Reducing the pain of intramuscular benzathine penicillin injections in the rheumatic fever population of Counties Manukau District Health Board

Intramuscular versus enteral penicillin prophylaxis to prevent progression of rheumatic heart disease: Study protocol for a noninferiority randomized trial (the GOALIE trial)

BACKGROUND

Rheumatic Heart Disease (RHD) persists as a major cardiovascular driver of mortality and morbidity among young people in low-and middle-income countries. Secondary antibiotic prophylaxis (SAP) with penicillin remains the cornerstone of RHD control, however, suboptimal treatment adherence undermines most secondary prevention programs. Many of the barriers to optimal SAP adherence are specific to the intramuscular form of penicillin and may potentially be overcome by use of oral penicillin. This noninferiority trial is comparing the efficacy of intramuscular to oral penicillin SAP to prevent progression of mild RHD at 2 years.

METHODS/DESIGN

The Intramuscular vs Enteral Penicillin Prophylaxis to Prevent Progression of Rheumatic Heart Disease (GOALIE) trial is randomizing Ugandan children aged 5 to 17 years identified by echocardiographic screening with mild RHD (Stage A or B as defined by 2023 World Heart Federation criteria) to Benzathine Benzyl Penicillin G (BPG arm, every-28-day intramuscular penicillin) or Phenoxymethyl Penicillin (Pen V arm, twice daily oral penicillin) for a period of 2 years. A blinded echocardiography adjudication panel of 3 RHD experts and 2 cardiologists is determining the echocardiographic stage of RHD at enrollment and will do the same at study completion by consensus review. Treatment adherence and study retention are supported through peer support groups and case management strategies. The primary outcome is the proportion of children in the Pen V arm who progress to more advanced RHD compared to those in the BPG arm. Secondary outcomes are patient-reported outcomes (treatment acceptance, satisfaction, and health related quality of life), costs, and cost-effectiveness of oral compared to intramuscular penicillin prophylaxis for RHD. A total sample size of 1,004 participants will provide 90% power to demonstrate noninferiority using a margin of 4% with allowance for 7% loss to follow-up. Participant enrollment commenced in October 2023 and final participant follow-up is expected in December 2026. The graphical abstract (Fig. 1) summarizes the flow of echocardiographic screening, participant enrollment and follow-up.

DISCUSSION

The GOALIE trial is critical in global efforts to refine a pragmatic approach to secondary prevention for RHD control. GOALIE insists that the inferiority of oral penicillin be proven contemporarily and against the most important near-term clinical outcome of progression of RHD severity. This work also considers other factors that could influence the adoption of oral prophylaxis and change the calculus for acceptable efficacy including patient-reported outcomes and costs.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05693545.

Nursing practices to optimise rheumatic fever prevention in a high-risk country: An integrative review

BACKGROUND

New Zealand is one of the last high-income countries in the world experiencing significant rates of rheumatic fever. Nurses play a crucial role in rheumatic fever prevention; however, little is understood as to how nurses can best achieve this.

AIM

To explore nursing practices that optimise rheumatic fever prevention.

DESIGN

An integrative review.

METHODS

Four electronic databases (CINAHL, SCOPUS, Medline via, and Ovid) were searched for peer-reviewed empirical articles published from 2013 to 2023. Grey literature (guidelines/reports) was also sourced. Critical appraisal was applied using the Mixed-Methods Appraisal Tools and the Joanna Briggs Critical Appraisal checklist. Qualitative Research in Psychology, 3(2), 77-101, thematic analysis method was used to generate themes.

RESULTS

Seven research articles and three national reports were included. Four themes-in-depth nursing knowledge and improving prophylaxis adherence, cultural competency, and therapeutic nurse-patient relationships-were found.

CONCLUSION

While nursing knowledge and ways to improve injection adherence are essential, being culturally receptive and developing therapeutic relationships are equally important. Without strong and trusting relationships, it is difficult to deliver care required for prevention success.

IMPLICATIONS TO CARE

When working with vulnerable populations it is important to be culturally receptive in all interactions with patients and their families.

IMPACT

New Zealand has high rates of rheumatic fever, especially among vulnerable populations such as Pacific Islanders and Māori. Nurses are often frontline primary care providers who, when skilled with the right tools, can help reduce the prevalence of this disease.

REPORTING METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow chart.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution was required for this research.

"Hurts less, lasts longer"; a qualitative study on experiences of young people receiving high-dose subcutaneous injections of benzathine penicillin G to prevent rheumatic heart disease in New Zealand

BACKGROUND

Four-weekly intramuscular (IM) benzathine penicillin G (BPG) injections to prevent acute rheumatic fever (ARF) progression have remained unchanged since 1955. A Phase-I trial in healthy volunteers demonstrated the safety and tolerability of high-dose subcutaneous infusions of BPG which resulted in a much longer effective penicillin exposure, and fewer injections. Here we describe the experiences of young people living with ARF participating in a Phase-II trial of SubCutaneous Injections of BPG (SCIP).

