A scoping review of the epidemiology and treatment of painful procedures in hospitalized neonates: What has changed in the past three decades?

BACKGROUND: Care of newborns hospitalized in the neonatal intensive care unit (NICU) includes multiple painful procedures/day. Epidemiologic studies have reported the frequency and nature of procedures and treatment interventions. However, evidence on the changing trends in the nature and frequency of neonatal pain procedures or treatments over time is absent or inconclusive. We aimed to determine the frequency and nature of painful procedures/neonate/day in the NICU. DATABASES AND DATA TREATMENT: MEDLINE and Embase searches were conducted from database inception to July 2023. Studies that reported the nature and frequency of painful procedures and associated pain treatments in neonates were included. Standard inverse-variance random-effects meta-analyses were used to combine studies. Heterogeneity between studies was quantified using the I2 statistic. RESULTS: Of 2622 unique citations, 64 full-text articles were reviewed; 23 were included. Six additional studies identified in a previous review, and six publications from reference lists were added, resulting in 35 studies. The mean number of painful procedures/neonate/day was 7.38 (95% CI 5.60, 9.17; range <2 to 17). Although the frequency of painful procedures in more recent studies was reduced, it was not statistically significant (p = 0.16). Painful procedures were more frequent during longer observation periods. Needle-related procedures were most common and did not change over time. Procedure-related treatment was suboptimal and inconsistently reported. CONCLUSIONS: Frequency of painful procedures in the NICU has shown a clinically important decrease but has not significantly changed over time. A paradigm shift moving responsibility from providers to systems in changing pain practices in the NICU is required. SIGNIFICANCE STATEMENT: The decrease in the daily frequency of painful procedures in hospitalized neonates might be clinically relevant but is not yet statistically significant. Pain treatment is insufficiently documented and reported. This lack of progress in neonatal care might be a result of the complexity of defining pain and stress; inconsistencies in determining the burden of procedural pain; the influence of barriers and facilitators on practice change; and the focus on an individual rather than system responsibility for pain prevention and treatment.

Influence of Time of Admission on Endovascular Thrombectomy (EVT): Comparison of Outcomes During Business Hours Versus Off-Business Hours.

Purpose:To investigate the differences in endovascular thrombectomy (EVT) outcomes of patients treated for acute ischaemic stroke (AIS) during business versus off-business hours. Methods: A single-centre retrospective cohort study of patients with AIS treated with EVT from February 1, 2015, to May 31, 2021, was performed at a comprehensive stroke centre (CSC). Patients were divided into business (Monday to Friday, 8 AM-5 PM) versus off-business hours groups. The primary outcome was functional neurological disability, scored using the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included the rate of successful reperfusion and procedural workflow time delays. Differences in proportions were assessed using Fisher's exact and Chi-Square tests as appropriate. For continuous variables, differences in medians between groups were assessed using Mann-Whitney U tests. Results: A total of 676 patients were included, with 399 patients (59%) comprising the off-business-hour group. No significant differences were seen in age, sex, ASPECTS score, or NIHSS at arrival. Off-business hours strokes had a longer delay between CSC arrival to groin puncture (minutes: 81 vs 44, P < .0001) and between imaging to groin puncture (minutes: 67 vs 32, P < .0001) compared to the business hours strokes. There were no differences in the rate of successful reperfusion (mTICI ≥2b) between groups (82% vs 83%, P = .61). At 90 days, 65% of patients in both groups had an mRS ≤2 (P = .91). Conclusion: Despite workflow delays in initiating EVT during off-business hours, there were no differences in the rate of successful reperfusion or functional outcomes.

Anticodon sequence determines the impact of mistranslating tRNAAla variants.

Transfer RNAs (tRNAs) maintain translation fidelity through accurate charging by their cognate aminoacyl-tRNA synthetase and codon:anticodon base pairing with the mRNA at the ribosome. Mistranslation occurs when an amino acid not specified by the genetic message is incorporated into proteins and has applications in biotechnology, therapeutics and is relevant to disease. Since the alanyl-tRNA synthetase uniquely recognizes a G3:U70 base pair in tRNAAla and the anticodon plays no role in charging, tRNAAla variants with anticodon mutations have the potential to mis-incorporate alanine. Here, we characterize the impact of the 60 non-alanine tRNAAla anticodon variants on the growth of Saccharomyces cerevisiae. Overall, 36 tRNAAla anticodon variants decreased growth in single- or multi-copy. Mass spectrometry analysis of the cellular proteome revealed that 52 of 57 anticodon variants, not decoding alanine or stop codons, induced mistranslation when on single-copy plasmids. Variants with G/C-rich anticodons resulted in larger growth deficits than A/U-rich variants. In most instances, synonymous anticodon variants impact growth differently, with anticodons containing U at base 34 being the least impactful. For anticodons generating the same amino acid substitution, reduced growth generally correlated with the abundance of detected mistranslation events. Differences in decoding specificity, even between synonymous anticodons, resulted in each tRNAAla variant mistranslating unique sets of peptides and proteins. We suggest that these differences in decoding specificity are also important in determining the impact of tRNAAla anticodon variants.

