Decreasing Pain and Fear in Medical Procedures with a Pediatric Population (DREAM): A Pilot Randomized Within-Subject Trial.

BACKGROUND: Many children with injuries, including burns and fractures, experience moderate to severe pain during medical procedures. Recent studies claim that nonpharmacologic pain management using virtual reality (VR) could distract children from procedural pain by engaging multiple senses. AIMS: The aims of this pilot randomized clinical trial were to assess the acceptability and feasibility of VR distraction in children with burns or fractures undergoing painful medical procedures, as well as the staff nurses, and assess the preliminary efficacy of VR distraction on pain intensity, pain-related fear, and subsequent recall of both. MATERIALS AND METHOD: A within-subject study design, in which participants served as their own control, was used. A total of 20 children from 7 to 17 years old with an injury were recruited at the surgical-trauma outpatient clinics of the Centre hospitalier universitaire Sainte-Justine (CHU Sainte-Justine). Each participant received both standard and experimental treatments through randomized order. Pain (numerical rating scale) and pain-related fear (Children's Fear Scale) measures were taken before the procedure and after each sequence, followed by a measure of children's (graphic rating scale) and nurses' acceptability of the intervention through their satisfaction level. Recall of pain intensity and pain-related fear were assessed 24 hours after the procedure. Wilcoxon signed-rank tests were used, with a significance level at 0.05. RESULTS: Results showed that VR distraction was an acceptable and feasible intervention for children and nurses of these outpatient clinics. Preliminary effects showed that, compared to standard of care, children participants reported a significant decrease in pain intensity (p = .023) and pain-related fear (p = .011) during VR as well as less recalled pain-related fear (p = .012) at 24 hours after the procedure. No side effects were reported. CONCLUSION: VR is a promising intervention with children undergoing painful procedures because it is immersive and engages multiple senses. It is a low-cost intervention well accepted by children and nursing staff at this clinical site and is easy to implement in daily practice for procedural pain management.

Effects of a projector-based hybrid virtual reality on pain in young children with burn injuries during hydrotherapy sessions: A within-subject randomized crossover trial.

AIM: The aim of this study was to examine the effect of a water-friendly Projector-Based Hybrid Virtual Reality (VR) dome environment combined with standard pharmacological treatment on pain in young children undergoing burn wound care in hydrotherapy. METHODS: This study was a prospective, within-subject crossover trial of 38 children aged 6 months to 7 years old (mean age=1.8 years old). Each hydrotherapy procedure was divided into two equivalent wound care segments (No hybrid VR during one segment vs. Hybrid VR during the other segment, treatment order was randomized). Pain was measured using the 0-10 FLACC (Face, Legs, Activity, Cry Consolability scale) and the 0-10 NRS-obs (Numerical Rating Scale-obs). RESULTS: Projector-Based Hybrid VR significantly reduced procedural pain levels measured by the FLACC (p=0.026) and significantly increased patients' comfort levels (p=0.002). Patients' pain levels rated by the nurses using the NRS-obs were non-significant between both groups (p=0.135). No side effects were reported. CONCLUSION: Projector-Based Hybrid VR helped in reducing the pain related to hydrotherapy procedures in young children with burn wound injuries. This is the first study using virtual reality distraction with young children, and our findings are especially important because a large percentage of pediatric burn patients are very young. Additional research and development are recommended. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02986464, registered on June 12, 2016.

Revealing tacit knowledge used by experienced health professionals for interprofessional collaboration.

With the current interest in interprofessional collaboration in health care as a response to ever-increasing complexity of health issues and scarcity of resources, many higher education institutions are developing interprofessional education (IPE) programs. However, there has been little empirical work on what. With the current interest for interprofessional collaboration in health care ever-increasing knowledge and skills are required to work collaboratively between health professions. We have undertaken to describe interprofessional collaboration as a practice largely underpinned by tacit knowledge acquired by experienced clinicians. Clinicians from all health professions in a large francophone university in Eastern Canada were invited to participate in explicitation interviews. Explicitation interviews require participants to freely recall an interprofessional collaboration event (e.g., team meeting or joint care delivery) and describe specific actions they personally enacted. An experienced health professional encounters many interprofessional situations over time; the actions they describe reflect their personal theories about the practice. Hence, it is highly probable that they use them frequently when working with colleagues in clinical settings. Unveiled tacit knowledge was divided into four themes: the importance of a sense of belonging to a team, the imperative to meet face-to-face, the practice of soliciting the working hypotheses of colleagues, and the art of summarizing meeting discussions.

