Appropriateness of behavioural scales in the monitoring of pain in the critically ill patient unable to self-report

Appropriateness is a dimension of quality that evaluates the effective use of technologies, resources or interventions in specific situations or populations, assessing whether our interventions do more benefit than harm. The evidence regarding pain monitoring in the critically ill patient points to the periodic assessment of pain using appropriate tools, with the aim of improving pain management and more efficient use of analgesics in the intensive care unit. The first step would be to assess the patient's ability to communicate or self-report and, based on this, to select the most appropriate pain assessment tool. In patients who are unable to self-report, behavioural pain assessment tools are recommended. When we talk about the suitability of behavioural scales for pain monitoring in critically ill patients unable to self-report, we refer to their use with a clear clinical benefit, i.e. using the right tool for pain assessment to be effective, efficient and consistent with bioethical principles. To our knowledge, there are no published data on the suitability of pain assessment tools in unable to self-report critically ill patients, so, in the framework of continuous quality improvement in pain care, new research should incorporate this approach by integrating the best scientific evidence with current clinical practice.

'Learning by doing', a model for improving the promotion of healthy lifestyles by student nurses

BACKGROUND

'Learning by doing' is a learning model based on performing actions and gaining experience. The 'nursing process' is a systematic, rational method for providing nursing care. During their university education, nursing students need to acquire the ability to promote healthy lifestyles.

OBJECTIVE

To determine the effectiveness of a learning strategy based on learning by doing and grounded in the use of the nursing process, on the lifestyle of nursing students.

METHODS

This quasi-experimental intervention (before-after), performed over 2011-2022, involved 2300 nursing students at a university nursing school in Spain. The risk factors for chronic diseases-being a smoker, being overweight, or having high blood pressure-to which each student was exposed were recorded. Those positive for at least one risk factor selected companion students as 'support nursing students' who became responsible for designing an individualised care plan to reduce the risk(s) faced. To ensure the correct use of the nursing process, teachers approved and monitored the implementation of the care plans. Whether risk-reduction objectives were met was determined three months later.

RESULTS

The students with risk factors largely improved their lifestyles (targets for reducing smoking/body weight were met) with the help of their supporting peers.

CONCLUSIONS

The learning by doing method demonstrated its effectiveness, improving the lifestyle of at-risk students via the use of the nursing process.

Implementation of Evidence-Based Practice in Peripheral Intravenous Catheter Care

BACKGROUND

Inserting a peripheral intravenous (PIV) catheter is a common health care procedure; however, risks include phlebitis, extravasation, and accidental dislodgement. Using evidence-based practices (EBPs) can reduce these risks.

PURPOSE

The purpose of this study was to implement an evidence-based PIV catheter care bundle and a decision-making algorithm.

METHODS

A quasi-experimental study design was used. A care bundle and an evidence-based decision-making algorithm were implemented on a medical unit. Outcomes included length of PIV catheter dwell time, phlebitis and other complications, and health professionals' adherence to the interventions.

RESULTS

A total of 364 PIV catheters were assessed. PIV catheter dwell time decreased from 3.6 to 2.9 days ( P < .001), and phlebitis rates decreased from 14.8% to 4.9% ( P < .05). Health professionals' adherence increased from 84.3% to 91.8%.

CONCLUSIONS

Implementing EBPs can improve care provided to patients with PIV catheters.

Bibliometric analysis of original articles of journal Enfermería Intensiva in the period 2001-2020

INTRODUCTION

Bibliometric analysis allow the quantitative evaluation of the characteristics of a scientific publication.

OBJECTIVE

To perform a bibliometric analysis of original articles in the journal Enfermería Intensiva from 2001 to 2020.

RESULTS

The journal Enfermería Intensiva has published, between 2001 and 2020, 438 works, of which 259 are original articles (59.1%). These original articles are mostly quantitative studies (76.1%), with an average of 30.5 bibliographic references (SD 13.9), 4.9 citations (SD 1.7) in the Web of Science and Scopus repertoires, and 15,489.5 visits/downloads (median 9090 and interquartile range 4567-15,260) according to information on the magazine's website. These originals have been signed by 1345 authors, which represents a collaboration index of 5.2. 78.0% of the authors are sporadic, having published only one work. Most of the articles come from authors who work in institutionally located in hospitals and university centers, and geographically in the Communities of Madrid, Cataluña, Navarra and Andalucía.

