Blood glucose control using a computer-guided glucose management system in allogeneic hematopoietic cell transplant recipients.

Allogeneic hematopoietic cell transplantation (HCT) is a potentially curative treatment for patients with hematological malignancies. However, is associated with substantial rates of morbidity and mortality. We and others have shown that malglycemia is associated with adverse transplant outcome. Therefore, improving glycemic control may improve transplant outcome. In this prospective study we evaluated the feasibility of using Glucommander (a Computer-Guided Glucose Management System; CGGM) in order to achieve improved glucose control in hospitalized HCT patients. Nineteen adult patients contributed 21 separate instances on CGGM. Patients were on CGGM for a median of 43 h. Median initial blood glucose (BG) on CGGM was 244 mg/dL, and patients on 20 study instances reached the study BG target of 100-140 mg/dL after a median of 6 h. After BG reached the target range, the median average BG level per patient was 124 mg/dL. Six patients had a total of 10 events of BG <70 mg/dL (0.9% of BG measurements), and no patients experienced BG level <40 mg/dL. The total estimated duration of BG <70 mg/dL was 3 h (0.2% of the total CGGM time). In conclusion, our study demonstrates that stringent BG control in HCT patients using CGGM is feasible.

[Difficulties experienced at work by patients with multiple sclerosis]. / Difficultés ressenties au travail par les patients atteints de sclérose en plaques.

AIM: Multiple sclerosis (MS) is a disease of the central nervous system that affects young adults at a time when they launch into the workforce. The disease often has a great impact on working life. The objective of this survey was to identify the problems faced by people with multiple sclerosis in the context of their work. METHODS: To describe the difficulties experienced at work by patients with multiple sclerosis, we carried out in 2010 a regional survey including neurology and functional rehabilitation centers. RESULTS: Two hundred and seven MS patients of working age responded to the survey. The employment rate was 67.6%. Among difficulties expressed by patients, physical and mental fatigue appeared as the issues affecting work. For 41% of respondents, preventive measures at work could help maintain or resume employment. CONCLUSION: Problems of fatigability put forward by MS patients are elements that can predict a loss of employment.

Developmental care for promoting development and preventing morbidity in preterm infants.

BACKGROUND: Preterm infants experience a range of morbidity related to the immaturity of their organ systems and to concurrent disease states. There is concern that an unfavourable environment in the neonatal intensive care unit (NICU) may compound this morbidity. Modification of the environment could minimize the iatrogenic effects. Developmental care is a broad category of interventions designed to minimize the stress of the NICU environment. These interventions may include elements such as control of external stimuli (vestibular, auditory, visual, tactile), clustering of nursery care activities, and positioning or swaddling of the preterm infant. Individual strategies have also been combined to form programs, such as the 'Newborn Individualized Developmental Care and Assessment Program' (NIDCAP) (Als 1986). OBJECTIVES: In preterm infants, do developmental care interventions reduce neurodevelopmental delay, poor weight gain, length of hospital stay, length of mechanical ventilation, physiological stress and other clinically relevant adverse outcomes? SEARCH STRATEGY: The Neonatal Review Group search strategy was utilized. Searches were made of MEDLINE from 1966 to June, 2005 and of CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005), and conference and symposia proceedings in the English language from 1990 to June, 2005. A search of EMBASE was also made from 2003 to June 2005. A list of all relevant articles was sent to two experts in the field to identify any omissions or additional unpublished studies. SELECTION CRITERIA: Randomized trials in which elements of developmental care are compared to routine nursery care for infants < 37 weeks gestation and that measured clinically relevant outcomes. Reports were in English or a language for which a translator was available. Computerized searches were conducted and all potentially relevant titles and abstracts were extracted. Retrieved articles were assessed for relevance independently by two reviewers, based on predetermined criteria. Articles that met all criteria for relevance were assessed for methodological quality based on predetermined criteria. Articles judged to have the appropriate quality by both reviewers were included in the analysis. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the two authors. Meta-analyses were conducted for each intervention where the same outcome measures and/or instruments were used within comparable time points. MAIN RESULTS: This review detected 36 eligible randomized controlled trials involving four major groups of developmental care interventions, 19 sub-groups and multiple clinical outcomes. In addition, the long-term outcomes of a previously included trial were added to the review. The results of the review indicate that developmental care interventions demonstrate limited benefit to preterm infants with respect to: decreased moderate-severe chronic lung disease, decreased incidence of necrotizing enterocolitis and improved family outcome. Conversely, an increase in mild lung disease and an increase in the length of stay were demonstrated in infants receiving developmental care compared to controls. There is also very limited evidence of the long-term positive effect of NIDCAP on behavior and movement at 5 years corrected age but no effect on cognition. Other individualized developmental care interventions have also demonstrated some effect in enhancing neurodevelopmental outcome. Although a limited number of other benefits were demonstrated, those results were from single studies with small sample sizes. The lack of blinding of the assessors was a significant methodological flaw in half of the studies. The cost of the interventions and personnel was not considered in any of the studies. AUTHORS' CONCLUSIONS: Because of the inclusion of multiple interventions in most studies, the determination of the effect of any single intervention is difficult. Although there is evidence of limited benefit of developmental care interventions overall, and no major harmful effects reported, there were a large number of outcomes for which no or conflicting effects were demonstrated. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small sample sizes, and the findings were often not supported in other small trials. Before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed. The economic impact of the implementation and maintenance of developmental care practices should be considered by individual institutions.

Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants.

BACKGROUND: Non-nutritive sucking is used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants. The rationale for this intervention is that non-nutritive sucking facilitates the development of sucking behaviour and improves digestion of enteral feedings. Non-nutritive sucking has been considered to be a benign intervention, although it has the potential to have a negative effect on breastfeeding or on the incidence of later oral aversion. OBJECTIVES: To determine whether non-nutritive sucking (NNS) in preterm infants influences: a) weight gain, b) energy intake, c) heart rate, d) oxygen saturation, e) length of hospital stay, f) intestinal transit time, g) age at full oral feeds, or h) any other clinically relevant outcomes. SEARCH STRATEGY: MEDLINE and CINAHL databases back to 1976 and The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005) were searched. The EMBASE database was added to the search strategy for 2005. Reference lists/bibliographies of relevant articles and reviews were also searched. A comprehensive list of relevant articles was sent to two major authors in this area. They were asked if they knew of any other published or unpublished studies relevant to the area that had not been included in the original list. SELECTION CRITERIA: All trials utilizing experimental or quasi-experimental designs in which non-nutritive sucking in preterm infants was compared to no provision of non-nutritive sucking. Measured clinically relevant outcomes. Reports were in English or a language for which a translator was available.Computerized searches were conducted by both reviewers. All potentially relevant titles and abstracts identified by either reviewer were extracted. All retrieved articles were assessed for relevance independently by each reviewer, based on a pre-determined set of criteria. The reference lists/bibliographies of each article were reviewed independently for additional relevant titles and were also retrieved and assessed for relevance. Articles that met all relevance criteria were then assessed for methodologic quality based on a predetermined set of criteria. Those articles judged to have the appropriate quality by both reviewers were included in the analysis. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the two authors. No subgroup analyses were performed because of the small number of studies related to the relevant outcomes. MAIN RESULTS: This review consisted of 21 studies, 15 of which were randomized controlled trials. NNS was found to decrease significantly the length of hospital stay in preterm infants. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full oral feeds and behavioral state). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and better bottle feeding performance. No negative outcomes were reported in any of the studies. AUTHORS' CONCLUSIONS: This review found a significant decrease in length of stay in preterm infants receiving a NNS intervention. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full oral feeds and behavioral state). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and better bottle feeding performance. No negative outcomes were reported in any of the studies. There were also a number of limitations of the presently available evidence related to the design of the studies, outcome variability, and lack of long-term data. Based on the available evidence, NNS in preterm infants would appear to have some clinical benefit. It does not appear to have any short-term negative effects. In view of the fact that there are no long-term data, further investigations are recommended. In order to facilitate meta-analysis of these data, future research in this area should involve outcome measures consistent with those used in previous studies. In addition, published reports should include all relevant data.