Predictive Modeling for Personalized Three-Dimensional Burn Injury Assessments.

For patients with major burn injuries, an accurate burn size estimation is essential to plan appropriate treatment and minimize medical and surgical complications. However, current clinical methods for burn size estimation lack accuracy and reliability. To overcome these limitations, this paper proposes a 3D-based approach-with personalized 3D models from a limited set of anthropometric measurements-to accurately assess the percent TBSA affected by burns. First, a reliability and feasibility study of the anthropometric measuring process was performed to identify clinically relevant measurements. Second, a large representative stratified random sample was generated to output several anthropometric features required for predictive modeling. Machine-learning algorithms assessed the importance and the subsets of anthropometric measurements for predicting the BSA according to specific patient morphological features. Then, the accuracy of both the morphology and BSA of 3D models built from a limited set of measurements was evaluated using error metrics and maximum distances 3D color maps. Results highlighted the height and circumferences of the bust, neck, hips, and waist as the best predictors for BSA. 3D models built from three to four anthropometric measurements showed good accuracy and were geometrically close to gold standard 3D scans. Outcomes of this study aim to decrease medical and surgical complications by decreasing errors in percent TBSA assessments and, therefore, improving patient outcomes by personalizing care.

The development of a treatment pathway for dermal regenerative matrix (DRM).

The process of standardising burn care and creating protocols within burn centres has, at its core, evidence-based practice principles combined with the clinical experiences of burn care specialists. Although protocols and pathways have been created for certain topics of burn care, they tend to be tailored to the local individual needs of each burn centre, which is a limiting factor for consideration of larger/nationwide approaches. In order to continue to improve the short and long term outcomes after burn injuries, such as increasing the survival rate, reduction in the incidence of sepsis and organ failure, and improving wound healing and scarring, more generalised care pathways combining the recommendations of a nationwide working group of burn care specialists should be created around the topics of interest to ultimately improve patients' outcomes. We describe the steps put in place in Canada to design and adopt a nationwide protocol from a single burn centre on the topic of wound healing and dermal substitutes as the initial exemplary process. This report summarizes the Canadian experience for this type of initiative, which can be used as framework for developing additional guidelines/protocols in other relevant burn care related topics in Canada or other countries.

Projector-based virtual reality dome environment for procedural pain and anxiety in young children with burn injuries: a pilot study.

BACKGROUND: Virtual reality (VR) is a non-pharmacological method to distract from pain during painful procedures. However, it was never tested in young children with burn injuries undergoing wound care. AIM: We aimed to assess the feasibility and acceptability of the study process and the use of VR for procedural pain management. METHODS: From June 2016 to January 2017, we recruited children from 2 months to 10 years of age with burn injuries requiring a hydrotherapy session in a pediatric university teaching hospital in Montreal. Each child received the projector-based VR intervention in addition to the standard pharmacological treatment. Data on intervention and study feasibility and acceptability in addition to measures on pain (Face, Legs, Activity, Cry, Consolability scale), baseline (Modified Smith Scale) and procedural (Procedure Behavior Check List) anxiety, comfort (OCCEB-BECCO [behavioral observational scale of comfort level for child burn victims]), and sedation (Ramsay Sedation Scale) were collected before, during, and after the procedure. Data analyses included descriptive and non-parametric inferential statistics. RESULTS: We recruited 15 children with a mean age of 2.2±2.1 years and a mean total body surface area of 5% (±4). Mean pain score during the procedure was low (2.9/10, ±3), as was the discomfort level (2.9/10, ±2.8). Most children were cooperative, oriented, and calm. Assessing anxiety was not feasible with our sample of participants. The prototype did not interfere with the procedure and was considered useful for procedural pain management by most health care professionals. CONCLUSION: The projector-based VR is a feasible and acceptable intervention for procedural pain management in young children with burn injuries. A larger trial with a control group is required to assess its efficacy.

