Precision Rhinoplasty Cylindric Burrs-Sidewall Aesthetics.

The development of power instruments has led to great advances in rhinoplasty. It has helped to reduce operating time, minimize damage to the surrounding soft tissues, and allow precision bony modification compared with the use of manual rasps. Burrs help ensure precise results by (i) creating a smooth transition between the lateral nasal sidewall and the face, (ii) treating bony asymmetries, and (iii) producing homogeneous upper and middle thirds that softy translate into the upper lateral cartilages. The aim of this paper is to show applications of cylindrical burrs in rhinoplasty surgery to treat the dorsal upper and middle thirds as well as lateral sidewalls of the nose, regardless of whether the dorsal preservation or structure technique is used. This approach offers a safe, fast, and precise technique that can be used in conjunction with piezo osteotomy to obtain the optimal outcomes.

The Targeted Motor Control Screening Tool is Valid for Four-Year-Old Children.

OBJECTIVE: The objective was to determine the validity of the Targeted Motor Control (TMC) screening tool with the Neurosensory Motor Developmental Assessment (NSMDA) in 4-year-old children. METHODS: In this single cohort observational study, children (3 years 9 months to 4 years 5 months) completed the TMC and the NSMDA in a randomized order 5 to 14 days apart. RESULTS: Seventy-six children (mean age = 4 years 2 months; SD = 2.5 months; n = 35 male) completed both assessments. Forty-two children performed within the normal range on the NSMDA. There were significant and positive moderate correlations between item totals overall and for each area on the NSMDA and the TMC (r = 0.40 to 0.61) and between the NSMDA functional grade for each area and the corresponding TMC areas (r = 0.47 to 0.67). However, the correlation between the NSMDA sensorimotor functional grade and the TMC sensory score was significant but low and positive (r = 0.35). The optimal cut-off score for detecting children at risk of atypical development on the TMC was a score of <9 (n = 42) (sensitivity = 82.4%; specificity = 66.7%) with a positive likelihood ratio of 2.47 (95% CI = 1.57 to 3.89) and a negative likelihood ratio of 0.26 (95% CI = 0.12 to 0.56). CONCLUSIONS: The TMC is a valid screening tool to identify 4-year-old children at risk of motor delay. IMPACT: Early identification of developmental concerns using a validated screening tool is recommended. The TMC is a valid performance-based screening tool that can be used to identify children at risk of atypical motor development who would benefit from further developmental assessment so that, if indicated, timely intervention can be implemented.

An online pain management program for people with hypermobile Ehlers-Danlos Syndrome or hypermobility spectrum disorder: a three-staged development process.

PURPOSE: Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) are painful, chronic and multi-systemic conditions. No online pain management programs for hEDS/HSD currently exist. We aimed to develop one by exploring what people with hEDS/HSD want in such programs. MATERIALS AND METHODS: A Delphi was conducted via online surveys of stakeholders: participants with hEDS/HSD and healthcare professionals (HCP). In survey 1, participants were asked if a hEDS/HSD-specific online pain management program was important, listing up to 20 topics important to know about pain. In survey 2, participants rated the importance of those topics. Consensus was set as ≥75% rating of at least "important". Using topics that reached consensus, the online program was developed. Usability testing was performed using the Systems Usability Scale (SUS). RESULTS: 396 hEDS/HSD and 29 HCP completed survey 1; 151 hEDS/HSD and 12 HCP completed survey 2. 81% of hEDS/HSD and 69% of HCP rated a hEDS/HSD-specific program as at least "important". Thirty-five topics reached consensus to guide content for the HOPE program (Hypermobile Online Pain managemEnt). SUS score was 82.5, corresponding to "high acceptability". CONCLUSIONS: A hEDS/HSD-specific online pain management program is important to stakeholders. Utilising a Delphi approach to incorporate stakeholder input, an evidence-informed and user appropriate program was developed.

