Pain care for children with cognitive impairment: A parent-nurse partnership.

PURPOSE: To explore nurses' experiences of establishing partnerships with parents for pain care of hospitalized children with cognitive impairment (CI) and identify related facilitators and barriers. DESIGN AND METHODS: In this qualitative, interpretive descriptive study, individual semi-structured interviews were conducted via videoconferencing with pediatric nurses from inpatient wards in a Canadian pediatric quaternary hospital. Verbatim transcripts were analyzed using an inductive, data-driven thematic analysis approach. RESULTS: Eleven nurses were interviewed. The overarching theme was Assessing Pain as an Outsider: "A Complete Guessing Game". Seven major themes were identified.: Relying on Parent Expertise for Pain Assessment, Brainstorming with Parents for Pain Treatment, Supporting Parents as Advocates for Pain Care, Individualizing Pain Care with Parents, Involving the Child in Pain Care: A Spectrum, Barriers to Partnership in Pain Care and Facilitators to Partnership in Pain Care. CONCLUSIONS: Nurses described the many ways they involve parents as partners in pain care. However, nurses shared strong feelings of uncertainty associated with pain care in children with CI. Consequently, nurses felt the need to rely on parents for appropriately assessing and treating pain in children with CI. Findings highlighted the practice and education gaps that may contribute to nurses' uncertainty and reliance on parents. PRACTICE IMPLICATIONS: By identifying related practice and education gaps, healthcare organizations can implement strategies to further support nurses in establishing partnerships and potentially optimize pain care practices.

[Translating evidence: pain treatment in newborns, infants, and toddlers during needle-related procedures : German version]. / Umsetzung von Evidenz ­ Schmerztherapie bei Neugeborenen, Säuglingen und Kleinkindern während Nadelstichverfahren : Deutsche Fassung.

INTRODUCTION: Treatment of pain in preterm, sick, and healthy newborns and infants and toddlers (up to 2 years of age) is consistently reported to be inadequate, and effective strategies are poorly implemented. OBJECTIVES: To present existing evidence of effective pain treatment strategies during needle-related procedures and to highlight initiatives focused on translating evidence into practice. METHODS: This Clinical Update focuses on the 2022 International Association for the Study of Pain Global Year for Translating Pain Knowledge to Practice in the specific population of newborns, infants, and toddlers. Best evidence is reviewed, and existing knowledge translation strategies and programs available to implement evidence into practice are presented. RESULTS: Effective strategies for newborn and young infants during frequently occurring needle procedures include small volumes of sweet solutions, breastfeeding, or skin-to-skin care when feasible and culturally acceptable. In addition, strategies such as nonnutritive sucking, positioning, swaddling, gentle touch, facilitated tucking, and secure holding can be used. For toddlers, the evidence is less robust, and discerning between pain and distress is challenging. However, strategies recommended for needlerelated procedures include upright secure comfort holding by parents/caregivers, age-appropriate distraction, and topical anesthetics. Translation of effective pain management needs to involve the family, who need to be supported and empowered to comfort their child during painful procedures. Organizational, nationwide, and global initiatives aimed at improving implementation of effective pain treatments exist. CONCLUSION: There is evidence of effective pain management strategies for newborns, infants, and toddlers, and a great deal of effort is being made to translate knowledge into action.

Altered gene expression and PTSD symptom dimensions in World Trade Center responders.

Despite experiencing a significant trauma, only a subset of World Trade Center (WTC) rescue and recovery workers developed posttraumatic stress disorder (PTSD). Identification of biomarkers is critical to the development of targeted interventions for treating disaster responders and potentially preventing the development of PTSD in this population. Analysis of gene expression from these individuals can help in identifying biomarkers of PTSD. We established a well-phenotyped sample of 371 WTC responders, recruited from a longitudinal WTC responder cohort using stratified random sampling, by obtaining blood, self-reported and clinical interview data. Using bulk RNA-sequencing from whole blood, we examined the association between gene expression and WTC-related PTSD symptom severity on (i) highest lifetime Clinician-Administered PTSD Scale (CAPS) score, (ii) past-month CAPS score, and (iii) PTSD symptom dimensions using a 5-factor model of re-experiencing, avoidance, emotional numbing, dysphoric arousal and anxious arousal symptoms. We corrected for sex, age, genotype-derived principal components and surrogate variables. Finally, we performed a meta-analysis with existing PTSD studies (total N = 1016), using case/control status as the predictor and correcting for these variables. We identified 66 genes significantly associated with total highest lifetime CAPS score (FDR-corrected p < 0.05), and 31 genes associated with total past-month CAPS score. Our more granular analyses of PTSD symptom dimensions identified additional genes that did not reach statistical significance in our analyses with total CAPS scores. In particular, we identified 82 genes significantly associated with lifetime anxious arousal symptoms. Several genes significantly associated with multiple PTSD symptom dimensions and total lifetime CAPS score (SERPINA1, RPS6KA1, and STAT3) have been previously associated with PTSD. Geneset enrichment of these findings has identified pathways significant in metabolism, immune signaling, other psychiatric disorders, neurological signaling, and cellular structure. Our meta-analysis revealed 10 genes that reached genome-wide significance, all of which were downregulated in cases compared to controls (CIRBP, TMSB10, FCGRT, CLIC1, RPS6KB2, HNRNPUL1, ALDOA, NACA, ZNF429 and COPE). Additionally, cellular deconvolution highlighted an enrichment in CD4 T cells and eosinophils in responders with PTSD compared to controls. The distinction in significant genes between total lifetime CAPS score and the anxious arousal symptom dimension of PTSD highlights a potential biological difference in the mechanism underlying the heterogeneity of the PTSD phenotype. Future studies should be clear about methods used to analyze PTSD status, as phenotypes based on PTSD symptom dimensions may yield different gene sets than combined CAPS score analysis. Potential biomarkers implicated from our meta-analysis may help improve therapeutic target development for PTSD.

