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Skin Care for the Extremely Low-Birthweight Infant.

Extremely low-birthweight (ELBW) infants are at increased risk for infection because the innate immune function of their skin is underdeveloped as they lack a competent epidermal barrier. Thus, neonatal clinicians need to pay careful attention to skin care practices, particularly for periviable infants. In this review, we describe the challenges of skin care in ELBW infants and summarize strategies to prevent skin injury, minimize damage when it occurs, and enhance cutaneous innate immunity.

Staphylococcal Scalded Skin Syndrome, Identification, and Wound Care: A Case Report Series.

INTRODUCTION: Methicillin-susceptible Staphylococcus aureus (MSSA) infections cause diseases ranging from localized skin infections to serious invasive infections. Neonates are immunosuppressed, placing them at increased risk for MSSA infections, including staphylococcal scalded skin syndrome (SSSS), a rare severe skin presentation of MSSA. CLINICAL FINDINGS: We present a case series of 3 preterm infants with SSSS receiving care at a level 3 neonatal intensive care unit. PRIMARY DIAGNOSIS: The infants presented with symptoms of sepsis, including temperature instability, apnea, and bradycardia episodes. The infants had peeling skin at sites of external pressure, including peripheral intravenous (IV) sites, under dressings, or where devices had been in contact with skin. INTERVENTIONS: The infants were soaked in a tub with gel baby wash and water to remove leads without traumatizing the skin. Laboratory values were drawn, and cultures were obtained. Wound care was provided using mupirocin, soft silicone mesh wound contact layer, and soft cotton bandage gauze. Supportive respiratory care was provided, and IV antibiotics were administered. OUTCOMES: The infants were discharged to their homes with intact skin. One infant experienced a loss of pigment that persisted several weeks. All patients were without scarring by early childhood. PRACTICE RECOMMENDATIONS: Thorough assessment and careful hygiene of neonates' skin is crucial. MSSA is an infection that can appear on the skin. It is important to quickly diagnose and treat this type of infection, especially when it presents as a localized pustule, boil, tear, peeling, or crust before it becomes systemic.

Safety, Feasibility, and Effectiveness of Weighted Blankets in the Care of Infants With Neonatal Abstinence Syndrome: A Crossover Randomized Controlled Trial.

BACKGROUND: Nurses are caring for increasing numbers of infants diagnosed with neonatal abstinence syndrome (NAS). The recommended initial line of treatment to alleviate NAS symptoms includes nonpharmacologic interventions; however, there is little rigorous evidence on the effectiveness of nonpharmacologic interventions. PURPOSE: The purpose of this study was to assess the safety, feasibility, and effectiveness of weighted blankets in the care of NAS infants. METHODS: This pilot study was a crossover randomized nonblinded controlled trial conducted at a level III neonatal intensive care unit. Infants' care included 30-minute sessions utilizing either a nonweighted or weighted blanket, with infants serving as their own controls. RESULTS: A total of 16 patients were enrolled for a total of 67 weighted blanket sessions. To address safety, no adverse events were observed, the weighted blankets were never removed due to infant distress, and infants experienced no significant temperature change. To address feasibility, 94% of approached mothers were receptive to the use of weighted blankets and staff reported no obstacles to using the blanket. Finally, to assess effectiveness, there was a significant decrease in the infant's heart rate and Finnegan score when a weighted blanket was used. There was no significant change in respiratory rate with the use of a weighted blanket. IMPLICATIONS FOR PRACTICE: Weighted blankets may be safe, feasible, and effective in decreasing NAS symptoms. IMPLICATIONS FOR RESEARCH: Larger studies are needed to thoroughly study the use of weighted blankets in this population and examine additional outcomes, such as need for pharmacologic intervention, length of hospital stay, and cost of hospital stay.

Sleep disruption in caregivers of pediatric stem cell recipients.

Parents/caregivers of hospitalized patients are at risk of sleep disruption. We performed a cross-sectional quantitative and qualitative evaluation of sleep in parents/caregivers of children undergoing hematopoietic stem cell transplant (HSCT; n = 17). Additionally, we explored the frequency of room entries for hospitalized patients undergoing HSCT (n = 189 nights). Twelve caregivers (71%) demonstrated significant sleep disturbance, 12 (71%) described sleep quality as poor, 15 (88%) averaged < 6 hours of sleep per night, 14 (82%) awakened at least four times per night. Patient rooms were entered a median of 12 times per night (interquartile range 10-15). Intervention studies to improve caregiver sleep during hospitalization are needed.

Randomized Prospective Clinical Trial Comparing Room Temperature and Warmed Intravenous Fluid Boluses on Pediatric Patients' Comfort.