Pain is one of the most common and impactful symptom affecting those with Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD).Online pain management programs are effective in other chronic conditions such as Fibromyalgia and Rheumatoid Arthritis, but there are no programs specific for hEDS/HSD.People with hEDS or HSD and healthcare professionals with experience in these conditions feel that an online pain management program specific to their condition is important; consensus revealed thirty-five key topics important to these stakeholders.The first hEDS/HSD-specific online pain management program, called HOPE, was developed with stakeholder input and usability tested, ready for clinical trial testing.

N-acetyl-cysteine mitigates arsenic stress in lettuce: Molecular, biochemical, and physiological perspective.

Agricultural land contaminated with heavy metals such as non-biodegradable arsenic (As) has become a serious global problem as it adversely affects agricultural productivity, food security and human health. Therefore, in this study, we investigated how the administration of N-acetyl-cysteine (NAC), regulates the physio-biochemical and gene expression level to reduce As toxicity in lettuce. According to our results, different NAC levels (125, 250 and 500 µM) significantly alleviated the growth inhibition and toxicity induced by As stress (20 mg/L). Shoot fresh weight, root fresh weight, shoot dry weight and root dry weight (33.05%, 55.34%, 17.97% and 46.20%, respectively) were decreased in plants grown in As-contaminated soils compared to lettuce plants grown in soils without the addition of As. However, NAC applications together with As stress increased these growth parameters. While the highest increase in shoot fresh and dry weight (58.31% and 37.85%, respectively) was observed in 250 µM NAC application, the highest increase in root fresh and dry weight (75.97% and 63.07%, respectively) was observed in 125 µM NAC application in plants grown in As-polluted soils. NAC application decreased the amount of ROS, MDA and H2O2 that increased with As stress, and decreased oxidative damage by regulating hormone levels, antioxidant and enzymes involved in nitrogen metabolism. According to gene expression profiles, LsHIPP28 and LsABC3 genes have shown important roles in reducing As toxicity in leaves. This study will provide insight for future studies on how NAC applications develop resistance to As stress in lettuce.

Evaluation of genetic diversity using iPBS-SCoT marker methods in native hawthorn genetic resources and species identification by using DNA barcoding method.

Hawthorn is an important medicinal plant that spreads around the world and is used in traditional Chinese medicine. Its flowers and leaves contain flavonoids, vitamins, organic acids and essential oils. Its fruit is consumed as fresh and dried and is an important plant for human health. In this study, iPBS (Inter Primer Binding Site) and SCoT (Start Codon Target Polymorphism) markers were used to analyze genetic variation among 101 hawthorn genotypes collected from Çoruh Valley, Türkiye and ITS markers were used for DNA barcoding.  Ten iPBS primers were used and a total of 400 alleles were identified from ten iPBS primers with an average of 40 alleles. PIC values ranged from 0.239 (iPBS 2387) to 0.272 (iPBS 2244). Twenty SCoT primers were used and have an average of 50.05 alleles. The PIC values of the primers ranged from 0.251 (SCoT 2) to 0.297 (SCoT 34). For the DNA barcoding study, it was confirmed that the correct region was amplified and sequenced. The genotypes we used in the study matched 14 different accession numbers by searching a BLASTN in the NCBI. NCBI similarity rates of hawthorn genotypes are between 90.83% and 100%. The study emphasizes the genetic diversity of hawthorn grown from seed and the importance of preserving plant genetic resources.

How Schroth Therapists Vary the Implementation of Schroth Worldwide for Adolescents with Idiopathic Scoliosis: A Mixed Methods Study.

