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Objective: To determine the efficacy of 25% oral sucrose in the reduction of pain during a heel lance procedure in sick hospitalized infants. Methodology: In a blinded randomized- controlled trial, hospitalized infants were given either 1 mL 25% sucrose or 1 mL water 2 min prior to a heel lance procedure. Pain assessment comprised a four-point facial expression score, incidence and duration of crying, heart rate and oxygen saturation changes. Results: A total of 128 infants were included. Facial scores immediately upon heel lance, and at 1 and 2 min in the recovery period were reduced in the treatment (sucrose) group compared to the placebo (water) group (P

The Nurse Practitioner role is currently being implemented in most Australian states. This model of practice has existed overseas, predominantly in North America, for many years. The experiences of those countries can help inform the implementation of the role in Australia. This paper reviews the overseas literature concerning one practice context, that of the Neonatal Nurse Practitioner. The scope of the role, issues surrounding educational preparation, impact of the role on health outcomes, and factors identified as facilitating and constraining the role, are all discussed. The implications for the Australian context are highlighted.

Objective To evaluate a method of pain assessment to be used for hospitalized infants requiring blood test by a heel lance procedure. Design Observational study evaluating pain measurement and interrater reliability of pain measurement in hospitalized infants. Setting A Level III neonatal unit and a cardiac surgical unit at a major pediatric teaching hospital. Participants 20 infants whose gestational age ranged from 28 weeks to full-term. Main Outcome Measures Observations included behavioral measurements (facial expressions, body movements, and crying characteristics) and the physiologic measure of heart rate. Interrater reliability and the feasibility of using the procedural pain assessment method at the bedside were considered. Results The three behavioral measurements and heart rate were responsive to the heel lance. Interrater reliability was high for facial expressions and crying scores but was low for body movements. Conclusions Modifications have been made to the method of procedural pain assessment to be used in a subsequent study. The modified method is expected to be a reliable measure of procedural pain caused by a heel lance and can easily be used at the bedside during the course of further research.

A sub-analysis was conducted of data from a study of prolonged use of sucrose for hospitalized infants (N=50 infants) during heel lancing. Results showed that pain responses differed when opioid analgesics were administered concomitantly with sucrose (n=79 pain assessments), than when sucrose was administered alone (n=364 pain assessments).

Background Randomised controlled trials (RCTs) show that breastfeeding newborn infants during painful procedures reduces pain. Mechanisms are considered to be multifactorial and include sucking, skin-to-skin contact, warmth, rocking, sound and smell of the mother, and possibly endogenous opiates present in the breast milk. Objectives To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin-to-skin contact, expressed breast milk, formula milk, bottle feeding, sweet-tasting solutions (e.g. sucrose or glucose), distraction, or other interventions. Search methods We searched the following databases to 18 February 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE including In-Process & Other Non-Indexed Citations (OVID), Embase (OVID), PsycINFO (OVID), and CINAHL (EBSCO); the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (apps.who.int/trialsearch/) for ongoing trials. Selection criteria We included RCTs and quasi-RCTs involving infants aged 28 days postnatal to 12 months and receiving breastfeeding while undergoing a painful procedure. Comparators included, but were not limited to, oral administration of water, sweet-tasting solutions, expressed breast or formula milk, no intervention, use of pacifiers, positioning, cuddling, distraction, topical anaesthetics, and skin-to-skin care. Procedures included, but were not limited to: subcutaneous or intramuscular injection, venipuncture, intravenous line insertion, heel lance, and finger lance. We applied no language restrictions. Data collection and analysis We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. The main outcome measures were behavioural or physiological indicators and composite pain scores, as well as other clinically important outcomes reported by the authors of included studies. We pooled data for the most comparable outcomes and where data from at least two studies could be included. We used mean difference (MD) with 95% confidence interval (CI), employing a random-effects model for continuous outcomes measured on the same scales. For continuous outcomes measured on different scales, we pooled standardised mean differences (SMDs) and associated 95% CIs. For dichotomous outcomes, we planned to pool events between groups across studies using risk ratios (RRs) and 95% CIs. However, as insufficient studies reported dichotomous outcomes, we did not pool such events. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results We included 10 studies with a total of 1066 infants. All studies were conducted during early childhood immunisation. As the breastfeeding intervention cannot be blinded, we rated all studies as being at high risk of bias for blinding of participants and personnel. We assessed nine studies as being at low risk of bias for incomplete outcome data. In addition, we rated nine studies as high risk for blinding of outcome assessment. We scored risk of bias related to random sequence generation, allocation concealment, and selective reporting as unclear for the majority of the studies due to lack of information. Our primary outcome was pain. Breastfeeding reduced behavioural pain responses (cry time and pain scores) during vaccination compared to no treatment, oral water, and other interventions such as cuddling, oral glucose, topical anaesthetic, massage, and vapocoolant. Breastfeeding did not consistently reduce changes in physiological indicators, such as heart rate. We pooled data for duration of cry from six studies (n = 547 infants). Breastfeeding compared to water or no treatment resulted in a 38-second reduction in cry time (MD -38, 95% CI -50 to -26; P < 0.00001). The quality of the evidence according to GRADE for this outcome was moderate, as most infants were 6 months or younger, and outcomes may be different for infants during their 12-month immunisation. We pooled data for pain scores from five studies (n = 310 infants). Breastfeeding was associated with a 1.7-point reduction in standardised pain scores (SMD -1.7, 95% CI -2.2 to -1.3); we considered this evidence to be of moderate quality as data were primarily from infants younger than 6 months of age. We could pool heart rate data following injections for only two studies (n = 186); we considered this evidence to be of low quality due to insufficient data. There were no differences between breastfeeding and control (MD -3.6, -23 to 16). Four of the 10 studies had more than two study arms. Breastfeeding was more effective in reducing crying duration or pain scores during vaccination compared to: 25% dextrose and topical anaesthetic cream (EMLA), vapocoolant, maternal cuddling, and massage. No included studies reported adverse events. Authors' conclusions We conclude, based on the 10 studies included in this review, that breastfeeding may help reduce pain during vaccination for infants beyond the neonatal period. Breastfeeding consistently reduced behavioural responses of cry duration and composite pain scores during and following vaccinations. However, there was no evidence that breastfeeding had an effect on physiological responses. No studies included in this review involved populations of hospitalised infants undergoing other skin-breaking procedures. Although it may be possible to extrapolate the review results to this population, further studies of efficacy, feasibility, and acceptability in this population are warranted.

