Pain care for children with cognitive impairment: A parent-nurse partnership

PURPOSE

To explore nurses' experiences of establishing partnerships with parents for pain care of hospitalized children with cognitive impairment (CI) and identify related facilitators and barriers.

DESIGN AND METHODS

In this qualitative, interpretive descriptive study, individual semi-structured interviews were conducted via videoconferencing with pediatric nurses from inpatient wards in a Canadian pediatric quaternary hospital. Verbatim transcripts were analyzed using an inductive, data-driven thematic analysis approach.

RESULTS

Eleven nurses were interviewed. The overarching theme was Assessing Pain as an Outsider: "A Complete Guessing Game". Seven major themes were identified.: Relying on Parent Expertise for Pain Assessment, Brainstorming with Parents for Pain Treatment, Supporting Parents as Advocates for Pain Care, Individualizing Pain Care with Parents, Involving the Child in Pain Care: A Spectrum, Barriers to Partnership in Pain Care and Facilitators to Partnership in Pain Care.

CONCLUSIONS

Nurses described the many ways they involve parents as partners in pain care. However, nurses shared strong feelings of uncertainty associated with pain care in children with CI. Consequently, nurses felt the need to rely on parents for appropriately assessing and treating pain in children with CI. Findings highlighted the practice and education gaps that may contribute to nurses' uncertainty and reliance on parents.

PRACTICE IMPLICATIONS

By identifying related practice and education gaps, healthcare organizations can implement strategies to further support nurses in establishing partnerships and potentially optimize pain care practices.

[Translating evidence: pain treatment in newborns, infants, and toddlers during needle-related procedures : German version]

INTRODUCTION

Treatment of pain in preterm, sick, and healthy newborns and infants and toddlers (up to 2 years of age) is consistently reported to be inadequate, and effective strategies are poorly implemented.

OBJECTIVES

To present existing evidence of effective pain treatment strategies during needle-related procedures and to highlight initiatives focused on translating evidence into practice.

METHODS

This Clinical Update focuses on the 2022 International Association for the Study of Pain Global Year for Translating Pain Knowledge to Practice in the specific population of newborns, infants, and toddlers. Best evidence is reviewed, and existing knowledge translation strategies and programs available to implement evidence into practice are presented.

RESULTS

Effective strategies for newborn and young infants during frequently occurring needle procedures include small volumes of sweet solutions, breastfeeding, or skin-to-skin care when feasible and culturally acceptable. In addition, strategies such as nonnutritive sucking, positioning, swaddling, gentle touch, facilitated tucking, and secure holding can be used. For toddlers, the evidence is less robust, and discerning between pain and distress is challenging. However, strategies recommended for needlerelated procedures include upright secure comfort holding by parents/caregivers, age-appropriate distraction, and topical anesthetics. Translation of effective pain management needs to involve the family, who need to be supported and empowered to comfort their child during painful procedures. Organizational, nationwide, and global initiatives aimed at improving implementation of effective pain treatments exist.

CONCLUSION

There is evidence of effective pain management strategies for newborns, infants, and toddlers, and a great deal of effort is being made to translate knowledge into action.

A longitudinal observational study on the epidemiology of painful procedures and sucrose administration in hospitalized preterm neonates

Although sucrose is widely administered to hospitalized infants for single painful procedures, total sucrose volume during the entire neonatal intensive care unit (NICU) stay and associated adverse events are unknown. In a longitudinal observation study, we aimed to quantify and contextualize sucrose administration during the NICU stay. Specifically, we investigated the frequency, nature, and severity of painful procedures; proportion of procedures where neonates received sucrose; total volume of sucrose administered for painful procedures; and incidence and type of adverse events. Neonates <32 weeks gestational age at birth and <10 days of life were recruited from four Canadian tertiary NICUs. Daily chart reviews of documented painful procedures, sucrose administration, and any associated adverse events were undertaken. One hundred sixty-eight neonates underwent a total of 9093 skin-breaking procedures (mean 54.1 [±65.2] procedures/neonate or 1.1 [±0.9] procedures/day/neonate) during an average NICU stay of 45.9 (±31.4) days. Pain severity was recorded for 5399/9093 (59.4%) of the painful procedures; the majority (5051 [93.5%]) were heel lances of moderate pain intensity. Sucrose was administered for 7839/9093 (86.2%) of painful procedures. The total average sucrose volume was 5.5 (±5.4) mL/neonate or 0.11 (±0.08) mL/neonate/day. Infants experienced an average of 7.9 (±12.7) minor adverse events associated with pain and/or sucrose administration that resolved without intervention. The total number of painful procedures, sucrose volume, and incidence of adverse events throughout the NICU stay were described addressing an important knowledge gap in neonatal pain. These data provide a baseline for examining the association between total sucrose volume during NICU stay and research on longer-term behavioral and neurodevelopmental outcomes.

"Seeing the light in the shade of it": primary caregiver and youth perspectives on using an inpatient portal for pain care during hospitalization

ABSTRACT

Studies from multiple countries report that most hospitalized children, especially the youngest and sickest, experience pain that is often severe yet inadequately treated. Evidence suggests this can lead to immediate and lifelong consequences affecting children, families, and communities. Partnership and shared decision-making by children, families, and clinicians is the ideal pediatric healthcare model and can improve care quality and safety, including pain care. A growing evidence base demonstrates that inpatient portals (electronic personal health record applications linked to hospital electronic medical or health records) can improve child and family engagement, outcomes, and satisfaction during hospitalization. This study examined the perspectives of caregivers of hospitalized children and of hospitalized youth about using an inpatient portal to support their engagement in pain care while in hospital. A qualitative descriptive study design was used and 20 participants (15 caregivers and 5 youth) with various painful conditions in one pediatric hospital participated in semistructured interviews. The authors applied a reflexive content analysis to the data and developed 3 broad categories: (1) connecting and sharing knowledge about pain, (2) user-centred designs, and (3) preserving roles. These findings outlined caregiver and youth recommendations for portal configurations that deeply engage and empower children and families in pain care through multidirectional knowledge sharing, supporting caregiver and clinicians' roles without burdening, or replacing human interaction implicit in family-centered pain care. Further research should measure the impact of portals on pain-related outcomes and explore the perspectives of clinicians.

The clinical utility of PET/CT scan and tissue biopsy in the management and follow-up of paediatric Hodgkin lymphoma in South Africa

BACKGROUND

In low- to middle-income countries (LMICs) like South Africa, there is a need to understand the clinical practices surrounding diagnosis and surveillance of paediatric Hodgkin lymphoma (HL) to reduce the burden on health systems. Understanding the clinical utility of PET/CT scans may decrease repeated tissue biopsies during disease surveillance.

METHODS

This is a retrospective cohort study of patients aged less than 18 years treated for HL at Chris Hani Baragwanath Academic Hospital from 1 January 2009 to 31 December 2018.

RESULTS

Fifty-four patients were included in the study; male-to-female ratio was 5:1 with a mean age of 9 years. Seventy per cent of patients (n = 38) received a PET/CT and tissue biopsy during their initial diagnostic workup, whereas 20.4% (n = 11) of patients received a PET/CT and tissue biopsy during surveillance. Tissue biopsy and PET/CT showed slight agreement (κ = 0.14) in diagnosing relapsed disease during surveillance. The false negative rate for tissue biopsy during surveillance was 42.9%. Surveillance PET/CT showed a positive predictive value (PPV) of 66.7% and negative predictive value (NPV) of 100% when compared to tissue biopsy.

