"I have to obey my pain" - children's experiences of pain burden in cerebral palsy

PURPOSE

To explore pain experiences of children with cerebral palsy, and how it influences their everyday life.

METHOD

Fourteen children with CP between eight and seventeen years old were included, using a purposeful sampling strategy. They had different experiences of pain, and different degrees of physical and cognitive impairments. Sixteen individual semi-structured interviews were carried out, and analyzed using inductive thematic analysis.

RESULTS

Data analysis resulted in the main theme "I have to obey my pain" and four themes were identified. Experiences regarding pain varied ("My pain is mine alone"). Both pain itself and the use of cognitive strategies to cope with pain involved a mental struggle ("Pain brings me down"). The children had to make adjustments to manage their pain ("I want to participate, but I have to rest"). The most important help was to be understood, but adults also provided valuable help with interventions like stretching, medication and adjustment of activity levels ("Others can help me").

CONCLUSION

Pain was a determining feature in the lives of these children with CP. The wide variety of experiences and challenges emphasized the need for tailored management strategies developed together with each child and their parents.IMPLICATIONS FOR REHABILITATIONChildren with cerebral palsy had varied experiences of pain, and health professionals need to tailor their pain management approaches to the individual child.Health services should offer pain education to expand children's repertoire of pain management strategies.When a child's pain influences their daily activities, health services must ensure that the school is informed of the child's situation, and able to make necessary adjustments.Health professionals should strive to include children's own descriptions whenever possible to make sure children feel heard and believed.Even children with communicative and cognitive impairments were able to self-report when necessary adjustments in the communication situation were made.

Clinical pharmacist intervention to improve medication safety for hip fracture patients through secondary and primary care settings: a nonrandomised controlled trial

BACKGROUND

Hip fracture patients face a patient safety threat due to medication discrepancies and adverse drug reactions when they have a combination of high age, polypharmacy and several care transitions. Consequently, optimised pharmacotherapy through medication reviews and seamless communication of medication information between care settings is necessary. The primary aim of this study was to investigate the impact on medication management and pharmacotherapy. The secondary aim was to evaluate implementation of the novel Patient Pathway Pharmacist intervention for hip fracture patients.

METHODS

Hip fracture patients were included in this nonrandomised controlled trial, comparing a prospective intervention group (n = 58) with pre-intervention controls who received standard care (n = 50). The Patient Pathway Pharmacist intervention consisted of the steps: (A) medication reconciliation at admission to hospital, (B) medication review during hospitalisation, (C) recommendation for the medication information in the hospital discharge summary, (D) medication reconciliation at admission to rehabilitation, and (E) medication reconciliation and (F) review after hospital discharge. The primary outcome measure was quality score of the medication information in the discharge summary (range 0-14). Secondary outcomes were potentially inappropriate medications (PIMs) at discharge, proportion receiving pharmacotherapy according to guidelines (e.g. prophylactic laxatives and osteoporosis pharmacotherapy), and all-cause readmission and mortality.

RESULTS

The quality score of the discharge summaries was significantly higher for the intervention patients (12.3 vs. 7.2, p < 0.001). The intervention group had significantly less PIMs at discharge (- 0.44 (95% confidence interval - 0.72, - 0.15), p = 0.003), and a higher proportion received prophylactic laxative (72 vs. 35%, p < 0.001) and osteoporosis pharmacotherapy (96 vs. 16%, p < 0.001). There were no differences in readmission or mortality 30 and 90 days post-discharge. The intervention steps were delivered to all patients (step A, B, E, F = 100% of patients), except step (C) medication information at discharge (86% of patients) and step (D) medication reconciliation at admission to rehabilitation (98% of patients).

CONCLUSION

The intervention steps were successfully implemented for hip fracture patients and contributed to patient safety through a higher quality medication information in the discharge summary, fewer PIMs and optimised pharmacotherapy.

TRIAL REGISTRATION

NCT03695081.

Medication management for patients with hip fracture at a regional hospital and associated primary care units in Norway: a descriptive study based on a survey of clinicians' experience and a review of patient records

OBJECTIVE

Patients with hip fracture are at high risk of medication errors due to a combination of high age, comorbidities, polypharmacy and several care transitions after fracture. The aim was to study medication management tasks concerning patient safety: medication reconciliation, medication review and communication of key medication information in care transitions.

