Effects of automatic heel lancet on invasiveness in neonates: A systematic review and meta-analysis.

AIM: We conducted a meta-analysis comparing the invasiveness of automatic lancet devices, which can collect adequate amount of blood at shallow puncture depths, with conventional manual lance devices (lancet or needle) to statistically identify less invasive instruments for neonatal heel lance. METHODS: We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and Ichushi databases for studies comparing the invasiveness between automatic lancet and manual lancet or needle in term and preterm neonates in neonatal intensive care unit. RESULTS: This review included 9 out of 449 searched articles, with 673 neonates. Automatic lancet had significantly lower pain scores (standardised mean difference: -2.0, 95% confidence interval: -3.3 to -0.7), heart rate (mean difference: -8.0, 95% confidence interval: -13.8 to -2.1), cry duration (mean difference: -21.5, 95% confidence interval: -32.5 to -10.4), number of punctures (mean difference: -0.6, 95% confidence interval: -1.1 to -0.2), and duration of procedures (mean difference: -37.7, 95% confidence interval: -75.2 to -0.2) than manual lancet or needle. Furthermore, peripheral oxygen saturation was significantly higher in automatic lancet than in manual lancet or needle (mean difference: 4.5, 95% confidence interval: 0.5-8.5). CONCLUSION: Automatic heel lancet devices were less invasive than manual heel lance devices (lancet or needle).

Use of drugs for hyperlipidaemia and diabetes and risk of primary and secondary brain tumours: nested case-control studies using the UK Clinical Practice Research Datalink (CPRD).

OBJECTIVES: Previous studies have suggested that fibrates and glitazones may have a role in brain tumour prevention. We examined if there is support for these observations using primary care records from the UK Clinical Practice Research Datalink (CPRD). DESIGN: We conducted two nested case-control studies using primary and secondary brain tumours identified within CPRD between 2000 and 2016. We selected cases and controls among the population of individuals who had been treated with any anti-diabetic or anti-hyperlipidaemic medication to reduce confounding by indication. SETTING: Adults older than 18 years registered with a general practitioner in the UK contributing data to CPRD. RESULTS: We identified 7496 individuals with any brain tumour (4471 primary; 3025 secondary) in total. After restricting cases and controls to those prescribed any anti-diabetic or anti-hyperlipidaemic medication, there were 1950 cases and 7791 controls in the fibrate and 480 cases with 1920 controls in the glitazone analyses. Longer use of glitazones compared with all other anti-diabetic medications was associated with a reduced risk of primary (adjusted OR (aOR) 0.89 per year, 95% CI 0.80 to 0.98), secondary (aOR 0.87 per year, 95% CI 0.77 to 0.99) or combined brain tumours (aOR 0.88 per year, 95% CI 0.81 to 0.95). There was little evidence that fibrate exposure was associated with risk of either primary or secondary brain tumours. CONCLUSIONS: Longer exposure to glitazones was associated with reduced primary and secondary brain tumour risk. Further basic science and population-based research should explore this finding in greater detail, in terms of replication and mechanistic studies.

Consensus core outcome rating for the Japanese neonatal pain guidelines.

Introduction: The Japanese Neonatal Pain Guidelines Committee, led by the Japan Academy of Neonatal Nursing, uses the Grading of Recommendations, Assessment, Development, and Evaluation Working Group method to evaluate the quality of evidence and the strength of treatment recommendations. Ratings on the importance of outcomes related to neonatal pain have not been reported. This study aimed to reach a consensus on the importance of outcomes through a guideline panel composed of doctors, nurses, a nurse practitioner, a physical therapist, and families to ensure consistency in systematic reviews of neonatal pain and future revisions to the guidelines. Methods: A total of 26 professionals, including 21 medical personnel from clinical settings and academia and 5 parents from five family associations, participated in 3-stage eDelphi rounds. Results: The literature review and discussion identified 75 outcomes that were included in round one. The participants proposed three additional outcomes: 78 outcomes were scored in rounds two and three. Round three scores showed different stakeholder groups in terms of priority outcomes. Seventeen outcomes were included in the final core outcome and were considered critical for decision-making. Conclusion: Core outcomes of the development of neonatal pain guidelines in Japan were identified. The assessment process of importance from this study highlights the difference in the perspectives of medical providers and parents on neonatal pain, thus, involving parents in the assessment and as the spokesperson for the infant admitted to the neonatal intensive care unit is important for a more inclusive evaluation of pain prevention and management.