Developmental care for promoting development and preventing morbidity in preterm infants.

BACKGROUND: Preterm infants experience a range of morbidity related to the immaturity of their organ systems and to concurrent disease states. An unfavourable environment in the neonatal intensive care unit (NICU) may compound this morbidity. Modification of the environment could minimize the iatrogenic effects. Developmental care is a broad category of interventions designed to minimize the stress of the NICU environment. These interventions may include one or more elements such as control of external stimuli (vestibular, auditory, visual, tactile), clustering of nursery care activities, and positioning or swaddling of the preterm infant. Individual strategies have also been combined to form programs, such as the 'Neonatal Individualized Developmental Care and Assessment Program' (NIDCAP) (Als 1986). OBJECTIVES: In preterm infants, do developmental care interventions reduce neurodevelopmental delay, poor weight gain, length of hospital stay, length of mechanical ventilation, physiological stress and other clinically relevant adverse outcomes? SEARCH STRATEGY: The Neonatal Review Group search strategy was utilized. Searches were made of MEDLINE from 1966 to July, 2003, and of CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2003), and conference and symposia proceedings in the English language from 1990 to July, 2003. A list of all relevant articles was sent to two experts in the field to identify any omissions or additional unpublished studies. SELECTION CRITERIA: Randomized trials in which elements of developmental care are compared to routine nursery care for infants < 37 weeks gestation and that measured clinically relevant outcomes. Reports were in English or a language for which a translator was available. Computerized searches were conducted and all potentially relevant titles and abstracts were extracted. Retrieved articles were assessed for relevance independently by two reviewers, based on predetermined criteria. Articles that met all criteria for relevance were assessed for methodological quality based on predetermined criteria. Articles judged to have the appropriate quality by both reviewers were included in the analysis. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the two authors. Meta-analyses were conducted for each intervention where the same outcome measures and/or instruments were used within comparable time points. MAIN RESULTS: This review detected 32 eligible randomized controlled trials involving four major groups of developmental care interventions, 19 sub-groups and multiple clinical outcomes. The results of the review indicate that developmental care interventions demonstrate some benefit to preterm infants with respect to: improved short-term growth and feeding outcomes, decreased respiratory support, decreased length and cost of hospital stay, and improved neurodevelopmental outcomes to 24 months corrected age. These findings were based on two or three small trials for each outcome, and did not involve meta-analyses of more than two trials for any one outcome. Although a number of other benefits were demonstrated, those results were from single studies with small sample sizes. The lack of blinding of the assessors was a significant methodological flaw in half of the studies. The cost of the interventions and personnel was not considered in any of the studies. REVIEWER'S CONCLUSIONS: Because of the inclusion of multiple interventions in most studies, the determination of the effect of any single intervention is difficult. Although there is evidence of some benefit of developmental care interventions overall, and no major harmful effects reported, there were a large number of outcomes for which no or conflicting effects were demonstrated. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small sample sizes, and the findings were often not supported in other small trials. Before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed. The economic impact of the implementation and maintenance of developmental care practices should be considered by individual institutions.

Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants.