DESIGN

Descriptive study comprising a self-administered clinician survey (MedHipPro-Q) and a retrospective review of hospital medical records of patients with hip fracture.

SETTING

Regional hospital and the associated primary care units (South-Eastern Norway).

PARTICIPANTS

The survey received responses from 253 clinicians, 61 medical doctors and 192 nurses, involved in the medication management of patients with hip fracture, from acute admittance to the regional hospital, through an in-hospital fast track, primary care rehabilitation and back to permanent residence. Respondents' representativeness was unknown, introducing a risk of selection and non-response bias, and extrapolating findings should be done with caution. The patient records review included a random sample of records of patients with hip fracture (n=50).

OUTCOME MEASURES

Medication reconciliation, medication review and communication of medication information from two perspectives: the clinicians' (ie, experiences with medication management) and the practice (ie, documentation of completed medication management).

RESULTS

In the survey, most clinicians stated they performed medication reconciliation (79%) and experienced that patients often arrived without a medication list after care transition (37%). Doctors agreed that more patients would benefit from medication reviews (86%). In the hospital patient records, completed medication reconciliation was documented in most patients (76%). Medication review was documented in 2 of 50 patients (4%). Discharge summary guidelines were followed fully for 3 of 50 patients (6%).

CONCLUSION

Our study revealed a need for improved medication management for patients with hip fracture. Patients were at risk of medication information not being transferred correctly between care settings, and medication reviews seemed to be underused in clinical practice.

Pain burden in children with cerebral palsy (CPPain) survey: Study protocol

Pain is a significant health concern for children living with cerebral palsy (CP). There are no population‐level or large‐scale multi‐national datasets using common measures characterizing pain experience and interference (ie, pain burden) and management practices for children with CP. The aim of the CPPain survey is to generate a comprehensive understanding of pain burden and current management of pain to change clinical practice in CP. The CPPain survey is a comprehensive cross‐sectional study. Researchers plan to recruit approximately 1400 children with CP (primary participants) across several countries over 6‐12 months using multimodal recruitment strategies. Data will be collected from parents or guardians of children with CP (0‐17 years) and from children with CP (8‐17 years) who are able to self‐report. Siblings (12‐17 years) will be invited to participate as controls. The CPPain survey consists of previously validated and study‐specific questionnaires addressing demographic and diagnostic information, pain experience, pain management, pain interference, pain coping, activity and participation in everyday life, nutritional status, mental health, health‐related quality of life, and the effect of the COVID‐19 pandemic on pain and access to pain care. The survey will be distributed primarily online. Data will be analyzed using appropriate statistical methods for comparing groups. Stratification will be used to investigate subgroups, and analyses will be adjusted for appropriate sociodemographic variables. The Norwegian Regional Committee for Medical and Health Research Ethics and the Research Ethics Board at the University of Minnesota in USA have approved the study. Ethics approval in Canada, Sweden, and Finland is pending. In addition to dissemination through peer‐reviewed journals and conferences, findings will be communicated through the CPPain Web site (www.sthf.no/cppain), Web sites directed toward users or clinicians, social media, special interest groups, stakeholder engagement activities, articles in user organization journals, and presentations in public media.

Development and initial validation of MedHipPro-Q: a questionnaire assessing medication management of hip fracture patients in different care settings

Background

A validated questionnaire to assess medication management of hip fracture patients within and outside the hospital setting was lacking. The study aims were to describe the hip fracture patient pathway, and develop a valid and feasible questionnaire to assess clinicians’ experience with medication management of hip fracture patients in different care settings throughout the patient pathway.

Methods

This qualitative, descriptive methodological study used strategic and snowball sampling. The questionnaire was developed, and face and content validity explored through interviews with stakeholders. Phase I described the hip fracture patient pathway, and identified questionnaire dimensions in semi-structured interviews with management and clinicians (n = 37). The patient pathway was also discussed in six meetings (n = 70). Phase II refined a first draft of the questionnaire through cognitive interviews with future respondents (n = 23). The draft was modified after each interview. Post hoc, cognitive interview data were analysed using matrix analysis to condense problems and solutions into themes and subthemes. Phase III, converted the final version to a digital format, and tested its feasibility with a subset of the cognitive interview participants (n = 21) who completed the questionnaire and provided feedback.