A common complaint among pediatric patients receiving an intravenous (IV) fluid bolus is that their arm feels cold and uncomfortable. The purpose of this study is to test if administering warmed IV fluids, as compared to room temperature IV fluids, results in increased comfort among pediatric patients seeking care in an emergency department. A blinded randomized controlled trial was conducted and 126 pediatric patients were enrolled. Each patient's overall comfort, arm comfort, and arm temperature were measured prior to IV fluid administration, 15 minutes after the beginning of the infusion, and at the end of the 60-minute infusion. After the first 15 minutes of IV fluid administration, the patients who received warmed IV fluids reported higher comfort than the patients who received room temperature IV fluids, t(118)=2.04, p=0.04. Additionally, patients who received the room temperature IV fluids reported that their arms felt cooler than patients who received the warmed fluids, t(118)=3.25, p=0.0015. Warming IV fluids has the potential to improve the experience of IV bolus administration for pediatric patients.

Determining optimal waste volume from an intravenous catheter.

Waste is blood drawn from an intravenous (IV) catheter to remove saline or heparin before obtaining a blood sample. This study examines the minimum waste volume resulting in an undiluted sample. A repeated-measures design was used. Investigators placed an IV catheter in 60 healthy adults and obtained samples at baseline and following waste volumes ranging from 0.5 to 3 mL. A random effects mixed model was used to determine the stabilizing point, which was 1 mL of waste. Knowing that only 1 mL of waste is needed will prevent clinicians from obtaining extra waste and discarding blood needlessly.

A source of healthcare disparity: race, skin color, and injuries after rape among adolescents and young adults.

Differences in anogenital injury resulting from rape may occur because of racial or skin color differences in adult women. It is critical to determine if these differences also are associated with differences in injury prevalence and frequency in adolescents and young adults. In a retrospective review of medical records, we examined whether Black adolescent/young adult females had different anogenital injuries as compared to White females following rape. Next, we examined whether skin color differences explained a significant amount of the racial difference in injuries. We reviewed charts of 234 female victims of rape ages 14 to 29. Overall injury prevalence was 62.8%. Race was significantly associated with frequency of injuries in several anatomical locations, with White victims having a higher frequency of injuries than Black victims. Skin color was significantly associated with injury frequency in many anatomical locations, with victims with light skin sustaining more injuries than victims with dark skin. Even when skin color was included in the relationship, race remained a statistically significant factor, suggesting that the relationship between race and injuries may be more complicated than merely a skin color difference that has been mislabeled a racial difference.

Comparison of methods for identifying ano-genital injury after consensual intercourse.

BACKGROUND: Microtrauma occurs after consensual intercourse. Understanding the injury pattern from consensual intercourse may enlighten our understanding of the ano-genital injury after sexual assault. OBJECTIVE: The purpose of this report is to compare consensual intercourse-related ano-genital injury prevalence by using three different forensic examination techniques: 1) direct visual inspection, 2) colposcopy, and 3) toluidine-blue contrast application. METHODS: Using a descriptive, comparative design, 120 female volunteers, aged 21 years or older, were examined after consensual sexual intercourse using the above techniques. Ano-genital injuries were noted using the TEARS classification (Tears, Ecchymoses, Abrasions, Redness, and Swelling). RESULTS: Direct visualization and colposcopy yielded similar ano-genital injury findings. However, more tears and abrasions of the external genitalia were identified with toluidine-blue than with direct visual inspection or colposcopy (p < 0.05). More tears were identified on the anus with toluidine-blue as compared to direct visualization (p < 0.05), but not colposcopy. Fewer ecchymoses were identified on the internal genitalia and fewer areas of redness were identified on both the external and internal genitalia when toluidine-blue was used, as compared to either direct visualization or colposcopy (p < 0.05). CONCLUSIONS: The scientific community needs to continue to build information about ano-genital injury prevalence after consensual sexual intercourse. Understanding the ano-genital injury patterns, including frequency and prevalence, that occur with consensual sexual intercourse will help to identify the difference between injury related to consensual vs. non-consensual sexual intercourse. At this time, toluidine-blue staining may add value to the sexual assault forensic examination. It is the health care provider's role to collect all possible evidence and the courts' role to determine what evidence is admissible and to ensure a rightful conviction.

Health disparities in the forensic sexual assault examination related to skin color.

Little is known about the role of skin color in the forensic sexual assault examination. The purpose of this study was to determine whether anogenital injury prevalence and frequency vary by skin color in women after consensual sexual intercourse. The sample consisted of 120 healthy (63 Black, 57 White) women who underwent a forensic sexual assault examination following consensual sexual intercourse. Experienced sexual assault forensic examiners using visual inspection, colposcopy technique with digital imaging, and toluidine blue application documented the number, type, and location of anogenital injuries. Although 55% of the total sample was observed to have at least one anogenital injury of any type following consensual intercourse, the percentages significantly differed for White (68%) and Black (43%) participants (p= 0.02). When the presence of anogenital injury was analyzed by specific anatomical region, a significant difference between White and Black participants was only evident for the external genitalia (White = 56%, Black = 24%, p= .003), but not for the internal genitalia (White = 28%, Black = 19%, p= .20) or anus (White = 9%, Black = 10%, p= 0.99). A one standard deviation-unit increase in L* values (lightness) was related to a 150% to 250% increase in the odds of external genitalia injury prevalence (p < 0.001). While Black and White participants had a significantly different genital injury prevalence, dark skin color rather than race was a strong predictor for decreased injury prevalence. Sexual assault forensic examiners, therefore, may not be able to detect injury in women with dark skin as readily as women with light skin, leading to health disparities for women with dark skin.