METHODOLOGY

Participants (n = 20) attended a clinic in Wellington, New Zealand (NZ). After a physical examination, participants received 2% lignocaine followed by 13.8mL to 20.7mL of BPG (Bicillin-LA®; determined by weight), into the abdominal subcutaneous tissue. A Kaupapa Māori consistent methodology was used to explore experiences of SCIP, through semi-structured interviews and observations taken during/after the injection, and on days 28 and 70. All interviews were recorded, transcribed verbatim, and thematically analysed.

PRINCIPAL FINDINGS

Low levels of pain were reported on needle insertion, during and following the injection. Some participants experienced discomfort and bruising on days one and two post dose; however, the pain was reported to be less severe than their usual IM BPG. Participants were 'relieved' to only need injections quarterly and the majority (95%) reported a preference for SCIP over IM BPG.

CONCLUSIONS

Participants preferred SCIP over their usual regimen, reporting less pain and a preference for the longer time gap between treatments. Recommending SCIP as standard of care for most patients needing long-term prophylaxis has the potential to transform secondary prophylaxis of ARF/RHD in NZ and globally.

Subcutaneous infusion of high-dose benzathine penicillin G is safe, tolerable, and suitable for less-frequent dosing for rheumatic heart disease secondary prophylaxis: a phase 1 open-label population pharmacokinetic study

Since 1955, the recommended strategy for rheumatic heart disease (RHD) secondary prophylaxis has been benzathine penicillin G [BPG; 1.2 MU (900 mg)] injections administered intramuscularly every 4 weeks. Due to dosing frequency, pain, and programmatic challenges, adherence is suboptimal. It has previously been demonstrated that BPG delivered subcutaneously at a standard dose is safe and tolerable and has favorable pharmacokinetics, setting the scene for improved regimens with less frequent administration. The safety, tolerability, and pharmacokinetics of subcutaneous infusions of high-dose BPG were assessed in 24 healthy adult volunteers assigned to receive either 3.6, 7.2, or 10.8 MU (three, six, and nine times the standard dose, respectively) as a single subcutaneous infusion. The delivery of the BPG to the subcutaneous tissue was confirmed with ultrasonography. Safety assessments, pain scores, and penicillin concentrations were measured for 16 weeks post-dose. Subcutaneous infusion of penicillin (SCIP) was generally well tolerated with all participants experiencing transient, mild infusion-site reactions. Prolonged elevated penicillin concentrations were described using a combined zero-order (44 days) and first-order (t1/2 = 12 days) absorption pharmacokinetic model. In simulations, time above the conventionally accepted target concentration of 20 ng/mL (0.02 µg/mL) was 57 days for 10.8 MU delivered by subcutaneous infusion every 13 weeks compared with 9 days of every 4-weekly dosing interval for the standard 1.2 MU intramuscular dose (i.e., 63% and 32% of the dosing interval, respectively). High-dose SCIP (BPG) is safe, has acceptable tolerability, and may be suitable for up to 3 monthly dosing intervals for secondary prophylaxis of RHD.

Detection and management of latent rheumatic heart disease: a narrative review

Rheumatic heart disease (RHD) is a public health concern in many developing nations around the world. Early detection of latent or subclinical RHD can help in reversing mild lesions, retarding disease progression, reducing morbidity and mortality, and improving the quality of life of patients. Echocardiography is the gold-standard method for screening and confirming latent RHD cases. The rates and determinants of progression of latent RHD cases as assessed by echocardiography have been found to be variable through studies. Even though latent RHD has a slow rate of progression, the rate of progression of its subtype, 'definite' RHD, is substantial. A brief training of nonexpert operators on the use of handheld echocardiography with a simplified protocol is an important strategy to scale up the screening program to detect latent cases. Newer advancements in screening, such as deep-learning digital stethoscopes and telehealth services, have provided an opportunity to expand screening programs even in resource-constrained settings. Newer studies have established the efficacy and safety profile of secondary antibiotic prophylaxis in latent RHD. The concerned authorities in endemic regions of the world should work on improving the availability and accessibility of antibiotic prophylaxis.

The Effect of Buzzy Application on Pain Level During Vaccine Injection in Infants

BACKGROUND

Nonpharmacological interventions are needed to reduce pain during vaccine administration in infants.

PURPOSE

To determine the effect of the Buzzy device, which is a combination of cold and vibration, on pain during measles-mumps-rubella (MMR) vaccine administration in 12-month-old infants.

METHODS

A prospective randomized controlled experimental research design was used.

RESULTS

A total of 60 infants were included in the study. During and after vaccine injection, pain scores of infants who had the Buzzy device were significantly lower than those of infants in the control group ( P = .001).

CONCLUSIONS

Buzzy application may be an effective method in reducing pain during MMR vaccine administration. Use of the device is recommended for infants receiving vaccinations.

Recent Advances in the Rheumatic Fever and Rheumatic Heart Disease Continuum

Nearly a century after rheumatic fever (RF) and rheumatic heart disease (RHD) was eradicated from the developed world, the disease remains endemic in many low- and middle-income countries (LMICs), with grim health and socioeconomic impacts. The neglect of RHD which persisted for a semi-centennial was further driven by competing infectious diseases, particularly the human immunodeficiency virus (HIV) pandemic. However, over the last two-decades, slowly at first but with building momentum, there has been a resurgence of interest in RF/RHD. In this narrative review, we present the advances that have been made in the RF/RHD continuum over the past two decades since the re-awakening of interest, with a more concise focus on the last decade's achievements. Such primary advances include understanding the genetic predisposition to RHD, group A Streptococcus (GAS) vaccine development, and improved diagnostic strategies for GAS pharyngitis. Echocardiographic screening for RHD has been a major advance which has unearthed the prevailing high burden of RHD and the recent demonstration of benefit of secondary antibiotic prophylaxis on halting progression of latent RHD is a major step forward. Multiple befitting advances in tertiary management of RHD have also been realized. Finally, we summarize the research gaps and provide illumination on profitable future directions towards global eradication of RHD.

