Family Perceptions and Provision of Analgesia for Acutely Painful Conditions in Children: A Multi-Centred Prospective Survey

BACKGROUND: More than two-thirds of children who present to the emergency department (ED) complain of pain. It is well known that children’s pain is poorly managed in the ED compared to their adult counterparts. With respect to analgesic administration in the ED, discrepancies exist between physician self-report and institutional audit. Patient refusal of analgesia is a likely explanation. There is good evidence that misconceptions and fears about analgesia in children are common among caregivers and may contribute to withholding pain medication. To date, no study has surveyed caregivers presenting the the ED to assess frequency of analgesic administration and reasons for withholding analgesia. We hypothesize that there will be a significant proportion of care-givers and patients that refuse pain medication in the ED. We also hypothesize that there will be a wide range of reasons for refusal. The insight we gain from this study will help nurses, clinical educators, and physicians provide the appropriate information to parents in an effort to target misconceptions and allay fears.

OBJECTIVES: Our objectives were to characterize the degree of care-giver and patient provision of analgesia prior to arrival, refusal of analgesia in the ED, and reasons behind their decision-making process. We hope to identify specific misconceptions, attitudes, or beliefs that impair the optimal provision of analgesia to children in the ED.

DESIGN/METHODS: A novel survey was designed by a focus group using an iterative approach and implemented over a 16-week period across two Canadian tertiary care paediatric EDs. We included a consecutive sample of caregivers of children aged 4-17 years with an acutely painful condition (headache, abdominal pain, injury, otitis, pharyngitis). Caregivers were asked to answer questions covering five domains: (i) demographics, (ii) analgesia prior to arrival (iii) analgesia offered in the ED and reasons for refusal, (iv) perceptions of analgesia, and (v) caregiver satisfaction at discharge. Children were asked to rate their pain on arrival and at discharge. The primary outcome was the frequency of caregiver provision of analgesia prior to arrival and the proportion of caregivers who accept the offer of analgesia offered in the ED.

RESULTS: Three hundred forty-four caregivers completed the survey. The majority were female (269/339, 79%), aged 36 years or older (256/340, 75%) with a post-secondary education (237/336, 71%). Most (309/339, 91%) reported being able to “tell when their child was in pain”. All respondents rated their child’s maximal pain related to the presenting condition as at least a 6/10. With regards to the primary outcome, 229/338 (68%) of caregivers reported that they did not treat their child’s pain prior to arrival in the ED. Of those who did treat their child’s pain, ibuprofen was the most commonly used analgesic (77/112, 69%). The most common reasons for withholding analgesia was a lack of time (80/210, 38%), fear of masking seriousness of child’s condition (49/210, 23%), fear of masking signs and symptoms (48/210, 23%), and a lack of analgesia at home (47/210, 22%). Analgesia was offered to 186/344 (45%) of children in the ED and the majority of caregivers 157/186 (84%) accepted the offer. The most common reason for not accepting analgesia in the ED was child refusal (15/20, 75%). Most, 231/338 (68%) of caregivers felt that their child’s pain was managed well in the ED.

CONCLUSION: This survey of caregiver perceptions surrounding analgesia for children with acutely painful conditions presenting to the pae-diatric ED suggests that most do not treat their child’s pain prior to arrival, despite high levels of pain. Misconceptions surrounding analgesia prior to arrival are common. Despite this, most caregivers accepted analgesia in the ED. Our results suggest that educational strategies should be directed at caregiver awareness of the impact of pain on children and the need for prompt analgesic therapy, even when an ED visit is planned.

Hallucinations and illusions in migraine in children and the Alice in Wonderland Syndrome

DESIGN

A prospective observational study over 1 year.

SETTING

A District General Hospital, and Child and Adolescent Mental Health Department.

PATIENTS

Children aged 8-18 years living in the catchment area of a district hospital service with any type of unexplained hallucinations or illusions associated with or without an established diagnosis of migraine.

RESULTS

The study identified nine children with a combination of migraine and a variety of hallucinations and illusions, including illusions of size, time, colour, body shape, movement and visual and auditory hallucination. An average of 10 symptoms (range 7-15) were reported.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

None.

CONCLUSIONS

It is important to recognise these symptoms to enable appropriate history taking and diagnosis. These symptoms are common and currently seem to go unrecognised and may pose diagnostic difficulties if onset is before typical migraine headaches occur.