CONCLUSION

This study is the first cohort to explore the clinical utility of PET/CT scans and tissue biopsies in a lowresourced setting. Our findings showed slight agreement between the modalities in diagnosing relapsed disease during surveillance. A portion of this discordance can be attributed to false negative tissue biopsy results. While the sample is limited, our findings are consistent with the high NPV of PET/CT scans of > 95% as is reported in the literature.

Call to focus on digital health technologies in hospitalized children's pain care: clinician experts' qualitative insights on optimizing electronic medical records to improve care

ABSTRACT

Most hospitalized children experience pain that is often inadequately assessed and undertreated. Exposure to undertreated childhood pain is associated with negative short-term and long-term outcomes and can detrimentally affect families, health services, and communities. Adopting electronic medical records (EMRs) in pediatric hospitals is a promising mechanism to transform care. As part of a larger program of research, this study examined the perspectives of pediatric clinical pain experts about how to capitalize on EMR designs to drive optimal family-centered pain care. A qualitative descriptive study design was used and 14 nursing and medical experts from 5 countries (United States, Canada, United Kingdom, Australia, and Qatar) were interviewed online using Zoom for Healthcare. We applied a reflexive content analysis to the data and constructed 4 broad categories: "capturing the pain story," "working with user-friendly systems," "patient and family engagement and shared decision making," and "augmenting pain knowledge and awareness." These findings outline expert recommendations for EMR designs that facilitate broad biopsychosocial pain assessments and multimodal treatments, and customized functionality that safeguards high-risk practices without overwhelming clinicians. Future research should study the use of patient-controlled and family-controlled interactive bedside technology to and their potential to promote shared decision making and optimize pain care outcomes.

Exploring implementation processes of a parent-targeted educational video for improving newborn pain treatment: A sequential exploratory mixed-methods study

Despite known analgesic effects of breastfeeding (BF), skin-to-skin care (SSC), and sweet solutions (sucrose) for newborns, these interventions remain underutilized. Our team produced a five-minute parent-targeted video (BSweet2Babies) demonstrating BF, SSC, and sucrose during newborn blood sampling. We conducted a sequential exploratory mixed-methods study with eight maternal-newborn units across Ontario, Canada to identify barriers and facilitators to implementing the video and the three pain management strategies.Over a 6-month period, data collection included 15 telephone interviews, two email communications, and three community of practice teleconferences with the participating sites (n = 8). We used the Theoretical Domains Framework as the coding matrix. Participants discussed integrating the video in prenatal education and the importance of involving leadership when planning for practice change. Key barriers included lack of comfort with parental presence, perception of high complexity of the strategies, short postpartum stays, competing priorities, and interprofessional challenges. Key facilitators included alignment with the Baby-Friendly Hospital Initiative, modeling by Lactation Consultants, and frequent reminders.

Contracting retail pharmacies as a source of essential medicines for public sector clients in low- and middle-income countries: a scoping review of key considerations, challenges, and opportunities

BACKGROUND

Insurances in high-income countries (HIC) often contract with private community pharmacies to dispense medicines to outpatients. In contrast, dispensing of medicines in low- and middle-income countries (LMICs) often lacks such contractual arrangements. Furthermore, many LMICs lack sufficient investment in supply chains and financial and human resources to guarantee stock levels and services at public medicine-dispensing institutions. Countries striving to achieve universal health coverage (UHC) can, in principle, incorporate retail pharmacies into their supply chains to expand access to essential medicines (EMs). The objectives of this paper are (a) to identify and analyze key considerations, opportunities and challenges for public payers when contracting out the supply and dispensing of medicines to retail pharmacies and (b) to provide examples of strategies and policies to address these challenges.

METHODS

A targeted literature strategy was used to conduct this scoping review. We created an analytical framework of key dimensions: (1) governance (including medicine and pharmacy regulation); (2) contracting (3) reimbursement; (4) medicine affordability (5) equitable access; and (6) quality of care (including 'patient-centered' pharmaceutical care). Using this framework, we selected a mix of three HIC and four LMIC case studies and analyzed the opportunities and challenges encountered when contracting retail pharmacies.

RESULTS

From this analysis, we identified a set of opportunities and challenges that should be considered by public payers considering public-private contracting: (1) balancing business viability with medicine affordability; (2) incentivizing equitable access to medicines; (3) ensuring quality of care and delivery of services; (4) ensuring product quality; (5) task-sharing from primary care providers to pharmacies and (6) securing human resources and related capacity constraints to ensure sustainability of the contract.

CONCLUSION

Public-private partnerships offer opportunities to improve access to EMs. Nonetheless, managing these agreements is complex and is influenced by a variety of factors. For effective contractual partnerships, a systems approach is needed in which business, industry and regulatory contexts are considered in tandem with the health system. Special attention should be devoted to rapidly changing health contexts and systems, such as changes in patient preferences and market developments brought about by the COVID-19 pandemic.

World Trade Center-related asthma: clinical care essentials

Asthma is defined as a heterogeneous disease with respiratory symptoms (wheeze, shortness of breath, chest tightness and cough) that vary over time and intensity, and variable expiratory airflow limitation. Environmental and occupational exposures contribute to its causation. WTC-related or aggravated asthma is considered a World Trace Center (WTC) Health Program certifiable disease. Criteria include defined exposures to the WTC dust and fumes, the presence of symptoms, or aggravated symptoms that are present within 5 years after the last potential for WTC dust/fume exposures (the last 9/11 exposures occurred on July 31, 2002), and a WTC-provider diagnosis of asthma. Asthma is the 3^rd most common non-cancer certification among WTC responders and survivors. In this review we provide evidence-based information on the evaluation, diagnosis, and treatment of patients with WTC-related or aggravated asthma and include peer-reviewed research findings in WTC-exposed populations.

The effectiveness of repeated sucrose for procedural pain in neonates in a longitudinal observational study

Goal

To determine the analgesic effectiveness of repeated sucrose administration for skin-breaking (SB) procedures over the Neonatal Intensive Care Unit (NICU) hospitalization of preterm infants.

Methods

Longitudinal observational study, conducted in four level III Canadian NICUs. Eligible infants were <32 weeks gestational age at birth, and <10 days of life at enrollment. Infants received 24% sucrose (0.12 ml) prior to all painful procedures. The Premature Infant Pain Profile - Revised (PIPP-R) was used at 30 and 60 seconds after a medically-required SB procedure as soon as possible after enrollment and weekly up to three additional times for scheduled procedures.

Results

172 infants (57.3% male, gestational age 28.35 (±2.31) weeks) were included. The mean 30 s PIPP-R scores were 6.11 (±3.68), 5.76 (±3.41), 6.48 (±3.67), and 6.81 (±3.69) respectively; there were no statistically significant interactions of study site by time (p = 0.31) or over time (p = 0.15). At 60 s, mean PIPP-R scores were 6.05 (±4.09), 5.74 (±3.67), 6.19 (±3.7), and 5.99 (±3.76) respectively; there were no study site by time interactions (p = 0.14) or differences over time (p = 0.52). There was a statistically significant site difference in the effectiveness of sucrose at 30 and 60 seconds (p < 0.01).