Secondary Antibiotic Prophylaxis for Latent Rheumatic Heart Disease

BACKGROUND

Rheumatic heart disease affects more than 40.5 million people worldwide and results in 306,000 deaths annually. Echocardiographic screening detects rheumatic heart disease at an early, latent stage. Whether secondary antibiotic prophylaxis is effective in preventing progression of latent rheumatic heart disease is unknown.

METHODS

We conducted a randomized, controlled trial of secondary antibiotic prophylaxis in Ugandan children and adolescents 5 to 17 years of age with latent rheumatic heart disease. Participants were randomly assigned to receive either injections of penicillin G benzathine (also known as benzathine benzylpenicillin) every 4 weeks for 2 years or no prophylaxis. All the participants underwent echocardiography at baseline and at 2 years after randomization. Changes from baseline were adjudicated by a panel whose members were unaware of the trial-group assignments. The primary outcome was echocardiographic progression of latent rheumatic heart disease at 2 years.

RESULTS

Among 102,200 children and adolescents who had screening echocardiograms, 3327 were initially assessed as having latent rheumatic heart disease, and 926 of the 3327 subsequently received a definitive diagnosis on the basis of confirmatory echocardiography and were determined to be eligible for the trial. Consent or assent for participation was provided for 916 persons, and all underwent randomization; 818 participants were included in the modified intention-to-treat analysis, and 799 (97.7%) completed the trial. A total of 3 participants (0.8%) in the prophylaxis group had echocardiographic progression at 2 years, as compared with 33 (8.2%) in the control group (risk difference, -7.5 percentage points; 95% confidence interval, -10.2 to -4.7; P<0.001). Two participants in the prophylaxis group had serious adverse events that were attributable to receipt of prophylaxis, including one episode of a mild anaphylactic reaction (representing <0.1% of all administered doses of prophylaxis).

CONCLUSIONS

Among children and adolescents 5 to 17 years of age with latent rheumatic heart disease, secondary antibiotic prophylaxis reduced the risk of disease progression at 2 years. Further research is needed before the implementation of population-level screening can be recommended. (Funded by the Thrasher Research Fund and others; GOAL ClinicalTrials.gov number, NCT03346525.).

Distraction Using Buzzy or Handheld Computers During Venipuncture

OBJECTIVES

Venipuncture is one of the most frequently performed painful procedures in children. The aim of this study was to investigate the effectiveness of 2 analgesic strategies for venipuncture in children in a specific setting like a blood-drawing center.

METHODS

This was a prospective randomized controlled trial. It was conducted in the blood-drawing center of a tertiary level children's hospital in Italy, between November 2014 and February 2015. Eligible patients were children aged from 4 to 12 years referred to the blood-drawing center for venipuncture. Enrolled children were randomized to be distracted by Buzzy device or by playing with a handheld computer. The procedural pain was measured with the faces pain scale-revised by children aged from 4 to 7 years and with a numerical rating scale by children aged from 8 to 12 years.

RESULTS

Two hundred children with a median age of 8 years were enrolled in the study. The self-reported procedural pain was not statistically different between the Buzzy group and the handheld computer group: median (interquartile range) = 3.0 (1.0-4.8) and 2.0 (1.0-4.8), respectively (P = 0.72). Children reported significant pain in 25% of cases with both distraction strategies. The procedural success rate at the first attempt was not significantly different in the 2 groups.

CONCLUSIONS

Analgesia provided by Buzzy or by a handheld computer was not significantly different in children undergoing venipuncture in a blood-drawing center, with the great proportion of them reporting no or mild pain during procedure.

The effect of vibration stimulation on intramuscular injection pain and patient satisfaction: Single-blind, randomised controlled study

AIMS AND OBJECTIVES

The aim of this study was to assess the effect of vibration stimulation application in ventrogluteal region on intramuscular injection pain and patient satisfaction.

BACKGROUND

Intramuscular injection pain caused distress for the patients and affected their compliance with the treatment.

DESIGN

This was a prospective, single-blind, cross-over study. The study complied with the guidelines of Consolidated Standards of Reporting Trials (CONSORT).

METHODS

Eighty-four patients who applied to the adult emergency department received an intramuscular injection of amoxicillin\ cefuroxime sodium to the ventrogluteal site with and without vibration in a random order following a standard procedure by the same investigator. Pain and satisfaction were assessed immediately after the injection with Visual Analogue Scale (VAS), by a researcher blinded to the study. The data were evaluated using mean, standard deviation, percentage, Student's t-test, paired sample t-test, linear regression analysis and generalised linear mixed model.

RESULTS

A total of 174 injections were analysed. The result of the study revealed that vibration decreased the severity of pain and increased the patient satisfaction.