BACKGROUND: Non-nutritive sucking is used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants. The rationale for this intervention is that non-nutritive sucking facilitates the development of sucking behaviour and improves digestion of enteral feedings. Non-nutritive sucking has been considered to be a benign intervention, although it has the potential to have a negative effect on breastfeeding or on the incidence of later oral aversion. OBJECTIVES: To determine whether non-nutritive sucking (NNS) in preterm infants influences: a) weight gain, b) energy intake, c) heart rate, d) oxygen saturation, e) length of hospital stay, f) intestinal transit time, g) age at full oral feeds, or h) any other clinically relevant outcomes. SEARCH STRATEGY: MEDLINE and CINAHL databases back to 1976 and the Cochrane Controlled Trials register were searched. Reference lists/bibliographies of relevant articles and reviews were also searched. A comprehensive list of relevant articles was sent to two major authors in this area. They were asked if they knew of any other published or unpublished studies relevant to the area that had not been included in the original list. The searches of MEDLINE, CINAHL and CCTR were updated to December 2000. SELECTION CRITERIA: All trials utilizing experimental or quasi-experimental designs in which non-nutritive sucking in preterm infants was compared to no provision of non-nutritive sucking. Measured clinically relevant outcomes. Reports were in English or a language for which a translator was available. Computerized searches were conducted by both reviewers. All potentially relevant titles and abstracts identified by either reviewer were extracted. All retrieved articles were assessed for relevance independently by each reviewer, based on a pre-determined set of criteria. The reference lists/bibliographies of each article were reviewed independently for additional relevant titles and were also retrieved and assessed for relevance. Articles that met all relevance criteria were then assessed for methodologic quality based on a predetermined set of criteria. Those articles judged to have the appropriate quality by both reviewers were included in the analysis. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the two authors. No subgroup analyses were performed because of the small number of studies related to the relevant outcomes. MAIN RESULTS: This review consisted of 20 studies, 14 of which were randomized controlled trials. NNS was found to decrease significantly the length of hospital stay in preterm infants. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, and age at full oral feeds). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds, better bottle feeding performance and behavior. No negative outcomes were reported in any of the studies. REVIEWER'S CONCLUSIONS: This review found a significant decrease in length of stay in preterm infants receiving a NNS intervention. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, and age at full oral feeds). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds, better bottle feeding performance and behavior. No negative outcomes were reported in any of the studies. There were also a number of limitations of the presently available evidence related to the design of the studies, outcome variability, and lack of long-term data. Based on the available evidence, NNS in preterm infants would appear to have some clinical benefit. It does not appear to have any short-term negative effects. In view of the fact that there are no long-term data, further investigations are recommended. In order to facilitate meta-analysis of these data, future research in this area should involve outcome measures consistent with those used in previous studies. In addition, published reports should include all relevant data.

Developmental care for promoting development and preventing morbidity in preterm infants.

BACKGROUND: Preterm infants experience a range of morbidity related to the immaturity of their organ systems and to concurrent disease states. An unfavourable environment in the neonatal intensive care unit (NICU) may compound this morbidity. Modification of the environment could minimize the iatrogenic effects. Developmental care is a broad category of interventions designed to minimize the stress of the NICU environment. These interventions may include one or more elements such as control of external stimuli (vestibular, auditory, visual, tactile), clustering of nursery care activities, and positioning or swaddling of the preterm infant. Individual strategies have also been combined to form programs, such as the 'Neonatal Individualized Developmental Care and Assessment Program' (NIDCAP) (Als 1986). OBJECTIVES: In preterm infants, do developmental care interventions reduce neurodevelopmental delay, poor weight gain, length of hospital stay, length of mechanical ventilation, physiological stress and other clinically relevant adverse outcomes? SEARCH STRATEGY: The Neonatal Review Group search strategy was utilized. Searches were made of Medline from 1966 to July, 2000, and of CINAHL, The Cochrane Library, and conference and symposia proceedings in the English language from 1990 to July, 2000. A list of all relevant articles was sent to two experts in the field to identify any omissions or additional unpublished studies. SELECTION CRITERIA: Randomized trials in which elements of developmental care are compared to routine nursery care for infants < 37 weeks gestation and that measured clinically relevant outcomes. Reports were in English or a language for which a translator was available. Computerized searches were conducted and all potentially relevant titles and abstracts were extracted. Retrieved articles were assessed for relevance independently by two reviewers, based on predetermined criteria. Articles that met all criteria for relevance were assessed for methodological quality based on predetermined criteria. Articles judged to have the appropriate quality by both reviewers were included in the analysis. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the two authors. Meta-analyses were conducted for each intervention where the same outcome measures and/or instruments were used within comparable time points. MAIN RESULTS: This review detected 31 eligible randomized controlled trials involving four major groups of developmental care interventions, 19 sub-groups and multiple clinical outcomes. The results of the review indicate that developmental care interventions demonstrate some benefit to preterm infants with respect to: improved short-term growth outcomes, decreased respiratory support, decreased length and cost of hospital stay, and improved neurodevelopmental outcomes to 24 months corrected age. These findings were based on two or three small trials for each outcome, and did not involve meta-analyses of more than two trials for any one outcome. Although a number of other benefits were demonstrated, those results were from single studies with small sample sizes. The lack of blinding of the assessors was a significant methodological flaw in half of the studies. The cost of the interventions and personnel was not considered in any of the studies. REVIEWER'S CONCLUSIONS: Because of the inclusion of multiple interventions in most studies, the determination of the effect of any single intervention is difficult. Although there is evidence of some benefit of developmental care interventions overall, and no major harmful effects reported, there were a large number of outcomes for which no or conflicting effects were demonstrated. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small sample sizes, and the findings were often not supported in other small trials. Before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed. The economic impact of the implementation and maintenance of developmental care practices should be considered by individual institutions.