CONCLUSIONS

There is little international, regional and institutional collaboration, producing the highest level of collaboration between authors from the same center. The journal has established itself in the panorama of scientific nursing research in Spain and shows bibliometric indicators similar or even superior to other publications in its environment.

Prematurity: A medical history of obligatory consideration when assessing the retinal ganglion cell complex

INTRODUCTION

Premature children birth and survival is becoming more frequent due to the improvement in obstetric and neonatal care. This makes it increasingly common to find patients with history of preterm birth in ophthalmology clinics, both in pediatric and adult ages. Premature birth can lead to ocular structural changes, being possible to affect the ganglion cell complex (GCC), among other structures, which can be studied using optical coherence tomography.

MATERIALS AND METHODS

To carry out a bibliographic review of the studies that analyze GCC in patients with a history of prematurity compared with patients born at term.

RESULTS

Several studies that analyze GCC in patients with a history of prematurity are referenced and their results are studied.

CONCLUSIONS

In our clinical practice, knowing the history of prematurity is fundamental in the assessment of GCC measured by optical coherence tomography, since this layer is different in the patients with a history of prematurity compared to patients born at term.

Pain Behaviors Analyzed by Videorecording in Brain-Injured Patients Admitted to the Intensive Care Unit

AIM

To describe and classify pain behaviors (facial and body) in brain-injured patients with a low level of consciousness before, during, and after the performance of painful and non-painful care procedures.

METHODS

Facial behaviors and body movements in brain-injured patients were videotaped at rest, during the application of three care procedures (two painful and one non-painful), and 15 minutes after completion of these procedures. Each video recording was evaluated by expert evaluators blinded to each other. For each of the behaviors observed, all possible combinations between the three procedures and/or time were compared using the McNemar test. Effect size was measured by the difference in proportions using the Wilson score 95% confidence intervals.

RESULTS

Twenty-seven patients were included. The mean (standard deviation) Glasgow Coma Score was 5.4 (1.9). A total of 33 behaviors (29 active, four neutral) were registered. Expression of behaviors was more common during the painful procedures compared with the other time points (non-painful procedures, baseline, and final evaluation). Inter-evaluator agreement was substantial (Kappa index >0.7) in more than 50% of the observed behaviors.

CONCLUSIONS

In this study involving brain-injured patients with a low level of consciousness, facial, body, and ventilation-related behaviors were more common during painful procedures. Agreement between evaluators to detect the presence or absence of these behaviors was substantial. These findings underscore the need to develop pain assessment measures specific to this patient population.

Ophthalmological manifestations in 6 patients diagnosed with Williams-Beuren syndrome and literature review

Medical history of 6 patients diagnosed with Williams-Beuren Syndrome (SWB) in pediatric age was revised. All the patients presented characteristic elf facies and cardiovascular abnormalities. All presented good visual acuity, except one case of unilateral amblyopia. The most frequent refractive error was hyperopia (n = 6; 100%) and astigmatism (n = 5; 83.3%). Ocular motility alterations were found in 2 patients (1 case of exophoria with hyperfunction of right inferior oblique and another of congenital endotropia with bilateral hyperfunction of inferior oblique). On the cognitive function, 66.7% (n = 4) had visoperceptive disorders. Other findings were epicanthus (n = 6; 100%) and congenital obstruction of the nasolacrimal duct with unilateral epiphora (n = 1; 16.7%). SWB is a rare disorder with complex ophthalmological and systemic manifestations. For this reason, ophthalmological follow-up of these children is recommended.

[Lean Six Sigma in the implementation of automated dispensing systems: improving the safe use of medications in thoracic surgery.]

OBJECTIVE

Medications errors are a major problem that can cause a harm to inpatients. The main objective of the study was to compared medication errors in pharmacotherapeutic process before and after to carried out an intervention: to implant an automated dispensing cabine with to use Lean Six Sigma methodology. The secondary objective was to assess process performance, sigma level and defects per one million opportunities for medication error.