An exploratory case study investigating the implementation of a novel knowledge translation strategy in a pandemic: the Pandemic Practice Champion.

BACKGROUND: The clinical Pandemic Practice Champion (PPC) role was created in a large tertiary pediatric hospital as a knowledge translation (KT) strategy for implementing COVID-19 evidence-based knowledge. We aimed to describe the core components of the PPC role, the process of implementing the role, and the factors that hindered or facilitated role implementation. METHODS: An exploratory case study was undertaken. Semi-structured interviews were conducted virtually with stakeholders including PPC, managers, and front-line health care professionals (HCP). A directed approach to qualitative content analysis consistent with the Consolidated Framework for Implementation Research (CFIR) guided the analytic process. Inductive analyses and three stages of thematic synthesis were also conducted. RESULTS: Four PPC, 3 managers, and 6 HCP were interviewed. The core components of the PPC role consisted of (a) acting as knowledge experts and educators, (b) problem-solving for complex patient care issues, (c) conducting crisis management, and (d) acting as a resource to management, HCP, and families. Facilitators for successful implementation included access to external information, a supportive organizational context and culture, dedicated time and resources, and leadership support. Lack of clarity of role definition, insufficient time, pandemic uncertainty and fatigue, inability to change infrastructure, and access to external information hindered implementation. CONCLUSION: The PPC role was successfully implemented within a crisis context. Key barriers (role clarity, time, resources) and facilitators (organizational and leadership support) need to be considered when implementing the PPC role in practice. Future studies are needed to determine the intervention effectiveness of the champion role in changing HCP behavior and health outcomes and further examine implementation processes and mechanisms.

Evaluation of the Premature Infant Pain Profile-Revised (PIPP-R) e-Learning Module: Immediate and Sustained Competency.

BACKGROUND: Electronic health (e-health) learning is a potential avenue to educate health professionals about accurately using infant pain assessment tools, although little is known about the impact of e-health interventions on clinical competence. PURPOSE: To evaluate whether an e-health learning module for teaching the accurate use of the Premature Infant Pain Profile-Revised (PIPP-R) pain assessment tool results in immediate and sustained competency to assess infant pain. METHODS: Neonatal intensive care unit (NICU) nurses who participated in a larger study across 2 tertiary NICUs in Canada examining the implementation and clinical utility of the PIPP-R e-learning module completed 2 follow-up evaluations at 1 week and 3 months. Participants were asked to view a video recording of an infant undergoing a painful procedure and to assess the infant's pain intensity response using the PIPP-R measure. Immediate and sustained competency was assessed via interrater consensus of participant-reported PIPP-R scores compared with those of an experienced trained coder. RESULTS: Of the 25 eligible nurses, 22 completed 1-week and 3-month follow-up evaluations. At the 1-week follow-up, 84% of nurses scored the video accurately compared with 50% at 3 months. Behavioral pain indicators were more likely to be scored incorrectly than physiological indicators. IMPLICATIONS FOR PRACTICE: Follow-up training after completion of the initial e-learning module training may improve competency related to the clinical use of the PIPP-R tool to assess infant pain over time. IMPLICATIONS FOR RESEARCH: Additional study regarding the need and timing of e-health training to optimize sustained competency in infant pain assessment is warranted.

Implementation and Evaluation of the Premature Infant Pain Profile-revised (PIPP-R) e-Learning Module for Assessing Pain in Infants.