Prospective evaluation of a pediatric inpatient early warning scoring system.

PURPOSE: The present study evaluated the use of the Pediatric Early Warning Score (PEWS) for detecting clinical deterioration among hospitalized children. DESIGN/METHODS: A prospective, descriptive study design was used. The tool was used to score 2,979 patients admitted to a single medical unit of a pediatric hospital over a 12-month period. RESULTS: PEWS discriminated between children who required transfer to the pediatric intensive care unit and those who did not require transfer (area under the curve = 0.89, 95% CI = 0.84-0.94, p < .001). IMPLICATIONS: The PEWS tool was found to be a reliable and valid scoring system to identify children at risk for clinical deterioration.

Forensic sexual assault examination and genital injury: is skin color a source of health disparity?

PURPOSE: The study objectives were to (1) estimate the frequency, prevalence, type, and location of anogenital injury in black and white women after consensual sex and (2) investigate the role of skin color in the detection of injury during the forensic sexual assault examination. METHODS: A cross-sectional descriptive design was used with 120 healthy volunteers who underwent a well-controlled forensic examination after consensual sexual intercourse. RESULTS: Fifty-five percent of the sample had at least 1 anogenital injury after consensual intercourse; percentages significantly differed between white (68%) and black (43%) participants (P = .02). Race/ethnicity was a significant predictor of injury prevalence and frequency in the external genitalia but not in the internal genitalia or anus. However, skin color variables--lightness/darkness-, redness/greenness-, and yellowness/blueness-confounded the original relationship between race/ethnicity and injury occurrence and frequency in the external genitalia, and 1 skin color variable--redness/greenness--was significantly associated with injury occurrence and frequency in the internal genitalia. CONCLUSIONS: Although differences exist in anogenital injury frequency and prevalence between black and white women, such differences can be more fully explained by variations in skin color rather than race/ethnicity. Clinical recommendations and criminal justice implications are discussed.

Relationship of genital injuries and age in adolescent and young adult rape survivors.

OBJECTIVE: To examine the associations between age and genital injuries in adolescent and young adult women examined following rape. DESIGN & SETTING: A retrospective review of 234 medical records from an emergency department sexual assault program. SAMPLE: Women aged 14 to 29 years. Fifty percent of the sample was African American, 48% was White, and 2% was either Asian or an "other" race. MAIN OUTCOME MEASURES: Genital injury was described by injury prevalence, frequency, and anatomical locations of injuries. RESULTS: Overall genital injury prevalence was 62.8%. Younger age was not significantly associated with the presence or absence of genital injury. However, younger age was significantly associated with an increased number of genital injuries overall and to the thighs, labia minora, periurethral area, fossa navicularis, and vagina. CONCLUSION: These findings support the need for further research to determine if the current care provided to rape survivors is age appropriate.

Physical injury from intimate partner violence: measurement strategies and challenges.

Physical injury that occurs as a result of intimate partner violence needs to be treated to relieve pain, promote healing, and prevent infection. Detection of physical injury is an important component of the forensic examination because of its role in criminal justice proceedings. Better detection and measurement techniques are needed to quantify physical injuries and advance the science. This article addresses current practices of injury identification, challenges in injury measurement, and future directions for research.

The effects of age and ethnicity on physical injury from rape.

OBJECTIVE: To determine whether postmenopausal (age 50 years or older) women would sustain significantly more injury after rape than women younger than 50 and to determine the role of skin pigmentation in the observance of genital injury. DESIGN AND SETTING: Registry data from a sexual assault forensic nurse examiners program. PARTICIPANTS: Based on date of examination, records from women of age 50 years or older (n = 40) were matched to two other participants: a premenopausal group younger than 40 years and a perimenopausal group of 40 to 49 years. The final sample consisted of 120 subjects. MAIN OUTCOME MEASURES: Number, type, and location of injuries. RESULTS: A series of exact conditional logistic regression analyses indicated no significant association between age and genital, nongenital, or head injury. A significant association between race (Black versus White) and genital injury (adjusted odds ratio = 4.30, 95% confidence interval = 1.09-25.98, p = .03) indicated that Whites were more than four times as likely as Blacks to have genital injury. CONCLUSION: Although the primary hypothesis was not supported, the role of racial/ethnic differences and their association with the observance of injury need further exploration to determine whether the standard forensic examination is appropriate for all women. Health disparities may exist if women of color are less likely than others to have genital injuries identified and treated. Alternatively, skin properties may explain racial/ethnic differences in injury prevalence.