Results

Phase I: Hip fracture patients were cared for in at least three different care settings, and went through at least four handovers between and within primary and secondary care. Three questionnaire dimensions were identified: 1) Medication reconciliation and review, 2) Communication of key information, and 3) Profession and setting. Phase II: The MedHipPro-Q was representative of how the different professions experienced medication management in all settings, and hence showed face and content validity. Post hoc analysis: Problem themes (with sub-themes) were Representativeness (-of patient pathway and -of respondent reality) and Presentation (Language and Appearance). Solution themes (with sub-themes) were: Content (added or deleted) and Presentation (modified appearance or corrected language). Phase III: Participants did not identify technical, linguistic or content flaws in the questionnaire, and the digital version was considered feasible for use.

Conclusion

The novel MedHipPro-Q showed good face and content validity, and was feasible for use throughout the hip fracture patient pathway. The rigorous development process supports its construct validity and reliability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07524-2.

Nurses' perception, knowledge, and use of neonatal pain assessment

Preterm and sick newborn infants undergo several painful procedures during their hospital stay, potentially leading to short‐ and long‐term negative consequences. Pain assessment should be performed regularly to provide optimal pain management. Nurses' knowledge of and attitude toward neonatal pain assessment affect how pain is assessed and managed in the clinical situation. The aim of this study was to explore Swedish nurses' perception, knowledge, and use of neonatal pain assessment. This descriptive, cross‐sectional questionnaire study was conducted across all Swedish neonatal units (n = 38). Respondents were chosen through convenience sampling by the head nurses at each unit. Ten nurses from each unit were asked to complete the survey, which contained both closed and open questions. A majority of the units (30/38; 79%) participated and 232 surveys were returned, a response rate of 61%. Of the nurses, 91% thought that neonatal pain assessment was important. Many nurses mentioned various difficulties with pain assessment and concerns that the scales used might not assess pain correctly. About half of the nurses considered themselves to have enough knowledge of neonatal pain assessment. Those who reported having enough knowledge of pain assessment viewed the pain scales used at their units more positively. Of the nurses, 74% reported using a pain assessment scale several times per work shift. Pain management guidelines were available according to 75% of nurses, but only 53% reported that the guidelines were followed. Although nurses in general expressed a positive attitude toward pain assessment scales, this was not necessarily evident in their clinical practice. Lack of knowledge, available or accessible guidelines, or concerns regarding the validity of available pain scales seemed to limit their use.

The evidence supporting the association between the use of pain scales and outcomes in hospitalized children: A systematic review

BACKGROUND

Systematic use of pain intensity scales is considered a prerequisite for treatment of pain in hospitalized children, but already a decade ago, attention was called to the lack of robust evidence supporting the presumed positive association between their use and desired outcomes.

OBJECTIVES

To re-evaluate the evidence supporting the association between the use of pain scales and patient and process outcomes in hospitalized children.

DESIGN

Systematic literature review.

DATA SOURCES

The online databases PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched from inception to April 15, 2020.

REVIEW METHODS

We performed single screening of all records followed by duplicate screening of full texts of interest with a disagreement procedure in place. Studies where the authors evaluated outcomes from the use of self-report or behavioral-based pain scales in children 0-18 years in a hospital setting were included. Emergency care settings were excluded.

RESULTS

In a majority of the 32 included studies, complex interventions that included one or more pain scales were evaluated. Process outcomes (e.g., documentation) were most frequently studied. Interventions were commonly associated with improved documentation of pain assessment, while the effect on pain management documentation was inconsistent. However, improvements in process outcomes did not necessarily result in better patient outcomes. In regard to patient outcomes (e.g., pain intensity, side effects, or satisfaction with treatment), some authors reported reduced pain intensity on group level, but the effect on other functional outcomes, child and parent satisfaction, and aspects of safety were inconsistent. Methodological issues, e.g., weak study designs and small samples, biased the results, and it was not possible to determine how pain scales contributed to the overall effects since they were studied as part of complex interventions.

CONCLUSIONS

Although both a theoretically founded understanding of pain and clinical experience suggest that the use of pain scales will make a difference for hospitalized children with pain, there is still limited evidence to support this notion. As pain scales have been almost exclusively studied as an aspect of complex interventions, research that determines the active ingredient(s) in a complex intervention and their joint and individual effects on outcomes that are meaningful for the child (for example reduced pain intensity or improved function) are urgently needed. Tweetable abstract: Limited #research supports association between use of pediatric #pain scales and patient outcomes @_randida @PainPearl.