(1) Background: Schroth is a type of physiotherapeutic scoliosis specific exercise (PSSE) prescribed to adolescents with idiopathic scoliosis (AIS). Studies have investigated the effectiveness of Schroth but are yet to elucidate how Schroth is applied clinically and the factors that influence their prescription. (2) Methods: A mixed methods design was used comprising an anonymous survey and semi-structured interviews of Schroth therapists who treated AIS and who were publicly listed on the Barcelona Scoliosis Physical Therapy School or the International Schroth 3-dimensional Scoliosis Therapy School websites. The survey included 64 questions covering demographics, session and treatment characteristics, and whether therapists included other treatment modalities in their clinical practice. A convenience sample of survey participants were invited to participate in a semi-structured interview to further explore the factors that influenced their prescription of Schroth for AIS. Results from the survey were analyzed descriptively (n, %), whereas inductive thematic analysis was used for the interviews. (3) Results: of the 173 survey respondents (18% response rate), most were from Europe and North America (64.0%), female (78.6%), physiotherapists (96.0%), and worked in private settings (72.3%). Fifty-two per cent of participants used other types of PSSE as an adjunct to Schroth, the Scientific Exercise Approach to Scoliosis (SEAS) being the most frequently used (37.9%). Non-PSSE methods were used 'at some point' as an adjunct by 98.8% of participants, including massage and other soft tissue techniques (80.9%), Pilates (46.6%), and Yoga (31.5%). The Schroth techniques used by all survey respondents included breathing and pelvic corrections. Seven participants were interviewed, but data saturation was achieved after only four interviews. Thematic analysis revealed four, inter-related broad themes describing the factors that influenced Schroth prescription for AIS: (1) the adolescent as a whole, including physical, emotional and mental characteristics, and patient goals, (2) family, including parent relationship with the adolescent and the motivation of parents in regard to Schroth, (3) the systems within which the treatment was being offered, such as vicinity to the clinic and the presence of financial insurance support, and (4) therapist characteristics, such as their training and experience. (4) Conclusions: Schroth therapists worldwide use a variety of adjunctive methods to treat AIS. Therapists prescribing Schroth exercises to AIS consider the complex interplay of intra-, inter- and extra-personal factors in clinical practice. These considerations move beyond the three components of evidence-based practice of research, patient preferences, and clinical expertise, towards a systems-based reflection on exercise prescription.

Identification of Novel QTLs Associated with Frost Tolerance in Winter Wheat (Triticum aestivum L.).

Low temperature (cold) and freezing stress is a major problem during winter wheat growth. Low temperature tolerance (LT) is an important agronomic trait in winter wheat and determines the plants' ability to cope with below-freezing temperatures; thus, the development of cold-tolerant cultivars has become a major goal of breeding in various regions of the world. In this study, we sought to identify quantitative trait loci (QTL) using molecular markers related to freezing tolerance in winter. Thirty-four polymorphic markers among 425 SSR markers were obtained for the population, including 180 inbred lines of F12 generation wheat, derived from crosses (Norstar × Zagros) after testing with parents. LT50 is used as an effective selection criterion for identifying frost-tolerance genotypes. The progeny of individual F12 plants were used to evaluate LT50. Several QTLs related to wheat yield, including heading time period, 1000-seed weight, and number of surviving plants after overwintering, were identified. Single-marker analysis illustrated that four SSR markers with a total of 25% phenotypic variance determination were linked to LT50. Related QTLs were located on chromosomes 4A, 2B, and 3B. Common QTLs identified in two cropping seasons based on agronomical traits were two QTLs for heading time period, one QTL for 1000-seed weight, and six QTLs for number of surviving plants after overwintering. The four markers identified linked to LT50 significantly affected both LT50 and yield-related traits simultaneously. This is the first report to identify a major-effect QTL related to frost tolerance on chromosome 4A by the marker XGWM160. It is possible that some QTLs are closely related to pleiotropic effects that control two or more traits simultaneously, and this feature can be used as a factor to select frost-resistant lines in plant breeding programs.

Subgroups of Idiopathic Clubfoot Can Predict Short-term Outcomes.