Conclusions

Consistently low PIPP-R scores following a skin-breaking procedure indicated that the analgesic effectiveness of the minimal dose of sucrose was sustained over time in the NICU. Further research is required to determine the optimal combination of sucrose and other pain management strategies to improve clinical practice and the impact of consistent use of repeated use of sucrose on neurodevelopment.

The effectiveness of high-fidelity simulation on undergraduate nursing students' clinical reasoning-related skills: A systematic review

BACKGROUND

High-fidelity simulation is used widely in the education of healthcare professionals; however, its effectiveness in teaching undergraduate nursing students clinical reasoning skills is not known. The objective of this systematic review is to synthesise findings from current literature about the effectiveness of high-fidelity simulation on the development of clinical reasoning-related skills in undergraduate nurses.

METHODS

A systematic review of the effectiveness of high-fidelity simulation was conducted, guided by the Joanna Briggs Institute methodology. Studies included were experimental and quasi-experimental study designs published in English between 2014 and 2020 that investigated clinical reasoning-related skills for undergraduate nursing students. Databases searched included Medline, CINAHL, Embase and the Joanna Briggs Institute of Evidence-based Practice database.

RESULT

A total of 1980 studies were identified and 15 studies met the inclusion criteria. Seven studies were randomised controlled trials, and eight studies were quasi-experimental. The 15 included studies reported 19 outcomes, as studies examined one or more outcomes of clinical reasoning-related skills. Statistically significant results favouring the simulation groups were reported in the following outcomes: clinical reasoning skills (three studies of three studies), critical thinking skills (four out of eight studies), problem-solving (two of four studies), decision-making skills (one of two studies), and clinical judgment skills (two of two studies).

CONCLUSION

High-fidelity simulation was reported to be effective alone and in combination with traditional teaching or other simulation types in improving undergraduate nursing students' clinical reasoning-related skills acquisition. Limitations included cost and availability of high-fidelity simulation to large numbers of students, which have implications for practice. Further research is needed to determine the actual effect of high-fidelity simulation compared to other simulation types on undergraduate nursing students' clinical reasoning-related skills.

Identifying research priorities with children, youth, and families: A scoping review

Increased patient advocacy has resulted in a shift toward more active patient engagement in the research. A scoping review was conducted to explore the literature on healthcare research priority settings wherein children, youths, or their families were involved in the priority-setting process. Six databases including MEDLINE, CINAHL, PsycINFO, Embase, Web of Science, and Global Health and the James Lind Alliance website were searched up until September 2019. All primary studies involving children (<18 years of age) or families in developing research priorities in health care were included. All retrieved references were uploaded into Covidence, and two independent reviewers screened the search results. Descriptive thematic analysis was used to identify common themes. A total of 30 studies with 4247 participants were included. Less than half of the participants (n = 1237, (33%) were pediatric patients and their families. A total of 455 research priorities were identified. Three common themes emerged: (i) quality of care delivery, (ii) self-efficacy in health behaviors, and (iii) community engagement in care. This scoping review revealed priority research health topics from the perspectives of children, youths, or their families. The findings may be used as a foundation for future research to improve the health outcomes of children, youths, or their families according to their identified priorities.

Elevated Sound Levels in the Neonatal Intensive Care Unit: What Is Causing the Problem?

BACKGROUND

Premature and sick neonates may require weeks of hospitalization in a noisy neonatal intensive care unit (NICU) environment with sound levels that may reach 120 decibels. The American Academy of Pediatrics recommends a maximum sound level of 45 decibels.

PURPOSE

To measure sound levels in a level III NICU and to describe contributing environmental factors.

METHODS

Descriptive quantitative study. Sound levels were measured using a portable sound meter in an open-bay level III NICU. Contributing environmental factors were recorded and analyzed.

RESULTS

Mean sound levels for day, evening, and night shifts were 83.5, 83, and 80.9 decibels, respectively. Each period of time exceeded the recommended guidelines 90% of the time and was almost double the American Academy of Pediatrics' recommendation. Multiple linear regression findings demonstrated significant factors associated with elevated sound levels including number of neonates, number of people, number of alarms, acuity level, and shift type. Observational data explain 14.5% of elevated sound levels.

IMPLICATIONS FOR PRACTICE

An understanding of baseline sound levels and contributing environmental factors is the first step in developing strategies to mitigate excessive noise in the NICU.

IMPLICATIONS FOR RESEARCH

Research should focus on effective and sustainable ways to reduce sound levels in the NICU, including inside the isolette, in order to provide an environment that is conducive to optimal growth and neurodevelopment for preterm and sick infants.

Quantitative Determination of Campylobacter on Broilers along 22 United Kingdom Processing Lines To Identify Potential Process Control Points and Cross-Contamination from Colonized to Uncolonized Flocks

ABSTRACT

As part of a program to reduce numbers of the human pathogen Campylobacter on retail chickens, 22 broiler processing lines, representing more than 90% of UK production, were characterized by enumerating Campylobacter on pooled neck skins after exsanguination, scalding, defeathering, evisceration, crop removal, inside-outside washing, and air-chilling stages of processing. Sixteen of the processing lines investigated showed significant (P < 0.05) reductions in Campylobacter numbers because of carcass scalding. However, in all of these lines, the following defeathering stage caused a significant increase in Campylobacter contamination that effectively negated the reductions caused by scalding. On four processing lines, primary chilling also caused a significant reduction in numbers of Campylobacter. On three lines, there was a significant microbiological benefit from inside-outside washing. The stages where Campylobacter numbers were reduced require further investigation to determine the specific mechanisms responsible so that the observed pathogen reductions can be optimized and then more widely implemented. The transfer of up to 4 log CFU Campylobacter per g of neck skin from a colonized flock to a following uncolonized flock was observed. Cross-contamination was substantial and still detectable after 5,000 carcasses from an uncolonized flock had been processed. Numbers of Campylobacter recovered from the uncolonized flocks were highest on the first of the uncolonized birds to pass along the line, and in general, the numbers declined as more uncolonized birds were processed. Air sampling recovered low numbers at the processing stages monitored, indicating that airborne transmission was unlikely to be the primary transfer mechanism operating for cross-contamination between flocks.

HIGHLIGHTS

Children's fear and distress during a hospital-based family flu vaccine clinic: A parent survey

The aim of this study was to evaluate parents' perception of their child(ren)'s distress before, during, and after influenza (flu) vaccination, and their perceived effectiveness of pain and distress management strategies used during the vaccination process. This is a cross-sectional survey of parents attending Children's Hospital of Eastern Ontario's 2018 family flu clinic. After vaccination, parents completed a paper-based survey concerning demographics, fear and distress levels, and use and perceived effectiveness of pain/distress management interventions provided before and during the vaccination process. All survey data were entered into Research Electronic Data Capture (REDCap). Quantitative data were analyzed using descriptive statistics; qualitative data were analyzed using content analysis. A total of 164 parents completed the survey, reporting data on 327 children aged 6 months to 18 years (83% of children were vaccinated). Of 327 children, nearly half (n = 142, 44%) were reported to be moderately to severely distressed before, during, or after the vaccination process. The parents reported that 268 (82%) children received pain/distress management strategies during vaccination. Over half (n = 138, 57%) of the parents reported that the strategies used were very effective. Despite frequent use and parents' perceived effectiveness of pain/distress management interventions, nearly half of the children were perceived by parents as moderately to severely distressed during the vaccination process.

