Pain Behaviors Analyzed by Videorecording in Brain-Injured Patients Admitted to the Intensive Care Unit.

AIM: To describe and classify pain behaviors (facial and body) in brain-injured patients with a low level of consciousness before, during, and after the performance of painful and non-painful care procedures. METHODS: Facial behaviors and body movements in brain-injured patients were videotaped at rest, during the application of three care procedures (two painful and one non-painful), and 15 minutes after completion of these procedures. Each video recording was evaluated by expert evaluators blinded to each other. For each of the behaviors observed, all possible combinations between the three procedures and/or time were compared using the McNemar test. Effect size was measured by the difference in proportions using the Wilson score 95% confidence intervals. RESULTS: Twenty-seven patients were included. The mean (standard deviation) Glasgow Coma Score was 5.4 (1.9). A total of 33 behaviors (29 active, four neutral) were registered. Expression of behaviors was more common during the painful procedures compared with the other time points (non-painful procedures, baseline, and final evaluation). Inter-evaluator agreement was substantial (Kappa index >0.7) in more than 50% of the observed behaviors. CONCLUSIONS: In this study involving brain-injured patients with a low level of consciousness, facial, body, and ventilation-related behaviors were more common during painful procedures. Agreement between evaluators to detect the presence or absence of these behaviors was substantial. These findings underscore the need to develop pain assessment measures specific to this patient population.

Longitudinal Analysis of Continuous Pulse Oximetry as Prognostic Factor in Neonatal Respiratory Distress.

OBJECTIVE: Analysis of longitudinal data can provide neonatologists with tools that can help predict clinical deterioration and improve outcomes. The aim of this study is to analyze continuous monitoring data in newborns, using vital signs to develop predictive models for intensive care admission and time to discharge. STUDY DESIGN: We conducted a retrospective cohort study, including term and preterm newborns with respiratory distress patients admitted to the neonatal ward. Clinical and epidemiological data, as well as mean heart rate and saturation, at every minute for the first 12 hours of admission were collected. Multivariate mixed, survival and joint models were developed. RESULTS: A total of 56,377 heart rate and 56,412 oxygen saturation data were analyzed from 80 admitted patients. Of them, 73 were discharged home and 7 required transfer to the intensive care unit (ICU). Longitudinal evolution of heart rate (p < 0.01) and oxygen saturation (p = 0.01) were associated with time to discharge, as well as birth weight (p < 0.01) and type of delivery (p < 0.01). Longitudinal heart rate evolution (p < 0.01) and fraction of inspired oxygen at admission at the ward (p < 0.01) predicted neonatal ICU (NICU) admission. CONCLUSION: Longitudinal evolution of heart rate can help predict time to transfer to intensive care, and both heart rate and oxygen saturation can help predict time to discharge. Analysis of continuous monitoring data in patients admitted to neonatal wards provides useful tools to stratify risks and helps in taking medical decisions. KEY POINTS: · Continuous monitoring of vital signs can help predict and prevent clinical deterioration in neonatal patients.. · In our study, longitudinal analysis of heart rate and oxygen saturation predicted time to discharge and intensive care admission.. · More studies are needed to prospectively prove that these models can helpmake clinical decisions and stratify patients' risks..

Gender dysphoria: laparoscopic sigmoid vaginoplasty. Another utility of indocyanine green.

AIM: Gender dysphoria is the disagreement between the gender of birth and the one with which the patient identifies. For its management it is mandatory to have a multidisciplinary team. Gender confirmation surgery with penoscrotal skin flap is the procedure of choice, and a sigmoid vaginoplasty is a feasible alternative. The new technologies and the help of indocyanine green (ICG) fluorescence can help to guarantee a correct neovagina vascularization. The objective of this paper is to present the surgical technique of laparoscopic sigmoid vaginoplasty assisted by ICG. METHODS: We present two patients with gender dysphoria and a history of stricture of the penoscrotal skin flap vaginoplasty. We performed sigmoid vaginoplasty by the laparoscopic approach. We began the procedure with the mobilization and section of 30 cm of sigmoid colon, selective ligation of the vessels assisted by ICG, 180° sigmoid rotation, externalized on antiperistaltic position, construction of colovestibular anastomosis and promontory fixation. We finished the procedure with virtual ileostomy construction and drain placement. RESULTS: Patients recovered satisfactorily and were discharged on the seventh day after surgery without complications. CONCLUSION: Sigmoid vaginoplasty is a safe and feasible procedure. ICG has great value, contributing to the selective ligation of the vessels, allowing 180° sigmoid rotation and guaranteeing the irrigation of the neovagina.

Application of the Behavioural Indicators of Pain Scale in patients with traumatic brain injury.