CONCLUSIONS

Vibration is a non-pharmacologic approach, which can be effective in decreasing the injection pain and increasing patient satisfaction.

RELEVANCE TO CLINICAL PRACTICE

Intramuscular injection is the most frequently used nursing practice in the clinic. The use of vibration in decreasing pain due to intramuscular applications can help increase the self-confidence of nurses and the quality of the care they provide.

Effects of applying external cold and vibration to children during vaccination on pain, fear and anxiety

OBJECTIVES

This study aimed to evaluate the effectiveness of the application of external cold and vibration on children experiencing pain, fear and anxiety during vaccination.

DESIGN AND SETTING

This randomized controlled, experimental study was conducted in primary schools selected within the scope of school immunization days by a community health center. The study population consisted of first grade students who were scheduled to receive a booster dose of diphtheria, tetanus, and acellular pertussis, inactivated poliovirus vaccine (DTaP-IPV) vaccine within the scope of the school immunization program of the said community health center and the study sample consisted of 90 students (experimental: 45, control:45).

MAIN OUTCOME MEASURES

In the experimental group, a device that applies external cold and vibration (Buzzy®) was placed on the injection site for 30 s before administration of the vaccine. The device was then placed above the injection site and kept there during the injection. No intervention was made during the injections in children included in the control group. The same nurse administered the injections in the experimental and control groups.

RESULTS

In the current study, it was found that there was a statistically significant difference between the experimental group and the control group in terms of the children's pain, the nurse's pain, the nurse's fear and the children's anxiety (p < 0.05), but no statistically significant difference in terms of the children's fear (p > 0.05).

CONCLUSIONS

It was concluded that applying external cold and vibration during vaccination has an effect on the level of children's pain and anxiety.

Ending rheumatic heart disease in Australia: the evidence for a new approach

■The RHD Endgame Strategy: the blueprint to eliminate rheumatic heart disease in Australia by 2031 (the Endgame Strategy) is the blueprint to eliminate rheumatic heart disease (RHD) in Australia by 2031. Aboriginal and Torres Strait Islander people live with one of the highest per capita burdens of RHD in the world. ■The Endgame Strategy synthesises information compiled across the 5-year lifespan of the End Rheumatic Heart Disease Centre of Research Excellence (END RHD CRE). Data and results from priority research projects across several disciplines of research complemented literature reviews, systematic reviews and narrative reviews. Further, the experiences of those working in acute rheumatic fever (ARF) and RHD control and those living with RHD to provide the technical evidence for eliminating RHD in Australia were included. ■The lived experience of RHD is a critical factor in health outcomes. All future strategies to address ARF and RHD must prioritise Aboriginal and Torres Strait Islander people's knowledge, perspectives and experiences and develop co-designed approaches to RHD elimination. The environmental, economic, social and political context of RHD in Australia is inexorably linked to ending the disease. ■Statistical modelling undertaken in 2019 looked at the economic and health impacts of implementing an indicative strategy to eliminate RHD by 2031. Beginning in 2019, the strategy would include: reducing household crowding, improving hygiene infrastructure, strengthening primary health care and improving secondary prophylaxis. It was estimated that the strategy would prevent 663 deaths and save the health care system $188 million. ■The Endgame Strategy provides the evidence for a new approach to RHD elimination. It proposes an implementation framework of five priority action areas. These focus on strategies to prevent new cases of ARF and RHD early in the causal pathway from Streptococcus pyogenes exposure to ARF, and strategies that address the critical systems and structural changes needed to support a comprehensive RHD elimination strategy.

Intolerable Burden of Impetigo in Endemic Settings: A Review of the Current State of Play and Future Directions for Alternative Treatments

Impetigo (school sores) is a common superficial bacterial skin infection affecting around 162 million children worldwide, with the highest burden in Australian Aboriginal children. While impetigo itself is treatable, if left untreated, it can lead to life-threatening conditions, such as chronic heart and kidney diseases. Topical antibiotics are often considered the treatment of choice for impetigo, but the clinical efficacy of these treatments is declining at an alarming rate due to the rapid emergence and spread of resistant bacteria. In remote settings in Australia, topical antibiotics are no longer used for impetigo due to the troubling rise of antimicrobial resistance, demanding the use of oral and injectable antibiotic therapies. However, widespread use of these agents not only contributes to existing resistance, but also associated with adverse consequences for individuals and communities. These underscore the urgent need to reinvigorate the antibiotic discovery and alternative impetigo therapies in these settings. This review discusses the current impetigo treatment challenges in endemic settings in Australia and explores potential alternative antimicrobial therapies. The goals are to promote intensified research programs to facilitate effective use of currently available treatments, as well as developing new alternatives for impetigo.

Echocardiographic screening to determine progression of latent rheumatic heart disease in endemic areas: A systematic review and meta-analysis

BACKGROUND

The World Health Organisation previously recommended routine screening in school-aged children in countries with a high prevalence of rheumatic heart disease (RHD); however, it is unclear if screening-detected (latent) valve disease will inevitably evolve to a pathological lesion. Understanding the natural history of latent RHD is essential prior to recommendation of screening in endemic areas. Studies documenting the progression of latent RHD have had contrasting conclusions about the pathogenicity of latent valvular lesions. This review provides estimates of rates of progression of latent RHD.