A Quality Improvement Project on Pain Management at a Tertiary Pediatric Hospital

To assess and improve pain management practices for hospitalized children in an urban tertiary pediatric teaching hospital.

METHODS

Health Quality Ontario Quality Improvement (QI) framework informed this study. A pre (T1) - post (T2) intervention assessment included chart reviews and children/caregiver surveys to ascertain pain management practices. Information on self-reported pain intensity, painful procedures, pain treatment and satisfaction were obtained from children/caregivers. Documented pain assessment, pain scores, and pharmacological/non-pharmacological pain treatments were collected by chart review. T1 data was fed back to pediatric units to inform their decisions and pain management targets.

RESULTS

At T1, 51 (58% of eligible participants) children/caregivers participated. At T2, 86 (97%) chart reviews and 51 (54%) children/caregivers surveys were completed. Most children/caregivers at T1 (78%) and T2 (80%) reported moderate to severe pain during their hospitalization. A mean of 2.6 painful procedures were documented in the previous 24 h, with the most common being needle-related procedures at both T1 and T2. Pain management strategies were infrequently used during needle-related procedures at both time points.

CONCLUSION

No improvements in pain management as measured by the T1 and T2 data occurred. Findings informed further pain management initiatives in the participating hospital.

Be Sweet to Hospitalized Toddlers During Venipuncture: A Randomized Controlled Trial of Sucrose Compared With Water

OBJECTIVES

High-quality evidence demonstrates analgesic effects of sweet-tasting solutions for infants during painful procedures. However, evidence of the analgesic effects of sucrose beyond 12 months of age is less certain. The aim of this study was to ascertain the efficacy of oral sucrose in hospitalized toddlers (ages 12 to 36 mo) compared with placebo (water) during venipuncture.

MATERIALS AND METHODS

Blinded, 2-armed randomized controlled trial including hospitalized toddlers aged 12 to 36 months. Toddlers were randomized to either 25% sucrose or water before venipuncture, stratified by age (12 to 24 mo and more than 24 to 36 mo). Standard of care included topical anesthetics for both groups. Pain assessment included cry duration and FLACC (Face, Legs, Activity, Cry, Consolability) scores. Descriptive statistics and linear models were used to report the percentage of time crying and mean differences in FLACC scores. Data analysis was performed using R, version 3.6.3.

RESULTS

A total of 95 toddlers were randomized and 85 subsequently studied. The median percentage of time spent crying between insertion of the first needle and 30 seconds after the end of procedure in both groups was 81% (interquartile range=66%). There was no significant difference in crying time and FLACC scores between groups (P>0.05). When examining effects of sucrose for the younger toddlers (less than 24 mo of age) there was a reduction in crying time of 10% and a 1.2-point reduction in mean FLACC scores compared with the toddlers older than 24 months.

DISCUSSION

Findings highlight that toddlers become highly distressed during venipuncture, despite the standard care of topical anesthetics. In addition, sucrose does not effectively reduce distress especially in the older group of toddlers.

Using Social Media to Disseminate Effective Pain Treatments for Newborns During Needle-Related Painful Procedures in China

Social media has become a powerful approach to disseminating evidence to knowledge users. The BSweet2Babies video was developed in multiple languages showing the effectiveness of sweet solutions, skin-to-skin care, and breastfeeding during newborn painful procedures. This study aimed to disseminate the BSweet2Babies video in Chinese through social media platform of WeChat in China; evaluate the reach, acceptability, and recommendation of the video; and assess viewers' previous knowledge and experience of using the 3 strategies and intention to use these strategies in the future. Multiple dissemination strategies were used to maximize views for a 6-month dissemination period. The video received 19 812 views, 4306 "thumbs," and 671 participants completed surveys. Of the survey respondents, 393 were parents. Most respondents did not know these strategies and did not use or help parents use any of them. More healthcare professionals than parents intended to use or advocate for sweet solutions and breastfeeding. More healthcare professionals rated that the 3 strategies were easy to apply in real-life situations, but more parents evaluated that the length of the video was too long. Social media in China can be a promising approach to disseminating evidence on neonatal procedural pain treatments to healthcare professionals and the public.

A 7-year retrospective review of renal trauma in paediatric patients in Johannesburg

BACKGROUND

South African data on paediatric patients with renal trauma that are usually managed conservatively is scarce. This study aimed to review a 7-year experience of paediatric renal trauma and management.

METHODS

A retrospective review of all paediatric admissions with renal injury was conducted in the Department of Paediatric Surgery, University of the Witwatersrand, between 1 January 2012 and 31 December 2018. Data from medical records reviewed included patient age, gender, mechanism of injury, severity of injury, management and length of hospital stay.

RESULTS

Thirty-one patients with renal injuries were identified, of which 30 had complete data. Of these cases, 26/30 (87%) sustained blunt renal injuries and 4/30 (13%) were penetrating. The median age at presentation was 6 years, and 60% were females. Three patients had isolated renal injuries, and 23 had concomitant injuries including hepatic (9), thoracic (8), splenic (5), head (4), facial (3) and ureteric (1). Twenty-three patients were managed non-operatively. Two required renal exploration with resultant nephrectomies and one haemodynamically unstable patient died preoperatively. Four patients required operative intervention for concomitant injuries with no renal exploration. Two patients required ureteric stenting. The median length of hospital stay was 7 days (Range: 4-11 days, IQR 7 days).

CONCLUSION

Renal injuries in haemodynamically stable patients should be managed non-operatively. A 93% renal preservation rate was achieved in this cohort of patients with nephrectomy performed only in haemodynamically unstable patients with Grade V injuries, in keeping with international norms.

Neonatal surgical outcomes: a prospective observational study at a Tertiary Academic Hospital in Johannesburg, South Africa

PURPOSE

The neonatal period is the most vulnerable period for a child. There is a paucity of data on the burden of neonatal surgical disease in our setting. The aim of this study was to describe the frequency with which index neonatal surgical conditions are seen within our setting and to document the 30-day outcome of these patients.

METHODS

This was a single-centre prospective observational study in which all neonates with paediatric surgical pathology referred to the paediatric surgical unit with a corrected gestational age of 28 days were included.

RESULTS

Necrotising enterocolitis was the most frequent reason for referral to the paediatric surgical unit (n = 68, 34.34%). Gastroschisis was the most frequent congenital anomaly referred (n = 20, 10.10%). The overall morbidity was 57.58%. Surgical complications contributed to 18.51% of morbidities. The development of gram negative nosocomial sepsis was the most frequent cause of morbidity (n = 98, 50.78%). Mortality at 30 days was 21.74% (n = 40). Sepsis contributed to mortality in 35 patients (87.5%), 16 of which had gram negative sepsis.

CONCLUSION

Gram-negative sepsis was a major contributing factor in the development of morbidity and mortality in our cohort. Prevention and improvement in infection control are imperative if we are to improve outcomes in our surgical neonates.

The Psychometric Properties of the Visual Analogue Scale Applied by an Observer to Assess Procedural Pain in Infants and Young Children: An Observational Study

PURPOSE

The Visual Analogue Scale applied by an observer (VASobs) is widely used to quantify pain but the evidence to support validity is poor. The aim of this study was to evaluate the psychometric and practical properties of the VASobs used to assess procedural pain in infants and young children.