Be Sweet to Babies: Consumer Evaluation of a Parent-Targeted Video Aimed at Improving Pain Management Strategies in Newborn Infants Undergoing Painful Procedures.

BACKGROUND: Evidence for analgesic effects of parent-led pain management strategies during painful procedures in newborn infants exists; however, such strategies are inconsistently used in practice. A publicly available parent-targeted video demonstrates breastfeeding, skin-to-skin care, and sucrose during painful procedures. Australian parents' use and knowledge of this video and these strategies was unknown. PURPOSE: To determine parents' use of pain management strategies, and perceived acceptability and usefulness of the parent-targeted video. METHODS: A cross-sectional, online, anonymous survey with embedded video. Participants were recruited via social media channels of the Miracle Babies Foundation, an Australian parent support network. Target participants were parents or family members of infants currently or previously hospitalized in neonatal special and/or intensive care nurseries, or high dependency units. RESULTS: A total of 162 of 189 respondents provided sufficient data for analysis; all identified as mothers. Only 6 (4%) had previously seen the video; however, nearly all rated it as potentially useful and helpful (n = 124, 82%). Although most reported that sucrose had been used (n = 112, 84%), fewer reported having used skin-to-skin care (n = 50, 37%), or breastfeeding (n = 33, 25%). Most intended to advocate for skin-to-skin care (n = 108, 88%) or breastfeeding (n = 100, 81%) in future procedures. Perceived barriers to utilizing strategies included lack of information-sharing and organizational practices that excluded parent involvement. IMPLICATIONS FOR PRACTICE AND RESEARCH: The video may be valuable in supporting mothers to advocate for their involvement during painful procedures in preterm and sick hospitalized infants. Further research is recommended to explore coordinated strategies targeting parents and healthcare professionals to overcome barriers to implementing parent-led infant pain management strategies.

Autoimmune conditions in the World Trade Center general responder cohort: A nested case-control and standardized incidence ratio analysis.

BACKGROUND: The World Trade Center (WTC) general responder cohort (GRC) was exposed to environmental toxins possibly associated with increased risk of developing autoimmune conditions. OBJECTIVES: Two study designs were used to assess incidence and risks of autoimmune conditions in the GRC. METHODS: Three clinically trained professionals established the status of possible GRC cases of autoimmune disorders adhering to diagnostic criteria, supplemented, as needed, by specialists' review of consenting responders' medical records. Nested case-control analyses using conditional logistic regression estimated the risk associated with high WTC exposure (being in the 9/11/2001 dust cloud or ≥median days' response worked) compared with low WTC exposure (all other GRC members'). Four controls were matched to each case on age at case diagnosis (±2 years), sex, race/ethnicity, and year of program enrollment. Sex-specific and sensitivity analyses were performed. GRC age- and sex-adjusted standardized incidence ratios (SIRs) were compared with the Rochester Epidemiology Project (REP). Complete REP inpatient and outpatient medical records were reviewed by specialists. Conditions meeting standardized criteria on ≥2 visits were classified as REP confirmed cases. RESULTS: Six hundred and twenty-eight responders were diagnosed with autoimmune conditions between 2002 and 2017. In the nested case-control analyses, high WTC exposure was not associated with autoimmune domains and conditions (rheumatologic domain odds ratio [OR] = 1.03, 95% confidence interval [CI] = 0.77, 1.37; rheumatoid arthritis OR = 1.12, 95% CI = 0.70, 1.77). GRC members had lower SIR than REP. Women's risks were generally greater than men's. CONCLUSIONS: The study found no statistically significant increased risk of autoimmune conditions with WTC exposures.