METHODS

Quasi-experimental and randomized study carried out in a Thoracic Surgery Unit of a Spanish Hospital. A pharmaceutic recorded and assesed the medication errors detected during pre-intervention period (july-august 2017) and post-intervention period (march-april 2018). The steps analyzed were dispensing, storage and compounding/administration. The pharmacist observed a third of the medication dispensed, stored and compounded/administered during the study period. The observed medication was randomly selected using AleatorMetod.xls software. To perform the statistical analysis, Student's t test and Mann-Whitney U test were used to compare quantitative variables, and Chi-square test for qualitative variables. A significance level of p<0.05 was considered.

RESULTS

The pharmaceutic recorded 4,538 drugs. After intervention, medication errors were decreased a 49% in total pharmacotherapeutic process (12.06% vs 6.15%; p<0.001). In addition, errors were decreased a 91.6% (4.27% vs 0.36%; p=0.004) in the step of medication storage; and a 75.8% (22.52% vs 5.46%; p<0.001) in the step of drugs compounding/administration. However, medication errors were increased in the step of medication dispensing (4.51% vs 15.29%; p<0.001). The process performance increased a 6% (87.9% vs 93.9%), sigma level increased from 2.67 to 3.04 and defects per one million opportunities for medication error decreased a 49%.

CONCLUSIONS

To implant an automated dispensing cabinet with Lean Six Sigma methodology helps create a safer environment for the inpatient, reducing medication errors in the steps of storage and preparation/administration, as well as improving the total process performance and sigma level.

The Attitude towards Vaccination of Health Sciences Students at a Spanish University Improved over the First 18 Months of the COVID-19 Pandemic

It is important to know the attitudes of students of health sciences (SHSs) towards vaccination since they will be tomorrow's health professionals. Vaccination is a powerful tool in the fight against COVID-19. The aim of the present, cross-sectional study was to examine how the COVID-19 pandemic has influenced the attitude of SHSs towards vaccination. Data were collected in the form of a questionnaire from all students of nursing, physiotherapy and chiropody matriculated at a Madrid University for the academic year 2019/2020 (i.e., before the start of the pandemic [Q1]), and from all those matriculated for the year 2021/22 (i.e., c18 months after the pandemic was declared [Q2]). A multivariate analysis was performed to identify the influence of sex, degree being studied, course year and the time of answering (Q1 or Q2), on the dimensions Beliefs, Behaviours and General Attitude. Overall, 1894 questionnaires were returned (934 [49.3%] for Q1, and 960 [50.7%] for Q2), of which 70.5% were completed by students of nursing, 14% by students of physiotherapy and 15.4% by those studying chiropody. In Q2, the results for all three dimensions were significantly better (p < 0.05). The most important influencing factors were being a student of nursing, being in the final years of training (years 3 or 4), female gender and answering at the time of Q2. The results obtained are encouraging since student nurses (who showed Q1 and Q2 General Attitude scores of 3.34 and 3.47 (maximum possible 4), respectively [p < 0.05]) are the health professionals of tomorrow most likely to be involved in vaccination programmes.

Vaccine Coverage against Influenza and SARS-CoV-2 in Health Sciences Students during COVID-19 Pandemic in Spain

Vaccination against influenza and SARS-CoV-2 is recommended in health sciences students to reduce the risk of acquiring these diseases and transmitting them to patients. The aim of the study was to evaluate how the pandemic influenced the modification of influenza vaccination coverage during the 2019/2020 and 2021/2022 campaigns and to analyze the vaccination coverage against SARS-CoV-2 in health sciences students. A cross-sectional study was conducted among students of the Faculty of Nursing, Physiotherapy and Podiatry of the Complutense University of Madrid. A questionnaire was administered in two stages, the first, Q1, before the start of the pandemic, where we analyzed influenza coverage during the 2019/2020 campaign and a second, Q2, 18 months after the start of the pandemic where we analyzed influenza coverage during the 2021/2022 campaign and coverage against SARS-CoV-2. A total of 1894 students (58.78% of the total of those enrolled) participated. Flu vaccination coverage increased from 26.7% in Q1 to 35.0% in Q2 (p < 0.05), being higher in the age group older than 21 years, who studied nursing, were in their fourth year and lived with people at risk. Vaccination coverage against SARS-CoV-2 was very high (97.8%), especially in students vaccinated against influenza. Coverage of the influenza vaccine in health sciences students increased from 2019–2020 to 2021–2022, being higher in the age group older than 21 years, who studied nursing, were in their first and fourth year and lived with people at risk. Coverage of the SARS-CoV-2 vaccine in health sciences students was very high, especially in those vaccinated against influenza.