Effectiveness of a Virtual Program on Nurses' Pain-Related Knowledge and Pain-Measurement Skills.

BACKGROUND: Aim: To test whether a comprehensive virtual program for using pain scales to manage neonatal pain improved nurses' knowledge and skill acquisition. METHODS: This non-blind randomized controlled trial included 64 participants who were randomly divided into intervention and control groups; changes in scores between pre- and posttests were compared. Certified neonatal intensive care nurses were recruited from across Japan. The learning intervention group received online training in pain measurement using structured scales, such as the Face Scale for Pain Assessment of Preterm Infants and the Japanese version of the Premature Infant Pain Profile. The control group received no training. Independent t tests and χ2 tests were used to compare the baseline scores. The outcome measure was score change on a 40-point test (20 for knowledge and 20 for skill) before and after the e-learning program. RESULTS: No differences in baseline data were found between the groups. Generalized linear regression models yielded a significant difference in the least squared means (95% confidence interval [CI]) for the amount of change in the total, knowledge, and skill scores between groups: 6.22 (4.18, 8.26; p < .001) for total score, 4.66 (3.37, 5.95; p < .001) for knowledge score, and 1.53 (0.06, 3.00; p = .041) for skill score. CONCLUSIONS: The results showed that the e-learning program improved nurses' neonatal pain knowledge and pain-measurement skills compared with no training.

Verbal fluency as a quick and simple tool to help in deciding when to refer patients with a possible brain tumour.

BACKGROUND: Patients with brain tumours often present with non-specific symptoms. Correctly identifying who to prioritise for urgent brain imaging is challenging. Brain tumours are amongst the commonest cancers diagnosed as an emergency presentation. A verbal fluency task (VFT) is a rapid triage test affected by disorders of executive function, language and processing speed. We tested whether a VFT could support identification of patients with a brain tumour. METHODS: This proof-of-concept study examined whether a VFT can help differentiate patients with a brain tumour from those with similar symptoms (i.e. headache) without a brain tumour. Two patient populations were recruited, (a) patients with known brain tumour, and (b) patients with headache referred for Direct-Access Computed-Tomography (DACT) from primary care with a suspicion of a brain tumour. Semantic and phonemic verbal fluency data were collected prospectively. RESULTS: 180 brain tumour patients and 90 DACT patients were recruited. Semantic verbal fluency score was significantly worse for patients with a brain tumour than those without (P < 0.001), whether comparing patients with headache, or patients without headache. Phonemic fluency showed a similar but weaker difference. Raw and incidence-weighted positive and negative predictive values were calculated. CONCLUSION: We have demonstrated the potential role of adding semantic VFT score performance into clinical decision making to support triage of patients for urgent brain imaging. A relatively small improvement in the true positive rate in patients referred for DACT has the potential to increase the timeliness and efficiency of diagnosis and improve patient outcomes.

Effectiveness of e-Learning on Neonatal Nurses' Pain Knowledge and Pain Measurement Skills: A Pilot Study.