BACKGROUND: The Pirani scale is used for the assessment of Ponseti-managed clubfoot. Predicting outcomes using the total Pirani scale score has varied results, however, the prognostic value of midfoot and hindfoot components remains unknown. The purpose was to (1) determine the existence of subgroups of Ponseti-managed idiopathic clubfoot based on the trajectory of change in midfoot and hindfoot Pirani scale scores, (2) identify time points, at which subgroups can be distinguished, and (3) determine whether subgroups are associated with the number of casts required for correction and need for Achilles tenotomy. METHODS: Medical records of 226 children with 335 idiopathic clubfeet, over a 12-year period, were reviewed. Group-based trajectory modeling of the Pirani scale midfoot score and hindfoot score identified subgroups of clubfoot that followed statistically distinct patterns of change during initial Ponseti management. Generalized estimating equations determined the time point, at which subgroups could be distinguished. Comparisons between groups were determined using the Kruskal-Wallis test for the number of casts required for correction and binary logistic regression analysis for the need for tenotomy. RESULTS: Four subgroups were identified based on the rate of midfoot-hindfoot change: (1) fast-steady (61%), (2) steady-steady (19%), (3) fast-nil (7%), and (4) steady-nil (14%). The fast-steady subgroup can be distinguished at the removal of the second cast and all other subgroups can be distinguished at the removal of the fourth cast [ H (3) = 228.76, P < 0.001]. There was a significant statistical, not clinical, difference in the total number of casts required for correction across the 4 subgroups [median number of casts 5 to 6 in all groups, H (3) = 43.82, P < 0.001]. Need for tenotomy was significantly less in the fast-steady (51%) subgroup compared with the steady-steady (80%) subgroup [ H (1) = 16.23, P < 0.001]; tenotomy rates did not differ between the fast-nil (91%) and steady-nil (100%) subgroups [ H (1) = 4.13, P = 0.04]. CONCLUSIONS: Four distinct subgroups of idiopathic clubfoot were identified. Tenotomy rate differs between the subgroups highlighting the clinical benefit of subgrouping to predict outcomes in Ponseti-managed idiopathic clubfoot. LEVEL OF EVIDENCE: Level II, prognostic.

Precision Segmental Preservation Rhinoplasty: Avoiding Widening, Defining New Dorsal Esthetic Lines in Dorsal Preservation Rhinoplasty.

Experiencing great worldwide scientific excitement, the number of nose preservation surgeries has increased rapidly, promoting a considerable percentage of drawbacks and complications, causing many surgeons to recoil and return to classic resective techniques. In this study, we develop concepts that allow us to operate noses with preservation rhinoplasty that were previously considered to be among the absolute contraindications. Redefining new dorsal aesthetic lines, controlling the nasal lateral wall and the naso-facial groove surfaces, avoiding mid-vault widening and being precise in the design of bony and cartilaginous nasal profile, avoiding any type of irregularity, are strategies that will be presented.

Characterization of Two-Component System gene (TCS) in melatonin-treated common bean under salt and drought stress.

The two-component system (TCS) generally consists of three elements, namely the histidine kinase (HK), response regulator (RR), and histidine phosphotransfer (HP) gene families. This study aimed to assess the expression of TCS genes in P. vulgaris leaf tissue under salt and drought stress and perform a genome-wide analysis of TCS gene family members using bioinformatics methods. This study identified 67 PvTCS genes, including 10 PvHP, 38 PvRR, and 19 PvHK, in the bean genome. PvHK2 had the maximum number of amino acids with 1261, whilst PvHP8 had the lowest number with 87. In addition, their theoretical isoelectric points were between 4.56 (PvHP8) and 9.15 (PvPRR10). The majority of PvTCS genes are unstable. Phylogenetic analysis of TCS genes in A. thaliana, G. max, and bean found that PvTCS genes had close phylogenetic relationships with the genes of other plants. Segmental and tandem duplicate gene pairs were detected among the TCS genes and TCS genes have been subjected to purifying selection pressure in the evolutionary process. Furthermore, the TCS gene family, which has an important role in abiotic stress and hormonal responses in plants, was characterized for the first time in beans, and its expression of TCS genes in bean leaves under salt and drought stress was established using RNAseq and qRT-PCR analyses. The findings of this study will aid future functional and genomic studies by providing essential information about the members of the TCS gene family in beans. Supplementary Information: The online version contains supplementary material available at 10.1007/s12298-023-01406-5.