BACKGROUND: Despite the evidence and availability of numerous validated pain assessment tools and pain management strategies for infants and children, their use remains inconsistent in clinical practice.OBJECTIVES: To describe the prevalence of pain, pain assessment and pain management practices at a tertiary pediatric hospital in Canada.METHODS: The cross-sectional study design involved a combination of interviews with children and/or caregivers, and chart audits in five inpatient units. Information regarding pain intensity, painful procedures and pain management strategies was obtained from children and/or caregivers by interview. Patient charts were reviewed for information regarding pain assessment, pain scores, and pharmacological and nonpharmacological interventions.RESULTS: Sixty-two children (four days to 17 years of age) participated. Most children or their caregivers (n=51 [84%]) reported that pain was experienced during their hospitalization, with 40 (66%) reporting their worst pain as moderate or severe. Almost one-half reported analgesics were administered before or during their most recent painful procedure. Nineteen (32%) reported sucrose, topical anesthetics or nonpharmacological interventions were used; however, they were documented in only 17% of charts. Pain scores were documented in 34 (55%) charts in the previous 24 h. The majority of the children or their caregiver (n=44 [71%]) were satisfied with pain management at the study hospital.CONCLUSIONS: Most infants and children had experienced moderate or severe pain during their hospitalization. Analgesics were frequently used, and although nonpharmacological strategies were reported to be used, they were rarely documented. Most parents and children were satisfied with their pain management.

Strategies to target viral replication to tumor cells hold great promise for the treatment of cancer, but even with replicating adenoviruses complete tumor responses are rarely achieved. To evaluate replicating adenoviral vectors, we have used A549 human lung cancer nude mouse xenografts as a model system. Intratumoral injection of wild-type adenovirus (Ad309) significantly reduced tumor growth from day 14 (p = 0.04) onward; however, tumor volumes reached a plateau at day 50. At 100 days, high levels of titratable virus were present within persistent viable tumors. In contrast to viral injection into established tumors, when tumor cells were infected in vitro with wild-type virus and then mixed with uninfected tumor cells, 1% of infected cells was sufficient to prevent tumor establishment. An E1b-19kD-deleted viral mutant (Ad337) was more efficient than Ad309 in this cell-mixing model. Just 1 cell in 1000 infected with Ad337 prevented tumor growth. However, although better than wild-type virus, Ad337 was unable to eradicate established flank tumors. These data suggest that although replicating adenoviruses exhibit significant oncolytic activity, barriers within the established tumor, such as connective tissue and tumor matrix, may limit the spread of virus. Strategies to enhance viral spread through established tumors are therefore likely to greatly improve the therapeutic efficacy of replicating adenoviruses.

Abundant evidence demonstrates pain-reducing effects of sweet solutions in human infants and animals. Analgesic effects persist up to around 1 year of age in human infants, although the effects are more moderate than seen in the neonatal period. Effects are considered to be due to the relationship between sweet taste and the endogenous opiate system. Yet, despite extensive research, knowledge gaps remain relating to the exact mechanisms, the effectiveness and safety of sweet solutions when given over prolonged periods to preterm and sick infants, the effectiveness in sick infants receiving concomitant analgesics, and the effectiveness in children older than 12 months of age. Based on the extensive evidence to support sweet solutions, their use can be recommended prior to commonly performed short lasting minor painful procedures in newborn and young infants.

Background: World Trade Center (WTC) rescue and recovery workers were exposed to a complex mix of pollutants and carcinogens. Objective: The purpose of this investigation was to evaluate cancer incidence in responders during the first 7 years after 11 September 2001. Methods: Cancers among 20,984 consented participants in the WTC Health Program were identified through linkage to state tumor registries in New York, New Jersey, Connecticut, and Pennsylvania. Standardized incidence ratios (SIRs) were calculated to compare cancers diagnosed in responders to predicted numbers for the general population. Multivariate regression models were used to estimate associations with degree of exposure. Results: A total of 575 cancers were diagnosed in 552 individuals. Increases above registry-based expectations were noted for all cancer sites combined (SIR = 1.15; 95% CI: 1.06, 1.25), thyroid cancer (SIR = 2.39; 95% CI: 1.70, 3.27), prostate cancer (SIR = 1.21; 95% CI: 1.01, 1.44), combined hematopoietic and lymphoid cancers (SIR = 1.36; 95% CI: 1.07, 1.71), and soft tissue cancers (SIR = 2.26; 95% CI: 1.13, 4.05). When restricted to 302 cancers diagnosed ≥ 6 months after enrollment, the SIR for all cancers decreased to 1.06 (95% CI: 0.94, 1.18), but thyroid and prostate cancer diagnoses remained greater than expected. All cancers combined were increased in very highly exposed responders and among those exposed to significant amounts of dust, compared with responders who reported lower levels of exposure. Conclusion: Estimates should be interpreted with caution given the short follow-up and long latency period for most cancers, the intensive medical surveillance of this cohort, and the small numbers of cancers at specific sites. However, our findings highlight the need for continued follow-up and surveillance of WTC responders.

BACKGROUND: The Face, Legs, Activity, Cry, Consolability (FLACC) scale is a five-item tool that was developed to assess postoperative pain in young children. The tool is frequently used as an outcome measure in studies investigating acute procedural pain in young children; however, there are limited published psychometric data in this context.OBJECTIVE: To establish inter-rater and intrarater agreement of the FLACC scale in toddlers during immunization.METHODS: Participants comprised a convenience sample of toddlers recruited from an immunization drop-in service, who were part of a larger pilot randomized controlled trial. Toddlers were video- and audiotaped during immunization procedures. The first rater scored each video twice in random order over a period of three weeks (intrarater agreement), while the second rater scored each video once and was blinded to the first rater’s scores (inter-rater agreement). The FLACC scale was scored at four time-points throughout the procedure. Intraclass correlation coefficients were used to assess agreement of the FLACC scale.RESULTS: Thirty toddlers between 12 and 18 months of age were recruited, and video data were available for 29. Intrarater agreement coefficients were 0.88 at baseline, 0.97 at insertion of first needle, and 0.80 and 0.81 at 15 s and 30 s following the final injection, respectively. Inter-rater coefficients were 0.40 at baseline, 0.95 at insertion of first needle, and 0.81 and 0.78 at 15 s and 30 s following the final injection, respectively.CONCLUSIONS: The FLACC scale has sufficient agreement in assessing pain in toddlers during immunizations, especially during the most painful periods of the procedure.

Background Infant vaccinations are necessary for public health, but are painful, causing distress to the infant and caregivers. Breastfeeding and sucrose effectively reduce infants’ pain during vaccinations, and these strategies are recommended in health care provider (HCP)-targeted education and vaccination pain guidelines. However studies show these strategies are infrequently used. YouTube is a popular medium to publicly share and watch videos, and many consumer posted YouTube videos show distressed infants being vaccinated with no pain treatment. The aims of this study were to evaluate the reach and impact of a consumer-targeted YouTube video demonstrating use of effective pain reduction strategies during infant vaccinations. Methods A brief consumer-targeted video showing two infants being vaccinated was posted onto YouTube on October 2013. One infant was breastfed and another infant received sucrose by mouth before and during the injection. A link to a viewer survey was visible on a banner near the end of the video. An intensive strategically planned knowledge dissemination strategy using the media, social media and messages to professional organizations took place to promote the video. Data analysis of the viewer survey, YouTube analytics of the reach of the video in terms of number of views, country of viewers, and comments relating to the video took place 12 months after the video was posted. Results Twelve months after posting, the video had 65,478views, 68 comments, 245 likes, 17 dislikes, and 90 shares. Average duration of viewer time was 65% of the video. The viewer survey was completed by 156 (0.24%) viewers; 90 (58%) answered as HCPs and 66 (42%) as parents. Survey results showed that the video was persuasive; intent to use or support breastfeeding or sucrose was high in both parents and HCPs after viewing the video. Comments posted were often emotional in nature, and were related to anti-vaccination (n = 26, 38%); effectiveness or positive personal experiences (n = 21, 32%); research team comments or promotion (n = 12, 18%); pro-vaccination (n = 6, 8%) and barriers to using breastfeeding or sucrose during vaccinations (n = 3, 4%). Conclusion The video posted onto YouTube demonstrating effective pain treatment during infant vaccinations was viewed by large numbers of people around the world, however the response rate to the linked survey was extremely low. Using YouTube videos for knowledge dissemination has an extensive reach, however it is difficult to evaluate impact on behaviours and practices.