Study protocol: parents as pain management in Swedish neonatal care - SWEpap, a multi-center randomized controlled trial

BACKGROUND

During the first period of life, critically ill as well as healthy newborn infants experience recurrent painful procedures. Parents are a valuable but often overlooked resource in procedural pain management in newborns. Interventions to improve parents' knowledge and involvement in infants' pain management are essential to implement in the care of the newborn infant. Neonatal pain research has studied a range of non-pharmacological pain alleviating strategies during painful procedures, yet, regarding combined multisensorial parent-driven non-pharmacological pain management, research is still lacking.

METHODS/DESIGN

A multi-center randomized controlled trial (RCT) with three parallel groups with the allocation ratio 1:1:1 is planned. The RCT "Parents as pain management in Swedish neonatal care - SWEpap", will investigate the efficacy of combined pain management with skin-to-skin contact, breastfeeding and live parental lullaby singing compared with standard pain care initiated by health care professionals, during routine metabolic screening of newborn infants (PKU-test).

DISCUSSION

Parental involvement in neonatal pain management enables a range of comforting parental interventions such as skin-to-skin contact, breastfeeding, rocking and soothing vocalizations. To date, few studies have been published examining the efficacy of combined multisensorial parent-driven interventions. So far, research shows that the use of combined parent-driven pain management such as skin-to-skin contact and breastfeeding, is more effective in reducing behavioral responses to pain in infants, than using the pain-relieving interventions alone. Combined parental soothing behaviors that provide rhythmic (holding/rocking/vocalizing) or orogustatory/orotactile (feeding/pacifying) stimulation that keep the parent close to the infant, are more effective in a painful context. In the SWEpap study we also include parental live lullaby singing, which is an unexplored but promising biopsychosocial, multimodal and multisensory pain alleviating adjuvant, especially in combination with skin-to-skin contact and breastfeeding.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT04341194 ) 10 April 2020.

The Complexities of Nurses' Pain Assessment in Hospitalized Preverbal Children

BACKGROUND

Preverbal children are at increased risk for underassessment of pain. Pain is a social transaction involving the child in pain and the nurse assessor. However, our understanding of the nurse's part in this transaction is limited.

AIMS

The aim of this study was to explore nurses' assessment of pain in hospitalized preverbal children based on self-selected clinical examples.

DESIGN

Qualitative, descriptive design.

SETTINGS

Five different hospital units in Canada and Norway. All units had an observational pain scale for preverbal children available for use.

PARTICIPANTS/SUBJECTS

Nurses (N = 22) with ≥1 year experience caring for preverbal children.

METHODS

Individual, semistructured interviews. Data were analyzed using inductive thematic analysis.

RESULTS

Nurses' assessment of pain in hospitalized preverbal children emerged as a nonlinear complex process incorporating different actions and reflections in response to the child's situation and expression of distress. Information from parents was routinely included in the assessment, although further parental involvement varied considerably. Although each assessment was personalized to the individual child, the nurse used previous experiences to interpret observations of and information from the child and the parents. Few nurses described using structured pain scales, but when used, these scales were included as only one aspect of their overall assessment.

CONCLUSIONS

Nurses preferred pain assessment based on clinical judgment and tailored to the individual child. Implementation strategies that aim to integrate structured pain scales with clinical judgment to assess pain may be more likely to succed. Further examination of this approach is warranted.

Cultural adaptation and harmonization of four Nordic translations of the revised Premature Infant Pain Profile (PIPP-R)

Background

Preterm infants are especially vulnerable to pain. The intensive treatment often necessary for their survival unfortunately includes many painful interventions and procedures. Untreated pain can lead to both short- and long-term negative effects. The challenge of accurately detecting pain has been cited as a major reason for lack of pain management in these non-verbal patients. The Premature Infant Pain Profile (PIPP) is one of the most extensively validated measures for assessing procedural pain in premature infants. A revised version, PIPP-R, was recently published and is reported to be more user-friendly and precise than the original version. The aims of the study were to develop translated versions of the PIPP-R in Finnish, Icelandic, Norwegian, and Swedish languages, and to establish their content validity through a cultural adaptation process using cognitive interviews.