Assessing the Reconceptualization of Pain in Graduate-Entry Physiotherapy Students Using the Concept of Pain Inventory for Adults: The University of Technology Sydney Physiotherapy Student Surveys Project.

INTRODUCTION: Validly and reliably assessing conceptual change is essential for evaluating the effectiveness of pain science education for physiotherapy students. We aimed to 1) evaluate concept of pain before and after a 14-week pain science education university subject, 2) assess structural validity of the Concept of Pain Inventory for Adults (COPI-Adult) in postgraduate entry-level physiotherapy students, and 3) explore possible relationships between baseline variables and baseline COPI-Adult scores. REVIEW OF LITERATURE: As the COPI-Adult is a newly developed questionnaire, there is a lack of data regarding its psychometric properties. SUBJECTS: Of 129 enrolled students at an Australian university, 124 (96%) and 114 (88%) completed the baseline and follow-up questionnaires, respectively. METHODS: In this prospective cohort study, students who commenced the degree in 2020 or 2021 completed online questionnaires, including the COPI-Adult, at the start and end of their first semester. This semester included a 14-week pain science education subject and other physiotherapy-related subjects. Higher COPI-Adult scores (range = 0-52) indicate better alignment with contemporary pain science. We 1) compared differences in concept of pain before and after the semester, 2) performed a confirmatory factor analysis on the COPI-Adult, and 3) performed exploratory regression analyses. RESULTS: Concept of Pain Inventory for Adults scores increased from baseline (median [interquartile range]: 39 [36-44]) to follow-up (48 [44-51]). The COPI-Adult retained its 1-factor structure, with acceptable internal consistency (Cronbach's alpha = 0.80). Exploratory analysis showed that previously completing a subject on pain was related to higher COPI-Adult baseline scores. Age, gender, and mental health diagnosis did not relate to baseline COPI-Adult scores. DISCUSSION AND CONCLUSION: Following a 14-week pain science education subject embedded within a physiotherapy degree, students improved their concept of pain. The COPI-Adult maintains a 1-factor structure in this population. Completing a previous subject on pain was associated with higher COPI-Adult scores.

The type and scope of physiotherapy is under-utilised in Australian residential aged care facilities: a national, cross-sectional survey of physiotherapists.

BACKGROUND: With an increasingly ageing population in Australia, more older adults who are frail are living in residential aged care facilities (RACFs). The aim of this study was to detail the type, scope, and funding of physiotherapy utilised in Australian RACFs. METHODS: Registered physiotherapists (n = 219, 72% female, mean age (SD) = 38.6 (12.9) years) working in Australian RACFs participated in a nationwide, cross-sectional online survey. The survey was developed iteratively through a review of the literature and clinical guidelines, consensus of final survey items by an expert panel of five senior physiotherapists and aged care managers. Survey questions related to the characteristics of the physiotherapists (e.g., age, gender, employment status), characteristics of the RACFs (e.g., state, remoteness, sector), the type and scope of physiotherapy provided by respondents, and the availability of equipment and certain spaces (e.g., gyms) in the RACFs that respondents worked in. Survey responses were analysed and presented descriptively. Correlation using Spearman's rho (ρ) and the associated 95% confidence intervals (CI) were used to determine whether the availability of equipment or space at the RACF was associated with the time dedicated to performing non-Aged Care Funding Instrument (ACFI) tasks. RESULTS: Common reasons for physiotherapy referral were chronic pain management as per the ACFI framework (89.7%), falls (69.2%), and reduced mobility (35.9%). Rehabilitation or short-term restorative care was provided in only 22.2% of the facilities. The ACFI funded 91.4% of all participants, which limited physiotherapists to low-value chronic pain management including massage and electrical stimulation. Respondents spent 64.5% of their time on ACFI tasks, which equated to 19 h per week. More time was spent on non-ACFI tasks particularly when resistance bands (ρ = 0.28, 95%CI 0.14-0.41) and a dedicated therapy space or gym (ρ = 0.19, 95%CI 0.04-0.33) were available. CONCLUSIONS: The expertise of physiotherapists is currently being under-utilised in Australian RACFs, which may be related to the availability of public funding, equipment, and space for therapy. Therefore, public health policy should address the urgent need for high-value, evidence-based physiotherapy that supports the reablement and independence of older adults living in RACFs.