This study examines how particular characteristics of news releases influence the media's news decisions. The hostile takeover attempt by Tustin, California-based MAI/Basic Four (MBF) to acquire a controlling interest in Natick, Massachusetts-based Prime Computer provides an arena in which to study journalists' use of companies' press releases. In order to measure the effectiveness of each company's press releases, the study, using an agenda setting framework, considered the number and types of press releases against subsequent press clippings in terms of length and content. Both quantity (number of column lines and average articles per company) and quality (lead and point of view) of newspaper coverage were examined. Supplementary explanatory information was also developed through interviews with the reporters who wrote the newspaper stories.

Early thrombosis (ET) contributes to autogenous arteriovenous fistula (AVF) failure. We studied patients undergoing AVF placement in the Hemodialysis Fistula Maturation Study, a prospective, observational cohort study, using a nested case-control analysis to identify preoperative and intraoperative predictors of ET.ET cases were compared with controls, who were matched for gender, age, diabetes, dialysis status, and surgeon fistula volume. ET was defined as thrombosis diagnosed by physical examination or ultrasound within 18 days of AVF creation. Conditional logistic regression models were fit to identify risk factors for ET.Thirty-two ET cases (5.3%) occurred among 602 study participants; 198 controls were matched. ET was associated with female gender (odds ratio [OR], 2.75; 95% confidence interval [CI], 1.19-6.38; P = .018), fistula location (forearm vs upper arm; OR, 2.76; 95% CI, 1.05-7.23; P = .039), feeding artery (radial vs brachial; OR, 2.64; 95% CI, 1.03-6.77; P = .043) and arterial diameter (OR, 1.52; 95% CI, 1.02-2.26; P = .039, per mm smaller). The draining vein diameter was nonlinearly associated with ET, with highest risk in 2- to 3-mm veins. Surprisingly, ET risk was lower in diabetics (OR, 0.19; 95% CI, 0.07-0.47; P = .0004), lower with less nitroglycerin-mediated brachial artery dilation (OR, 0.42; 95% CI, 0.20-1.92; P = .029 for each 10% lower) and higher with lower carotid-femoral pulse wave velocity (OR, 1.49; 95% CI, 1.02-2.20; P = .041, for each m/s lower). Intraoperative protamine use was associated with a higher ET risk (OR, 3.26; 95% CI, 1.28-∞; P = .038). Surgeon's intraoperative perceptions were associated with ET: surgeons' greater concern about maturation success (likely, marginal, unlikely) was associated with higher thrombosis risk (OR, 8.09; 95% CI, 4.03-∞; P.0001, per category change), as were absence vs presence of intraoperative thrill (OR, 21.0; 95% CI, 5.07-∞; P = .0001) and surgeons' reported frustration during surgery (OR, 6.85; 95% CI, 2.70-∞; P = .0004). Decreased extent of intraoperative thrill (proximal, mid or distal third of the forearm or upper arm, based on AVF placement) was also associated with ET (OR, 2.91; 95% CI, 1.31-∞; P = .007, per diminished level). Oral antithrombotic medication use was not significantly associated with ET.ET was found to be associated with female gender, forearm AVF, smaller arterial size, draining vein diameter of 2 to 3 mm, and protamine use. Paradoxically, diabetes and stiff, noncompliant feeding arteries were associated with a lower frequency of ET. Absent or attenuated intraoperative thrill, and both surgeon frustration and concern about successful maturation during surgery, were correlated strongly with ET.

The use of oral sucrose has been the most extensively studied pain intervention in newborn care to date. More than 150 published studies relating to sweet-taste-induced calming and analgesia in human infants have been identified, of which 100 (65%) include sucrose. With only a few exceptions, sucrose, glucose, or other sweet solutions reduced pain responses during commonly performed painful procedures in diverse populations of infants up to 12 months of age. Sucrose has been widely recommended for routine use during painful procedures in newborn and young infants, yet these recommendations have not been translated into consistent use in clinical practice. One reason may be related to important knowledge and research gaps concerning analgesic effects of sucrose. Notably, the mechanism of sweet-taste-induced analgesia is still not precisely understood, which has implications for using research evidence in practice. The aim of this article is to review what is known about the mechanisms of sucrose-induced analgesia; highlight existing evidence, knowledge gaps, and current controversies; and provide directions for future research and practice.

Chloral hydrate is generally considered a safe and effective single dosing procedural sedative for neonates in the clinical setting. However, its safety profile as a repetitive dosing maintenance sedative is largely unknown. This study aimed to document current administration practices of chloral hydrate in the Neonatal Unit, Royal Children's Hospital, Melbourne, Australia, over a 6-month period.Patients who had been prescribed chloral hydrate during the specified audit period were recruited into the study and prospectively followed for a period of 28 days, or until they were discharged from the unit. Demographic data were collected on recruitment, and daily documentation of chloral hydrate administration was recorded.A total of 238 doses of chloral hydrate were administered to a cohort of 32 patients during the study period. The majority of the audited doses (84%) were ordered as repeating doses. Doses were more likely to be given at night than during the day, and the median dosage for repetitive dosing was found to be above the study site's recommended dosing range. Pre-dose and/or post-dose assessment of distress/agitation accompanied dosage approximately half of the time. The audit did not reveal any recognisable pattern of sedation maintenance or weaning process for patients who received multiple doses.Health-care professionals caring for hospitalised infants should be made aware of the potential risks of chloral hydrate as a repetitive dosing sedative, and of the importance of systematically evaluating the appropriateness and effectiveness of utilising such pharmacological intervention for managing and treating distress.

The study aims to identify pain management practices used during scheduled childhood immunisation.A survey of members of the Australian Nurses Federation (Victorian Branch) Immunisation Nurses Special Interest Group. Questions included frequency of use of pain reduction strategies during immunisations for infants, toddlers and children, injection techniques and existence of an articulated pain management policy.The survey was emailed to 274 Immunisation Nurses Special Interest Group members with registered email addresses, and 125 (46%) completed the survey. Nineteen respondents (15.2%) stated their main place of employment had a pain management policy during immunisations and 20 (16.0%) respondents were not sure. Distraction strategies were frequently used during immunisation for all age groups, with 95 (76.0%) replying that distraction was used often or always. Breastfeeding during immunisation for infants younger than 6 months was used occasionally (n = 54, 44.6%), often (n = 11, 9.1%) or never (n = 55, 45.5%) and was used even less frequently for infants aged 6-12 months. Sucrose or other sweet solutions were almost never used for infants prior to, or during, immunisation. As a reward, lollies were frequently given to children after immunisations. Topical anaesthetics were almost never used in any age groups. Over half the respondents used a rapid injection technique; 55 (44.7%) used a slow technique and four respondents aspirated the needle before injections.Many distraction strategies were used during and following immunisation but sweet solutions, breastfeeding or topical anaesthetics were rarely used. Use of these strategies where feasible, should be facilitated in diverse settings where immunisations take place.