Septo-optic dysplasia: Ophthalmological abnormalities in a series of 5 cases

Septo-optic dysplasia (SOD) is a rare congenital condition of unknown cause, with a characteristic triad that includes optic nerve hypoplasia, pituitary function abnormalities and midline brain defects, in addition to a broad spectrum of symptoms and associations. A total of five clinical cases are presented, four of which met the complete classic triad. All of them showed a wide variety of ophthalmological, endocrinological and neurological alterations. Within the ophthalmological spectrum of SOD, papillary hypoplasia and ocular motility alterations (nystagmus, strabismus) stand out. Other less frequent ones may also appear, such as pupillary alterations, microphthalmia and coloboma. Given the suspicion of SOD, brain MRI scan should be performed, as well as consultation with the paediatric department in order to complete the study and indicate, if necessary, systemic treatment.

Lateral Kangaroo Care in Hemodynamic Stability of Extremely Preterm Infants: Protocol Study for a Non-Inferiority Randomized Controlled Trial CANGULAT

INTRODUCTION

This study aims to assess the efficacy of the modified kangaroo care lateral position on the thermal stability of preterm neonates versus conventional kangaroo care prone position.

MATERIAL AND METHODS

A non-inferiority randomized parallel clinical trial. Kangaroo care will be performed in a lateral position for the experimental group and in a prone position for the control group preterm. The study will take place at the neonatal intensive care unit (NICU) of a University Hospital. The participants will be extremely premature infants (under 28 weeks of gestational age) along the first five days of life, hemodynamically stable, with mother or father willing to do kangaroo care and give their written consent to participate in the study. The sample size calculated was 35 participants in each group. When the premature infant is hemodynamically stable and one of the parents stays in the NICU, the patient will be randomized into two groups: an experimental group or a control group. The primary outcome is premature infant axillary temperature. Neonatal pain level and intraventricular hemorrhage are secondary outcomes.

DISCUSSION

There is no scientific evidence on modified kangaroo care lateral position. Furthermore, there is little evidence of increased intraventricular hemorrhage association with the lateral head position necessary in conventional or prone kangaroo care in extremely premature newborns. Kangaroo care is a priority intervention in neonatal units increasing the time of use more and more, making postural changes necessary to optimize comfort and minimize risks with kangaroo care lateral position as an alternative to conventional prone position kangaroo care. Meanwhile, it is essential to ensure that the conventional kangaroo care prone position, which requires the head to lay sideways, is a safe position in terms of preventing intraventricular hemorrhage in the first five days of life of children under 28 weeks of gestational age. Trial registration at clinicaltrials.gov: NCT03990116.

[Variability in the neuropsychological performance of patients with acute coronary syndrome]

INTRODUCTION

There is a growing interest in the study of the relationship between heart disease, including acute coronary syndrome (ACS) and cognitive impairment, and although the factors mediating ACS and cognitive impairment are not well understood, the debate revolves around the role of the left ventricular ejection fraction (LVEF).

AIMS

To determine the presence of cognitive impairment in patients with ACS and explore its association with various factors, including sociodemographic, medication use and performance on cardiac function tests (in particular LVEF).

PATIENTS AND METHODS

Sociodemographic, medical and neuropsychological variables were collected in 80 patients with ACS participating in a cardiac rehabilitation programme. Their scores on the neuropsychological battery were compared with normative population data to determine which subjects showed deficient performance. Regression analyses were conducted to determine which factors are associated with performance on neuropsychological tests.

RESULTS

Compared to their normative group, 37.5% of the subjects had low scores on three or more neuropsychological tests. Age, low educational level and low LVEF explained up to 51% of the variability in neuropsychological test results.

CONCLUSIONS

Patients with ACS are more likely to have impaired cognitive functions, such as attention, memory and executive functions, along with a slower information processing speed. An LVEF below 50% could be a major explanatory factor for such cognitive impairment.

Prospective cohort study on the management and complications of peripheral venous catheter in patients hospitalised in Internal Medicine

OBJECTIVE

To analyse compliance with the recommendations on the insertion-maintenance of peripheral venous catheter (PVC) and the incidence of complications according to the healthcare department that inserted the PVCs.