DESIGN AND METHODS

In an observational study, 26 clinicians applied the VASobs independently to video segments of 100 children aged six to 42 months undergoing a procedure to generate pain and distress scores. Each video segment was scored by four randomly selected reviewers.

RESULTS

Reliability for pain scores was poor to fair (ICC 0.35 to 0.55) but higher for distress scores (ICC 0.6 to 0.89). At a cut-off score of 3, sensitivity and specificity were 84.7% and 95.0%, respectively for pain and 91.5% and 77.5% respectively for distress. Linear mixed modelling confirmed responsiveness. An increase in pain scores (regression slope 4.95) and distress scores (regression slope 5.52) across phases (baseline to procedure) was seen for painful procedures. The correlation between VASobs pain and FLACC scores was good (r = 0.74) and correlations between VASobs distress and FLACC scores were excellent (r = 0.89).

CONCLUSION

VASobs was easily applied and preferred by clinicians. Despite evidence of sensitivity and responsiveness to pain, the reliability results were poor, and this scale cannot be recommended for use.

PRACTICE IMPLICATIONS

The results of this study prevent recommending the VASobs for assessing procedural pain in infants and young children for clinical or research purposes.

The validity of skin conductance for assessing acute pain in mechanically ventilated infants: A cross-sectional observational study

BACKGROUND

Assessing pain in mechanically ventilated infants is challenging. The assessment of skin conductance (SC) is based on the sympathetic nervous system response to stress. This study purpose was to evaluate the validity of SC for assessing pain in mechanically ventilated infants.

METHODS

A prospective cross-sectional observational design was used to study SC and its relation to: the category of procedure (i.e., painful or non-painful); the phase of procedure (i.e., before, during and after), and referent pain measurements (i.e., Premature Infant Pain Profile-Revised (PIPP-R) and Neonatal Facial Coding System (NFCS)). Eligible infants were those up to 12 months of age, in intensive care units, who were mechanically ventilated, and required painful and non-painful procedures.

RESULTS

From October 2017 to November 2018, 130 eligible infants were identified, and 55 infants were studied. SC (number of waves per second) during painful procedures (median 0.27, interquartile range 0.2-0.4) was statistically significantly higher than those during non-painful procedures (0, 0-0.09). SC during painful procedures was statistically significantly higher than those before (0, 0-0.07) and after painful procedures (0, 0-0.07). SC showed moderate statistically significant positive correlations with PIPP-R (Spearman's rho = 0.4-0.62) and the four-item NFCS (Spearman's rho = 0.31-0.67) before, during and after painful or non-painful procedures respectively. SC had excellent performance (area under the receiver operator curve = 0.979) with excellent sensitivity (92.31%), specificity (95.42%) and negative predictive value (99.21%) but only sufficient positive predictive value (66.67%) when used to discriminate moderate-to-severe pain.

CONCLUSIONS

SC showed good validity for assessing pain in critically ill infants requiring mechanical ventilation.

SIGNIFICANCE OF THE STUDY

Pain assessment in mechanically ventilated infants is challenging. In this study, the validity of skin conductance (SC) for pain assessment is evaluated in the same population of infants during painful and nonpainful procedures. SC showed good validity for assessing acute pain in relation to category of procedure, phase of procedure, and referent pain measurements. SC is a promising method, especially with other pain assessment methods and other determinants of pain, in a multimodal pain assessment approach to understand the complexity of pain in mechanically ventilated infants.

Validating the Implementation Leadership Scale in Chinese nursing context: A cross-sectional study

AIM

This study aimed to evaluate the validity, reliability and acceptability of the Implementation Leadership Scale in the Chinese nursing context.

DESIGN

This study utilized a cross-sectional design.

METHODS

This study was conducted in one general tertiary hospital with 234 nurses (85.3% response rate) from 35 clinical units in China. Content validity, structural validity, convergent validity, reliability (internal consistency), agreement indices and acceptability were evaluated. The data collection was from December 1st, 2017 to June 30th, 2018.

RESULTS

Confirmatory factor analysis demonstrated a good model fit to the four-factor implementation leadership model. The psychometric testing also indicated good convergent validity, high internal consistency and acceptable aggregation. Most participants completed the scale in two minutes or less and agreed or strongly agreed that the questions were relevant to implementation leadership, clear and easy to answer.

CONCLUSIONS

This study demonstrated that the Chinese Implementation Leadership Scale is a valid, reliable and pragmatic tool for measuring strategic leadership for implementing evidence-based practices.

Comparison of the Psychometric Properties of the FLACC Scale, the MBPS and the Observer Applied Visual Analogue Scale Used to Assess Procedural Pain

Purpose

The purpose of this study was to compare the psychometric data and feasibility and clinical utility of the Face Legs, Activity, Cry and Consolability scale (FLACC), the Modified Behavioral Pain Scale (MBPS) and the Visual Analogue Scale for observers (VASobs) used to assess procedural pain in infants and young children.

Patients and Methods

Twenty-six clinicians assessed videorecorded segments of 100 infants and young children who underwent a painful and/or distressing procedure in the emergency department using the FLACC scale, the MBPS and the VASobs pain and VASobs distress.

Results

VASobs pain scores were lowest across all procedures and phases of procedures (p < 0.001). Inter-rater reliability was lowest for VASobs pain scores (ICC 0.55). Sensitivity and specificity were highest for FLACC scores (94.9% and 72.5%, respectively) at the lowest cut-off score (pain score two). Observers changed their MBPS scores more often than they changed FLACC or VASobs scores, but FLACC scores were more often incomplete. Reviewers did not consider any scale of use for procedural pain measurement.

Conclusion

The reliability and sensitivity of the FLACC and MBPS were supported by study data but concerns about the capacity of these scales to distinguish between pain- and non-pain-related distress were raised. The VASobs cannot be recommended. Despite its limitations, the FLACC scale may be better suited than other scales for procedural pain measurement.

Mental health stigma and barriers to care in World Trade Center responders: Results from a large, population-based health monitoring cohort

BACKGROUND

Nearly 20 years after the terrorist attacks of September 11, 2001, multiple studies have documented the adverse mental consequences among World Trade Center (WTC) rescue, recovery, and clean-up workers. However, scarce research has examined mental health stigma and barriers to care in WTC-exposed individuals, and no known study has examined whether rates of endorsement may differ between police and "nontraditional" responders, the latter comprising a heterogeneous group of workers and volunteers.

OBJECTIVE

To identify the prevalence and correlates of mental health stigma and barriers to care in WTC responders.

METHODS

Mental health stigma and barriers to care and their correlates were examined in 6,777 police and 6,272 nontraditional WTC responders.

RESULTS

Nontraditional responders endorsed more stigma or barriers to care concerns than police responders. Within a subsample who screened positive for a psychiatric disorder, police were more likely than nontraditional responders to endorse "concerns that negative job consequences might result" (17.9% vs. 9.1%), while nontraditional responders were more likely to endorse "I don't know where to go to find counseling services" (18.4% vs.6.6%). Within this subsample, mental health service need and more severe WTC-related posttraumatic stress disorder symptoms were associated with increased likelihood of endorsing stigma or barriers; pre-9/11 psychiatric history and non-Hispanic Black race/ethnicity were associated with lower likelihood of endorsing stigma or barriers.