OBJECTIVES: The Premature Infant Pain Profile-revised (PIPP-R) is a well-established measure for infant pain assessment. The aim of this study was to evaluate the implementation and clinical utility of the PIPP-R electronic learning (e-Learning) module to promote standardized health care training for nurses. MATERIALS AND METHODS: A descriptive mixed-methods study was conducted in 2 tertiary Neonatal Intensive Care Units in Canada. Nurses were recruited and asked to complete the PIPP-R e-Learning Module and evaluate it. A 26-item questionnaire was used to describe nurse demographics and clinical experience and to evaluate implementation success (ie, acceptability, feasibility, usability) and clinical utility. RESULTS: In all, 98 nurses from 2 settings in Central and Eastern Canada participated; most were registered nurses highly experienced in neonatal nursing care. The majority had received previous training on the PIPP-R (61.2%) and routinely used it in practice (67.4%). They considered the e-Learning module as acceptable and feasible as it was easy to access (94.9%) and to navigate (94.8%). Content was considered clear (98.9%) and met users' learning needs (99.0%). Nurses agreed that completing the module improved their understanding of neonatal pain (96.0%) and was clinically useful in improving their ability to assess pain in neonates (97.9%). The module was accessed primarily from work settings (77.8%) using desktop computers (49.0%) or tablets (28.0%) and was usually completed in a single session (75.7%). DISCUSSION: Nurses' evaluation of the PIPP-R e-Learning module was overwhelmingly positive. The module was perceived as easy to implement, clinically useful, and was considered as a promising online educational tool. Further testing in clinical practice is needed to build on the results of this study and support the importance of dissemination of this module for standardized training purposes.

Usability, acceptability, and feasibility of the Implementation of Infant Pain Practice Change (ImPaC) Resource.

The Implementation of Infant Pain Practice (ImPaC) Resource is an eHealth tool designed to support infant pain practice change and ultimately enhance pain outcomes. The aim of this study was to determine users' perspectives on usability, acceptability, and feasibility of the ImPaC Resource. A descriptive prospective mixed-methods quality improvement study was conducted at a pediatric hospital in Canada. Individual "think aloud" interviews were conducted in a nonclinical environment (Phase A); "near live" testing was conducted while users interacted with the Resource in clinical setting (Phase B); individual "think-aloud" interviews were conducted in a nonclinical environment (Phase C). Outcomes included usability (System Usability Scale-SUS), acceptability (Acceptability E-Scale-AES), and feasibility. Interview transcripts were coded per a priori themes using deductive content analysis to create a structured categorization matrix. In Phase A, 10 clinicians interacted with the Resource in individual sessions. Median SUS score was 73.75 (range 52.5-92.5). In Phase B, four clinicians implemented the Resource in the neonatal intensive care unit (NICU) over 4 months. Median SUS score was 85 (82.5-92.5), and median AES score was 24 (21-24). In Phase C, an enhanced prototype was produced, and the same users from Phase B navigated the Resource in individual sessions. Median SUS score was 88.75 (85-95), and median AES score was 27.5 (25-29). Users considered the Resource as feasible for implementation, easy to navigate, engaging, intuitive, comprehensive, and evidence-based. Users highlighted the potential transferability of the Resource to other contexts and settings. The enhanced version of the ImPaC Resource was usable, acceptable, feasible, and met users' expectations and requirements. Results lead the way for evaluation of the Resource in a nationwide cluster randomized trial including 18 NICUs. This knowledge-rich platform is expected to enhance infant pain practices and outcomes in diverse clinical settings.

Molecular characterization and morphological description of cryptic haemoproteids in the laughingthrushes (Leiothrichidae) in the western and eastern Himalaya, India.

Background: Laughingthrushes (family: Leiothrichidae) consists of diverse and widespread species found in the Indian subcontinent but there is a lack of information on their avian haemosporidians.  Methods: We sampled 231 laughingthrushes of 8 species in the western and eastern Himalaya in India. Using parasite morphology and cytochrome b sequences we describe 2 new Haemoproteus species harbored in 3 species of laughingthrushes and report a case of cryptic speciation. Results: First Haemoproteus lineage TROERY01 (GenBank: KY623720) found in Trochalopteron erythrocephalum (27.47%) and Trochalopteron variegatum (2.9%) in mid to high altitude tropical forests in the western and eastern Himalaya, was described as Haemoproteus (Parahaemoproteus) leiothrichus n. sp. (Haemosporida: Haemoproteidae). Second Haemoproteus lineage TROERY02 (GenBank: KY623721) described as Haemoproteus (Parahaemoproteus) homoleiothrichus n. sp. (Haemosporida: Haemoproteidae) was found in T. erythrocephalum (2.19%) and Trochalopteron lineatum (3.84%), albeit in low intensity, only in the western Himalaya. Both H. homoleiothrichus n. sp. and H. leiothrichus n. sp. showed no significant difference in morphological features in blood stages. A genetic divergence of 4.4% along with distinct phylogenetic position indicates that these 2 lineages represent cryptic species. Previously, T. erythrocephalum has been described as an additional host for a morphologically described Haemoproteus timalus in the oriental region. Our described species have several morphological features that are absent in H. timalus. These are, the presence of dumbbell-like shaped mature gametocytes, 'arm' like extensions of gametocytes and lateral displacement of nuclei of infected erythrocytes. Illustrations of blood stages of the new species are given, and phylogenetic analysis with morphologically described Haemoproteus species identifies parasites closely related to the 2 described parasites. Conclusions: The lineages described here have been recorded only in the laughingthrushes so far. These are the first parasites to be described with T. erythrocephalum as a type host from the western and eastern Himalaya in India.