Phylogenetic relationship among taxa in the genus Adonis L. collected from Türkiye based on nrDNA internal transcribed spacer (ITS) markers.

BACKGROUND: Genus Adonis L. contain approximately 40 annual and perennial species, which are widely distributed in the temperate zones of Asia and Europe, and less frequently in southwestern Asia, northern Africa and the Mediterranean region. The aim of the study was to evaluate the phylogenetic relationship among Adonis taxa collected from Türkiye based on nrDNA Internal transcribed spacer (ITS) markers. METHODS: Samples of 64 individual genotypes from 21 populations of 10 Adonis taxa were collected from different regions of the country during vegetation period between 2014 and 2018. ITS1, ITS4, P16 and P25 primers within ITS technique was used to genotype the plant materials. Then, genotypic data was used to estimate magnitude and organization of infraspecific variation in different populations of Adonis. RESULTS: About 600 bp DNA sequences were obtained from each 64 Adonis genotypes belonging to 21 different populations. The dendrogram obtained from Adonis taxa and out-group sequences had two large main groups. While the out-group species were placed in the first large main group, the sect. Consiligo (perennial) and sect. Adonis (annuals) were placed in different sub-groups of the second large main group. Genetic similarity among Adonis taxa varied between A. microcarpa and A. dentata (98.46%). Principal component analysis indicated that two important components in Adonis taxa genotypes. The expected heterozygosity ranged from 0.0252 (sub-population A) to 0.3460 (sub-population C), with an average of 0.1154. In addition, population differentiation measurements (Fst) ranged from 0.0025 (sub-population C) to 0.9016 (sub-population A) with a relatively high average 0.6601. CONCLUSIONS: Present analyses revealed that phylogenetic classification (grouping) of Adonis taxa largely depended on morphological structure and present ITS primers were quite efficient in putting forth the genetic diversity of such species. The results of this study suggested that ITS markers could be used in the identification of genetic diversity among the Adonis taxa. The results obtained from molecular data can be used to explore the genetic variation pattern, population structure, and the evolutionary history of genus Adonis in the future.

What is the definition of acute episodic and chronic pain in critically ill neonates and infants? A global, four-stage consensus and validation study.

OBJECTIVES: To define and validate types of pain in critically ill neonates and infants by researchers and clinicians working in the neonatal intensive care unit (NICU) and high dependency unit (HDU). DESIGN: A qualitative descriptive mixed-methods design. PROCEDURE/S: Each stage of the study was built on and confirmed the previous stages. Stage 1 was an expert panel to develop definitions; stage 2 was a different expert panel made up of neonatal clinicians to propose clinical characteristics associated with the definitions from stage 1; stage 3 was a focus group of neonatal clinicians to provide clinical case scenarios associated with each definition and clinical characteristics; and stage 4 was a survey administered to neonatal clinicians internationally to test the validity of the definitions using the clinical case scenarios. RESULTS: In stage 1, the panel (n=10) developed consensus definitions for acute episodic pain and chronic pain in neonates and infants. In stage 2, a panel (n=8) established clinical characteristics that may be associated with each definition. In stage 3, a focus group (n=11) created clinical case scenarios of neonates and infants with acute episodic pain, chronic pain and no pain using the definitions and clinical characteristics. In stage 4, the survey (n=182) revealed that the definitions allowed an excellent level of discrimination between case scenarios that described neonates and infants with acute episodic pain and chronic pain (area under the receiver operating characteristic=0.87 and 0.89, respectively). CONCLUSIONS: This four-stage study enabled the development of consensus-based and clinically valid definitions of acute episodic pain and chronic pain. There is a need to define and validate other pain types to inform a taxonomy of pain experienced by neonates and infants in the NICU and HDU.