BackgroundThousands of rescue and recovery workers descended on the World Trade Center (WTC) in the wake of the terrorist attack of September 11, 2001 (9/11). Recent studies show that respiratory illness and post-traumatic stress disorder (PTSD) are the hallmark health problems, but relationships between them are poorly understood. The current study examined this link and evaluated contributions of WTC exposures.MethodParticipants were 8508 police and 12 333 non-traditional responders examined at the WTC Medical Monitoring and Treatment Program (WTC-MMTP), a clinic network in the New York area established by the National Institute for Occupational Safety and Health (NIOSH). We used structural equation modeling (SEM) to explore patterns of association among exposures, other risk factors, probable WTC-related PTSD [based on the PTSD Checklist (PCL)], physician-assessed respiratory symptoms arising after 9/11 and present at examination, and abnormal pulmonary functioning defined by low forced vital capacity (FVC).ResultsFewer police than non-traditional responders had probable PTSD (5.9% v. 23.0%) and respiratory symptoms (22.5% v. 28.4%), whereas pulmonary function was similar. PTSD and respiratory symptoms were moderately correlated (r=0.28 for police and 0.27 for non-traditional responders). Exposure was more strongly associated with respiratory symptoms than with PTSD or lung function. The SEM model that best fit the data in both groups suggested that PTSD statistically mediated the association of exposure with respiratory symptoms.ConclusionsAlthough longitudinal data are needed to confirm the mediation hypothesis, the link between PTSD and respiratory symptoms is noteworthy and calls for further investigation. The findings also support the value of integrated medical and psychiatric treatment for disaster responders.

The study aims to determine whether there has been improved uptake of the evidence for the management of procedural pain in neonates throughout Australia.An Australian-wide survey was undertaken to determine the use of breastfeeding and sucrose and whether a clinical practice guideline (CPG) or pain assessment tool was used.Data were available from 196 (91%) of the 215 eligible hospitals. A CPG informed the management of neonatal pain in 76 (39%) of the hospitals. There was wide variation in their use between the states, and a significantly higher use of a CPG in higher-level care units. A pain assessment tool was only used in 21 (11%) of the units with greater use in the higher level care neonatal intensive care units (50%) and surgical neonatal intensive care units (80%). Awareness of breastfeeding for procedural pain was reported by 90% of the 196 respondents while 78% reported that it was actually used. Awareness of sucrose for procedural pain was lower than breastfeeding at 79%, with 53% reporting that they used sucrose in their unit. Overall, 89% of the respondents reported that either breastfeeding or sucrose was used for the management of procedural pain in their units.There has been an increase in awareness and use of sucrose and breastfeeding for procedural pain in Australia since previous surveys were undertaken in 2004. Continued resources, local pain champions and a national interest group to promote the use of pain management for procedural pain in neonates are needed for continued uptake of the evidence.

Objective: Determine if World Trade Center (WTC) disaster responders had lowerlungfunctionandhigherbronchodilatorresponsivenessthanthosewith respiratory symptoms and conditions. Methods: We evaluated cardinal respiratory symptoms (dyspnea, wheezing, dry cough, productive cough) and determinedthedifferenceinFEV1,FVC, andbronchodilatorresponsiveness. Results: All respiratory symptoms were associated with a lower FEV1 and FVC, and a larger bronchodilator response. Responders reporting chronic productive cough, starting during WTC work and persisting, had a mean FEV1 109 mL lower than those without chronic persistent cough; their odds of having abnormally low FEV1 was 1.40 times higher; and they were 1.65 times as likely to demonstrate bronchodilator responsiveness. Conclusions: Responders reporting chronic persistent cough, wheezing or dyspnea at first medical examination were more likely to have lower lung function and bronchodilator responsiveness.

Background More than 20,000 responders have been examined through the World Trade Center (WTC) Medical Monitoring and Treatment Program since September 11, 2001. Studies on WTC firefighters have shown elevated rates of sarcoidosis. The main objective of this study was to report the incidence of “sarcoid like” granulomatous pulmonary disease in other WTC responders. Methods Cases of sarcoid like granulomatous pulmonary disease were identified by: patient self-report, physician report and ICD-9 codes. Each case was evaluated by three pulmonologists using the ACCESS criteria and only “definite” cases are reported. Results Thirty-eight patients were classified as “definite” cases. Six-year incidence was 192/100,000. The peak annual incidence of 54 per 100,000 person-years occurred between 9/11/2003 and 9/11/2004. Incidence in black responders was nearly double that of white responders. Low FVC was the most common spirometric abnormality. Conclusions Sarcoid like granulomatous pulmonary disease is present among the WTC responders. While the incidence is lower than that reported among firefighters, it is higher than expected. Am. J. Ind. Med. 54:175–184, 2011. © 2010 Wiley-Liss, Inc.

Background Various methods of pain assessment in infants have been trialled in the search for objective, specific, physiologic measures of responses to pain. Skin conductance (SC) measured in the palm of the hand or on the plantar aspect of the foot may be one such measure. SC in these sites reflects the emotional sweating due to sympathetic nerve activity. The skin conductance response (SCR), which results from filling and reabsorption of sweat in the sweat glands, has previously been suggested to be the most sensitive SC parameter of sympathetic nerve activity in response to painful stimulation. Aim To study SCRs within and between medically stable hospitalised infants while at rest. Methods SCRs were measured in infants during at least six periods of monitoring in a maximum 48-h period. Behavioural state was recorded throughout the data collection periods. Results SC recordings ( n = 91) from 15 infants during sleep showed that frequency of SCRs varied between 0 and 0.04 SCRs per second (SCRs/s), median 0.002 SCRs/s. 73% of the total variation was within-infant variation, with the remaining 27% of variation due to variation between the mean SCR values of different infants. Conclusion This pilot study contributes to establishing baseline phasic SC activity in hospitalised infants at rest by measuring SCRs. These data can be used as a reference for future studies to determine the validity and reliability of SC measurement in infants exposed to painful or stressful interventions within a neonatal unit.