METHODS AND FINDINGS

In this systematic review and meta-analysis, we searched EMBASE, MEDLINE, Global Index Medicus, Africa Wide, Cochrane Database of Systematic Reviews and Global Health Database for studies published before April 30, 2019. Study data were extracted from all studies which reported follow-up data on progression of latent valve lesions. Studies with control cohorts were used to calculate comparative prevalence ratios. This study is registered with PROSPERO, number CRD42019119427. We identified 12 studies reporting follow-up data on latent RHD for 950 people in 9 countries. The estimated pooled prevalence rate for progression per year of latent RHD was 5%/year (95% CI 2-8). Eight studies reported on the progression of borderline latent RHD with an estimated pooled prevalence of 2%/year (95% CI 0-4). Three studies included control groups. There was a significant increase in the risk of progression of valvular disease in the latent group compared with controls (RR = 3.57 (95%CI = 1.65-7.70, P = 0.001). The overall risk of bias was low. Given most studies included penicillin administration we were unable to document the natural history of latent RHD. Furthermore, we were unable to perform a sensitivity analysis to determine the effect of administering penicillin prophylaxis on progression of valve disease given prescription of penicillin was not standardised.

CONCLUSION

Latent RHD has a slow rate of progression but it is significantly higher compared to controls, with definite latent RHD having a higher rate of progression compared with borderline latent disease. There are a massive number of individuals at risk for RHD in the developing world as well as logistical challenges of screening and delivering penicillin prophylaxis. The low rate of progression from untargeted screening may be an important consideration in resource-constrained environments.

Determining the impact of Benzathine penicillin G prophylaxis in children with latent rheumatic heart disease (GOAL trial): Study protocol for a randomized controlled trial

Rheumatic heart disease (RHD) remains a high prevalence condition in low- and middle-income countries. Most individuals with RHD present late, missing the opportunity to benefit from secondary antibiotic prophylaxis. Echocardiographic screening can detect latent RHD, but the impact of secondary prophylaxis in screen-detected individuals is not known.

METHODS/DESIGN

This trial aims to determine if secondary prophylaxis with every-4-week injectable Benzathine penicillin G (BPG) improves outcomes for children diagnosed with latent RHD. This is a randomized controlled trial in consenting children, aged 5 to 17 years in Northern Uganda, confirmed to have borderline RHD or mild definite RHD on echocardiography, according to the 2012 World Heart Federation criteria. Qualifying children will be randomized to every-4-week injectable intramuscular BPG or no medical intervention and followed for a period of 2 years. Ongoing intervention adherence and retention in the trial will be supported through the establishment of peer support groups for participants in the intervention and control arms. A blinded echocardiography adjudication panel consisting of four independent experts will determine the echocardiographic classification at enrollment and trajectory through consensus review. The primary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic progression of latent RHD compared to those in the control arm. The secondary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic regression of latent RHD compared to those in the control arm. A sample size of 916 participants will provide 90% power to detect a 50% relative risk reduction assuming a 15% progression in the control group. The planned study duration is from 2018-2021.

DISCUSSION

Policy decisions on the role of echocardiographic screening for RHD have stalled because of the lack of evidence of the benefit of secondary prophylaxis. The results of our study will immediately inform the standard of care for children diagnosed with latent RHD and will shape, over 2-3 years, practical and scalable programs that could substantially decrease the burden of RHD in our lifetime.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03346525. Date Registered: November 17, 2017.

A Vibrating Cold Device to Reduce Pain in the Pediatric Emergency Department: A Randomized Clinical Trial

OBJECTIVE

Pain of intravenous (IV) catheter insertion can be mitigated with appropriate analgesia, thereby avoiding unnecessary distress. Our objective was to compare the self-reported pain of IV catheter insertion in children when using a vibrating cold device (VCD) versus standard of care 4% topical lidocaine cream (TL).

METHODS

This was a 2-arm randomized controlled noninferiority trial with a convenience sample of 4- to 18-year-olds requiring nonemergent IV catheter insertion. Self-reported pain was measured with the Faces Pain Scale-Revised, anxiety with the Child's Rating of Anxiety scale, and observed pain with the Face, Legs, Activity, Crying, Consolability scale. Caregivers and nurses completed satisfaction surveys.

RESULTS

Two hundred twenty-four children were included in the analysis: 114 (90%) of 127 in the VCD group and 110 (89%) of 124 in the TL group. Faces Pain Scale-Revised scores for both groups were equivalent (median, 2.0 cm; interquartile range, 0-5 cm; linear regression difference, 0 [95% confidence interval, -0.82 to 0.82]), as were median Face, Legs, Activity, Crying, Consolability scale scores (difference, 0.33 [95% confidence interval, -0.01 to 0.68]). The time of completion for the IV procedure was significantly shorter for the VCD group compared with the TL group (median, 3.0 vs 40.5 minutes; P < 0.0001). There were no significant differences between groups for self-reported state or trait anxiety, success of IV catheter insertion on first attempt, or satisfaction of caregivers or staff.

CONCLUSIONS

A VCD and TL showed equal effectiveness in reducing pain and distress for children undergoing IV catheter insertion. The VCD has the added benefit of quick onset time and an acceptable alternative for caregivers and nurses.

