Assessment of pain in the neonate Maxwell, Lynne G; Malavolta, Carrie P; Fraga, Maria V
Clinics in perinatology,
09/2013, Letnik:
40, Številka:
3
Journal Article
Recenzirano
Accurate pain assessment in preterm and term neonates in the neonatal intensive care unit (NICU) is of vital importance because of the high prevalence of painful experiences in this population, ...including both daily procedural pain and postoperative pain. Over 40 tools have been developed to assess pain in neonates, and each NICU should choose a limited number of pain assessment tools for different populations and contexts. Only two pain assessment tools have a metric adjustment to account for differences of pain assessment in prematurity. Preterm neonates do not display behavior and physiologic indicators of pain as reliably and specifically as full term infants, and preterm infants are vulnerable to long term sequelae of painful experiences. "Brain-oriented" approaches for more objective measurement of pain in neonates may become available in the future. In the meantime, neonatal pain assessment tools need to be taught, implemented, and their ongoing use optimized to form a consistent, reproducible basis for the safe and effective treatment of neonatal pain.
Urinary tract infections (UTI) are often over-diagnosed and over-treated, which can induce and select for resistant pathogens. After observing wide-spread outpatient use of ertapenem, a ...broad-spectrum antibiotic, a structured antimicrobial stewardship initiative (ASI) to improve appropriate antimicrobial prescribing was undertaken. ASI objectives were to achieve a goal of reducing ertapenem utilization for extended spectrum beta lactamase Enterobacteriaceae (ESBL-EB) UTI by 10% and evaluate the clinical outcomes associated with the ASI.
A pre-to-post cohort study was conducted at a single-center integrated healthcare system between November 1, 2014 and February 26, 2017. An intensive, 90-day, pharmacist-driven, structured ASI was implemented between November 1, 2015 and January 29, 2016. Female patients aged ≥18 years who were treated for an uncomplicated, ESBL-EB urinary tract infection (UTI) were included. Primary outcome was clinical resolution defined as cure, persistence, relapse and recurrence. Secondary outcome measured was monthly ertapenem use expressed as number of days of therapy (DOT)/1000 adjusted patient days (APD). Segmented regression analysis for interrupted time series was performed to estimate ASI intervention effect.
A total of 184 patients were included in the study. Ertapenem utilization decreased from 0.0145 DOT/1000 APD in Nov. 2014 to 0.0078 DOT/1000 APD Feb. 2017(p < 0.01). The mean ertapenem DOT declined 19% overall from the pre vs. post intervention periods (32 vs 26, p < 0.01). Frequency of recurrent UTIs between treatments did not significantly differ and no adverse effects were reported in patients treated with aminoglycosides.
A structured ASI for uncomplicated ESBL-EB UTI was associated with a clinically meaningful decrease in ertapenem utilization and once-daily, 5-day aminoglycoside treatment was well-tolerated.
Doubly labelled water (DLW) is considered the reference standard method of measuring total energy expenditure (TEE), but there is limited information on its use in the Intensive Care Unit (ICU) and ...acute care setting. This scoping review aims to systematically summarize the available literature on TEE measured using DLW in these contexts.
Four online databases (MEDLINE, Embase, Emcare and CINAHL) were searched up to Dec 12, 2020. Studies in English were included if they measured TEE using DLW in adults in the ICU and/or acute care setting. Key considerations, concerns and practical recommendations were identified and qualitatively synthesized.
The search retrieved 7582 studies and nine studies were included; one in the ICU and eight in the acute care setting. TEE was measured over 7–15-days, in predominantly clinically stable patients. DLW measurements were not commenced until four days post admission or surgery in one study and following a 10–14-day stabilization period on parenteral nutrition (PN) in three studies. Variable dosages of isotopes were administered, and several equations used to calculate TEE. Four main considerations were identified with the use of DLW in these settings: variation in background isotopic abundance; excess isotopes leaving body water as carbon dioxide or water; fluctuations in rates of isotope elimination and costs.