A number of evidence-based consensus statements relating to pain in infants include recommendations concerning effective pain management during painful procedures. Yet numerous studies have shown that procedural pain remains poorly managed in neonatal intensive care units. The aim of this prospective clinical audit was to ascertain analgesics administered during skin-breaking, minor painful procedures occurring over the entire course of a hospitalization in a cohort of infants with a length of stay of 28 days or more. Data were collected on aspects relating to utilization of oral sucrose specifically for minor painful procedures as well as administration of opioid analgesics or other strong analgesics on the day the procedures were performed. A total of 3605 minor painful procedures were recorded for 55 infants during the study period, a mean of 65 minor procedures per infant. The majority of procedures recorded were heel lance (71%), followed by intravenous catheter insertion or venepuncture (14%). Either oral sucrose was specifically administered or background opioid analgesics were being administered during 85% of all minor painful procedures. These results show considerably higher frequency of analgesic use during acute minor painful procedures compared with similar studies of pain management practices in neonatal intensive care units. Perspective This study ascertained analgesics administered to sick infants during minor painful procedures during a prolonged hospitalization. Oral sucrose or morphine was administered during the most painful procedures, whereas 15% of procedures were performed with no analgesics. This illustrates a vast improvement compared with similar studies.

Neonates have blood work for newborn screening in their first days of life, and preterm and sick hospitalized infants often require repeated invasive needle-related procedures over the duration of their hospitalization. Reducing newborn infants' pain during such painful procedures is important and may reduce the risk of negative sequela of poorly treated procedural pain. High-quality synthesized evidence demonstrates analgesic effects of three pain manage- ment strategies: breastfeeding; skin-to-skin care, also referred to as kangaroo care; and small amounts of sweet solutions. These strategies are simple to use, easily accessible, and extremely cost-effective. Published neonatal and infant pain guidelines include recommendations to use these strategies prior to and during painful procedures. Yet, despite the robust evidence and pain management recommendations in guidelines and national and international organizations, knowledge has not been translated into consistent normalized care in diverse maternal newborn, neonatal, and pediatric settings where painful procedures for infants take place. There may be knowledge gaps or barriers impeding consistent use of effective pain management for newborn infants. This paper will present a brief review of methods used to assess neonatal pain, followed by a summary of the evidence supporting breastfeeding, skin-to-skin care, and sweet solutions for procedural pain reduction with a discussion about barriers and facilitators to using these strategies in the clinical setting. Finally, a review of recommendations included in current neo- natal pain guidelines will be presented.

Given the pivotal role of nurses in providing and supervising patient care, it is essential that nursing professionals are engaged fully in making care safer. Nursing involvement was instrumental in the Michigan Health and Hospital Association Keystone ICU Project, which resulted in rapid reduction in catheter-related blood stream infection rates and ventilator-associated pneumonia rates. Nurses of every credential and every nursing position participated in this broad scale improvement effort. This article describes the MHA Keystone ICU Project, including challenges implicit in changing nursing practice and team behavior in the ICU. The improvement strategies implemented by Keystone ICU teams, and lessons learned by nurses engaged in the work, are likely to have application in other clinical settings.

Reliable and valid methods of measuring pain responses in infants continue to be sought as a means of evaluating the effectiveness of pain reduction strategies. Skin conductance has recently been shown to be a promising physiological indicator of pain and stress in premature and term infants.To evaluate changes in skin conductance in hospitalised infants under different environmental conditions and during both painful and non-painful procedures.Measurements of skin conductance activity were made in infants under three different environmental temperature conditions (open cot, incubator and overhead radiant heater), during the routine non-painful nursing procedure of either nappy change or oral feeding, and whilst undergoing the painful procedure of heel lancing for blood sampling.Skin conductance activity in 21 infants was studied on 43 separate occasions. Skin conductance activity was highly variable between infants but did not differ significantly under the three environmental conditions. Routine nursing care did not result in a significant increase in skin conductance activity above baseline; however, on cessation of care there was a significant reduction to levels below baseline (p0.05). Conversely, during the heel lance procedure, skin conductance activity significantly increased upon lance (p0.05) and remained elevated following completion of the procedure. There were no statistically significant differences between skin conductance activity changes from baseline as a result of routine nursing care compared to that of the heel lance procedure.Due to large variability in skin conductance activity further studies are needed before this technology can be recommended as a clinically useful indicator of pain and stress in neonates.

Despite the vast number of traumatic injuries that are orthopaedic in nature, comprehensive epidemiological data that characterise orthopaedic trauma are limited. The aim of this study was to investigate the nature of orthopaedic trauma admitted to adult Level 1 Trauma Centres.Data were obtained from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), which includes all patients with orthopaedic trauma admitted to the two adult Level 1 Trauma Centres in Victoria (Australia). Information was collected from the medical record and hospital databases on patients' demographics and injury event, diagnoses and management.Data were analysed on 784 patients recruited between August 2003 and March 2004. Patients were mainly young (65 years) (70.7%), male (59.1%) and injured in a transport collision (51.3%). Fractures of the femur (23.7%) and spine (23.5%) were the most common injuries and were predominately managed with operative (87.6%) and conservative (78.8%) methods, respectively. Differences in most parameters were evident between younger (65 years) and older (or =65 years) patients.This study presents epidemiological data on patients with orthopaedic trauma who were admitted to adult Level 1 Trauma Centres. This information is critical for the future monitoring and evaluation of the outcomes of orthopaedic trauma.

Objective: The aim of this study was to validate a clinician-friendly pain assessment tool for all groups of critically ill infants cared for in the specific neonatal intensive care units (NICUs) studied. Design: A prospective study was undertaken to test the Pain Assessment Tool (PAT). Interrater reliability of the PAT score was assessed by two nurses who simultaneously determined an infant's PAT score. The PAT was validated against the CRIES score—crying, requires increased oxygen administration, increased vital signs, expression, sleeplessness—and the mother's assessment of her infant's discomfort using the Visual Analogue Scale (VAS). Setting: The NICUs at two children's hospitals. Patients: Participants were 144 preterm and term infants. Infants on a ventilator and those who had undergone surgery were included. Results: The interrater reliability of the PAT was .85 with a mean difference of 0.17 (standard deviation: 1.73). There was a strong correlation between the PAT and CRIES scores (r = 0.76) and a moderate correlation (.38) between the PAT score and the VAS scores of the infant's mother. The correlation coefficient between the PAT score and CRIES score was significant for all groups (p .01). Conclusions: The PAT score was shown in this study to be a valid, reliable, and clinician-friendly pain assessment measurement tool for all infants nursed in the NICU.

Background. The importance of interdisciplinary collaboration has been attested to by a number of authors. Some have suggested that Nurse Practitioners (NPs) may be able to improve collaboration between doctors and nurses, but this assertion does not appear to have been researched. Aims and objectives. To investigate doctors’ and nurses’ perceptions of interdisciplinary collaboration in two neonatal intensive care units, and to assess the impact of a Neonatal Nurse Practitioner (NNP) practice model on these perceptions. The study was conducted as part of a larger project to develop a NNP model of practice. Design. Survey, pre- and post-intervention. Methods. Medical and nursing staff in both units were surveyed before and after introduction of the NP model of practice. The instrument consisted of 25 statements relating to nurse–doctor interactions, with which respondents indicated their level of agreement on a five-point Likert scale. The Mann–Whitney U-test was used to compare scores for individual items and for overall collaboration between various groups of staff, and between the first and second surveys. Results. Significant differences between the responses of nurses and doctors were found on both surveys. Areas of disagreement chiefly concerned doctors’ behaviour and their attitudes towards nurses, rather than nurses’ behaviour or environmental factors. Doctors consistently reported a higher degree of collaboration than did nurses. Few differences were found between first and second surveys. Conclusions. Results suggest that problems in nurse–physician interactions exist in both units. No impact of the NNP role, as established in this project, on interdisciplinary collaboration could be demonstrated. Further research in this area is warranted.