Methods

PIPP-R was translated using the recommendations from the International Society for Pharmacoeconomics and Outcomes Research and enhanced with cognitive interviews. The respondent nurse was given a copy of the translated, national version of the measure and used this together with a text describing the infant in the film to assess the pain of an infant in a short film. During the assessment the nurse was asked to verbalize her thought process (thinking aloud) and upon completion the interviewer administered probing questions (verbal probing) from a structured interview guide. The interviews were recorded, transcribed, and analyzed using a structured matrix approach.

Results

The systematic approach resulted in translated and culturally adapted versions of PIPP-R in the Finnish, Icelandic, Norwegian and Swedish languages. During the cultural adaptation process several problems were discovered regarding how the respondent understood and utilized the measure. The problems were either measure problems or other problems. Measure problems were solved by a change in the translated versions of the measure, while for other problems different solutions such as education or training were suggested.

Conclusions

This study have resulted in translations of the PIPP-R that have content validity, high degree of clinical utility and displayed beginning equivalence with each other and the original version of the measure.

Pain assessment practices in Swedish and Norwegian neonatal care units

BACKGROUND

The use of measurement scales to assess pain in neonates is considered a prerequisite for effective management of pain, but these scales are still underutilised in clinical practice.

AIM

The aim of this study was to describe and compare pain assessment practices including the use of pain measurement scales in Norwegian and Swedish neonatal care units.

METHODS

A unit survey investigating practices regarding pain assessment and the use of pain measurement scales was sent to all neonatal units in Sweden and Norway (n = 55). All Norwegian and 92% of Swedish units responded.

RESULTS

A majority of the participating units (86.5%) assessed pain. Swedish units assessed and documented pain and used pain measurement scales more frequently than Norwegian units. The most frequently used scales were different versions of Astrid Lindgren's Pain Scale (ALPS) in Sweden and Echelle Douleur Inconfort Noveau-Ne (EDIN), ALPS and Premature Infant Pain Profile (PIPP) in Norway. Norwegian head nurses had more confidence in their pain assessment method and found the use of pain measurement scales more important than their Swedish colleagues.

CONCLUSION

The persisting difference between Swedish and Norwegian units in pain assessment and the use of pain measurement scales are not easily explained. However, the reported increased availability and reported use of pain measurement scales in neonatal care units in both countries may be seen as a contribution towards better awareness and recognition of pain, better pain management and potentially less suffering for vulnerable neonates.

Assessment of continuous pain in newborns admitted to NICUs in 18 European countries

AIM

Continuous pain occurs routinely, even after invasive procedures, or inflammation and surgery, but clinical practices associated with assessments of continuous pain remain unknown.

METHODS

A prospective cohort study in 243 neonatal intensive care units (NICUs) from 18 European countries recorded the frequency of pain assessments, use of mechanical ventilation, sedation, analgesia or neuromuscular blockade for each neonate for up to 28 days after NICU admission.

RESULTS

Only 2113 of 6648 (31.8%) of neonates received assessments of continuous pain, occurring variably among tracheal ventilation (TrV, 46.0%), noninvasive ventilation (NiV, 35.0%) and no ventilation (NoV, 20.1%) groups (p < 0.001). Daily assessments for continuous pain occurred in only 10.4% of all neonates (TrV: 14.0%, NiV: 10.7%, NoV: 7.6%; p < 0.001). More frequent assessments of continuous pain occurred in NICUs with pain guidelines, nursing champions and surgical admissions (all p < 0.01), and for newborns <32 weeks gestational age, those requiring ventilation, or opioids, sedatives-hypnotics, general anaesthetics (O-SH-GA) (all p < 0.001), or surgery (p = 0.028). Use of O-SH-GA drugs increased the odds for pain assessment in the TrV (OR:1.60, p < 0.001) and NiV groups (OR:1.40, p < 0.001).

CONCLUSION

Assessments of continuous pain occurred in less than one-third of NICU admissions and daily in only 10% of neonates. NICU clinical practices should consider including routine assessments of continuous pain in newborns.

The COMFORT behavioural scale provides a useful assessment of sedation, pain and distress in toddlers undergoing minor elective surgery

AIM

The COMFORT behavioural scale was developed to assess sedation, pain and distress in children unable to report pain. Our aims were to test construct validity of the scale in toddlers undergoing minor surgery and determine the inter-rater reliability of the scale.