PATIENTS AND METHODS

We conducted a prospective cohort follow-up study of PVCs, from their insertion in the emergency or internal medicine (IM) department until their withdrawal.

RESULTS

We monitored 590 PVCs, 274 from the emergency department and 316 from IM. In terms of compliance with the process indicators, there was a cannulation rate in the antecubital fossa of 3.5 and 1.6 per 100 catheters-day (P<.001) in the emergency and IM departments, respectively. The sterile placement rates were 1.6 and 12.4 (P<.001), and the rate for transparent dressing was 2.1 and 11.5 (P<.001) per 100 catheters-day in the emergency and IM departments, respectively. The complications rates showed no differences between the departments. The most common complication was phlebitis (95 cases, 16.1%).

CONCLUSIONS

Compliance with the insertion-maintenance recommendations for PVC showed differences between the departments; however, the incidence of complications was similar.

Prospective cohort study on the management and complications of peripheral venous catheter in patients hospitalised in internal medicine

OBJECTIVE

To analyse compliance with the recommendations on the insertion-maintenance of peripheral venous catheter (PVC) and the incidence of complications according to the healthcare department that inserted the PVCs.

PATIENTS AND METHODS

We conducted a prospective cohort follow-up study of PVCs, from their insertion in the emergency or internal medicine (IM) department until their withdrawal.

RESULTS

We monitored 590 PVCs, 274 from the emergency department and 316 from IM. In terms of compliance with the process indicators, there was a cannulation rate in the antecubital fossa of 3.5 and 1.6 per 100 catheters-day (p < .001) in the emergency and IM departments, respectively. The sterile placement rates were 1.6 and 12.4 (p < .001), and the rate for transparent dressing was 2.1 and 11.5 (p < .001) per 100 catheters-day in the emergency and IM departments, respectively. The complications rates showed no differences between the departments. The most common complication was phlebitis (95 cases, 16.1%).

CONCLUSIONS

Compliance with the insertion-maintenance recommendations for PVC showed differences between the departments; however, the incidence of complications was similar.

[Hematuria as the first sign of pelvic chondrosarcoma]

Chondrosarcoma is a malignant tumor which often affects the pelvic ring and its symptomathology is non-specific and insidious. We display a case of a right iliopubic branch chondrosarcoma in a 62-year-old male whose first sing was a four-year history of sporadic macroscopic haematuria, related to efforts. After being studied by the Urology Department by cystoscopy and biopsy of bladder tumor, chondral cells were appreciated. Further study with imaging tests diagnosed low-grade chondrosarcoma with bladder infringement. The case is assessed by Musculoskeletal Tumors Committee and a multidisciplinary approach is carried out through en bloc resection and pelvic floor reconstruction. Currently the patient remains asymptomatic.

Application of the Behavioural Indicators of Pain Scale in patients with traumatic brain injury

AIM

To develop and psychometrically test the Behavioural Indicators of Pain Scale (ESCID) in patients with traumatic brain injury (TBI).

DESIGN

A prospective observational study to test the psychometric properties of the Behavioural Indicators of Pain Scale in patients with TBI.

METHOD

A convenience sample of patients with TBI, who were non-communicative and using invasive mechanical ventilation was selected. Pain was evaluated by two observers who were blinded from each other. Assessments were performed at baseline via the performance of a painful procedure (aspiration of secretions) and a non-painful procedure (rubbing with a gauze). Assessments were repeated after application of procedures on days 1 and 6 of hospitalization in an intensive care unit. Data were collected between January-December 2016.

RESULTS

About 134 patients were included in the study. Of these, 76.1% were men. The mean age of participants was 45.2 (SD 17.5) years. The pain score significantly increased during the painful procedure when compared with the baseline measure and non-painful procedure (p < .001). Patients displayed a greater number of pain-indicating behaviours during the painful procedure on day 6, compared with day 1 (p < .05). This finding coincided with a reduced level of sedation and a greater level of consciousness.

CONCLUSION

The ESCID scale detects pain behaviours and discriminates among the different types of stimulation in patients with brain injury, who are uncommunicative and with mechanical ventilation, with good reliability. The ability for patients with brain injury to express behaviours is limited because of the low level of consciousness and the deep level of sedation.