BACKGROUND: Reported benefits of virtual programs include user satisfaction and feasibility to train nurses to utilize pain scales. However, the effectiveness of the virtual neonatal pain management program on nurses' knowledge and scoring skill acquisition has not been examined. PURPOSE: This study developed a comprehensive virtual program on neonatal pain management and examined its effectiveness on nurses' knowledge and skill acquisition of selected pain scales. METHODS: Evidence-based content was designed as a virtual program and pre-and posttests to examine skill and knowledge acquisition were developed and validated. Analysis of covariance was used to assess the differences from pre- to posttest based on the intensity of participants' involvement while examining the overall effectiveness of the program. RESULTS: A total of 115 nurses representing 7 hospitals completed the virtual neonatal pain management program, and 52 nurses completed the posttest. The Student paired t test showed an increase in posttest scores from pretest scores among participants. Participants' final degrees and years of experience were not related to posttest scores. The analysis of covariance showed that the high study group had a significantly higher amount of change in total scores and pain measurement skill scores than the low study group on the posttest. IMPLICATIONS FOR PRACTICE: The virtually delivered neonatal pain management program can be useful for nurses' attainment of knowledge and skills for managing neonatal pain, including an appropriate use of selected scoring tools. IMPLICATIONS FOR RESEARCH: It is necessary to examine how organizational unit attendance rate for e-learning and posttest results are related to patient outcomes. VIDEO ABSTRACT AVAILABLE AT: https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=46.

Family Presence Restrictions and Telemedicine Use in Neonatal Intensive Care Units during the Coronavirus Disease Pandemic.

We aimed to describe parental presence policy and telemedicine use in Japanese neonatal intensive care units (NICUs) before and during the coronavirus disease (COVID-19) pandemic. This cross-sectional study was performed through an online survey in 110 level III units from 19 November 2020 to 18 December 2020. Nurses' evaluation of the current situation (during COVID-19) was compared with their retrospective pre-COVID-19 (December 2019) evaluation. Responses were received from 52 NICUs distributed across all regions in Japan. The median allowed parental presence time decreased from 12 h to 1 h, and 29 NICUs allowed entry of parents simultaneously during COVID-19. There was an increase in the number of units providing telemedicine through telephone and online visits during COVID-19 compared to that before COVID-19 (from 2% to 19%). The hybrid design NICUs, with 11-89% of beds in single-patient rooms, allowed a longer parental presence time in the NICUs than those with ≥90% of beds in multi-bed rooms. The number of units implementing kangaroo care decreased during COVID-19 compared to that before COVID-19. The need for telemedicine increased among Japanese NICUs to mitigate the adverse effect of parental restriction and limited physical contact due to the COVID-19 pandemic.

Can Event-Related Potentials Evoked by Heel Lance Assess Pain Processing in Neonates? A Systematic Review.

To clarify the possibility of event-related potential (ERP) evoked by heel lance in neonates as an index of pain assessment, knowledge acquired by and problems of the methods used in studies on ERP evoked by heel lance in neonates were systematically reviewed, including knowledge about Aδ and C fibers responding to noxious stimuli and Aß fibers responding to non-noxious stimuli. Of the 863 reports searched, 19 were selected for the final analysis. The following points were identified as problems for ERP evoked by heel lance in neonates to serve as a pain assessment index: (1) It is possible that the ERP evoked by heel lance reflected the activation of Aß fibers responding to non-noxious stimuli and not the activation of Aδ or C fibers responding to noxious stimulation; (2) Sample size calculation was presented in few studies, and the number of stimulation trials to obtain an averaged ERP was small. Accordingly, to establish ERP evoked by heel lance as a pain assessment in neonates, it is necessary to perform a study to clarify ERP evoked by Aδ- and C-fiber stimulations accompanied by heel lance in neonates.

Economic evaluation of GPs' direct access to computed tomography for identification of brain tumours.

BACKGROUND: When GPs suspect a brain tumour, a referral for specialist assessment and subsequent brain imaging is generally the first option. NICE has recommended that GPs have rapid direct access to brain imaging for adults with progressive sub-acute loss of central nervous function; however, no studies have evaluated the cost-effectiveness. METHODS: We developed a cost-effectiveness model based on data from one region of the UK with direct access computed tomography (DACT), routine data from GP records and the literature, to explore whether unrestricted DACT for patients with suspected brain tumour might be more cost-effective than criteria-based DACT or no DACT. RESULTS: Although criteria-based DACT allows some patients without brain tumour to avoid imaging, our model suggests this may increase costs of diagnosis due to non-specific risk criteria and high costs of diagnosing or 'ruling out' brain tumours by other pathways. For patients diagnosed with tumours, differences in outcomes between the three diagnostic strategies are small. CONCLUSIONS: Unrestricted DACT may reduce diagnostic costs; however, the evidence is not strong and further controlled studies are required. Criteria-based access to CT for GPs might reduce demand for DACT, but imperfect sensitivity and specificity of current risk stratification mean that it will not necessarily be cost-effective.