A stabilization period on intravenous fluid and PN regimens is recommended prior to DLW measurement. The DLW technique can be utilized in medically stable ICU and acute care patients, with careful considerations given to protocol design.
Background
There is growing interest in computed tomography (CT) measures of skeletal muscle cross‐sectional area (CSA) for nutrition assessment. Multiple software programs are available, but little ...work has been done comparing programs. We aimed to determine if CT–derived measures of skeletal muscle CSA at the level of the L3 are influenced by the software program used. We also demonstrate the importance of the ImageJ corrigendum published in this journal.
Methods
Two software programs, National Institutes of Health ImageJ and Tomovision sliceOmatic, were compared. ImageJ measures were obtained using both the original tutorial and corrigendum instructions. Skeletal muscle CSA at the level of the L3 was measured in advanced heart failure and head and neck cancer populations by 3 different investigators. Intraclass correlation coefficients were used to calculate intrarater and interrater reliability. Bland‐Altman analysis was used to assess agreement.
Results
Both software programs yielded excellent intrarater and interrater reliability scores (intraclass correlation coefficients, 0.985–1.000). The overall mean difference (ImageJ tutorial with corrigendum − sliceOmatic) for the entire sample (N = 51) was found to be 1.53 cm2 (95% CI, 0.59–2.47 cm2). The overall mean difference (ImageJ corrected − original) for the entire sample (N = 51) was found to be −11.35 cm2 (95% CI, −12.75 to −9.95 cm2).
Conclusion
Measures of skeletal muscle CSA at the L3 were found to be ∼1.53 cm2 higher with ImageJ than sliceOmatic. This difference was not found to affect interpretation against a published cut point. The importance of accounting for the ImageJ tutorial corrigendum was shown to be clinically significant when applied to published cut points.
Background
No global consensus exists on diagnostic criteria for malnutrition. Muscular deficits and functional impairments are major components of available malnutrition diagnostic frameworks ...because these facets of nutrition status significantly impact outcomes. The purpose of this review is to explore which body composition assessment (BCA) and functional status assessment (FSA) tools are being used for nutrition assessment (NA) and monitoring the response to nutrition interventions (RNIs) in adult inpatients.
Methods
A literature search of Embase, Medline (Ovid), Web of Science, and Cochrane Central was performed to identify studies that used BCA and/or FSA tools for NA (along with an accepted NA diagnostic framework) and/or for monitoring RNI in adult inpatients.
Results
The search yielded 3667 articles; 94 were included in the review. The number of studies using BCA and/or FSA tools for NA was 47 and also 47 for monitoring RNI. Seventy‐nine percent of studies used bioimpedance for BCA, and 97% that included FSA utilized handgrip strength. When compared against sets of diagnostic criteria, many of the BCA and FSA tools showed promising associations with nutrition status.
Conclusion
Bioimpedance methods are the most widely used bedside BCA tools, and handgrip strength is the most widely used FSA tool; however, these methods are being used with a variety of protocols, algorithms, and interpretation practices in heterogeneous populations. To create a standardized nutrition status assessment process there is a need for validation studies on bedside methods and the development of globally standardized assessment protocols in clinical inpatient settings.
Background
The risk of infection with avian influenza A viruses currently circulating in wild and domestic birds in the Americas is considered low for the general public; however, detections in ...humans have been reported and warning signs of increased zoonotic potential have been identified. In December 2022, two Canada geese residing on the grounds of an urban hospital in Maine tested positive for influenza A H5N1 clade 2.3.4.4b.
Aims
Given the opportunity for exposure to staff and hospital visitors through potentially infected faeces on the property, public health authorities determined mitigation efforts were needed to prevent the spread of disease. The ensuing response relied on collaboration between the public health and animal health agencies to guide the hospital through efforts in preventing possible zoonotic transmission to humans.