CONCLUSIONS

Results of this study underscore the burden of mental health stigma and barriers to care in WTC responders, and highlight the need for targeted interventions to address these concerns and promote mental healthcare utilization in this population.

The feasibility, acceptability and preliminary efficacy of parent-targeted interventions in vaccination pain management of infants: a pilot randomized control trial (RCT)

Aim: To evaluate the feasibility, acceptability and preliminary efficacy of parent interventions for improving the use of pain management strategies during vaccination of infants, a two-armed pilot randomized control trial (RCT) was conducted. Materials & methods: 151 parents were randomized in two groups: Group 1) 'Be Sweet to Babies' videos and a tip sheet (n = 76); Group 2) As per Group 1 plus a motivational interviewing informed Affirmative Statements and Questions (AS&Q) (n = 75). Results & conclusion: Feasibility was evaluated by success of the recruitment (151 people in a week), rates of completed consent forms (85%), and surveys (59%). Over 94% satisfaction with interventions, processes and 88% intention to recommend the strategies to others determined the acceptability. Preliminary efficacy was evident by over 95% use of pain management strategies following the interventions. Clinical trial registration number: NCT03968432.

A 7-year retrospective review of renal trauma in paediatric patients in Johannesburg

ABSTRACT BACKGROUND: South African data on paediatric patients with renal trauma that are usually managed conservatively is scarce. This study aimed to review a 7-year experience of paediatric renal trauma and management METHODS: A retrospective review of all paediatric admissions with renal injury was conducted in the Department of Paediatric Surgery, University of the Witwatersrand, between 1 January 2012 and 31 December 2018. Data from medical records reviewed included patient age, gender, mechanism of injury, severity of injury, management and length of hospital stay RESULTS: Thirty-one patients with renal injuries were identified, of which 30 had complete data. Of these cases, 26/30 (87%) sustained blunt renal injuries and 4/30 (13%) were penetrating. The median age at presentation was 6 years, and 60% were females. Three patients had isolated renal injuries, and 23 had concomitant injuries including hepatic (9), thoracic (8), splenic (5), head (4), facial (3) and ureteric (1). Twenty-three patients were managed non-operatively. Two required renal exploration with resultant nephrectomies and one haemodynamically unstable patient died preoperatively. Four patients required operative intervention for concomitant injuries with no renal exploration. Two patients required ureteric stenting. The median length of hospital stay was 7 days (Range: 4-11 days, IQR 7 days CONCLUSION: Renal injuries in haemodynamically stable patients should be managed non-operatively. A 93% renal preservation rate was achieved in this cohort of patients with nephrectomy performed only in haemodynamically unstable patients with Grade V injuries, in keeping with international norms Keywords: paediatric, renal injuries, conservative management, South Africa

Retrospective Assessment of Risk Factors for Head and Neck Cancer Among World Trade Center General Responders

Objective: To assess the reliability of a questionnaire designed to reconstruct risk factors for head and neck cancer relative to the 9/11 World Trade Center (WTC) response and over the lifetime. Methods: As part of a nested case-control study, 200 WTC Health Program (WTCHP) General Responder Cohort (GRC) members completed a newly-developed study questionnaire via telephone (with a trained interviewer) or online (self-administered). We assessed agreement between measures of tobacco and alcohol use in our questionnaire results and data collected previously during WTCHP-GRC monitoring visits using Cohens Kappa (κ) and intraclass correlation coefficient (ICC) for categorical and continuous measures, respectively. We compared agreement by disease status, survey mode, and year of WTCHP enrollment. Results: We observed high agreement between measures of lifetime, pre-WTC, and post-WTC smoking prevalence (all κ > 0.85) and smoking duration (all ICC > 0.84). There was moderate agreement between measures of smoking frequency (ICC: 0.61-0.73). Agreement between measures of smoking frequency, but not duration, differed by disease status, and agreement between smoking measures was higher for participants who completed our survey by phone than by web. Among cases, there were no differences based on enrollment in the WTCHP before or after diagnosis. Conclusion: Agreement between measures was generally high, although potential reporting bias and a mode effect that should be considered when interpreting analyses of self-reported data in this population; however differential misclassification appears to be minimal. Our questionnaire may be useful for future studies examining similar behavioral risk factors among disaster-exposed populations.

Barriers and Facilitators to Effective Procedural Pain Treatments for Pediatric Patients in the Chinese Context: A Qualitative Descriptive Study

PURPOSE

To explore nurse and physician leaders' perceptions of barriers and facilitators to using evidence-based procedural pain treatments (i.e., sweet solutions, breastfeeding, and topical anesthetics) for hospitalized infants and children in the Chinese context.

DESIGN AND METHODS

A descriptive qualitative study was conducted at three pediatric inpatient surgical units in one hospital in China. Purposive sampling was used to recruit nurse/physician leaders who were engaged in the clinical management of the 3 units. Data collection included a focus group and individual interviews. The Consolidated Framework for Implementation Research (CFIR) was used to guide the analysis of the data.

RESULTS

Ten participants attended the focus group and 13 took part in individual interviews. The findings highlight 41 implementation determinants, including two neutral influencing factors, 22 barriers, and 17 facilitators. These influencing factors aligned with the four CFIR domains and 25 of the 29 CFIR constructs. Common barriers to using evidence-based pain treatments across different contexts were identified, such as health care professionals' limited knowledge and misconceptions on pediatric pain management, no specific policies, low priority, heavy workload, staff shortage, and limited time. Unique determinants in the Chinese context were also identified, including parents' concerns of these new interventions, parent wrath, hierarchical managerial system, and lower authority of nurses.

CONCLUSIONS

Multiple barriers as well as facilitators to using evidence-based pain management strategies were identified.

PRACTICE IMPLICATIONS

The findings inform further development of implementation strategies and could be used as baseline data for comparing the barriers and facilitators evaluated during and after implementation.

"Be sweet to babies": Use of Facebook as a method of knowledge dissemination and data collection in the reduction of neonatal pain

The Be Sweet to Babies video demonstrates the analgesic effects of breastfeeding, skin‐to‐skin care, and sweet‐tasting solutions as interventions to reduce pain during blood sampling in newborns. Although effective and safe, these strategies are implemented inconsistently in clinical settings. Given the increasing popularity of social media, there is a potential to disseminate and promote health information through it. The study aim was to  evaluate the use of Facebook as a means of disseminating the Be Sweet to Babies video in Portuguese, and to evaluate respondents’ prior knowledge, previous use of the three pain management strategies and intent to use the strategies in the future. We conducted a cross‐sectional study, using the “virtual snowball” sampling method. A Facebook webpage was created, in which the video was posted along with a brief survey. Data analyzed included number of views and visits to the page, number of views of the video, likes, dislikes, and survey responses. One year after posting, the page had 70 753 views and 2199 accesses; there were 1553 “likes”, no dislikes, and 43 positive comments. The survey was completed by 930 respondents (42% response rate based on the page access). Over two thirds of the respondents had previous knowledge about breastfeeding, skin‐to‐skin care, and sweet solutions for pain relief. After watching the video, 87% of the respondents intended to use breastfeeding or skin‐to‐skin care in the future, and 71% intended to use sweet solutions. Almost all viewers rated the video as very useful (n = 917, 99%), easy to understand (n = 926, 99%), and easy to apply in real‐life situations (n = 903, 97%). Using Facebook to deliver and evaluate an intervention is feasible, rapid in obtaining responses, low cost, and it is promising for data collection and knowledge dissemination. Further studies are warranted to evaluate the actual impact of the use of social media in practice change.