Estimating prevalence of avian haemosporidians in natural populations: a comparative study on screening protocols.

BACKGROUND: Birds harbour an astonishing diversity of haemosporidian parasites. Renewed interest in avian haemosporidians as a model system has placed a greater emphasis on the development of screening protocols to estimate parasite prevalence and diversity. Prevalence estimates are often based on the molecular or blood-smear microscopy techniques. However, variation in diagnostic sensitivity among screening methodologies represents a potential source of bias that may lead to erroneous inference in comparisons of prevalence across studies. Here, we analyzed a suite of blood samples for the presence of parasites using four diagnostic tools and compared method-specific estimates of detection probability to assess the relative performance of screening strategies. METHODS: We screened a total of 394 bird blood samples collected in India (n = 203) and Sweden (n = 191) for the combined presence of Plasmodium, Haemoproteus and Leucocytozoon with three PCR assays: (i) qPCR; (ii) restriction enzyme-based assay; and (iii) nested protocol. In addition, we examined blood smears for estimates of parasite intensity which was further screened using qPCR method to evaluate if parasite intensity shows a relationship with qPCR (Ct values). Furthermore, we used single infected samples from parasite intensities: low, medium, high, very high to establish the reproducibility in qPCR. RESULTS: For the combined data sets from India and Sweden, detection probability for submicroscopic and low intensity infections was highest for the qPCR method, followed by the nested protocol and the restriction enzyme-based assay. For high parasite intensities, the qPCR had high PCR reproducibility, with three out of three PCR replicates being positive and with consistent Ct values across all tenfold dilution series. For parasite intensities at very low and submicroscopic samples, the qPCR was reproducible in one out of the three replicates. The intensity of parasitemia estimated from smears showed inverse relationship with Ct values in both the Indian and Swedish data sets. CONCLUSIONS: Our study highlights the importance of accounting for methodological issues to better estimate infection in parasitological studies and illustrates how a wider deployment of diagnostic tools combined with statistical approaches is needed for each study, in order to provide adequate insight into the most appropriate approach to avoid erroneous inferences.

Formin-mediated actin polymerization at cell-cell junctions stabilizes E-cadherin and maintains monolayer integrity during wound repair.

Cadherin-mediated cell-cell adhesion is required for epithelial tissue integrity in homeostasis, during development, and in tissue repair. E-cadherin stability depends on F-actin, but the mechanisms regulating actin polymerization at cell-cell junctions remain poorly understood. Here we investigated a role for formin-mediated actin polymerization at cell-cell junctions. We identify mDia1 and Fmnl3 as major factors enhancing actin polymerization and stabilizing E-cadherin at epithelial junctions. Fmnl3 localizes to adherens junctions downstream of Src and Cdc42 and its depletion leads to a reduction in F-actin and E-cadherin at junctions and a weakening of cell-cell adhesion. Of importance, Fmnl3 expression is up-regulated and junctional localization increases during collective cell migration. Depletion of Fmnl3 or mDia1 in migrating monolayers results in dissociation of leader cells and impaired wound repair. In summary, our results show that formin activity at epithelial cell-cell junctions is important for adhesion and the maintenance of epithelial cohesion during dynamic processes, such as wound repair.

Design of symmetric TIM barrel proteins from first principles.

