Travel patterns and health risks for patients infected with HIV.

International travelers are at increased risk of acquiring infectious diseases. These risks are even greater for individuals visiting resource-poor tropical regions and for immunocompromised travelers, including those with HIV infection. We reviewed ten years of consultative charts from the International Health Clinic at the Ottawa Hospital General Campus to describe travel risks and preventative measures for international travelers infected with HIV. A total of 100 patients infected with HIV (63 male, 37 female; mean age 42.2 years) were referred to the clinic prior to international travel. More than half (57%) were born in countries endemic for tropical diseases. Overall the median HIV viral load (VL) was <50 copies/ml (i.e. undetectable) and the median CD4 count was 440 cells/microL (IQR=285-630). The most common destination regions were sub-Saharan Africa (55 patients) and the Caribbean (14 patients). Endemic-born patients took longer trips than Canadian-born travelers (mean 45.2 vs. 22.7 days, p<0.05), were more likely to travel to visit friends and relatives (80.7% vs. 4.7%, p<0.05), and frequented regions with higher risks of malaria and other infectious tropical diseases. Endemic-born travelers infected with HIV stay abroad longer and are more likely to visit malarious regions than their Canadian-born counterparts. More research is needed to ensure the best preventive care of these special needs travelers.

Does sucrose analgesia promote physiologic stability in preterm neonates?

A double-blind, randomized controlled trial was conducted with infants born <31 weeks of gestational age and recruited within 48 h of life. The infants were randomized to receive up to three doses of 0.1 ml of either 24% sucrose or sterile water (placebo) for every painful procedure during the 1st week of life. The purpose of this study was to test the efficacy of treating all procedural pain with sucrose on overall physiological stability. The hypotheses were that infants who received 24% sucrose for all painful procedures would be less stressed as measured by salivary cortisol, and more physiologically stable as measured by pulse rate variability than those who received placebo. Salivary cortisol was measured before and 30 min after a painful procedure, whereas the pulse rate was continuously recorded, from second to second, from a pulse oximeter. There were no group differences in the cortisol response to a painful stimulus or in pulse rate variability over time. There was, however, a significant correlation between standard deviation of pulse rate and number of doses of sucrose only in the group who received high doses of sucrose.

Repeated neonatal pain influences maternal behavior, but not stress responsiveness in rat offspring.

Early preterm neonates in the Neonatal Intensive Care Unit (NICU) are subjected to repeated painful procedures which could sensitize their responses to pain and potentiate neuroendocrine and behavioral responses to subsequent stressors in the long-term. In this study, we used the model of the neonatal rat to test the effects of repeated pain during the first 2 weeks of life on neuroendocrine responses (CRF, ACTH and corticosterone) to stressors varying in intensity and on maternal behavior in the postnatal period. To closely mimic the type of repeated painful stimulus experienced by preterm neonates (i.e., heelstick), neonatal rats aged day 2-14 were submitted daily to having their rear heels warmed to 34 degrees C and pricked (handled and pain, HP) or not (handled, H) with a needle. For the procedure, all pups were separated from their mothers for a total period of 15 min and reunited afterwards. Unhandled (UH) pups not subjected to daily maternal separation were used as controls. On days 6 and 12, litters from the HP and H groups were videotaped for 90 min upon return with the mother and maternal behavior was analyzed. Frequency of ultrasonic vocalizations (USV) were recorded during the procedure and upon return of pups with the mother. On day 15 and 20, rat pups from all groups were exposed to a 3-min ether vapor stressor or to an openfield for 10 min. Plasma ACTH and corticosterone concentrations were determined at 0, 5, 30, 60 and 120 min after stress onset. Our results show that repeated pain did not modify body weight of the pups, however, on day 6 of life, maternal pup grooming was increased significantly (P<0.05) in the HP group compared to the H group. Frequency of USV was not changed between H and HP rats either during the separation or after reunion with the mother. Plasma ACTH and corticosterone levels under basal or stimulated conditions were not different between UH, H and HP groups. However, the UH pups showed a tendency towards higher ACTH secretion after stress compared to H and HP groups. These results suggest that repeated pain during the first 2 weeks of life in the rat does not lead to significant changes in stress responsiveness in 2-week-old pups, but we suggest that changes in mother-pup interaction (increased grooming) might act as a buffer on the cumulative effect of pain on stress responsiveness.

Routine sucrose analgesia during the first week of life in neonates younger than 31 weeks' postconceptional age.

OBJECTIVE: To determine the efficacy of sucrose analgesia for procedural pain during the first week of life in preterm neonates in neonatal intensive care units on enhancing later clinical outcomes. METHODS: A total of 107 preterm neonates who were born at <31 weeks' postconceptional age (PCA) entered this double-blind, randomized, controlled trial within 48 hours of birth at 3 level III university-affiliated neonatal intensive care units in Canada, and 103 completed the study. Sucrose (0.1 mL of 24%) or sterile water was administered orally up to 3 times, 2 minutes apart, for every invasive procedure during a 7-day period. Motor development and vigor, and alertness and orientation components of the Neurobehavioral Assessment of the Preterm Infant were measured at 32, 36, and 40 weeks' PCA; Score for Neonatal Acute Physiology was measured on the last day of intervention; and Neuro-Biological Risk Score (NBRS) was measured at 2 weeks of age and at discharge. Primary analyses of covariance were applied for each outcome to compare group differences followed by secondary analyses using standard linear regression within each group to determine predictors of outcomes. RESULTS: Although there were no differences between the groups on any outcomes, there were significant dose-related effects within each group. In the sucrose group only, higher number of doses of sucrose predicted lower scores on motor development and vigor, and alertness and orientation at 36 weeks', lower motor development and vigor at 40 weeks', and higher NBRS at 2 weeks' postnatal age. Higher number of invasive procedures was predictive of higher NBRS both times in the water group. CONCLUSIONS: Repeated use of sucrose analgesia in infants <31 weeks' PCA may put infants at risk for poorer neurobehavioral development and physiologic outcomes. Additional study is needed to determine the most appropriate age and duration of sucrose analgesia in preterm infants.