The Importance of a Three-dimensional-Based Approach With Personalized Models for Accurately Assessing TBSA.

In this article, the relevance of a new three-dimensional computer-Based computer-based framework with personalized 3D models for accurately assessing the TBSA is demonstrated through preliminary results and validation studies. First, a 3D rendering interface was developed for representation and calculation of TBSA. The personalized 3D models were built from anthropometric measurements using MakeHuman software. Fifteen paired models were randomly built with an equal BSA but a different morphology. The difference of local BSA, TBSA burned, and Parkland fluids between each paired models were observed to highlight the impact of morphology's variation on the TBSA. Finally, a preliminary validation study was made on 4 mannequins by 14 volunteers to assess the accuracy of the 3D models built with MakeHuman software and TBSA burned assessment with the proposed method. Small variations in the morphology impacted the TBSA assessment. Mannequin's 3D models built with MakeHuman software presented an absolute error of 3 ± 2.2 % with no significant difference with their scans. The proposed approach allows for a better assessment of TBSA with a lower variability. No significant difference in the scores for expert and nonexpert conditions was observed. Personalized 3D model to the patient's morphology is suggested to overcome the difficulty of patients with specific morphologies such as obese and children. The proposed framework appears to be relevant for personalizing and accurately assessing TBSA and could reduce morbidity and mortality.

[Madness is Conforming to One's Own Norms, and No Others: Psychiatry in Post-war Quebec]. / La folie, c'est de n'avoir pas d'autres normes que soi-même : la psychiatrie au cours de l'après-guerre au Québec.

In the early 1950s, both the publication of the first Diagnostic and Statistical Manual (DSM-I) and the advent of psychopharmacology - particularly the development of chlorpromazine (Thorazine - RP4650) - set the stage for models of psychiatric thought, research and practice that remain dominant today. It was during this pivotal period, in 1955, that the Département de psychiatrie de l'Université de Montréal was founded by a cohort of young researchers newly arrived from well-known universities in France and the northeastern United States. This influential group quickly became staunch critics of the province's religion-based asylum system and lobbied for a government review that culminated into the 1962 Commission d'étude des hôpitaux psychiatriques (popularly known as the Bédard Report). What followed in Quebec between 1965 and 1975 was the secularization of psychiatric institutions and widespread deinstitutionalization. This paper illuminates cultural changes and intellectual shifts that have been overlooked in historical studies of post-war psychiatry by exploring the expansion of such "anti-psychiatry" schools of thought in Quebec in this period.

Acute blistering diseases on the burn ward: Beyond Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis.

OBJECTIVE: Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis are on a spectrum of rare reactions primarily attributable to drugs. Timely diagnosis, cessation of the offending drug and burn center care are associated with favorable outcomes. Acute blistering disease has a wide differential diagnosis, including autoimmune bullous disease and other drug reactions. The aim of our study was to identify the final diagnosis in patients transferred for widespread blistering disease and to identify clinical features at admission predicting final diagnosis. METHODS: We performed a 5-year retrospective chart review (2006-2011) of the clinical features at admission of patients transferred to a burn ward with widespread blistering disease. Clinical features at admission were compared between patients. RESULTS: 12 patients had a final diagnosis of Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis and 7 patients had an alternative final diagnosis. Skin detachment surface area at admission was superior in the Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis group. Presence of tense bullae and pustules was associated with an alternative final diagnosis. CONCLUSION: Extensive skin detachment surface and morphological features (tense bullae, pustules) were statistically significant clinical clues to final diagnosis. Patients transferred for widespread blistering disease should be thoroughly evaluated in order to exclude other causes of acute blistering disease.

The social integration of the mentally ill in Quebec prior to the Bédard Report of 1962.

This article on the first initiatives of social integration of the mentally ill, using the example of Saint-Jean-de-Dieu Hospital, explores the implementation of dehopsitalization (the transition between hospital and community care) in the early decades of the 20th century. Our study is part of the recent historiographical stream that offers a reinterpretation of the period just prior to the Quiet Revolution in Quebec. We aim to contribute to this research by showing that the policies, strategies, and practices of the Sisters of Providence and the psychiatrists of Saint-Jean-de-Dieu already comprised a deinstitutionalization system that was reintegrating patients into their families as early as the 1910s--half a century before the first wave of deinstitutionalization of the 1960s was orchestrated by the authors of the Bédard Report.

