colored Analog Scale (CAS). Parents and nurses provided independent ratings using the same measures. RESULTS: Results showed that parents and nurses rated significantly more pain when using scales with a smiling rather than a neutral "no pain" face. This pattern was not as clear for the children's ratings, although their highest ratings were provided when using a smiling "no pain" faces scale. Children's and nurses' ratings on the CAS were generally more similar to their ratings using scales with neutral "no pain" faces, whereas parents' CAS ratings tended to fall in between ratings provided on the smiling and neutral "no pain" faces scales. Scale preference, age and sex differences in pain ratings, and child-parent-nurse agreement in pain ratings are also examined. DISCUSSION: Children's and parents' ratings of postoperative pain intensity are influenced by the presence of a smiling "no pain" face at the beginning of faces scales, with such scales producing significantly higher ratings than scales with neutral "no pain" faces. Ratings on the independent CAS measure were more comparable to those provided on faces scales with neutral "no pain" faces. Nurses are also susceptible to the influencing effect of a smiling face at the beginning of a faces scale.     

Hb Kenya among Luo adults and young children in malaria holoendemic Western Kenya: screened by high performance liquid chromatography and confirmed by polymerase chain reaction

Hb Kenya, a fusion hemoglobin (Hb) resulting from a crossover between the (A)gamma- and beta-globin genes, is accompanied by an increased level of fetal Hb (Hb F) in adult life. This study describes the use of cation exchange high performance liquid chromatography (HPLC) in the identification of Hb Kenya and of a polymerase chain reaction (PCR) method for confirmatory diagnosis. Data came from 584 children and 406 adults who were screened for eligibility for malaria vaccine trials at Kombewa, Western Kenya. Sixteen subjects (13 children and three adults) had elevated Hb F (5.0-28.4%; normal <5.0%). Of these, 11 had an apparent markedly elevated Hb A(2) (9.2-22.9%) and were confirmed by gap-PCR as having the 22.7 kb deletion characteristic of Hb Kenya. Of the five cases with elevated Hb F but normal A(2), none had Hb Kenya. We propose that in this population, the finding by cation exchange HPLC of an elevated Hb F (>9.0%) and of an apparently increased Hb A(2) (>9.2%), may suggest the presence of Hb Kenya. However, given the inability of differentiating Hb Kenya from a truly elevated Hb A(2) by routine cation exchange HPLC, it is imperative to confirm the Hb Kenya mutation by gap-PCR.     

Consensus guidelines for sustained neuromuscular blockade in critically ill children

BACKGROUND: The United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group is a multidisciplinary expert panel created to produce consensus guidelines on sedation, analgesia and neuromuscular blockade in critically ill children and forward knowledge in these areas. Neuromuscular blockade is recognized as an important element in the care of the critically ill and adult clinical practice guidelines in this area have been available for several years. However, similar clinical practice guidelines have not previously been produced for the critically ill pediatric patient. METHODS: A modified Delphi technique was employed to allow the Working Group to anonymously consider draft recommendations in up to three Delphi rounds with predetermined levels of agreement. This process was supported by a total of four consensus conferences and once consensus had been achieved, a systematic review of the available literature was carried out. RESULTS: A set of consensus guidelines was produced including six key recommendations. An evaluation of the existing literature supporting these recommendations is provided. CONCLUSIONS: Multidisciplinary consensus guidelines for maintenance neuromuscular blockade in critically ill children (excluding neonates) have been successfully produced and are supported by levels of evidence. The Working Group has highlighted the paucity of high quality evidence in these important clinical areas and this emphasizes the need for further randomized clinical trials in this area.     

Plasma concentrations of flumazenil following intranasal administration in children

PURPOSE: A pharmacokinetic study in children to determine plasma flumazenil concentrations after the intranasal administration of 40 microg x kg(-1). METHODS: Following institutional approval and informed written consent, 11 ASA physical status I-II patients, aged two to six years, undergoing general anesthesia for dental surgery were recruited. After induction, 40 microg x kg(-1) flumazenil Anexate, Roche, 0.1 mg x mL(-1) (0.4 mL x kg(-1))) were administered via a syringe as drops, prior to nasal intubation. Venous plasma samples were drawn prior to administration of flumazenil (t = 0), and then at 2, 4, 6, 8, 10, 15, 20, 30, 40, 60, and 120 min thereafter. The plasma samples were immediately processed by the on-site laboratory and then stored at -70 degrees C, before batch analysis via high performance liquid chromatography assay. Pharmacokinetic data calculations were performed using WinNonLin software (Scientific Consulting Inc.). RESULTS: Eleven patients were studied, but data for one patient were discarded due to insufficient sampling. The median age was 4.3 yr (range 3 to 6), with a median weight of 18.9 kg (range 14.9 to 22.2). There were seven boys and three girls. Mean Cmax was 67.8 ng x mL(-1) (SD 41.9), with Tmax at two minutes. The calculated half-life was 122 min (SD 99). CONCLUSION: The mean plasma concentrations of flumazenil attained were similar to those reported after intravenous administration, and may be sufficient to antagonize the side-effects of benzodiazepines. This route of administration may be useful when the intravenous route is not readily available.     

Absence of capsular contracture in 319 consecutive augmentation mammaplasties: Dependent drains as a possible factor

Capsular contracture is one of the major complications of augmentation mammaplasty. A review of 638 augmented breasts in 319 consecutive patients who underwent primary augmentation, with an average follow-up of 17.2 months and without a single case of capsular contracture of any degree to date, is presented, along with a discussion of the surgical technique and complications, and an analysis of measures used to prevent capsular contraction. Each patient received a pair of smooth saline-filled implants (Mentor, USA) placed in the submuscular space through an inframammary incision. In all operated breasts, many of the known measures commonly used for capsular contracture prevention were implemented. As well, a dependent drain was used as the final hemostatic step to prevent blood accumulation in the pocket. Leaving a dependent drain in the dissected pocket overnight, as one of the sequence of measures aimed at eliminating blood accumulation, is believed to be a contributing factor in capsular contracture prevention.     

The influence of individual characteristics and contraceptive beliefs on parent-teen sexual communications: A structural model

PurposeTo explore relationships between parent and teen demographic characteristics, parent beliefs about the effectiveness, safety and usability of condoms and oral contraceptives, and parent-teen sexual communication.MethodsOne thousand parents of 13–17-year-olds were surveyed. Structural equation modeling was used to test direct and indirect relationships between parent and teen characteristics, parent effectiveness beliefs, and amount of parent-teen communication about the negative consequences of sex and where to obtain birth control.ResultsParent effectiveness beliefs were directly related to parent-teen communication levels. Minority, religious, politically conservative, and low income parents reported lower effectiveness beliefs than other parent groups. Low income, minority parents reported more discussion with their teens about the negative consequences of sex and where to obtain birth control than high income, White parents. Politically conservative, religious parents reported more discussion with their teen about the negative consequences of sex than their liberal and nonreligious counterparts. In general, nonreligious parents reported more discussion about where to obtain birth control than religious parents. Parents were less likely to talk with males, younger teens, and teens not believed to be romantically involved. Parent and teen gender interacted to predict the amount of parent-teen communication.ConclusionsParent beliefs about condom and oral contraceptive efficacy, safety and usability related directly to amount of parent-teen sexual communication. Parent beliefs and communication levels varied across a number of demographic groups. Educating parent groups may result in more frequent and accurate sexual communications with their teenage children.