Exploration and Validation of Behavioral Pain Measures and Physiological Pain Measures Factor Structure Extracted From the Pain Assessment Tool Item Scores for Infants Admitted to Neonatal Intensive Care.

OBJECTIVE: The objective of the study was to explore and then validate the factor structure of the Pain Assessment Tool (PAT). MATERIALS AND METHODS: A retrospective medical record review was performed of all infants who were admitted to a neonatal intensive care unit between 2008 and 2018 and had 1 PAT assessment (n=2111). Scores on items of the PAT were collected. Infants were randomized to either the principal component analysis (n=1100) to explore the factor structure or confirmatory factor analysis (n=1011). RESULTS: Infants in the 2 samples were demographically comparable. A 2-factor model, consisting of factors Behavioral and Physiological Pain Measures, was extracted, explaining 39.8% of the total variance. There was a low interfactor correlation (r=0.12), and both Behavioral (r=0.59) and Physiological Pain (r=0.37) Measures factor scores were correlated with nurses' perception of pain scores. When the frequencies in the gestational age at birth categories were compared between upper and lower quartile score infants, there was more with pain at preterm than at term (χ2(3)=44.9, P<0.001) for the Physiological Pain Measures factor, whereas Behavioral Pain Measures frequency was higher at term than at preterm (χ2(3)=8.1, P<0.043). A similar pattern was observed for postmenstrual age at assessment categories: Behavioral Pain Measures (χ2(3)=41.8, P<0.001) Physiological Pain Measures (χ2(3)=46.1, P<0.001). The 2-factor correlated model performed better at explaining the observed variances: (χ2(13)=41.6, P<0.001) compared with rival models. DISCUSSION: The PAT assesses both Behavioral Pain and Physiological Pain Measures, and these dimensions need to be considered separately when assessing pain in infants in the neonatal intensive care unit. Behavioral item scores may be insufficient for detecting pain in premature infants if used alone.

Neonates as intrinsically worthy recipients of pain management in neonatal intensive care.

One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate's family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.

Trajectories of post-surgical pain in infants admitted to neonatal intensive care.

BACKGROUND: The aim of this study was (a) to statistically identify distinct trajectories of pain following surgery in infants less than 6 months of age, and (b) to compare these trajectories to descriptions of chronic pain in infants in the neonatal intensive care unit (NICU). METHODS: This was a retrospective medical record review of infants admitted to a NICU between 2008 and 2018 following surgery. All infants who underwent one major procedure to the abdomen or thorax and returned to the NICU following surgery were included. Pain was assessed regularly using a validated Pain Assessment Tool. Group-based trajectory analysis was used to determine the trajectory of recovery from pain following surgery. RESULTS: A total of 726 infants were included in the study. A two-group trajectory model, defined as typical and atypical pain trajectories, was selected. The typical group (n = 467) consisted of infants who had significantly fewer days (1.5 ± 2.3 vs 5.3 ± 5.5, p < .001) and recorded instances of pain (2.0 ± 3.4 vs 9.7 ± 10.5, p < .001) compared to infants in the atypical group (n = 259). The incidence of iatrogenic neonatal abstinence syndrome was greater in the atypical than the typical group (11% vs 5%, p = .001). CONCLUSIONS: This study has revealed two distinct pain trajectories in infants after surgery. While recovery from pain occurs within days in the typical group, the atypical group demonstrates pain for a significantly longer period, often weeks and months following surgery. This latter group adheres closely to current descriptions of chronic pain in infants.