Randomized trial of breastfeeding support in very low-birth-weight infants.

OBJECTIVE: To determine if supplementary structured breastfeeding counseling (SSBC) for both parents compared with conventional hospital breastfeeding support (CHBS) improves the duration of breastfeeding in very low-birth-weight infants up to 1 year old. DESIGN: Randomized trial with longitudinal follow-up of infants at term, and ages 1, 3, 6, and 12 months (infant ages corrected for prematurity). SETTING: A tertiary-level neonatal intensive care unit (NICU) and geographically defined region in central-west Ontario, Canada. PARTICIPANTS: Parents of infants with a birth weight less than 1500 g, who planned to breastfeed. INTERVENTIONS: The SSBC consisted of viewing a video on breastfeeding for preterm infants; individual counseling by the research lactation consultant; weekly personal contact in the hospital; and frequent postdischarge contact through the infants' first year or until breastfeeding was discontinued. The CHBS group had standard breastfeeding support from regular staff members confined to the period of hospitalization in the NICU. MAIN OUTCOME MEASURE: Duration of breastfeeding. RESULTS: At study entry, there were no statistically significant differences in major demographic characteristics between groups. The mean duration of breastfeeding was 26.1 weeks (SD = 20.8; median, 17.4) in the SSBC group and 24.0 weeks (SD = 20.5; median, 17.4) in the CHBS group (not statistically significant). CONCLUSIONS: Long-term breastfeeding counseling of parents of very low-birth-weight infants in this study did not demonstrate a significant difference in duration of breastfeeding. These results may be explained by the high motivation to breastfeed in both groups, a relatively advantaged population, and the availability of community breastfeeding resources, which may have diminished any significant differences that could have resulted from a breastfeeding intervention. The results of this study, compared with previous studies of very low-birth-weight infants, indicate a new trend to longer duration of breastfeeding in preterm infants.

Resources to enhance evidence-based nursing practice.

Evidence-based practice means integrating the best available research evidence with information about patient preferences, clinician skill level, and available resources to make decisions about patient care. Barriers to the use of research-based evidence occur when time, access to journal articles, search skills, critical appraisal skills, and understanding of the language used in research are lacking. Resources are available to overcome these barriers and support an evidence-based nursing practice. This article highlights available resources and describes strategies that nurses can use to develop and sustain an evidence-based nursing practice.

Developmental care for promoting development and preventing morbidity in preterm infants.