THE LEPIDOPTERA OF BERMUDA: THEIR FOOD PLANTS, BIOGEOGRAPHY, AND MEANS OF DISPERSAL

The 183 species of Lepidoptera recorded from Bermuda are discussed with respect to their world distribution, origin, long-range dispersal capability, host plants, nomenclature, and the circumstances of their occurrence in Bermuda; most are illustrated. Fifty-nine species are reported from Bermuda for the first time; Oenobotys invinacealis Ferguson (Pyralidae) and Tetanolita mynesalis inaequalis Ferguson (Noctuidae) are described as new. Four new genus–species combinations and four new synonymies are proposed.The Bermuda islands have a distressed fauna dominated by introduced pest species and migrants from the North American mainland and Caribbean Region. About 125 of the 183 recorded species are thought to be established residents; the remainder are assumed to be vagrants. Of approximately 50 resident species identified as probably indigenous, 11 species and three subspecies are endemic, and one of these, Semiothisa ochrifascia (Warren), is believed extinct.All Bermudian Lepidoptera are of American origin except the few introduced Old World species that are nearly cosmopolitan. Like Norfolk Island, Australia, Bermuda has a supersaturated lepidopterous fauna — more recorded species than its land area might support, which can be explained only by a high incidence of migrants and transients. This migratory component is explained relative to long-range movements of the same or congeneric species elsewhere; and hypotheses are proposed concerning the natural history of long-range dispersal in eastern North America and the ability of these moths to reach Bermuda. From a list of 113 species of Lepidoptera identified as frequent south–north migrants on the mainland, 76 are recorded from Bermuda. These include 38 of the 40 best-known cutworm moths of the eastern United States. It is argued that such moths reach Bermuda repeatedly without man's assistance and must regularly travel similar distances in North America.

BioWeld® Tube and surgical glue for experimental sutureless venous microanastomosis

Background

The medial wall of mammalian veins is generally thin and fragile compared with the thick muscle seen in arteries. This makes venous microanastomoses time consuming and challenging. This study aimed to determine the feasibility and effectiveness of using the BioWeld® Tube in conjunction with a surgical glue (butyl-2-cyanoacrylate) in performing sutureless venous microanastomoses.

Methods

The feasibility and effectiveness of microvascular anastomoses in a rabbit jugular vein model were investigated in six animals, using the BioWeld® Tube in conjunction with butyl-2-cyanoacrylate surgical glue. Patency and tissue repair mechanisms at the anastomotic site were assessed 1 week after the procedure.

Results

All anastomoses remained patent at 1 week. Muscle necrosis occurred only in areas where the tissue was subject to the fold-and-bond procedure.

Conclusion

The study showed the feasibility and short-term effectiveness of the BioWeld® Tube in facilitating venous anastomoses.

Artery of percheron infarction: imaging patterns and clinical spectrum

BACKGROUND AND PURPOSE

Occlusion of the AOP results in a characteristic pattern of ischemia: bilateral paramedian thalamus with or without midbrain involvement. Although the classic imaging findings are often recognized, only a few small case series and isolated cases of AOP infarction have been reported. The purpose of this study was to characterize the complete imaging spectrum of AOP infarction on the basis of a large series of cases obtained from multiple institutions.

MATERIALS AND METHODS

Imaging and clinical data of 37 patients with AOP infarction from 2000 to 2009 were reviewed retrospectively. The primary imaging criterion for inclusion was an abnormal signal intensity on MR imaging and/or hypoattenuation on CT involving distinct arterial zones of the bilateral paramedian thalami with or without rostral midbrain involvement. Patients were excluded if there was a neoplastic, infectious, or inflammatory etiology.

RESULTS

We identified 4 ischemic patterns of AOP infarction: 1) bilateral paramedian thalamic with midbrain (43%), 2) bilateral paramedian thalamic without midbrain (38%), 3) bilateral paramedian thalamic with anterior thalamus and midbrain (14%), and 4) bilateral paramedian thalamic with anterior thalamus without midbrain (5%). A previously unreported finding (the "V" sign) on FLAIR and DWI sequences was identified in 67% of cases of AOP infarction with midbrain involvement and supports the diagnosis when present.

CONCLUSIONS

The 4 distinct patterns of ischemia identified in our large case series, along with the midbrain V sign, should improve recognition of AOP infarction and assist with the neurologic evaluation and management of patients with thalamic strokes.

Are there more bowel symptoms in children with autism compared to normal children and children with other developmental and neurological disorders?: A case control study

There is considerable controversy as to whether there is an association between bowel disorders and autism. Using a bowel symptom questionnaire we compared 51 children with autism spectrum disorder with control groups of 35 children from special school and 112 from mainstream school. There was a significant difference in the reporting of certain bowel symptoms (constipation, diarrhoea, flatulence) and food faddiness between the autism group and the mainstream school control group. There was no significant difference between the autism group and children in the special schools except for faddiness, which is an autism specific symptom and not a bowel symptom. This study confirms previously reported findings of an increase in bowel symptoms in children with autism. It would appear, however, that this is not specifically associated with autism as bowel symptoms were reported in similar frequency to a comparison group of children with other developmental and neurological disorders.

Clinical dilemmas in children with life-limiting illnesses: decision making and the law

Decision making about interventions for children and young people with life-limiting illnesses is fraught with difficulties but faced regularly by staff in children's hospices and paediatric wards. The perspectives of the child, various family members and professionals may all be different. The process of discussion and negotiation and the mechanism by which a decision is arrived at is complex. Various laws have recently changed in the UK that have an impact on this process. This article discusses several clinical scenarios to better understand these decisions and the effects of changes in the law. It also discusses how multidisciplinary teams in children's hospices (and other supportive clinical systems) can best support young people and families with and without recourse to the law.