Elevated Sound Levels in the Neonatal Intensive Care Unit: What Is Causing the Problem?

BACKGROUND: Premature and sick neonates may require weeks of hospitalization in a noisy neonatal intensive care unit (NICU) environment with sound levels that may reach 120 decibels. The American Academy of Pediatrics recommends a maximum sound level of 45 decibels. PURPOSE: To measure sound levels in a level III NICU and to describe contributing environmental factors. METHODS: Descriptive quantitative study. Sound levels were measured using a portable sound meter in an open-bay level III NICU. Contributing environmental factors were recorded and analyzed. RESULTS: Mean sound levels for day, evening, and night shifts were 83.5, 83, and 80.9 decibels, respectively. Each period of time exceeded the recommended guidelines 90% of the time and was almost double the American Academy of Pediatrics' recommendation. Multiple linear regression findings demonstrated significant factors associated with elevated sound levels including number of neonates, number of people, number of alarms, acuity level, and shift type. Observational data explain 14.5% of elevated sound levels. IMPLICATIONS FOR PRACTICE: An understanding of baseline sound levels and contributing environmental factors is the first step in developing strategies to mitigate excessive noise in the NICU. IMPLICATIONS FOR RESEARCH: Research should focus on effective and sustainable ways to reduce sound levels in the NICU, including inside the isolette, in order to provide an environment that is conducive to optimal growth and neurodevelopment for preterm and sick infants.

Evaluating the French version of an online training course for a pediatric pain assessment scale / Évaluation de la version française d'une formation en ligne sur l'appropriation d'une échelle d'évaluation de la douleur pédiatrique

Context: There is no French-language training to educate nurses on the use of the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale, whose scores guide the treatment of pediatric pain. Aims: The aim of this study was to evaluate a French online training program for the FLACC scale offered to Francophone undergraduate nursing students. Methods: Online training was offered to nursing students enrolled in a pediatric nursing course. Participants completed online questionnaires pre- and post-training to assess their perception of their knowledge and confidence, the accuracy of their pain assessment scores, as well as the usefulness and user-friendliness of the training. Results: The FLACC online training improved students' perceived knowledge (p = 0.0004) and confidence (p = 0.0053) in the FLACC pediatric pain scale. Students' accuracy of severe pain assessment scores significantly improved (p = 0.0159) and slightly improved for moderate pain (p = 0.6363). However, accuracy for mild pain assessment was slightly decreased post-training (p = 0.7686). Discussion: An improvement of the quality of videos linked to mild pain, and the quantity of videos for all levels of pain, is required for this study to be replicated among a larger sample. Conclusion: The online training fills the gap in nurses' lack of knowledge about the use of the FLACC pain scale and improves access to quality training in French.

Contexte: Il n'existe aucune formation pour éduquer les infirmières quant à l'utilisation de l'échelle d'évaluation de la douleur pédiatrique Faces-Legs-Activity-Cry-Consolability (FLACC), dont les scores obtenus guident le traitement adéquat de la douleur. Objectif: Cette étude visait à évaluer une formation en ligne portant sur l'échelle FLACC. Méthode: La formation a été offerte aux étudiantes inscrites à un cours de soins infirmiers pédiatriques offert lors de la 3e année du baccalauréat en sciences infirmières. Les participantes ont rempli des questionnaires en ligne avant et après la formation afin d'évaluer leur perception quant à leurs connaissances et leur confiance, l'exactitude de leurs scores d'évaluation de la douleur, ainsi que l'utilité et la fonctionnalité de la formation. Résultats: La formation augmente les connaissances (p = 0,0004) et la confiance (p = 0,0053), selon les participantes. Elle améliore l'exactitude des scores de l'évaluation de la douleur sévère des étudiantes (p = 0,0159) et celle des scores de douleur modérée (p = 0,6363), mais diminue l'exactitude de leurs scores de douleur faible (p = 0,7686). Discussion: La qualité des vidéos reliées à la douleur faible et la quantité des vidéos pour tous les niveaux de douleur devront être améliorées. Conclusion: La formation rehausse l'éducation quant à l'utilisation appropriée de l'échelle FLACC et accroît le nombre de formations de qualité en français.

Cardiovascular disease in the World Trade Center Health Program General Responder Cohort.