Effects of Vibration and Cold Application on Pain and Anxiety During Intravenous Catheterization

PURPOSE

To determine the effects of vibration and cold gel pack application on pain and anxiety levels of patients undergoing intravenous (IV) catheterization.

DESIGN

A randomized controlled, pretest and post-test experimental study.

METHODS

Catheterization was performed 60 seconds before the IV catheterization procedure was started by applying vibration and cold gel pack to patients in the experimental group. Patients in the control group underwent catheterization using standard procedures.

FINDINGS

The mean pain scores of patients in the experimental group were lower than those of the patients in the control group. Intragroup analysis demonstrated that the mean scores obtained from the state anxiety and trait anxiety inventories after the study were not significantly different from those obtained before the study.

CONCLUSIONS

Vibration and cold gel pack application is suggested to relive pain during IV catheterization in adults.

Comparison of the Effectiveness of Two Different Methods of Decreasing Pain During Phlebotomy in Children: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to examine the effect of the applications of external cold and vibration and blowing soap bubbles during phlebotomy in children aged between 3 and 6 years.

DESIGN

This study is a randomized controlled trial.

METHODS

The sample was obtained using block randomization. Children were divided into three groups: "external cold and vibration group," "blowing soap bubbles group," and "control group." Children, their parents, the nurse, and the researcher rated the children's pain during phlebotomy.

FINDINGS

A statistically significant difference between groups was found on pain scores. Pain scores were lower in the groups of external cold and vibration, and blowing soap bubbles than the control group.

CONCLUSIONS

The methods of external cold and vibration and blowing soap bubbles had a pain relieving effect in children aged between 3 and 6 years during phlebotomy.

Influencing Vaccinations: A Buzzy Approach to Ease the Discomfort of a Needle Stick-a Prospective, Randomized Controlled Trial

BACKGROUND

The rate of annual influenza immunization in both the general public and health care workers is less than desirable. Mechanisms to improve compliance with recommendations are needed; prevention of immunization site pain has been suggested as a viable route because fear of pain and needles has been cited as a barrier.

AIMS

This study aimed to evaluate the impact of thermomechanical stimulation (Buzzy) on postprocedure pain ratings during vaccination in adults.

DESIGN

This was a randomized controlled trial of Buzzy during immunization.

SETTINGS

Three hospitals and two community health centers which are part of a large, integrated health system.

PARTICIPANTS/SUBJECTS

Employees presenting to employer-sponsored annual influenza vaccination clinics.

METHODS

A 10-cm visual analog scale was used to rate preinjection anxiety and expectation of pain as well as postprocedure pain scores; participants also rated their satisfaction with the vaccine injection on a 10-point Likert scale.

RESULTS

In total, 497 employee volunteers were recruited to participate. Preprocedure anxiety was similar between the experimental and control groups (1.53 vs. 1.48, p = .82), whereas self-reported postprocedure pain scores were significantly lower in the group that received the Buzzy during injection (0.87 vs. 1.12, p = .035). Mean satisfaction scores did not vary between the intervention and control groups (9.11 vs. 9.09, p = .87); however, more participants rated their experience as better than previous vaccination experiences in the Buzzy group than control (62.0% vs. 23.9%, p < .0001).

CONCLUSIONS

These results suggest that Buzzy reduced pain experienced by adults undergoing annual influenza vaccination and may improve overall experience. Buzzy can be used in adult patients to reduce pain during immunization and is especially effective in those with high levels of anxiety.

Effects of Thermomechanical Stimulation during Vaccination on Anxiety, Pain, and Satisfaction in Pediatric Patients: A Randomized Controlled Trial

PURPOSE

Vaccination can be a significant source of pain for pediatric patients, which could result in fear of medical procedures and future reluctance to seek medical care. It is important for nurses to provide pain prevention during these procedures. This study sought to measure the impact of an intervention combining cold and vibration on pain scores during routine pediatric immunization.

DESIGN AND METHODS

A prospective, open-label, randomized controlled trial to examine the effectiveness of the Buzzy device (thermomechanical stimulation) compared to no intervention (control group) in reducing child-reported pain during routine immunization. The Wong Baker Faces scale was used to collect child, parent, and observer reported anxiety and pain. Parents reported satisfaction with the procedure and overall office visit.

RESULTS

Fifty children between the ages of 3 and 18 were included in the present analysis. Mean child-reported pain scores were significantly lower in the group receiving thermomechanical stimulation compared to control (3.56 vs 5.92, p=0.015). Buzzy did not impact child-reported anxiety or how much pain the child expected. Parent-reported satisfaction did not vary significantly between groups, but was strongly associated with parent-reported pain scores.

CONCLUSIONS

Thermomechanical stimulation with the Buzzy device significantly reduced pain during pediatric immunization over a wide range of ages compared to control, but did not impact pre-procedure anxiety.

PRACTICE IMPLICATIONS

The Buzzy device is an easy to implement intervention to reduce pediatric pain during vaccination. It may have the greatest impact in younger children but could be offered during all immunizations.

Aboriginal children and penicillin injections for rheumatic fever: how much of a problem is injection pain?