BACKGROUND: Preterm infants experience a range of morbidity related to the immaturity of their organ systems and to concurrent disease states. An unfavourable environment in the neonatal intensive care unit (NICU) may compound this morbidity. Modification of the environment could minimize the iatrogenic effects. Developmental care is a broad category of interventions designed to minimize the stress of the NICU environment. These interventions may include one or more elements such as control of external stimuli (vestibular, auditory, visual, tactile), clustering of nursery care activities, and positioning or swaddling of the preterm infant. Individual strategies have also been combined to form programs, such as the 'Neonatal Individualized Developmental Care and Assessment Program' (NIDCAP) (Als 1986). OBJECTIVES: In preterm infants, do developmental care interventions reduce neurodevelopmental delay, poor weight gain, length of hospital stay, length of mechanical ventilation, physiological stress and other clinically relevant adverse outcomes? SEARCH STRATEGY: The Neonatal Review Group search strategy was utilized. Searches were made of Medline from 1966 to July, 2000, and of CINAHL, The Cochrane Library, and conference and symposia proceedings in the English language from 1990 to July, 2000. A list of all relevant articles was sent to two experts in the field to identify any omissions or additional unpublished studies. SELECTION CRITERIA: Randomized trials in which elements of developmental care are compared to routine nursery care for infants < 37 weeks gestation and that measured clinically relevant outcomes. Reports were in English or a language for which a translator was available. Computerized searches were conducted and all potentially relevant titles and abstracts were extracted. Retrieved articles were assessed for relevance independently by two reviewers, based on predetermined criteria. Articles that met all criteria for relevance were assessed for methodological quality based on predetermined criteria. Articles judged to have the appropriate quality by both reviewers were included in the analysis. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the two authors. Meta-analyses were conducted for each intervention where the same outcome measures and/or instruments were used within comparable time points. MAIN RESULTS: This review detected 31 eligible randomized controlled trials involving four major groups of developmental care interventions, 19 sub-groups and multiple clinical outcomes. The results of the review indicate that developmental care interventions demonstrate some benefit to preterm infants with respect to: improved short-term growth outcomes, decreased respiratory support, decreased length and cost of hospital stay, and improved neurodevelopmental outcomes to 24 months corrected age. These findings were based on two or three small trials for each outcome, and did not involve meta-analyses of more than two trials for any one outcome. Although a number of other benefits were demonstrated, those results were from single studies with small sample sizes. The lack of blinding of the assessors was a significant methodological flaw in half of the studies. The cost of the interventions and personnel was not considered in any of the studies. REVIEWER'S CONCLUSIONS: Because of the inclusion of multiple interventions in most studies, the determination of the effect of any single intervention is difficult. Although there is evidence of some benefit of developmental care interventions overall, and no major harmful effects reported, there were a large number of outcomes for which no or conflicting effects were demonstrated. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small sample sizes, and the findings were often not supported in other small trials. Before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed. The economic impact of the implementation and maintenance of developmental care practices should be considered by individual institutions.

A randomized trial comparing peripherally inserted central venous catheters and peripheral intravenous catheters in infants with very low birth weight.

BACKGROUND/PURPOSE: To determine whether percutaneously inserted central venous catheters (PICC) and peripheral intravenous catheters (PIV) in infants with very low birth weight (VLBW) differ with respect to (1) incidence of sepsis, (2) number of insertion attempts and catheters required for total intravenous therapy, (3) courses of antibiotics, and (4) total duration of intravenous (IV) use. METHODS: A randomized comparative trial was conducted involving 63 VLBW infants (<1,251 g) who required IV therapy. Infants were assigned randomly at 1 week of age to either a PIV or a PICC catheter and followed up prospectively until an IV was no longer required or the infant was transferred out of the neonatal intensive care unit. RESULTS: Data were analyzed on an intention-to-treat basis. There was no difference in the incidence of sepsis (P = .64), number of courses of antibiotics (P = .16), or total duration of IV use (P= .34) between the 2 groups. The number of insertion attempts required for total IV therapy was significantly lower in the PICC group than in the PIV group (P = .008). There also was a significantly lower number of total catheters utilized in the PICC group (P = .002). When data were controlled for birth weight strata the results were similar. CONCLUSION: PICC lines reduced the number of painful IV procedures in VLBW infants without additional morbidity.

Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants.