We have learned much about the respiratory disorders since the exposures of responders at the World Trade Center (WTC) site, especially from the publications of Prezant and colleagues about the presentations, follow-up, and impairments of pulmonary function and bronchial reactivity of the fire fighters and emergency medical technicians of the New York City Fire Department (Banauch et al. 2003, 2005, 2006; Prezant et al. 2002). These reports are especially informative because of the availability of preexposure clinical and spirometric data. We appreciate the report of much-awaited results among 9,442 workers from the WTC Worker and Volunteer Medical Screening Program (Herbert et al. 2006). Because of the potential for major illness, the large number of subjects at risk, and the resultant enormous public interest, it is important that the information reported be properly understood. A number of limitations in this report must be pointed out. Although the title identified this report (Herbert et al. 2006) as a 5-year assessment, screening examinations were performed between 16 July 2002 and 16 April 2004, < 1 year through < 3 years after 11 September 2001. There were no follow-up examinations, either at the 5-year or at any other interval. Summary conclusions (Herbert et al. 2006), heavily reported in the media, lump all respiratory symptoms: … 69% reported new or worsened respiratory symptoms while performing WTC work. Symptoms persisted to the time of examination in 59% of these workers. The 69% with “any respiratory symptom” included 23.3% with no “lower respiratory symptoms.” A far smaller percentage of all workers (17.3%) complained of what may be considered the most important respiratory symptom, dyspnea, which was not quantified by any standard scale. Such a reliance on symptoms is subject to recall biases both for symptoms present before 9/11 and for the onset, worsening, and persistence of symptoms after 9/11. Because physical examination and chest radiographs were unrevealing (Herbert et al. 2006), the only objective results were from pulmonary function tests. These were confined to spirometry, which does not provide insight into all aspects of respiratory impairment. The data presented by Herbert et al. (2006) are limited. Mean values for subsets (classified by WTC exposure, previous smoking history, etc.) are not given. Despite the frequency of cough (42.8%), wheeze (15.1%), and chest tightness (15.4%) and the common diagnoses of asthma/reactive airways dysfunction, only 7.6% of all responders showed airway obstruction, defined as a ratio of forced expiratory volume in 1 sec (FEV1) to forced vital capacity (FVC) less than the 5th percentile of the reference population. Unlike virtually all spirometric surveys of a large population (reviewed by Miller et al. 1991), Herbert et al. (2006) found little difference in impairment by smoking status. Most spirometric impairments were classified as restrictive, uncharacteristic of the symptoms and clinical diagnoses. This frequency of low FVC (22.7%) raises several issues: a) the effects of other clinical factors not reported on, such as obesity; b) technical considerations in subject performance or technician monitoring of the FVC maneuver, despite the investigators attention to these; and c) the appropriateness of the reference-predicted values. We await further information and follow-up from these investigators, including results of additional diagnostic procedures not included in routine screening. These include a wider array of pulmonary function tests (full lung volumes, diffusing capacity), measurement of bronchial reactivity, computed tomography scans, and—in appropriate patients—bronchoalveolar lavage and lung biopsies, which would truly elucidate the respiratory disorders following WTC exposure.

The Nurse Executive Council at a 540-bed community teaching health center planned and implemented Shared Governance in a 10-bed Medical Intensive Care Unit (MICU). Paid time was provided for nurses to take part in one of four councils. After a pilot year resulting in satisfaction with job autonomy and input into decision-making, staff reaffirmed their commitment to shared governance as a permanent "way of life" in the MICU. During the second year, patient care assistants and unit clerks were integrated into the Councils and staff began serving as consultants to other units and institutions.

The loss of lean body mass accompanying acquired immunodeficiency syndrome (AIDS)-associated cachexia is refractory to current modes of therapy. GH and insulin-like growth factor-I (IGF-I) stimulate protein accretion, but resistance to GH action has been reported in malnutrition and infection. We hypothesized that GH resistance occurs in AIDS-associated cachexia, but that treatment with IGF-I would be anabolic. A single injection of GH produced a smaller increase in circulating IGF-I in 21 patients with AIDS compared to that in 23 age-matched controls (141 +/- 15 vs. 194 +/- 15 micrograms/L; P0.02), indicating partial GH resistance. Ten subjects received either low or high dose iv recombinant IGF-I 12 h daily for 10 days. Cumulative nitrogen retention was positive for both dosage groups (low dose, 15.42 +/- 6.37 g; high dose, 3.62 +/- 4.15 g), but a significant increase in daily nitrogen retention occurred only in the low dose group on days 2, 4, 5, 6, and 7. Nitrogen balance and protein turnover (estimated by [13C]leucine and [15N] glycine kinetics) during the final 3 days of treatment were unchanged compared to baseline values, confirming the transient nature of the anabolic response. Repeated administration of IGF-I decreased IGF-binding protein-3 levels, producing lower intrainfusion levels of IGF-I and limiting its therapeutic efficacy. The basal metabolic rate increased with high dose IGF-I and may have contributed to the lack of anabolic effect. We conclude that partial GH resistance occurs in AIDS-associated cachexia. Treatment with low dose recombinant IGF-I produces significant, but transient, nitrogen retention. Alternate routes of IGF-I administration or coadministration with GH may prevent attenuation of IGF-I action.

189 husband-wife pairs indicated how likely they were to disclose to their spouses when they were experiencing problems, and their reasons for disclosing and/or not disclosing. Wives disclosed significantly more than husbands. Both gave similar reasons for disclosing, but different reasons for not disclosing. Husbands and wives who were more likely to disclose to their spouses also reported greater marital and life satisfaction, but level of disclosing was not related to measures of mental and physical well-being or job satisfaction.