[First initiatives for social integration of the mentally ill in one phase of pre-deinstitutionalization. The example of Saint-Jean-de-Dieu, 1910-1950]. / Premières initiatives d'intégration sociale des malades mentaux dans une phase de pré-désinstitutionnalisation. L'exemple de Saint-Jean-de-Dieu, 1910-1950

This article on the first initiatives of social integration of the mentally ill, using the example of the Hôpital St-Jean-de-Dieu, explores the implementation of a period of deinstitutionalization in the early decades of the 20th century. Our study is situated in the recent historiography that offers a rereading of the period just prior to the Quiet Revolution in Quebec. We intend to contribute by demonstrating that the policies, strategies and practices of the Sisters of Providence and the psychiatrists of St-Jean-de-Dieu developed a system of deinstitutionalization that reintegrated patients into their family as early as the 1910s, half a century before the first wave of deinstitutionalization of the 1960s was orchestrated by the authors of the Bédard report.

Venous thromboembolism in plastic surgery: incidence, current practice and recommendations.

Venous thromboembolic events (VTEs) are an important concern due to their frequently asymptomatic presentation and significant morbidity and/or mortality. The true incidence of this disease process is unknown as (i) screening procedures and (ii) prophylaxis protocols are frequently lacking in this patient population. The purpose of this study was to identify published thromboprophylactic recommendations established in the plastic surgery literature and to provide a review on thromboembolism and current methods of prophylaxis. A systematic evaluation of all published guidelines for thromboembolism prophylaxis in plastic surgery was conducted. We report on 24 studies in favour of, and three studies against, mechanical and/or pharmacological prophylaxis. Thromboprophylactic recommendations were published by a small randomised trial (grade B, level 2), six retrospective studies (grade C, level IV), two literature reviews (grade C, level V), two surveys (grade C, level V), three narrative reviews (Continuing Medical Education) (grade C, level V) and 10 expert recommendations (grade C, level V). The three publications against prophylaxis were composed of a retrospective study (grade C, level IV) and two case series with no control group (grade C, level V). There is a significant paucity of category A or B evidence favouring thromboprophylaxis in the plastic surgery patient population. There is a need for further research in established thromboprophylaxis guidelines in plastic and reconstructive surgery.

Prevention of surgical site infection and appropriateness of antibiotic prescribing habits in plastic surgery.

OBJECTIVES: The use of antimicrobial prophylaxis against surgical site infection (SSI) is widespread in plastic surgery, while results from prospective randomised controlled trials in guiding antibiotic use are lacking. The purpose of this study was to identify the incidence and risk factors for SSI in plastic surgery, and to evaluate the appropriateness of prophylactic antibiotic prescribing habits in a tertiary university centre. METHODS: A retrospective chart review was conducted over a 6-month period. Co-morbidities, types of procedure, prophylactic antimicrobial administration, SSI rates, and clinical outcomes were evaluated. RESULTS: The incidence of SSI was 9.3% for 335 procedures. The cumulative incidence of SSI for breast surgery (n=80) was 16.3%, with a 78.8% prescription rate. For head and neck procedures (n=68), the incidence of SSI was 10.3%, with 80.9% of patients receiving antibiotic prophylaxis. For hand and upper limb procedures (n=170), 70.6% of patients received antimicrobial prophylaxis, with a 4.7% SSI incidence. According to category A prophylaxis guidelines published in the plastic surgery literature, over prescribing was identified in 27.5% of breast, 61.8% of head and neck, and 19.4% of hand and upper limb procedures. CONCLUSIONS: This is the first study evaluating appropriateness of antimicrobial prophylaxis use by plastic surgeons. Despite widespread use of prophylactic antibiotics, significant SSI rates were still present and frequently responsible for re-hospitalisations and re-interventions. The appropriateness of administration and indications for perioperative prophylactic antibiotic use must be evaluated.