IMPACT

This research will have an impact on the practice of pain assessment in patients with brain injury, representing a first step to adapt the content of the ESCID.

Paediatric optical coherence tomography normative databases: A real need

INTRODUCTION

Optical coherence tomography (OCT) has become an essential tool in paediatric ophthalmology. However, none of the currently available OCT devices include any kind of normative database for the paediatric population, which can lead to important interpretation errors.

OBJECTIVE

To review the paediatric OCT normative databases.

MATERIAL AND METHODS

The applications and implications of the use of paediatric OCT normative databases are reviewed.

RESULTS

The paediatric normative databases that have been published so far in scientific literature with different OCT devices for Spanish and European population are presented.

CONCLUSIONS

The knowledge and interpretation of paediatric OCT normative databases in our daily clinical practice is crucial in order for the correct interpretation of OCT thickness maps.

Phase II study of high-sensitivity genotyping of KRAS, NRAS, BRAF and PIK3CA to ultra-select metastatic colorectal cancer patients for panitumumab plus FOLFIRI: the ULTRA trial

BACKGROUND

Several studies show the importance of accurately quantifying not only KRAS and other low-abundant mutations because benefits of anti-EGFR therapies may depend on certain sensitivity thresholds. We assessed whether ultra-selection of patients using a high-sensitive digital PCR (dPCR) to determine KRAS, NRAS, BRAF and PIK3CA status can improve clinical outcomes of panitumumab plus FOLFIRI.

PATIENTS AND METHODS

This was a single-arm phase II trial that analysed 38 KRAS, NRAS, BRAF and PIK3CA hotspots in tumour tissues of irinotecan-resistant metastatic colorectal cancer patients who received panitumumab plus FOLFIRI until disease progression or early withdrawal. Mutation profiles were identified by nanofluidic dPCR and correlated with clinical outcomes (ORR, overall response rate; PFS, progression-free survival; OS, overall survival) using cut-offs from 0% to 5%. A quantitative PCR (qPCR) analysis was also performed.

RESULTS

Seventy-two evaluable patients were enrolled. RAS (KRAS/NRAS) mutations were detected in 23 (32%) patients and RAS/BRAF mutations in 25 (35%) by dPCR, while they were detected in 7 (10%) and 11 (15%) patients, respectively, by qPCR. PIK3CA mutations were not considered in the analyses as they were only detected in 2 (3%) patients by dPCR and in 1 (1%) patient by qPCR. The use of different dPCR cut-offs for RAS (KRAS/NRAS) and RAS/BRAF analyses translated into differential clinical outcomes. The highest ORR, PFS and OS in wild-type patients with their lowest values in patients with mutations were achieved with a 5% cut-off. We observed similar outcomes in RAS/BRAF wild-type and mutant patients defined by qPCR.

CONCLUSIONS

High-sensitive dPCR accurately identified patients with KRAS, NRAS, BRAF and PIK3CA mutations. The optimal RAS/BRAF mutational cut-off for outcome prediction is 5%, which explains that the predictive performance of qPCR was not improved by dPCR. The biological and clinical implications of low-frequent mutated alleles warrant further investigations.

CLINICALTRIALS.GOV NUMBER

NCT01704703.

EUDRACT NUMBER

2012-001955-38.

Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD

AIMS

Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients' levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR.

METHOD

An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units.

RESULTS

One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium.

CONCLUSIONS

The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874).

Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients

OBJECTIVE

To assess the psychometric properties of the behavioral indicators of pain scale (ESCID) when applied to a wide range of medical and surgical critical patients.

DESIGN

A multicentre, prospective observational study was designed to validate a scale measuring instrument.

SETTING

Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System.

PARTICIPANTS

A total of 286 mechanically ventilated, unable to self-report critically ill medical and surgical adult patients.

PROCEDURE

Pain levels were measured by two independent evaluators simultaneously, using two scales: ESCID and the behavioral pain scale (BPS). Pain was observed before, during, and after two painful procedures (turning, tracheal suctioning) and one non-painful procedure.

MAIN VARIABLES

ESCID reliability was measured on the basis of internal consistency using the Cronbach-α coefficient. Inter-rater and intra-rater agreement were measured. The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS.