OBJECTIVE

To explore young Aboriginal people's and clinicians' experiences of injection pain for the 10 years of penicillin injections children are prescribed to prevent rheumatic fever recurrences.

METHODS

Aboriginal children on the penicillin regimen and clinicians were purposively recruited from four remote sites in Australia. Semi-structured interviews and participant observations were conducted. Views were synthesised and thematically analysed.

RESULTS

A total of 29 Aboriginal children and 59 clinicians were interviewed. Sixteen participants appeared to become accustomed to the injection pain, eight did not find pain an issue, and five found injection pain difficult. A further five believed the injections made them unwell. Patients expressed varying abilities to negotiate with clinicians about the use of pain reduction measures. Clinicians revealed good knowledge of pain reduction measures, but offered them inconsistently. All clinicians found administering the injections distressing.

CONCLUSION

Repeated painful procedures in children necessitate well-planned and child-focused care. Current practices are not in line with guidance from the Royal Australasian College of Physicians about effects of repeated painful procedures on children. Initiating the long-term injection regimen for rheumatic fever is a special event requiring expert input. A newly reported finding of a subset of young people feeling unwell after receiving the injection requires further investigation. Implications for public health: Improvement of local and jurisdictional guidelines on use of pain reduction measures for children who have been prescribed repeated painful injections for rheumatic fever is needed.

Enablers and barriers to secondary prophylaxis for rheumatic fever among Māori aged 14-21 in New Zealand: a framework method study

Background

Acute rheumatic fever (ARF) rates have declined to near zero in nearly all developed countries. However, in New Zealand rates have not declined since the 1980s. Further, ARF diagnoses in New Zealand are inequitably distributed--occurring almost exclusively in Māori (the indigenous population) and Pacific children--with very low rates in the majority New Zealand European population. With ARF diagnosis, secondary prophylaxis is key to prevent recurrence. The purpose of this study was to identify the perceived enablers and barriers to secondary recurrence prophylaxis following ARF for Māori patients aged 14–21.

Methods

This study took a systems approach, was informed by patient voice and used a framework method to explore potential barriers and enablers to ongoing adherence with monthly antibiotic injections for secondary prophylaxis. Qualitative interviews were conducted with 19 Māori ARF patients receiving recurrence prophylaxis in the Waikato District Health Board region. Participants included those fully adherent to treatment, those with intermittent adherence or those who had been “lost to follow-up.”

Results

Barriers and enablers were presented around three factors: system (including access/resources), relational and individual. Access and resources included district nurses coming to patients as an enabler and lack of income and time off work as barriers. Relational characteristics included support from family and friends as enablers and district nurse communication as predominantly a positive although not enabling factor. Individual characteristics included understanding, personal responsibility and fear/pain of injections.

Conclusion

This detailed exploration of barriers and enablers for ongoing secondary prophylaxis provides important new information for the prevention of recurrent ARF. Among other considerations, a national register, innovative engagement with youth and their families and a comprehensive pain management programme are likely to improve adherence to ongoing secondary prophylaxis and reduce the burden of RHD for New Zealand individuals, families and health system.

Community-Based Prescribing for Impetigo in Remote Australia: An Opportunity for Antimicrobial Stewardship

Background

To support antibiotic prescribing for both hospital and community-based health professionals working in remote North Western Australia, a multidisciplinary Antimicrobial Stewardship (AMS) Committee was established in 2013. This Committee is usually focused on hospital-based prescribing. A troubling increase in sulfamethoxazole/trimethoprim resistance in Staphylococcus aureus antibiograms from 9 to 18% over 1 year prompted a shift in gaze to community prescribing.

What we did

Finding a paucity of relevant research, we first investigated contextual factors influencing local prescribing. We also designed a systematic survey of experts with experience relevant to our setting using a structured response survey (12 questions) to better understand specific AMS risks. Using these findings, recommendations were formulated for the AMS Committee.

What we learned

Prescribing recommendations in a regional Skin Infections Protocol had previously been altered in December 2014. From 15 experts, we received 9 comprehensive responses (60%) about AMS risks in community prescribing. If feasible, prescribing audits also would have been valuable. Ten recommendations regarding specific antibiotic recommendations were submitted to the AMS Committee.

Strengthening AMS in remote settings

As AMS Committees in Australia usually focus on hospital-based prescribing, novel methods such as external expert opinion could inform deliberations about community-based prescribing. Our approach meant that this AMS Committee was able to intervene in the 2017 organizational review of the regional Skin Infections Protocol used by prescribers likely unaware of AMS risks. This experience demonstrates the value of incorporating AMS principles in community-based prescribing in context of a remote setting.