BACKGROUND: Non-nutritive sucking is used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants. The rationale for this intervention is that non-nutritive sucking facilitates the development of sucking behaviour and improves digestion of enteral feedings. Non-nutritive sucking has been considered to be a benign intervention, although it has the potential to have a negative effect on breastfeeding or on the incidence of later oral aversion. OBJECTIVES: To determine whether non-nutritive sucking (NNS) in preterm infants influences: a) weight gain, b) energy intake, c) heart rate, d) oxygen saturation, e) length of hospital stay, f) intestinal transit time, g) age at full oral feeds, or h) any other clinically relevant outcomes. SEARCH STRATEGY: MEDLINE and CINAHL databases back to 1976 and the Cochrane Controlled Trials register were searched. Reference lists/bibliographies of relevant articles and reviews were also searched. A comprehensive list of relevant articles was sent to two major authors in this area. They were asked if they knew of any other published or unpublished studies relevant to the area that had not been included in the original list. SELECTION CRITERIA: All trials utilizing experimental or quasi-experimental designs in which non-nutritive sucking in preterm infants was compared to no provision of non-nutritive sucking. Measured clinically relevant outcomes. Reports were in English or a language for which a translator was available. Computerized searches were conducted by both reviewers. All potentially relevant titles and abstracts identified by either reviewer were extracted. All retrieved articles were assessed for relevance independently by each reviewer, based on a pre-determined set of criteria. The reference lists/bibliographies of each article were reviewed independently for additional relevant titles and were also retrieved and assessed for relevance. Articles that met all relevance criteria were then assessed for methodologic quality based on a predetermined set of criteria. Those articles judged to have the appropriate quality by both reviewers were included in the analysis. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the two authors. No subgroup analyses were performed because of the small number of studies related to the relevant outcomes. MAIN RESULTS: This review consisted of 19 studies, 13 of which were randomized controlled trials. NNS was found to decrease significantly the length of hospital stay in preterm infants. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, and age at full oral feeds). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and behavior. No negative outcomes were reported in any of the studies. REVIEWER'S CONCLUSIONS: This review found a significant decrease in length of stay in preterm infants receiving a NNS intervention. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, and age at full oral feeds). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and behavior. No negative outcomes were reported in any of the studies. There were also a number of limitations of the presently available evidence related to the design of the studies, outcome variability, and lack of long-term data. Based on the available evidence, NNS in preterm infants would appear to have some clinical benefit. It does not appear to have any short-term negative effects. In view of the fact that there are no long-term data, further investigations are recommended. In order to facilitate meta-analysis of these data, future research in this area should involve outcome measures

A comparison of continuous infusion and intermittent flushing methods in peripheral intravenous catheters in neonates.

The purpose of this study was to compare two methods of maintaining peripheral intravenous devices in neonates: continuous infusion (CI) and intermittent flushing (IF). There was no significant difference in the mean duration of patency between the two groups, but there was a significant difference with respect to reasons for removal or loss of patency. The main reason for removal in the CI group was infiltration or phlebitis, and in the IF group the reason was occlusion.

Effects of family coping and resources on family adjustment and parental stress in the acute phase of the NICU experience.

PURPOSE: To determine the relationship between family coping and resources and family adjustment and parental stress in the acute phase of the NICU experience. DESIGN: Correlational study based on the Resiliency Model of Family Stress, Adjustment, and Adaptation. Main study instruments included the State Anxiety scale of the State-Trait Anxiety Inventory, the Family Inventory of Resources for Management, the Family Crisis Oriented Personal Evaluation Scales, and the General Functioning subscale of the McMaster Family Assessment Device. SAMPLE: Data collected from 124 mother and father pairs within two to four days of their infant's admission to the NICU. MAIN OUTCOME VARIABLES: Family adjustment and parental stress. RESULTS: Adequate resources were more strongly related to positive adjustment and decreased stress than were either coping or being a first-time parent. The relationships among the variables were generally the same for both parents. Mothers utilized more coping strategies than did fathers. PRACTICE RECOMMENDATIONS: Families with limited resources should be identified early to facilitate their adjustment to the NICU.

How rewarding can a pacifier be? A systematic review of nonnutritive sucking in preterm infants.