Following the World Trade Center disaster, a large number of individuals involved in rescue and recovery activity were exposed to significant amounts of dust, and reported symptoms of chronic nasal and sinus inflammation. An unusually high prevalence of obstructive sleep apnea (OSA) has also been observed in this World Trade Center Responder population. This project aims to examine the relationship between nasal pathology and OSA. Our hypothesis is that increased nasal resistance due to nasal inflammation predisposes to OSA in this population. Continuous Positive Airway Pressure (CPAP) is the standard therapy for OSA but despite its efficacy has poor adherence. Subjects with high nasal resistance may have greater difficulty in tolerating this therapy than those who do not have high nasal resistance. Reduction of excess expiratory positive pressure by the modality known as Cflex™ during Continuous Positive Airway Pressure therapy (CPAPFlex) has been suggested to improve comfort without compromising efficacy. We will compare CPAP to CPAPFlex in subjects with OSA. Subjects with new onset habitual snoring will be screened for OSA using home sleep studies and rhinomanometry will be used to determine nasal resistance. In 400 subjects with OSA we will perform a randomized double blind cross-over study comparing CPAP to CPAPflex, and relate nasal resistance to adherence to CPAP therapy. This is the first multicenter trial designed to test the hypothesis that adherence to CPAP therapy relates to nasal resistance and CPAPFlex will improve adherence to CPAP in those subjects with high nasal resistance. We anticipate the following results from this trial: 1. Increased nasal resistance is associated with decreased adherence to CPAP therapy. 2. Use of CPAPFlex improves adherence with CPAP therapy in subjects with high nasal resistance, but not in those with low nasal resistance. 3. The benefit of CPAPFlex on adherence is greatest when offered at CPAP therapy initiation rather than as a “rescue” therapy in subjects with high nasal resistance. ClinicalTrials.gov Identifier: NCT01753999 , Date: 12 December 2012

Background Early childhood immunizations, although vital for preventative health, are painful and too often lead to fear of needles. Effective pain management strategies during infant immunizations include breastfeeding, sweet solutions, and upright front-to-front holding. However, it is unknown how often these strategies are used in clinical practice. We aimed to review the content of YouTube videos showing infants being immunized to ascertain parents’ and health care professionals’ use of pain management strategies, as well as to assess infants’ pain and distress. Methods A systematic review of YouTube videos showing intramuscular injections in infants less than 12 months was completed using the search terms "baby injection" and "baby vaccine" to assess (1) the use of pain management strategies and (2) infant pain and distress. Pain was assessed by crying duration and pain scores using the FLACC (Face, Legs, Activity, Cry, Consolability) tool. Results A total of 142 videos were included and coded by two trained individual viewers. Most infants received one injection (range of one to six). Almost all (94%) infants cried before or during the injections for a median of 33 seconds (IQR = 39), up to 146 seconds. FLACC scores during the immunizations were high, with a median of 10 (IQR = 3). No videos showed breastfeeding or the use of sucrose/sweet solutions during the injection(s), and only four (3%) videos showed the infants being held in a front-to-front position during the injections. Distraction using talking or singing was the most commonly used (66%) pain management strategy. Conclusions YouTube videos of infants being immunized showed that infants were highly distressed during the procedures. There was no use of breastfeeding or sweet solutions and limited use of upright or front-to-front holding during the injections. This systematic review will be used as a baseline to evaluate the impact of future knowledge translation interventions using YouTube to improve pain management practices for infant immunizations.

OBJECTIVE To analyze nurses' knowledge and practices regarding pain management of newborns admitted to Neonatal Intensive Care Units. METHOD A descriptive and cross-sectional study. Data were collected from 51 nurses based on an adapted questionnaire aimed at evaluating knowledge and practices regarding the management of neonatal pain in six hospitals in Curitiba and its Metropolitan Region. RESULTS For most nurses (86.0%), neonates feel pain. A total of 34.7% of the nurses reported never using pain assessment scales. Pain management was recorded by 84.3% of the nurses. Administered pharmacological measures were Paracetamol and Fentanyl (47.1%) and Morphine (17.6%); while non-pharmacological measures adopted were sweetened solution (68.6%), non-nutritive sucking (58.8%) and positioning (56.9%). CONCLUSION Nurses considered neonatal pain a real event; however, they do not perform pain assessment or treatment of newborns in a systematized way.It is necessary to implement knowledge translation strategiesin order to improve pain management in newborns. Resumen OBJETIVO Verificar el conocimiento y las prácticas de los enfermeros sobre el manejo del dolor de recién nacidos admitidos en Unidades de Tratamiento Intensivo Neonatal. MÉTODO Estudio descriptivo y transversal. Los datos fueron recolectados con 51 enfermeros, mediante un cuestionario adaptado que tiene el fin de evaluar el conocimiento y las prácticas acerca del manejo del dolor neonatal, en seis hospitales de Curitiba y Región Metropolitana. RESULTADOS Para la mayoría de los enfermeros (86,0%), los neonatos sienten dolor. Un total del 34,7% afirmaron nunca utilizar escalas de evaluación del dolor. El registro del manejo del dolor fue realizado por el 84,3% de los enfermeros. Las medidas farmacológicas realizadas fueron Paracetamol y Fentanilo (47,1%) y Morfina (17,6%); las no farmacológicas adoptadas fueron solución azucarada (68,6%), succión no nutritiva (58,8%) y posicionamiento (56,9%). CONCLUSIÓN Los enfermeros consideraron el dolor neonatal como un evento real; sin embargo, no realizaban evaluación o tratamiento del dolor en el recién nacido de modo sistematizado. Es necesario implantar estrategias de traducción del conocimiento a fin de perfeccionar el manejo del dolor de recién nacidos. Resumo OBJETIVO Verificar o conhecimento e as práticasdos enfermeiros sobreo manejo da dor de recém-nascidos admitidos em Unidades de Tratamento Intensivo Neonatal. MÉTODO Estudo descritivo e transversal. Os dados foram coletados com 51 enfermeiros, a partir de um questionário adaptado que visa avaliar o conhecimento e as práticas sobre o manejo da dor neonatal, em seis hospitais de Curitiba e Região Metropolitana. RESULTADOS Para a maioria dos enfermeiros(86,0%), os neonatos sentem dor. Um total de 34,7% afirmaramnunca utilizar escalas de avaliaçãoda dor. O registro do manejo da dor foi realizado por 84,3% dos enfermeiros. As medidas farmacológicas realizadas foram Paracetamol e Fentanil (47,1%) e Morfina (17,6%);as não farmacológicas adotadas foram solução adocicada (68,6%), sucção não nutritiva (58,8%) e posicionamento (56,9%). CONCLUSÃO Os enfermeiros consideraram a dor neonatal como um evento real, porém não realizavam avaliação ou tratamento da dor no recém-nascido de modosistematizado. É necessário implementarestratégias de tradução do conhecimento paraaprimorar o manejo da dor de recém-nascidos.

Background The disasters at Seveso, Three Mile Island, Bhopal, Chernobyl, the World Trade Center (WTC) and Fukushima had historic health and economic sequelae for large populations of workers, responders and community members. Methods Comparative data from these events were collected to derive indications for future preparedness. Information from the primary sources and a literature review addressed: i) exposure assessment; ii) exposed populations; iii) health surveillance; iv) follow-up and research outputs; v) observed physical and mental health effects; vi) treatment and benefits; and vii) outreach activities. Results Exposure assessment was conducted in Seveso, Chernobyl and Fukushima, although none benefited from a timely or systematic strategy, yielding immediate and sequential measurements after the disaster. Identification of exposed subjects was overall underestimated. Health surveillance, treatment and follow-up research were implemented in Seveso, Chernobyl, Fukushima, and at the WTC, mostly focusing on the workers and responders, and to a lesser extent on residents. Exposure-related physical and mental health consequences were identified, indicating the need for a long-term health care of the affected populations. Fukushima has generated the largest scientific output so far, followed by the WTCHP and Chernobyl. Benefits programs and active outreach figured prominently in only the WTC Health Program. The analysis of these programs yielded the following lessons: 1) Know who was there; 2) Have public health input to the disaster response; 3) Collect health and needs data rapidly; 4) Take care of the affected; 5) Emergency preparedness; 6) Data driven, needs assessment, advocacy. Conclusions Given the long-lasting health consequences of natural and man-made disasters, health surveillance and treatment programs are critical for management of health conditions, and emergency preparedness plans are needed to prevent or minimize the impact of future threats.