BACKGROUND: Over 90,000 rescue and recovery responders to the September 2001 World Trade Center (WTC) attacks were exposed to toxic materials that can impair cardiac function and increase cardiovascular disease (CVD) risk. We examined WTC-related exposures association with annual and cumulative CVD incidence and risk over 17 years in the WTC Health Program (HP) General Responder Cohort (GRC). METHODS: Post 9/11 first occurrence of CVD was assessed in 37,725 responders from self-reported physician diagnosis of, or current treatment for, coronary artery disease, myocardial infarction, stroke and/or congestive heart failure from WTCHP GRC monitoring visits. Kaplan-Meier estimates of CVD incidence used the generalized Wilcoxon test statistic to account for censored data. Cox proportional hazards regression analyses estimated the CVD hazard ratio associated with 9/11/2001 arrival in responders with and without dust cloud exposure, compared with arrival on or after 9/12/2001. Additional analyses adjusted for comorbidities. RESULTS: To date, 6.3% reported new CVD. In covariate-adjusted analyses, men's CVD 9/11/2001 arrival risks were 1.40 (95% confidence interval [CI] = 1.26, 1.56) and 1.43 (95% CI = 1.29, 1.58) and women's were 2.16 (95% CI = 1.49, 3.11) and 1.59 (95% CI = 1.11, 2.27) with and without dust cloud exposure, respectively. Protective service employment on 9/11 had higher CVD risk. CONCLUSIONS: WTCHP GRC members with 9/11/2001 exposures had substantially higher CVD risk than those initiating work afterward, consistent with observations among WTC-exposed New York City firefighters. Women's risk was greater than that of men's. GRC-elevated CVD risk may also be occurring at a younger age than in the general population.

Mental health stigma and barriers to care in World Trade Center responders: Results from a large, population-based health monitoring cohort.

BACKGROUND: Nearly 20 years after the terrorist attacks of September 11, 2001, multiple studies have documented the adverse mental consequences among World Trade Center (WTC) rescue, recovery, and clean-up workers. However, scarce research has examined mental health stigma and barriers to care in WTC-exposed individuals, and no known study has examined whether rates of endorsement may differ between police and "nontraditional" responders, the latter comprising a heterogeneous group of workers and volunteers. OBJECTIVE: To identify the prevalence and correlates of mental health stigma and barriers to care in WTC responders. METHODS: Mental health stigma and barriers to care and their correlates were examined in 6,777 police and 6,272 nontraditional WTC responders. RESULTS: Nontraditional responders endorsed more stigma or barriers to care concerns than police responders. Within a subsample who screened positive for a psychiatric disorder, police were more likely than nontraditional responders to endorse "concerns that negative job consequences might result" (17.9% vs. 9.1%), while nontraditional responders were more likely to endorse "I don't know where to go to find counseling services" (18.4% vs.6.6%). Within this subsample, mental health service need and more severe WTC-related posttraumatic stress disorder symptoms were associated with increased likelihood of endorsing stigma or barriers; pre-9/11 psychiatric history and non-Hispanic Black race/ethnicity were associated with lower likelihood of endorsing stigma or barriers. CONCLUSIONS: Results of this study underscore the burden of mental health stigma and barriers to care in WTC responders, and highlight the need for targeted interventions to address these concerns and promote mental healthcare utilization in this population.

A Cross-Sectional Review of Pain Management Interventions Used for Painful Pediatric Blood Draw Procedures in Hospital.

BACKGROUND: Hospitalized children continue to experience procedural pain due to inconsistent implementation of readily available, evidence-based pain interventions. AIMS: To explore the prevalence of painful blood-testing procedures, pain management interventions, child-caregiver perceptions of effectiveness of, and satisfaction with, pain interventions, and adherence to best practice guidelines. DESIGN: A single-site cross-sectional study using a combination of child-caregiver interviews and chart reviews for hospitalized children, 0-18 years. METHODS: Interviews gathered information about the child's most recent blood test, procedural pain management intervention use, and participant perceptions of effectiveness of and satisfaction with these interventions. Concurrently, patient charts were reviewed for procedure documentation and pain management strategies used, including topical anesthetic and oral sucrose orders. Data were analyzed using descriptive statistics. RESULTS: Fifty children were included. At the time of data collection, 34 (68%) had experienced painful blood-testing procedures during their current admission. Pharmacologic pain interventions were documented for only 7 (21%) procedures and were often inconsistent with participant reports. Almost all interview respondents (n = 31, 91%) identified at least one pain intervention for the child's most recent painful blood-test. Twenty (59%) participants perceived pain interventions as effective and most were satisfied with utilized interventions (n = 27, 79%). CONCLUSIONS: A multi-modal procedural pain management approach was infrequently used and documented, highlighting undertreatment based on recommended practices and guidelines. Perceived intervention effectiveness and satisfaction with pain management were however found to be relatively high.