Effectiveness of a parent-targeted video on neonatal pain management: Nonrandomized pragmatic trial

The “Be sweet to babies” video is a knowledge translation tool targeted at parents on the use of analgesic strategies during painful procedures performed in neonates. This study aimed to evaluate the effectiveness of the Portuguese version of this video on maternal involvement in neonatal pain management during the newborn screening blood test. Nonrandomized, pragmatic clinical trial. The study was conducted in a rooming‐in unit. All mothers received a pamphlet regarding neonatal pain management and were invited to participate in daily education sessions conducted by nurses, which included the video. The intervention group included mothers who voluntarily watched the video, while the control group was comprised of mothers who did not attend the education sessions or left the session before watching the video. Data were collected by interviews conducted by the research team. Descriptive and inferential analysis considered a confidence interval of 95%. A total of 73 mothers were included in the study. Analgesic strategies were used in 14 (40%) of the procedures in the intervention group and 9 (24%) in the control group, a clinically important difference of 16% points between groups, although no statistically significant difference was found (P = .13). Breastfeeding was the most commonly used strategy. Watching the video increased the chance of implementing analgesic strategies by 2.1 times (P = .19), while nurses suggesting the use of analgesia increased this chance by 5.5 times (P = .006). Although no statistical significance was found, the results suggest the clinical significance and feasibility of the “Be sweet to babies” video as a KT tool targeted at parents on neonatal pain management during nonurgent painful procedures. In addition, maternal involvement in pain care significantly increased when pain relief strategies were recommended by nurses, which suggests that nurses have a key role in facilitating parental participation.

Development and Pilot Evaluation of an Educational Tool for the FLACC Pain Scale

BACKGROUND

The FLACC (Face, Legs, Activity, Cry, Consolability) pain scale is commonly used for pediatric pain assessment; however, no online educational tool exists to facilitate the use of the scale.

AIMS

This study aimed to develop an online educational tool and evaluate its effect on nurse knowledge, user confidence, and scoring accuracy.

DESIGN AND METHODS

In phase 1, semistructured interviews were conducted to identify preferred educational features and content. Eight informants were interviewed in phase 1. Recommendations informed the development of the educational tool. Data were analyzed via conventional content analysis. Phase 2 involved a pre-post evaluation of the tool through online surveys. Posteducational data were collected immediately after the tool was completed. Wilcoxon signed rank and McNemar-Bowker tests were used to compare pre- and post-training knowledge, confidence, and FLACC scores. Scoring accuracy was examined using percentage agreement and consensus analysis.

RESULTS

Thirty-four nurses participated in phase 2. The educational tool significantly improved knowledge (p < .0001) and increased user confidence, although not to a significant level (p = .06). There was a significant improvement in correct assessment of moderate pain (p = .04). Almost all nurses correctly assessed severe pain before and after education (91%). However, there was a decrease in accurate assessment of mild pain (p = .01).

CONCLUSIONS

Because the intervention improved knowledge, user confidence, and assessment accuracy of moderate pain, it would be useful to implement such a tool as part of clinician education. However, further modifications will be needed to improve assessment of mild pain.

How to translate scientific knowledge into practice? Concepts, models and application

OBJECTIVES

to present the concept of Knowledge Translation and Exchange as it has been used in the international literature and in Canada, particularly. Next, to describe a renowned conceptual model to guide its implementation, entitled Knowledge-to-Action Cycle.

RESULTS

we described the use of the model in the context of the municipal primary health care system in southern Brazil for the implementation of pain management strategies during vaccination.

CONCLUSIONS

in this theoretical reflection, we argue that in order to promote health equity and quality of care in the Unified Health System (Brazilian SUS) it is important to translate scientific knowledge to various practice settings and create opportunities for exchange with users of this knowledge, such as health professionals, managers, policy makers, patients, family members and other stakeholders.

A cluster randomized clinical trial to evaluate the effectiveness of the Implementation of Infant Pain Practice Change (ImPaC) Resource to improve pain practices in hospitalized infants: a study protocol

BACKGROUND

Hospitalized infants undergo multiple painful procedures daily. Despite the significant evidence, procedural pain assessment and management continues to be suboptimal. Repetitive and untreated pain at this vital developmental juncture is associated with negative behavioral and neurodevelopmental consequences. To address this knowledge to practice gap, we developed the web-based Implementation of Infant Pain Practice Change (ImPaC) Resource to guide change in healthcare professionals' pain practice behaviors. This protocol describes the evaluation of the intervention effectiveness and implementation of the Resource and how organizational context influences outcomes.

METHODS

An effectiveness-implementation hybrid type 1 design, blending a cluster randomized clinical trial and a mixed-methods implementation study will be used. Eighteen Neonatal Intensive Care Units (NICUs) across Canada will be randomized to intervention (INT) or standard practice (SP) groups. NICUs in the INT group will receive the Resource for six months; those in the SP group will continue with practice as usual and will be offered the Resource after a six-month waiting period. Data analysts will be blinded to group allocation. To address the intervention effectiveness, the INT and SP groups will be compared on clinical outcomes including the proportion of infants who have procedural pain assessed and managed, and the frequency and nature of painful procedures. Data will be collected at baseline (before randomization) and at completion of the intervention (six months). Implementation outcomes (feasibility, fidelity, implementation cost, and reach) will be measured at completion of the intervention. Sustainability will be assessed at six and 12 months following the intervention. Organizational context will be assessed to examine its influence on intervention and implementation outcomes.

DISCUSSION

This mixed-methods study aims to determine the effectiveness and the implementation of a multifaceted online strategy for changing healthcare professionals' pain practices for hospitalized infants. Implementation strategies that are easily and effectively implemented are important for sustained change. The results will inform healthcare professionals and decision-makers on how to address the challenges of implementing the Resource within various organizational contexts.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03825822. Registered 31 January 2019.

Severe Obstructive Sleep Apnea Is Associated with Alterations in the Nasal Microbiome and an Increase in Inflammation

RATIONALE

Obstructive sleep apnea (OSA) is associated with recurrent obstruction, subepithelial edema, and airway inflammation. The resultant inflammation may influence or be influenced by the nasal microbiome.

OBJECTIVES

To evaluate whether the composition of the nasal microbiota is associated with obstructive sleep apnea and inflammatory biomarkers.

METHODS

Two large cohorts were used: 1) a discovery cohort of 472 subjects from the WTCSNORE (Seated, Supine and Post-Decongestion Nasal Resistance in World Trade Center Rescue and Recovery Workers) cohort, and 2) a validation cohort of 93 subjects rom the Zaragoza Sleep cohort. Sleep apnea was diagnosed using home sleep tests. Nasal lavages were obtained from cohort subjects to measure: 1) microbiome composition (based on 16S rRNA gene sequencing), and 2) biomarkers for inflammation (inflammatory cells, IL-8, and IL-6). Longitudinal 3-month samples were obtained in the validation cohort, including after continuous positive airway pressure treatment when indicated.