The usefulness of symptoms alone or combined for general practitioners in considering the diagnosis of a brain tumour: a case-control study using the clinical practice research database (CPRD) (2000-2014).

OBJECTIVES: To evaluate the utility of different symptoms, alone or combined, presented to primary care for an adult brain tumour diagnosis. DESIGN AND SETTING: Matched case-control study, using the data from Clinical Practice Research Datalink (2000-2014) from primary care consultations in the UK. METHOD: All presentations within 6 months of the index diagnosis date (cases) or equivalent (controls) were coded into 32 symptom groups. Sensitivity, specificity, positive predictive values (PPVs) and positive likelihood ratios were calculated for symptoms and combinations of symptoms with headache and cognitive features. Diagnostic odds ratios were calculated using conditional logistic regression, adjusted for age group, sex and Charlson comorbidity. Stratified analyses were performed for age group, sex and whether the tumour was of primary or secondary origin. RESULTS: We included 8,184 cases and 28,110 controls. Seizure had the highest PPV of 1.6% (95% CI 1.4% to 1.7%) followed by weakness 1.5% (1.3 to 1.7) and confusion 1.4% (1.3 to 1.5). Combining headache with other symptoms increased the PPV. For example, headache plus combined cognitive symptoms PPV 7.2% (6.0 to 8.6); plus weakness 4.4% (3.2 to 6.2), compared with headache alone PPV 0.1%. The diagnostic ORs were generally larger for patients <70 years; this was most marked for confusion, seizure and visual symptoms. CONCLUSION: We found seizure, weakness and confusion had relatively higher predictive values than many other symptoms. Headache on its own was a weak predictor but this was enhanced when combined with other symptoms especially in younger patients. Clinicians need to actively search for other neurological symptoms such as cognitive problems.

The impact of the guideline for pain management in Japanese neonatal intensive care units: A 5-year follow-up.

BACKGROUND: This study presented the guidelines for the prevention and management of procedural pain management in Japan and investigated the impact of these guidelines on Japanese neonatal intensive care units (NICUs). The aim of this study was to investigate whether the published national guidelines influenced organizational factors that could lead to improved pain management and, if so, whether the number of units that perform pain assessments, the administration of local guidelines and collaboration among health care professionals had improved in the 5-year period from 2012 to 2017. METHOD: An anonymous questionnaire was sent to 106 Level 3 NICUs across Japan. RESULTS: The response rate was 78% (81 units). In almost all cases, the implementation of organizational factors had increased. Forty-seven units (47%) reported that health care professionals collaborated in pain management, compared with 11 units (17.7%) in 2012. In addition, compliance with the guidelines for pain assessment improved over the 5-year period. Twenty-four units (30%) reported that they used a structured scale for pain measurement, compared with nine units (15%) in 2012. CONCLUSION: The current study suggested that the national guidelines published in 2014 influenced the organizational factors that could lead to improved pain management in Japanese NICUs. The number of units that used a structured scale for pain measurement, the development of local guidelines, and collaboration among health care professionals increased over the 5-year period from 2012 to 2017.

Symptoms in primary care with time to diagnosis of brain tumours.