AIM: To develop and psychometrically test the Behavioural Indicators of Pain Scale (ESCID) in patients with traumatic brain injury (TBI). DESIGN: A prospective observational study to test the psychometric properties of the Behavioural Indicators of Pain Scale in patients with TBI. METHOD: A convenience sample of patients with TBI, who were non-communicative and using invasive mechanical ventilation was selected. Pain was evaluated by two observers who were blinded from each other. Assessments were performed at baseline via the performance of a painful procedure (aspiration of secretions) and a non-painful procedure (rubbing with a gauze). Assessments were repeated after application of procedures on days 1 and 6 of hospitalization in an intensive care unit. Data were collected between January-December 2016. RESULTS: About 134 patients were included in the study. Of these, 76.1% were men. The mean age of participants was 45.2 (SD 17.5) years. The pain score significantly increased during the painful procedure when compared with the baseline measure and non-painful procedure (p < .001). Patients displayed a greater number of pain-indicating behaviours during the painful procedure on day 6, compared with day 1 (p < .05). This finding coincided with a reduced level of sedation and a greater level of consciousness. CONCLUSION: The ESCID scale detects pain behaviours and discriminates among the different types of stimulation in patients with brain injury, who are uncommunicative and with mechanical ventilation, with good reliability. The ability for patients with brain injury to express behaviours is limited because of the low level of consciousness and the deep level of sedation. IMPACT: This research will have an impact on the practice of pain assessment in patients with brain injury, representing a first step to adapt the content of the ESCID.

Pain Assessment in Mechanically Ventilated, Noncommunicative Severe Trauma Patients.

The aim of this study was to measure pain levels in noncommunicative patients with severe trauma who required tracheal suctioning and mobilization and to determine the utility of the Behavioral Indicators of Pain Scale (ESCID) in these cases. The pain scores for the procedures were recorded on Days 1, 3, and 6 of the patients' stay in the intensive care unit. These assessments were performed at 3 moments: before, during, and after the application of the procedures. Because of the longitudinal character of the study, data were fitted into a multivariate model using the Generalized Estimating Equations method. The sample of 124 patients comprised 77.4% males and 22.6% females with an average age of 45.93 (SD = 16.43) years. A significant increase (p < .01) in the ESCID score was observed during the application of the procedures that produced similar pain levels. Kappa coefficient value obtained for interobserver agreement of ESCID scale scores during the application of care procedures at the intervals being evaluated was greater than 0.84, which should be interpreted as almost perfect. The ESCID scores increased during 2 care procedures that are frequently carried out in intensive care units and indicated that they produced similar pain levels.

Effect of early cryoprecipitate transfusion versus standard care in women who develop severe postpartum haemorrhage (ACROBAT) in the UK: a protocol for a pilot cluster randomised trial.

INTRODUCTION: The incidence of severe postpartum haemorrhage (PPH) that requires blood transfusion is on the increase. Fibrinogen levels have been shown to drop early and significantly during PPH, which is associated with worse outcomes. Early fibrinogen replacement could potentially improve outcomes. No studies have investigated the clinical impact of early cryoprecipitate transfusion in PPH. Prior to performing a full-scale trial, a pilot study is needed to determine feasibility of the intervention and recruitment. METHODS: ACROBAT is a cluster-randomised pilot study with a qualitative evaluation. Four large London maternity units are randomised to either the intervention or control group. The intervention group will adapt their major obstetric haemorrhage procedures to administer cryoprecipitate early for primary PPH. The control group will retain their standard of care.We include women at >24 weeks gestation who are actively bleeding within 24 hours of delivery and for whom transfusion of red blood cells (RBCs) has been started. We exclude women who decline blood transfusions in advance or have inherited Factor XIII or fibrinogen deficiency. Due to the emergency nature of the intervention, informed consent for administering the intervention is waived.The primary objective is to assess the feasibility of administering cryoprecipitate within 90 min of RBC request, as compared with standard treatment where cryoprecipitate is given later or not at all. Secondary objectives include the feasibility of recruitment and data collection, reasons for and barriers to consent, preliminary maternal clinical outcomes, identification of the optimal infrastructure pathways for study delivery, and acceptability of the intervention and outcomes. ETHICS AND DISSEMINATION: The trial has approvals from the London-Brighton & Sussex Research Ethics Committee (ref. 18/LO/2062), the Confidentiality Advisory Group (ref. 18/CAG/0199) and Health Research Authority (IRAS number 237959). Data analysis and publication of manuscripts will start in Q3 2020. TRIAL REGISTRATION NUMBER: ISRCTN12146519.

Surface adsorption, intracellular accumulation and compartmentalization of Pb(II) in batch-operated lagoons with Salvinia minima as affected by environmental conditions, EDTA and nutrients.

The effects of environmental factors and nutrients on the various possible removal mechanisms (surface adsorption, intracellular accumulation and precipitation to sediments) and partitioning of lead among various compartments (plant biomass, water column and sediments) in Salvinia minima batch-operated lagoons, were evaluated. Surface adsorption was found to be the predominant mechanism for Pb(II) removal under all environmental conditions tested in the absence of nutrients (an average of 54.3%) and in a nutrient medium (modified Hutner 1/10 medium) free of EDTA and phosphates (54.41%) at "high" initial Pb(II) concentrations (in the range of 10.3+/-0.13 to 15.2+/-0.05 mg/L). Under these conditions, the bioconcentration factors (BCFs) were 2,431+/-276 and 2,065+/-35, respectively. Lead removal was very rapid during the first 4 h and reached 70% in the absence of nutrients at the "medium" light intensity and temperature (LIT) tested, 88% in nutrient medium free of EDTA and supplemented with synthetic wastewater (at the "lowest" LIT tested), and 85% in medium free of EDTA and phosphates. It was concluded that the mechanisms of lead removal by S. minima, and the compartmentalization of this metal in the microcosm of batch-operated lagoons, are primarily a function of the presence of certain nutrients and chelants, with secondary dependence on environmental conditions. In addition, the results indicate that the percentage of lead removed is only a gross parameter and that the complementary use of BCF and compartmentalization analysis is required to gain a full insight into the metal removal process.