MEASUREMENTS AND MAIN RESULTS

In both cohorts, we identified that: 1) severity of OSA correlated with differences in microbiome diversity and composition; 2) the nasal microbiome of subjects with severe OSA were enriched with Streptococcus, Prevotella, and Veillonella; and 3) the nasal microbiome differences were associated with inflammatory biomarkers. Network analysis identified clusters of cooccurring microbes that defined communities. Several common oral commensals (e.g., Streptococcus, Rothia, Veillonella, and Fusobacterium) correlated with apnea-hypopnea index. Three months of treatment with continuous positive airway pressure did not change the composition of the nasal microbiota.

CONCLUSIONS

We demonstrate that the presence of an altered microbiome in severe OSA is associated with inflammatory markers. Further experimental approaches to explore causal links are needed.

Risk factors for head and neck cancer in the World Trade Center Health Program General Responder Cohort: results from a nested case-control study

OBJECTIVES

Head and neck cancers (HNCs) may be among the health consequences of involvement in the World Trade Center (WTC) response on and after 11 September 2001. We conducted a nested case-control study of WTC Health Program (WTCHP) general responders to examine the effects of WTC exposures and behavioural risk factors on HNC.

METHODS

We enrolled 64 cases and 136 controls, matched on age, sex and race/ethnicity within risk sets. We assessed tobacco and alcohol use, sexual activity, and occupational exposures prior to, during and after WTC exposure until case diagnosis via questionnaire. We obtained WTC exposure information (duration (first to last day), total days and location of work) from the WTCHP General Responder Data Center. We assessed associations with HNC, and interaction among exposures, using conditional logistic regression.

RESULTS

Responders in protective services versus other occupations had increased odds (OR: 2.51, 95% CI 1.09 to 5.82) of HNC. Among those in non-protective services occupations, arriving to the WTC effort on versus after 11 September 2001 was significantly associated with HNC (OR: 3.77, 95% CI 1.00 to 14.11). Duration of work was not significantly associated with HNC. Lifetime and post-WTC years of cigarette smoking and post-WTC number of sex partners were positively and significantly associated with HNC, while alcohol consumption was not.

CONCLUSIONS

These findings suggest opportunities for HNC risk factor mitigation (eg, smoking cessation, human papillomavirus vaccination) and contribute to a risk factor profile which may assist WTCHP clinicians with identifying high-risk responders and improve detection and treatment outcomes in this population.

Consequences of Using Two Types of Skin Samples from Chilled Chicken Broiler Carcasses To Measure the Degree of Contamination by Campylobacter spp

HIGHLIGHTS

Campylobacter levels on chicken neck and breast skin were compared. Neck skin was significantly more contaminated (P < 0.05) than breast skin. No relationship between the two skin types was found for Campylobacter levels. A UK government reduction target for highly contaminated chicken was not achieved.

Moving on: Transition experiences of young adults with chronic pain

Purpose: The purpose of this study was to explore the transition experience of young adults with chronic pain in Canada from the pediatric health care setting to the adult health care setting.

Materials and Methods: A qualitative descriptive approach using semistructured interviews was used to capture the transition experiences of young people with chronic pain who have recently transferred from the pediatric setting to the adult health care setting. Participants were recruited from west, central, and the east coast of Canada to situate the findings within the context of Canada. Interviews were transcribed and analyzed using qualitative inductive content analysis.

Results: Nine participants were interviewed, three from each part of Canada (west, central, and east). Five common categories were determined to describe the transition experience of young adults with chronic pain which include (1) independence (I can do it, maybe?), (2) pain trajectory (stress and pain along for the ride), (3) social support networks (need a shoulder to lean on), (4) parental support (obviously they are there), and (5) collaborative systems (the bridge).

Conclusion: Young people with chronic pain experience unique challenges when faced with transitioning to the adult health care setting. Supporting the young person and his or her family in preparation and readiness and collaboration between the pediatric and adult health care settings are essential to ensure a smooth transition and avoid negative transition outcomes. Further research is needed to determine the best ways to prepare young people for transition and the care activities required in both pediatric and adult health care settings to improve pain-related outcomes posttransition.

Self-management behaviors in World Trade Center rescue and recovery workers with asthma

BACKGROUND

Asthma is a major source of morbidity among World Trade Center (WTC) rescue and recovery workers. While physical and mental health comorbidities have been associated with poor asthma control, the potential role and determinants of adherence to self-management behaviors (SMB) among WTC rescue and recovery workers is unknown.

OBJECTIVES

To identify modifiable determinants of adherence to asthma self-management behaviors in WTC rescue and recovery worker that could be potential targets for future interventions.

METHODS

We enrolled a cohort of 381 WTC rescue and recovery workers with asthma. Sociodemographic data and asthma history were collected during in-person interviews. Based on the framework of the Model of Self-regulation, we measured beliefs about asthma and controller medications. Outcomes included medication adherence, inhaler technique, use of action plans, and trigger avoidance.

RESULTS

Medication adherence, adequate inhaler technique, use of action plans, and trigger avoidance were reported by 44%, 78%, 83%, and 47% of participants, respectively. Adjusted analyses showed that WTC rescue and recovery workers who believe that they had asthma all the time (odds ratio [OR]: 2.37; 95% confidence interval [CI]: 1.38-4.08), that WTC-related asthma is more severe (OR: 1.73; 95% CI: 1.02-2.93), that medications are important (OR: 12.76; 95% CI: 5.51-29.53), and that present health depends on medications (OR: 2.39; 95% CI: 1.39-4.13) were more likely to be adherent to their asthma medications. Illness beliefs were also associated with higher adherence to other SMB.

CONCLUSIONS

Low adherence to SMB likely contributes to uncontrolled asthma in WTC rescue and recovery workers. Specific modifiable beliefs about asthma chronicity, the importance of controller medications, and the severity of WTC-related asthma are independent predictors of SMB in this population. Cognitive behavioral interventions targeting these beliefs may improve asthma self-management and outcomes in WTC rescue and recovery workers. Key message: This study identified modifiable beliefs associated with low adherence to self-management behaviors among World Trade Center rescue and recovery rescue and recovery workers with asthma which could be the target for future interventions.

CAPSULE SUMMARY

Improving World Trade Center-related asthma outcomes will require multifactorial approaches such as supporting adherence to controller medications and other self-management behaviors. This study identified several modifiable beliefs that may be the target of future efforts to support self-management in this patient population.

Allergen Sensitization and Asthma Outcomes among World Trade Center Rescue and Recovery Workers

A large number of World Trade Center (WTC) rescue and recovery workers are affected by asthma. While physical and mental health comorbidities have been associated with poor asthma control in this population, the potential role of allergen sensitization is unknown. This study examined the association of indoor sensitization and exposure as a risk factor for increased asthma morbidity in WTC workers. We used data from a prospective cohort of 331 WTC workers with asthma. Sensitization to indoor allergens was assessed by measurement of antigen-specific serum immunoglobulin E (IgE) levels. We used validated tools to evaluate the exposure to indoor allergens. Asthma morbidity outcomes included level of control (Asthma Control Questionnaire, ACQ), quality of life (Asthma Quality of Life Questionnaire, AQLQ) and acute resource utilization. The prevalence of sensitization to cat, dog, mouse, dust mite, cockroach, and mold allergens were 33%, 21%, 17%, 40%, 17%, and 17%, respectively. Unadjusted and regression analyses showed no significant relationship between sensitization and increased asthma morbidity (p > 0.05 for all comparisons), except for sensitization to Aspergillus Fumigatus, cat and mouse epithelium, which were associated with decreased morbidity.