Materials and Methods
Mitigation efforts included staff communication and education, environmental cleaning and disinfection, enhanced illness surveillance among staff and patients, and exposure and source reduction.
Results
No human H5N1 cases were identified, and no additional detections in birds on the property occurred. Hospital staff identified barriers to preparedness resulting from a lack of understanding of avian influenza A viruses and transmission prevention methods, including avian influenza risk in resident wild bird populations and proper wildlife management methods.
Conclusion
As this virus continues to circulate at the animal‐human interface, this event and resulting response highlights the need for influenza A H5N1 risk awareness and guidance for facilities and groups not traditionally involved in avian influenza responses.
Background: Using the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition (Academy/ASPEN) Consensus malnutrition definition, we estimated malnutrition ...prevalence in a sample of individuals with head and neck cancer (HNC) and compared it with the Patient‐Generated Subjective Global Assessment (PG‐SGA). We also investigated the utility of the 50‐kHz phase angle (PA) and 200‐kHz/5‐kHz impedance ratio (IR) to identify malnutrition. Materials and Methods: Nineteen individuals (18 males, 1 female) scheduled to undergo chemoradiotherapy were seen at 5 time points during and up to 3 months after treatment completion. Multiple‐frequency bioelectrical impedance analysis, PG‐SGA, nutrition‐focused physical examination, anthropometry, dietary intake, and handgrip strength data were collected. Results: Using the Consensus, 67% were found to be malnourished before treatment initiation; these criteria diagnosed malnutrition with overall good sensitivity (94%) and moderate specificity (43%) compared with PG‐SGA. Over all pooled observations, “malnourished” (by Consensus but not PG‐SGA category) had a lower mean PA (5.2 vs 5.9; P = .03) and higher IR (0.82 vs 0.79; P = .03) than “well‐nourished” categorizations, although the clinical relevance of these findings is unclear. PA and IR were correlated with higher PG‐SGA score (r = −0.35, r = 0.36; P < .01) and handgrip strength (r = 0.48, r = −0.47; P < .01). Conclusion: The Academy/ASPEN Consensus and the PG‐SGA were in good agreement. It is unclear whether PA and IR can be used as surrogate markers of nutrition status or muscle loss.
Developmental dyslexia (DD) and attention-deficit/hyperactivity disorder (ADHD) are two of the most common neurodevelopmental disorders among school-age children. These disorders frequently co-occur, ...with up to 40–50% of children with one diagnosis meeting criteria for the other, and similar percentages of children with either DD or ADHD exhibiting impaired executive functions (EF). Although both ADHD and EF deficits are common in dyslexia, there is little evidence about how ADHD and EF deficits specifically influence the brain basis of reading difficulty in dyslexia, and whether the influences of ADHD and EF on dyslexia can be disentangled. The goal of the current study was to investigate, at both behavioral and brain levels, whether reading performance in individuals with dyslexia is more strongly associated with EF or with diagnostic status of comorbid ADHD. We examined reading abilities and EF in children (8-13 years old) with typical reading ability, DD only, or both DD + ADHD. Across both groups with dyslexia, impaired EF was associated with greater impairment on measures loading onto a reading fluency, but not a reading accuracy, factor. There were no significant differences between the DD and DD + ADHD groups on measures of reading fluency or reading accuracy. During functional magnetic resonance imaging (fMRI) while performing a rhyme-matching reading task requiring phonological awareness, typically developing readers showed greater left-hemisphere reading network activation than children with DD or DD + ADHD. Children with DD and DD + ADHD did not show differential activation, but DD children with unimpaired EF showed greater activation than those with impaired EF in reading-related areas. Thus, ADHD status alone had no measurable influence on reading performance or brain activation. Impaired EF in dyslexia, independent of ADHD status, was associated with greater deficits in reading fluency and greater reductions of activation in response to print in the typical left-hemisphere reading network.
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