BACKGROUND: Although clinical narratives – described as free-text notations – have been noted to be a source of patient information, no studies have examined the composition of pain narratives in hospitalized children’s medical records.OBJECTIVES: To describe the structure and content of health care professionals’ narratives related to hospitalized children’s acute pain.METHODS: All pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized in 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was performed.RESULTS: Three major structural elements with their respective categories and subcategories were identified: information sources, including clinician, patient, parent, dual and unknown; compositional archetypes, including baseline pain status, intermittent pain updates, single events, pain summation and pain management plan; and content, including pain declaration, pain assessment, pain intervention and multidimensional elements of care.CONCLUSIONS: The present qualitative analysis revealed the multidimensionality of structure and content that was used to document hospitalized children’s acute pain. The findings have the potential to inform debate on whether the multidimensionality of pain narratives’ composition is a desirable feature of documentation and how narratives can be refined and improved. There is potential for further investigation into how health care professionals’ pain narratives could have a role in generating guidelines for best pain documentation practice beyond numerical representations of pain intensity.

Background Extensive evidence exists showing analgesic effects of sweet solutions for newborns and infants. It is less certain if the same analgesic effects exist for children one year to 16 years of age. This is an updated version of the original Cochrane review published in Issue 10, 2011 (Harrison 2011) titled Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years. Objectives To determine the efficacy of sweet tasting solutions or substances for reducing needle-related procedural pain in children beyond one year of age. Search methods Searches were run to the end of June 2014. We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Cochrane Methodology Register, Health Technology Assessment, the NHS Economic Evaluation Database, MEDLINE, EMBASE, PsycINFO, and ACP Journal Club (all via OvidSP), and CINAH (via EBSCOhost). We applied no language restrictions. Selection criteria Published or unpublished randomised controlled trials (RCT) in which children aged one year to 16 years, received a sweet tasting solution or substance for needle-related procedural pain. Control conditions included water, non-sweet tasting substances, pacifier, distraction, positioning/containment, breastfeeding, or no treatment. Data collection and analysis Outcome measures included crying duration, composite pain scores, physiological or behavioral pain indicators, self-report of pain or parental or healthcare professional-report of the child's pain. We reported mean differences (MD), weighted mean difference (WMD), or standardized mean difference (SMD) with 95% confidence intervals (CI) using fixed-effect or random-effects models as appropriate for continuous outcome measures. We reported risk ratio (RR), risk difference (RD), and the number needed to treat to benefit (NNTB) for dichotomous outcomes. We used the I2 statistic to assess between-study heterogeneity. Main results We included one unpublished and seven published studies (total of 808 participants); four more studies and 478 more participants than the 2011 review. Six trials included young children aged one to four years receiving sucrose or candy lollypops for immunisation pain compared with water or no treatment. Usual care included topical anaesthetics, upright parental holding, and distraction. All studies were well designed blinded RCTs, however, five of the six studies had a high risk of bias based on small sample sizes. Two studies included school-aged children receiving sweet or unsweetened chewing gum before, or before and during, immunisation and blood collection. Both studies, conducted by the same author, had a high risk of bias based on small sample sizes. Results for the toddlers/pre-school children were conflicting. Duration of cry, using a random-effects model, was not significantly reduced by sweet taste (six trials, 520 children, WMD -15 seconds, 95% CI -54 to 24, I2 = 94%). Composite pain score at time of first needle was reported in four studies (n = 121 children). The scores were not significantly different between the sucrose and control group (SMD -0.26, 95% CI -1.27 to 0.75, I2 = 86%). A Children's Hospital of Eastern Ontario Pain Scale score > 4 was significantly less common in the sucrose group compared to the control group in one study (n = 472, RR 0.55, 95% CI 0.45 to 0.67; RD -0.29, 95% CI -0.37 to -0.20; NNTB 3, 95% CI 3 to 5; tests for heterogeneity not applicable. For school-aged children, chewing sweet gum before needle-related painful procedures (two studies, n = 111 children) or during the procedures (two studies, n = 103 children) did not significantly reduce pain scores. A comparison of the Faces Pain Scale scores in children chewing sweet gum before the procedures compared with scores of children chewing unsweetened gum revealed a WMD of -0.15 (95% CI -0.61 to 0.30). Similar results were found when comparing the chewing of sweet gum with unsweetened gum during the procedure (WMD 0.23, 95% CI -0.28 to 0.74). The Colored Analogue Scale for children chewing sweet gum compared to unsweetened gum before the procedure was not significantly different (WMD 0.24 (-0.69 to 1.18)) nor was it different when children chewed the gum during the procedure (WMD 0.86 (95% CI -0.12 to 1.83)). There was no heterogeneity for any of these analyses in school-aged children (I2 = 0%). Authors' conclusions Based on the eight studies included in this systematic review update, two of which were subgroups of small numbers of eligible toddlers from larger studies, and three of which were pilot RCTs with small numbers of participants, there is insufficient evidence of the analgesic effects of sweet tasting solutions or substances during acutely painful procedures in young children between one and four years of age. Further rigorously conducted, adequately powered RCTs are warranted in this population. Based on the two studies by the same author, there was no evidence of analgesic effects of sweet taste in school-aged children. As there are other effective evidence-based strategies available to use in this age group, further trials are not warranted. Despite the addition of four studies in this review, conclusions have not changed since the last version of the review.

Background Children often need support in health decision-making. The objective of this study was to review characteristics and effectiveness of interventions that support health decision-making of children. Methods A systematic review. Electronic databases (PubMed, the Cochrane Library, Web of Science, Scopus, ProQuest Dissertations and Theses, CINAHL, PsycINFO, MEDLINE, and EMBASE) were searched from inception until March 2012. Two independent reviewers screened eligibility: a) intervention studies; b) involved supporting children (≤18 years) considering health-related decision(s); and c) measured decision quality or decision-making process outcomes. Data extraction and quality appraisal were conducted by one author and verified by another using a standardized data extraction form. Quality appraisal was based on the Cochrane Risk of Bias tool. Results Of 4313 citations, 5 studies were eligible. Interventions focused on supporting decisions about risk behaviors (n = 3), psycho-educational services (n = 1), and end of life (n = 1). Two of 5 studies had statistically significant findings: i) compared to attention placebo, decision coaching alone increased values congruence between child and parent, and child satisfaction with decision-making process (lower risk of bias); ii) compared to no intervention, a workshop with weekly assignments increased overall decision-making quality (higher risk of bias). Conclusions Few studies have focused on interventions to support children’s participation in decisions about their health. More research is needed to determine effective methods for supporting children’s health decision-making.