RESULTS

A total of 4386 observations were made in 286 patients (62% medical and 38% surgical). High correlation was found between ESCID and BPS (r=0.94-0.99; p<0.001), together with high intra-rater and inter-rater concordance. ESCID was internally reliable, with a Cronbach-α value of 0.85 (95%CI 0.81-0.88). Cronbach-α coefficients for ESCID domains were high: facial expression 0.87 (95%CI 0.84-0.89), calmness 0.84 (95%CI 0.81-0.87), muscle tone 0.80 (95%CI 0.75-0.84), compliance with mechanical ventilation 0.70 (95%CI 0.63-0.75) and consolability 0.85 (95%CI 0.81-0.88).

CONCLUSION

ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients. CLINICALTRIALS.GOV: NCT01744717.

Short-term Recovery Following Resistance Exercise Leading or not to Failure

This study analyzed the time course of recovery following 2 resistance exercise protocols differing in level of effort: maximum (to failure) vs. half-maximum number of repetitions per set. 9 males performed 3 sets of 4 vs. 8 repetitions with their 80% 1RM load, 3×4(8) vs. 3×8(8), in the bench press and squat. Several time-points from 24 h pre- to 48 h post-exercise were established to assess the mechanical (countermovement jump height, CMJ; velocity against the 1 m·s(-1) load, V1-load), biochemical (testosterone, cortisol, GH, prolactin, IGF-1, CK) and heart rate variability (HRV) and complexity (HRC) response to exercise. 3×8(8) resulted in greater neuromuscular fatigue (higher reductions in repetition velocity and velocity against V1-load) than 3×4(8). CMJ remained reduced up to 48 h post-exercise following 3×8(8), whereas it was recovered after 6 h for 3×4(8). Significantly greater prolactin and IGF-1 levels were found for 3×8(8) vs. 3×4(8). Significant reductions in HRV and HRC were observed for 3×8(8) vs. 3×4(8) in the immediate recovery. Performing a half-maximum number of repetitions per set resulted in: 1) a stimulus of faster mean repetition velocities; 2) lower impairment of neuromuscular performance and faster recovery; 3) reduced hormonal response and muscle damage; and 4) lower reduction in HRV and HRC following exercise.

Validation of the Behavioural Indicators of Pain Scale ESCID for pain assessment in non-communicative and mechanically ventilated critically ill patients: a research protocol

AIM

To investigate the validity and reliability of the Behavioural Indicators of Pain Scale (ESCID) in medically and surgically non-communicative and mechanically ventilated critical patients.

BACKGROUND

Scales based on behavioural indicators of pain are suggested to measure pain in non-communicative critically ill patients. Scales proposed thus far have a range not comparable to those used with patients who can report their pain. A scale with a 0-10 range and more behavioural indicators is proposed to improve the detection and measurement of pain.

DESIGN

A multicentre prospective observational design to validate a scale-measuring instrument.

METHODS

Three hundred non-communicative and mechanically ventilated critical patients from 20 different intensive care units will be observed for 5 minutes before, during and 15 minutes after three procedures: turning, tracheal suctioning and soft friction with gauze on healthy tissue. Two independent observers will assess the pain of subjects with the Behavioural Pain Scale and the ESCID scale simultaneously. Descriptive and inferential statistics will be used. Student's t-test will be used to compare components of the twos scales. Inter-rater and intrarater agreement will be investigated. The reliability scale will be measured using Cronbach's alpha. Approval date for this protocol was January 2012.

DISCUSSION

A greater number of behavioural indicators in the ESCID scale than in previously validated scales, with a 0-10 score range, can improve the detection and measurement of pain in non-communicative and mechanically ventilated critical patients. Funding granted in 2011 by the Spanish Health Research Fund (PI 11/00766, Health Ministry).

TRIAL REGISTRATION

Study registered with www.clinicaltrials.gov (NCT01744717).

[Outcomes after operative treatment of distal radius fractures - an analysis of 721 patients]

AIM OF THE STUDY

Treatment strategies in distal radius fractures differ nationally and internationally. Conservative and operative treatment options compete as well as implants, postoperative therapy regimens and the necessity of implant removal. In our institution operative treatment is favoured. In the following the results of 721 surgically treated patients are presented.