Background: Brain tumours often present with varied, non-specific features with other diagnoses usually being more likely. Objective: To examine how different symptoms and patient demographics predict variations in time to brain tumour diagnosis. Methods: We conducted a secondary analysis of brain tumour cases from National Audit of Cancer Diagnosis in Primary Care. We grouped neurological symptoms into six domains (headache, behavioural/cognitive change, focal neurology, 'fits, faints or falls', non-specific neurological, and other/non-specific) and calculated times for patient presentation, GP referral, specialist consultation and total pathway interval. We calculated odds ratios (ORs) for symptom domains comparing the slowest to other quartiles. Results: Data were available for 226 cases. Median (interquartile range) time for the total pathway interval was 24 days (7-65 days). The most common presentation was focal neurology (33.2%) followed by 'fits, faints or falls' and headache (both 20.8%). Headache only (OR = 4.11, 95% CI = 1.10, 15.5) and memory complaints (OR = 4.82, 95% CI = 1.15, 20.1) were associated with slower total pathway compared to 'fits, faints or falls'. GPs were more likely to consider that there had been avoidable delays in referring patients with headache only (OR = 4.17, 95% CI = 1.14, 15.3). Conclusion: Patients presenting to primary care with headache only or with memory complaints remain problematic with potentially avoidable delays in referral leading to a longer patient pathway. This may or may not impact on the efficacy and morbidity of therapies. Additional aids are required to help doctors differentiate when to refer headaches and memory complaints urgently for a specialist opinion.

Dietary Protein Intake and Stroke Risk in a General Japanese Population: The Hisayama Study.

BACKGROUND AND PURPOSE: The influence of dietary protein intake on stroke risk is an area of interest. We investigated the association between dietary protein intake and stroke risk in Japanese, considering sources of protein. METHODS: A total of 2400 subjects aged 40 to 79 years were followed up for 19 years. Dietary protein intake was estimated using a 70-item semiquantitative food frequency questionnaire. The risk estimates for incident stroke and its subtypes were calculated using a Cox proportional hazards model. RESULTS: During the follow-up, 254 participants experienced stroke events; of these, 172 had ischemic stroke, and 58 had intracerebral hemorrhage. Higher total protein intake was significantly associated with lower risks of stroke and intracerebral hemorrhage (both P for trend <0.05). With regard to sources of protein, the risks of total stroke and ischemic stroke significantly decreased by 40% (95% confidence interval, 12%-59%) and 40% (5%-62%), respectively, in subjects with the highest quartile of vegetable protein intake compared with those with the lowest one. In contrast, subjects with the highest quartile of animal protein intake had a 53% (4%-77%) lower risk of intracerebral hemorrhage. Vegetable protein intake was positively correlated with intakes of soybean products, vegetable, and algae, whereas animal protein intake was positively correlated with intakes of fish, meat, eggs, and milk/dairy products. Both types of protein intakes were negatively correlated with intakes of rice and alcohol. CONCLUSIONS: Our findings suggest that higher dietary protein intake is associated with a reduced risk of stroke in the general Japanese population.

A Quality Improvement Collaborative Program for Neonatal Pain Management in Japan.

BACKGROUND: Neonatal pain management guidelines have been released; however, there is insufficient systematic institutional support for the adoption of evidence-based pain management in Japan. PURPOSE: To evaluate the impact of a collaborative quality improvement program on the implementation of pain management improvements in Japanese neonatal intensive care units (NICUs). METHODS: Seven Japanese level III NICUs participated in a neonatal pain management quality improvement program based on an Institute for Healthcare Improvement collaborative model. The NICUs developed evidence-based practice points for pain management and implemented these over a 12-month period. Changes were introduced through a series of Plan-Do-Study-Act cycles, and throughout the process, pain management quality indicators were tracked as performance measures. Jonckheere's trend test and the Cochran-Armitage test for trend were used to examine the changes in quality indicator implementations over time (baseline, 3 months, 6 months, and 12 months). FINDINGS: Baseline pain management data from the 7 sites revealed substantial opportunities for improvement of pain management, and testing changes in the NICU setting resulted in measurable improvements in pain management. During the intervention phase, all participating sites introduced new pain assessment tools, and all sites developed electronic medical record forms to capture pain score, interventions, and infant responses to interventions. IMPLICATIONS FOR PRACTICE: The use of collaborative quality improvement techniques played a key role in improving pain management in the NICUs. IMPLICATIONS FOR RESEARCH: Collaborative improvement programs provide an attractive strategy for solving evidence-practice gaps in the NICU setting.

Dietary pattern, inflammation and cognitive decline: The Whitehall II prospective cohort study.