PURPOSE: To determine whether nonnutritive sucking (NNS) in preterm infants influences selected outcome variables. DESIGN: A systematic review, based on the Cochrane Collaboration format, of trials utilizing experimental or quasi-experimental designs in which NNS (by pacifier) was compared to no provision of NNS; related to naso/orogastric tube feedings, bottle feedings, or not associated with feeding. SAMPLE: All infants born at < 37 weeks gestation. This review consisted of 19 studies; 13 were randomized controlled trials. Sample sizes ranged from 10 to 59 infants and totaled 518 infants. MAIN OUTCOME VARIABLE: Weight gain, energy intake, heart rate, oxygen saturation, length of hospital stay, intestinal transit time, and postconceptional age at full oral feedings. RESULTS: NNS significantly decreased the length of hospital stay in preterm infants. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables. No negative outcomes were reported in any of the studies.

Variables associated with parental stress in neonatal intensive care units.

A descriptive study was conducted to identify sources of parental stress in two types of NICUs. Data were collected from 212 parents and a single interview was done within three weeks of the infant's admission. Parents completed the Parental Stressor Scale: NICU, Spielberger State-Trait Anxiety Inventory, Life Events Scale, and Parent Questionnaire. Data extracted from the infant's chart were used to complete the Neonatal Morbidity Scale and Baby Data Sheet. Data were analyzed using multiple regression techniques. Findings indicate that mothers and fathers differed in their responses to this experience. How parents perceived the severity of their infant's illness was the most powerful variable associated with their stress scores. Trait anxiety, desire for the pregnancy, and where and when parents first saw the baby were other variables significantly correlated with stress scores.

The clinical nurse specialist/nurse practitioner: oxymoron or match made in heaven?

This paper traces the evolution and proposed merger of the two major advanced practice nursing roles, the clinical nurse specialist and nurse practitioner. The paper presents a review of the differences in the origins of the roles of the clinical nurse specialist and nurse practitioner, and analyzes the changes in these roles since the 1970's in Canada and the U.S. The positive and negative aspects of merging the clinical nurse specialist and nurse practitioner roles are also analyzed with respect to current issues and future trends. Changes in nursing roles, functions and education have occurred since the inception of the profession. Concurrently, there has been debate and conflict about the direction that these changes should take. Since the 1980's, the nursing literature has reflected these discussions, particularly with respect to the development of advanced practice nursing. The purpose of this paper is to review and analyze the differences in the origins of the roles of clinical nurse specialist (CNS) and nurse practitioner (NP), and to examine the benefits and costs of merging the roles.

A new measure of parent satisfaction with medical care provided in the neonatal intensive care unit.

The objective of this study was to develop a valid and reliable discriminative index that measures parent satisfaction with the medical care of their infant in the NICU. We developed an initial questionnaire (Item Reduction Questionnaire) by reviewing the literature, surveying 63 NICU clinicians, and interviewing 125 parents of infants in 2 tertiary level NICUs regarding what they liked and disliked about the medical care of their infants. We administered the Item Reduction Questionnaire, which included 154 items, to 60 parents, who rated the frequency and importance of these items. We included the items identified most frequently as sources of dissatisfaction and rated most important in a second, briefer instrument, the Neonatal Index of Parent Satisfaction (NIPS). To measure reliability we administered the NIPS to 47 parents twice, separated by a 1-week interval. We assessed validity by comparing actual to predicted correlations between NIPS scores and other measures: parent's global rating of satisfaction, medical caregiver ratings of mother's satisfaction, medical caregiver ratings of father's satisfaction, and parents' perception of their infant's health status. We also compared mean NIPS scores for parents who did and who did not report incidents when errors occurred in the medical care of the infant. Of 154 items generated, we included 27 in the NIPS. The intraclass correlation between two administrations of the NIPS to the same 47 parents was 0.71. As predicted, there was a high correlation (0.61) between the NIPS score and parent global rating of satisfaction, and much lower correlations with other variables. Mean NIPS scores for parents who did and who did not report errors differed significantly (difference, 14.6; 95% CI around difference, 5.8-23.5; p < 0.001). The NIPS is likely to be a useful measure for discriminating between parents who differ in terms of their satisfaction with the medical care of their infant in the NICU.