BACKGROUND: Computational protein design is a rapidly maturing field within structural biology, with the goal of designing proteins with custom structures and functions. Such proteins could find widespread medical and industrial applications. Here, we have adapted algorithms from the Rosetta software suite to design much larger proteins, based on ideal geometric and topological criteria. Furthermore, we have developed techniques to incorporate symmetry into designed structures. For our first design attempt, we targeted the (α/ß)8 TIM barrel scaffold. We gained novel insights into TIM barrel folding mechanisms from studying natural TIM barrel structures, and from analyzing previous TIM barrel design attempts. METHODS: Computational protein design and analysis was performed using the Rosetta software suite and custom scripts. Genes encoding all designed proteins were synthesized and cloned on the pET20-b vector. Standard circular dichroism and gel chromatographic experiments were performed to determine protein biophysical characteristics. 1D NMR and 2D HSQC experiments were performed to determine protein structural characteristics. RESULTS: Extensive protein design simulations coupled with ab initio modeling yielded several all-atom models of ideal, 4-fold symmetric TIM barrels. Four such models were experimentally characterized. The best designed structure (Symmetrin-1) contained a polar, histidine-rich pore, forming an extensive hydrogen bonding network. Symmetrin-1 was easily expressed and readily soluble. It showed circular dichroism spectra characteristic of well-folded alpha/beta proteins. Temperature melting experiments revealed cooperative and reversible unfolding, with a Tm of 44 °C and a Gibbs free energy of unfolding (ΔG°) of 8.0 kJ/mol. Urea denaturing experiments confirmed these observations, revealing a Cm of 1.6 M and a ΔG° of 8.3 kJ/mol. Symmetrin-1 adopted a monomeric conformation, with an apparent molecular weight of 32.12 kDa, and displayed well resolved 1D-NMR spectra. However, the HSQC spectrum revealed somewhat molten characteristics. CONCLUSIONS: Despite the detection of molten characteristics, the creation of a soluble, cooperatively folding protein represents an advancement over previous attempts at TIM barrel design. Strategies to further improve Symmetrin-1 are elaborated. Our techniques may be used to create other large, internally symmetric proteins.

Jack of all trades: functional modularity in the adherens junction.

Adherens junctions, broadly defined as attachment sites in which cadherin adhesion receptors connect the actin cytoskeletons of neighboring animal cells, are multi-tasking by nature. In addition to mediating cell-cell adhesion and providing the tissue with mechanical continuity and barrier function, they maintain polarity, are sites of mechanosensing and signaling, and they regulate actomyosin dynamics and can thus generate forces to drive morphogenesis. Here we propose that the key to performing such diverse tasks is the integration within the cadherin adhesome of functional modules that evolved independently to perform other duties within the cell, and we discuss three such functional modules: force transmission, actin dynamics regulation, and contractile force generation. We compare each module to a more ancient cellular structure with similar function, identify shared components, and speculate on how the module was integrated into the cadherin adhesome.

An optogenetic tool for the activation of endogenous diaphanous-related formins induces thickening of stress fibers without an increase in contractility.

We have developed an optogenetic technique for the activation of diaphanous-related formins. Our approach is based on fusion of the light-oxygen-voltage 2 domain of Avena sativa Phototrophin1 to an isolated Diaphanous Autoregulatory Domain from mDia1. This "caged" diaphanous auto-regulatory domain was inactive in the dark but in the presence of blue light rapidly activated endogenous diaphanous-related formins. Using an F-actin reporter, we observed filopodia and lamellipodia formation as well as a steady increase in F-actin along existing stress fibers, starting within minutes of photo-activation. Interestingly, we did not observe the formation of new stress fibers. Remarkably, a 1.9-fold increase in F-actin was not paralleled by an increase in myosin II along stress fibers and the amount of tension generated by the fibers, as judged by focal adhesion size, appeared unchanged. Our results suggest a decoupling between F-actin accumulation and contractility in stress fibers and demonstrate the utility of photoactivatable diaphanous autoregulatory domain for the study of diaphanous-related formin function in cells.

Regulation of adherens junction dynamics by phosphorylation switches.

Adherens junctions connect the actin cytoskeleton of neighboring cells through transmembrane cadherin receptors and a network of adaptor proteins. The interactions between these adaptors and cadherin as well as the activity of actin regulators localized to adherens junctions are tightly controlled to facilitate cell junction assembly or disassembly in response to changes in external or internal forces and/or signaling. Phosphorylation of tyrosine, serine, or threonine residues acts as a switch on the majority of adherens junction proteins, turning "on" or "off" their interactions with other proteins and/or their enzymatic activity. Here, we provide an overview of the kinases and phosphatases regulating phosphorylation of adherens junction proteins and bring examples of phosphorylation events leading to the assembly or disassembly of adherens junctions, highlighting the important role of phosphorylation switches in regulating their dynamics.