PATIENTS

PATIENTS who underwent operative treatment of their distal radius fractures in our institution between 2008 and 2011 were retrospectively analysed. Following patient characteristics have been surveyed regarding age, sex, location of plate osteosynthesis, operation time, time of cast immobilisation and complications like infections, tendon ruptures, need of revision surgery.

RESULTS

721 patients (mean age: 59.03 years) were retrospectively analysed. 514 of them (71.29 %) were female. Time of operation was after a mean duration of 5.48 days. In 558 (77.39 %) patients we performed palmar plate osteosynthesis. 89 (12.34 %) had dorsal plate osteosynthesis and 74 (10.3 %) cases were treated with either K-wires or screws. 18 (2.5 %) patients had concomitant traumatic carpal tunnel syndrome and a concomitant SL rupture was seen in 38 (5.27 %) patients. 40 (5.55 %) patients underwent operative revision because of posttraumatic carpal tunnel syndrome (n = 15), tendon ruptures (n = 7), malposition of screws (n = 6), loss of reduction (n = 6) and infection (n = 3). Mean duration of in-hospital stay after operation was 6.6 days. Implant removal was performed in 77 (10.7) patients; 59 (8.2 %) patients had palmar plate osteosynthesis and 18 (2.5 %) patients had dorsal plating.

CONCLUSION

Because of the low complication rate after operative treatment of distal radius fractures, osteosynthesis of this fracture seems to be warranted. Regarding the patients' higher age we have seen an unexpectedly long in-hospital stay with a mean time of 6.6 days. Herein attempts should be made to reduce time of in-hospital stay. In our opinion implant removal should not be recommended routinely.

[Pain assessment of tracheal suctioning on brain injury patients by pain behavioral indicator scale (ESCID)]

OBJECTIVE

To assess pain response on patients with moderate to severe head injury before a common nursing procedure: tracheal suctioning.

MATERIAL AND METHOD

An observational longitudinal pilot study with consecutive sampling performed from September to December of 2012. Pain was assessed by a pain behavioral indicator scale 5 minutes before, meanwhile and 15 minutes after tracheal suctioning the days 1, 3 and 6 of their intensive care unit (ICU) stay, as well as a non-painful procedure: rubbing with gauze the forearm of the patient. Pseudo-analgesia and hemodynamic variables were also recorded. Descriptive analysis of the variables, inferential statistics with t-student and Anova with SPSS 17.0; statistical tests were considered significant if the critical level observed was less than 5% (P<.05).

RESULTS

Pain was assessed on 27 patients. 82% suffered from severe head trauma and 18% moderate. The average pain value during nursing procedure day 1 was 3, 18±2.6, day 3: 2, 59±2 and day 6: 3, 94±2.3. There was a significant increase in mean pain while performing suctioning during the three days of assessment (P<.05); however no significant differences between the average pain value on the three days of the assessment (P>.05) were shown. Data for the painless procedure were significantly different on day 6 (P<.05) CONCLUSION: During tracheal suctioning in patients with head injury in the first 6 days in the ICU, objective mild-moderate pain according to ESCID scale has been detected.

From transcription to cell surface expression, the induction of MHC class II I-A alpha by interferon-gamma in macrophages is regulated at different levels

Using mouse bone marrow-derived macrophages we determined the role of interferon (IFN)-gamma at the different steps in expression of the I-A alpha chain of MHC class II molecules, from transcription to the cell surface. Levels of transcription, RNA, and protein were low in cells not stimulated with IFN-gamma. Treatment with IFN-gamma for 24 or 48 h induced an increase in mRNA levels (7- and 12-fold) that did not correlate with the increase in transcription (2.5- and 2.7-fold). The half-life of mRNA was not modified by IFN-gamma. These data suggest a block at the level of translation. In fact, IFN-gamma increased ribosome loading, which confirms regulation at the translational level. Treatment with IFN-gamma increased protein synthesis (6-fold after 48 h) and level of expression at the cell surface (3- and 9-fold after 24 and 48 h, respectively). Interestingly, treatment with IFN-gamma also increased the I-A alpha protein half-life from 2 to 6-7 h. This is the first attempt to determine qualitatively and quantitatively the regulation of an inducible gene at all the putative levels of control. The data indicate that IFN-gamma plays a critical role in MHC class II protein expression in macrophages through the regulation of different steps, from transcription to surface expression.