BACKGROUND & AIMS: Low-grade inflammation appears to play an etiological role in cognitive decline. However the association between an inflammatory dietary pattern and cognitive decline has not been investigated. We aimed to investigate dietary patterns associated with inflammation and whether such diet is associated with cognitive decline. METHODS: We analyzed 5083 participants (28.7% women) from the Whitehall II cohort study. Diet and serum interleukin-6 (IL-6) were assessed in 1991-1993 and 1997-1999. We used reduced rank regression methods to determine a dietary pattern associated with elevated IL-6. Cognitive tests were performed in 1997-1999 and repeated in 2002-2004 and 2007-2009. The association between dietary pattern and cognitive decline between ages 45 and 79 was assessed using linear mixed models. RESULTS: We identified an inflammatory dietary pattern characterized by higher intake of red meat, processed meat, peas and legumes, and fried food, and lower intake of whole grains which correlated with elevated IL-6 both in 1991-1993 and 1997-1999. A greater decline in reasoning was seen in participants in the highest tertile of adherence to the inflammatory dietary pattern (-0.37 SD; 95% confidence interval [CI] -0.40, -0.34) compared to those in the lowest tertile (-0.31; 95% CI -0.34, -0.28) after adjustment for age, sex, ethnicity, occupational status, education, and total energy intake (p for interaction across tertiles = 0.01). This association remained significant after multivariable adjustment. Similarly for global cognition, the inflammatory dietary pattern was associated with faster cognitive decline after multivariable adjustment (p for interaction across tertiles = 0.04). Associations were stronger in younger participants (<56 years), reducing the possibility of reverse causation. CONCLUSIONS: Our study found that a dietary pattern characterized as higher intake of red and processed meat, peas, legumes and fried food, and lower intake of whole grains was associated with higher inflammatory markers and accelerated cognitive decline at older ages. This supports the case for further research.

Midlife and Late-Life Smoking and Risk of Dementia in the Community: The Hisayama Study.

OBJECTIVES: To clarify the association between midlife and late-life smoking and risk of dementia. DESIGN: Prospective cohort study. SETTING: The Hisayama Study, Japan. PARTICIPANTS: Japanese community-dwellers without dementia aged 65 to 84 (mean age 72) followed for 17 years (1988-2005) (N = 754), 619 of whom had participated in a health examination conducted in 1973-74 (mean age, 57) and were included in the midlife analysis. MEASUREMENTS: The risk estimates of smoking status on the development of dementia were computed using a Cox proportional hazards model. RESULTS: During follow-up, 252 subjects developed all-cause dementia; 143 had Alzheimer's disease (AD), and 76 had vascular dementia (VaD). In late life, the multivariable-adjusted risk of all-cause dementia was significantly greater in current smokers than in never smokers; similar associations were seen for all-cause dementia, AD, and VaD in midlife current smokers. Meanwhile, no significant association was observed between past smoking and risk of any type of dementia in late or midlife. Multivariable analysis showed that smokers in midlife and late life had significantly greater risks than lifelong nonsmokers of all-cause dementia (adjusted hazard ratio (aHR) = 2.28, 95% confidence interval (CI) = 1.49-3.49), AD (aHR = 1.98, 95% CI = 1.09-3.61), and VaD (aHR = 2.88, 95% CI = 1.34-6.20). Such associations were not observed for midlife smokers who quit smoking in late life. CONCLUSION: Persistent smoking from mid- to late life is a significant risk factor for dementia and its subtypes in the general Japanese population.

Development of a Neonatal End-of-Life Care Education Program for NICU Nurses in Japan.

We developed the first end-of-life care education program for neonatal intensive care unit (NICU) nurses in Japan. It focused on ethical decision making, care of dying neonates, bereavement, and cultural communication. The program improved nurses' knowledge, F(2.16, 62.5) = 260.6, p < .001, and understanding, F(2.05, 59.4) = 29.1, p < .001, and significantly reduced weaknesses in neonatal end-of-life care. It was considered well designed and may provide further mentoring support for NICU nurses.