The role of evaluation in the development of a service for children with life-limiting conditions in the community

BACKGROUND

Much of the care for children and young people with life-limiting conditions is now delivered in the home and new services have developed to support families in this setting. It is essential to monitor and evaluate whether these services are meeting the needs of families.

AIMS

To evaluate a new rural community palliative care service for children according to the perceptions of families and service providers, to make changes suggested by families and to re-evaluate 1 year later.

METHOD

In 2005, 2 years after the onset of the service, 24 families were sent postal questionnaires, including the Measure of Process of Care (MPOC-UK). Changes suggested by families were then implemented. In 2006, all of the families receiving care from the service (n=27) were given the option of completing the questionnaire independently or with the support of an impartial researcher. Two families also completed qualitative interviews about their experience of the service with an impartial researcher. In both years, the service providers, (n=12 and n=15, respectively) were asked to complete the Measure of Process of Care for Service Providers (MPOC-SP). The service providers were the clinicians providing direct care (paediatrician, community nurses, dietician, psychologist, occupational therapist, physiotherapist, and speech and language therapist).

RESULTS

Seven (29%) of families completed the survey in 2005. Families rated 'respectful and supportive care' as the highest domain in the MPOC-UK and 'providing general information' as the lowest. Particular emphasis was placed on improving provision of information during the following year. Fourteen (52%) families completed the survey in 2006. Scores increased across all domains in the second survey. The largest increase was 'providing general information'.

CONCLUSION

The results from both of the MPOC tools were extremely useful in helping providers to identify aspects of the service in need of improvement and hence implement valued changes.

Future innovations in anti-platelet therapies

Platelets have long been recognized to be of central importance in haemostasis, but their participation in pathological conditions such as thrombosis, atherosclerosis and inflammation is now also well established. The platelet has therefore become a key target in therapies to combat cardiovascular disease. Anti-platelet therapies are used widely, but current approaches lack efficacy in a proportion of patients, and are associated with side effects including problem bleeding. In the last decade, substantial progress has been made in understanding the regulation of platelet function, including the characterization of new ligands, platelet-specific receptors and cell signalling pathways. It is anticipated this progress will impact positively on the future innovations towards more effective and safer anti-platelet agents. In this review, the mechanisms of platelet regulation and current anti-platelet therapies are introduced, and strong, and some more speculative, potential candidate target molecules for future anti-platelet drug development are discussed.

National biosecurity approaches, plans and programmes in response to diseases in farmed aquatic animals: evolution, effectiveness and the way forward

The rapid increase in aquaculture production and trade, and increased attention to the negative effects of disease, are becoming stimuli for developing national biosecurity strategies for farmed fisheries, for which the World Organisation for Animal Health (OIE) Aquatic Animal Health Code and Manual of Diagnostic Tests for Aquatic Animals serve as an excellent framework. Using examples from a few countries and selected diseases, this paper provides a general overview of the development of approaches to implementing biosecurity strategies, including those emerging in the national legislation and regulations of some countries, and those being initiated by industries themselves. The determination of disease status in different epidemiological units (from a farm to a nation), appropriate approaches for preventing the introduction of disease and developing contingencies for disease control and eradication are also discussed. Important to the effectiveness of such strategies are provision of financial, personnel and other resources to implement them, including incentives such as indemnification or compensation in eradication programmes, and practical linkage to regulatory or government policy initiatives.

National aquatic animal health plans: the Australian experience

Following a major pilchard (Sardinops sagax) mortality event in 1995, Australia recognised the need for a national approach to aquatic animal health, particularly with respectto disease response. Cooperation between industry and government led to the development of AQUAPLAN, Australia's National Strategic Plan for Aquatic Animal Health. Under AQUAPLAN, institutional arrangements for the national technical response to aquatic animal health emergencies were developed based on existing arrangements for terrestrial animal health. The number and range of Australian Aquatic Veterinary Emergency Plan (AQUAVETPLAN) manuals are rising steadily; these are manuals that outline Australia's approach to national disease preparedness and propose the technical response and control strategies to be activated. Additional resources include standard diagnostic techniques and a disease field identification guide. Simulation exercises provide training to respond to aquatic emergency animal disease events. While resource issues and addressing governance remain priorities for the further implementation of AQUAPLAN, the highest priority is the development of a formal arrangement between governments and private sectors on the response to an aquatic emergency animal disease event.

Laser-assisted end-to-end BioWeld anastomosis in an ovine model

The BioWeld tube, an albumin-based exovascular stent, has been used for microsurgical anastomoses and compared to conventional sutures. The study presented investigated the potential of the BioWeld tube for vascular anastomosis in larger vessels. Laser-assisted BioWeld anastomoses were compared to conventional-sutured anatomoses of the carotid artery of Merino-x ewes. The BioWeld procedure resulted in 100% survival and 100% patency at 1 and 6 week post-operative periods, with no noticeable foreign body response. Sutured animals showed 100% survival and patency. The ischemic time for BioWeld anastomosis averaged 15 minutes compared with 10 minutes for sutures. This study indicates that the BioWeld tube is an easy to use anastomotic technique with equivalent success rates and comparable anastomotic times.