Comparison of Effects of Local Anesthesia and Two-Point Acupressure on the Severity of Venipuncture Pain Among Hospitalized 6-12-Year-Old Children

The aim of the present study was to compare the effects of topical anesthesia and acupressure at the Yintang (Extra 1) and the Laogong (P-8) points on the severity of venipuncture pain among hospitalized 6-12-year-old children. A sample (n = 120) of 6-12-year-old hospitalized children was recruited from two teaching hospitals located in Rafsanjan, Iran. The children were allocated to the topical anesthesia, acupressure, and control groups. For children in the topical anesthesia and the acupressure groups, eutectic mixture of local anesthetic (EMLA) cream and two-point acupressure were used, respectively, prior to performing venipuncture, whereas children in the control group only received routine prevenipuncture care. The severity of venipuncture pain was evaluated 5 minutes after performing venipuncture by using the Face, Leg, Activity, Cry, and Consolability behavioral pain assessment scale. The findings revealed that pain severity in both experimental groups was significantly lower than that in the control group, whereas there was no significant difference between the experimental groups regarding pain severity. Although acupressure was as effective as topical anesthesia cream in alleviating children's venipuncture pain, nurses are recommending to use acupressure instead of pharmacological pain management agents because of its greater safety, cost-effectiveness, and applicability.

The WHF Roadmap for Reducing CV Morbidity and Mortality Through Prevention and Control of RHD

Rheumatic heart disease (RHD) is a preventable non-communicable condition that disproportionately affects the world's poorest and most vulnerable. The World Heart Federation Roadmap for improved RHD control is a resource designed to help a variety of stakeholders raise the profile of RHD nationally and globally, and provide a framework to guide and support the strengthening of national, regional and global RHD control efforts. The Roadmap identifies the barriers that limit access to and uptake of proven interventions for the prevention and control of RHD. It also highlights a variety of established and promising solutions that may be used to overcome these barriers. As a general guide, the Roadmap is meant to serve as the foundation for the development of tailored plans of action to improve RHD control in specific contexts.

Sharing success - understanding barriers and enablers to secondary prophylaxis delivery for rheumatic fever and rheumatic heart disease

BACKGROUND

Rheumatic fever (RF) and rheumatic heart disease (RHD) cause considerable morbidity and mortality amongst Australian Aboriginal and Torres Strait Islander populations. Secondary antibiotic prophylaxis in the form of 4-weekly benzathine penicillin injections is the mainstay of control programs. Evidence suggests, however, that delivery rates of such prophylaxis are poor.

METHODS

This qualitative study used semi-structured interviews with patients, parents/care givers and health professionals, to explore the enablers of and barriers to the uptake of secondary prophylaxis. Data from participant interviews (with 11 patients/carers and 11 health practitioners) conducted in four far north Queensland sites were analyzed using the method of constant comparative analysis.

RESULTS

Deficits in registration and recall systems and pain attributed to injections were identified as barriers to secondary prophylaxis uptake. There were also varying perceptions regarding responsibility for ensuring injection delivery. Enablers of secondary prophylaxis uptake included positive patient-healthcare provider relationships, supporting patient autonomy, education of patients, care givers and healthcare providers, and community-based service delivery.

CONCLUSION

The study findings provide insights that may facilitate enhancement of secondary prophylaxis delivery systems and thereby improve uptake of secondary prophylaxis for RF/RHD.

Analgesia by cooling vibration during venipuncture in children with cognitive impairment

AIM

Children with cognitive impairment experience pain more frequently than healthy children and are more likely to require venipuncture or intravenous cannulation for various procedures. They are frequently unable to report pain and often receive poor pain assessment and management. This study assessed the effectiveness of physical analgesia during vascular access in children with cognitive impairments.

METHODS

We conducted a prospective randomised controlled study at a tertiary-level children's hospital in Italy from April to May 2015 to assess whether a cooling vibration device called Buzzy decreased pain during venipuncture and intravenous cannulation in children with cognitive impairment. None of the children had verbal skills and the main cognitive impairments were cerebral palsy, epileptic encephalopathy and genetic syndromes.

RESULTS

We tested 70 children with a median age of nine years: 34 in the Buzzy group and 36 in the no-intervention group. Parents were trained in the use of the Noncommunicating Children's Pain Checklist--postoperative version scale, and they reported no or mild procedural pain in 32 cases (91.4%) in the Buzzy group and in 22 cases (61.1%) in the no-intervention group (p = 0.003).

CONCLUSION

Cooling vibration analgesia during vascular access reduced pain in children with cognitive impairment.

Controlling acute rheumatic fever and rheumatic heart disease in developing countries: are we getting closer?

PURPOSE OF REVIEW

To describe new developments (2013-2014) in acute rheumatic fever (ARF) and rheumatic heart disease (RHD) relevant to developing countries.

RECENT FINDINGS

Improved opportunities for the primary prevention of ARF now exist, because of point-of-care antigen tests for Streptococcus pyogenes, and clinical decision rules which inform management of pharyngitis without requiring culture results. There is optimism that a vaccine, providing protection against many ARF-causing S. pyogenes strains, may be available in coming years. Collaborative approaches to RHD control, including World Heart Federation initiatives and the development of registers, offer promise for better control of this disease. New data on RHD-associated costs provide persuasive arguments for better government-level investment in primary and secondary prevention. There is expanding knowledge of potential biomarkers and immunological profiles which characterize ARF/RHD, and genetic mutations conferring ARF/RHD risk, but as yet no new diagnostic testing strategy is ready for clinical application.

SUMMARY

Reduction in the disease burden and national costs of ARF and RHD are major priorities. New initiatives in the primary and secondary prevention of ARF/RHD, novel developments in pathogenesis and biomarker research and steady progress in vaccine development, are all causes for optimism for improving control of ARF/RHD, which affect the poorest of the poor.