METHODS

We consecutively enrolled 45 children aged 12-36 months from a Norwegian surgical outpatient care unit. The level of sedation, pain and distress was assessed before and after surgery with the COMFORT behavioural scale. Inter-rater reliability was estimated and construct validity was tested based on a priori defined hypotheses. A 2.5-point (15%) change in the scale was considered clinically important.

RESULTS

We obtained 307 scores covering most of the scale's range, but a floor effect was clearly present. Inter-rater reliability was high between assessors (intraclass correlation coefficient = 0.96; 95% CI 0.92-0.98). Clinically important differences were seen between baseline and light sedation (3.1 points, p < 0.001) and between light and deep sedation (4.6 points, p = 0.002). The difference between baseline and our definition of a pain/distress state was not clinically important (1.5 points, p = 0.039).

CONCLUSION

The COMFORT behavioural scale can provide one aspect of an overall clinical assessment of sedation, and probably pain and distress, in toddlers before and after surgery.

The opinions of clinical staff regarding neonatal procedural pain in two Norwegian neonatal intensive care units

AIM

Neonates are subjected to numerous painful procedures without sufficient pain management. The aim of this study was to describe the opinions of Norwegian physicians, nurses and nurse assistants who care for neonates, regarding procedural pain in neonates.

METHODS

A replication of a previous questionnaire study was conducted in two Norwegian neonatal intensive care units (NICU's). The questionnaire aimed at evaluating procedure painfulness, the current use of pharmacological agents and comfort measures and the optimal use of both.

RESULTS

Ninety members of the clinical staff participated, which is a response rate of 87%. Opinions on how procedural pain is currently and optimally managed differed significantly. Although most respondents rated a majority of the listed procedures as being more than moderately painful, pharmacological agents were rarely used, except for the insertion of a chest tube and endotracheal intubation. Comfort measures were also believed to be underutilized, but not to the same degree as pharmacological agents.

CONCLUSION

Procedural pain in neonates is not sufficiently managed and both pharmacological agents and comfort measures are underutilized, according to clinicians at two Norwegian NICU's.

Treatment of distal ureteral stones in children: similarities to the american urological association guidelines in adults

PURPOSE

The American Urological Association (AUA) published clinical guidelines for the treatment of ureteral calculi in adults and note that up to 98% of stones less than 5 mm. in diameter will pass spontaneously. Ureteroscopy and shock wave lithotripsy were acceptable treatment choices for stones less than 10 mm. in diameter in the distal ureter. We reviewed our management of distal ureteral stones in children to see if the AUA Guidelines for adults would apply.

MATERIALS AND METHODS

A total of 14 males and 19 females with a mean age of 12 years (range 0.5 to 17) required hospitalization in the last 6 years for distal ureteral obstruction due to stones. Excretory urography or computerized tomography was performed in all cases, and mean stone size was 4 mm. (range 1 to 15). When stones did not pass spontaneously most patients were treated with ureteroscopic laser lithotripsy.

RESULTS

There were 12 (36%) with a mean age of 11 years and a mean stone size of 2 mm. (range 1 to 3) who passed stones spontaneously with intravenous hydration and narcotics. No child passed a stone 4 mm. or greater spontaneously in this series. Of 21 patients (64%) with a mean age of 12 years and a mean stone size of 5 mm. (range 1 to 15) 2 were treated with ureteral stents, 17 with ureteroscopic lithotripsy and 2 with shock wave lithotripsy. All patients were stone-free at the end of the procedures. The stone composition was predominantly calcium oxalate. Mean followup was 2 years.

CONCLUSIONS

Similar to the AUA guidelines in adults, most stones less than 3 mm. in diameter in the distal ureter of children will pass spontaneously. Stones 4 mm or greater in the distal ureter are likely to require endosurgical treatment. Ureteroscopy and shock wave lithrotripsy have a high success rate for stones between 4 and 15 mm. in the distal ureter. Needle ureteroscope and laser lithotripsy have allowed more stones to be treated safely and effectively in smaller children.

Genotypic analysis of a cluster of systemic Candida albicans infections in a neonatal intensive care unit

Five very low birth weight infants developed systemic Candida albicans infection during a 6-week period in an urban neonatal intensive care unit. In an effort to assess whether a common source outbreak was present, the genomic DNA of the clinical isolates was compared by EcoRI and XbaI restriction fragment analysis and Southern blot hybridization with 27A, a species-specific, transposon-like probe. Although the restriction fragment analysis suggested strong similarities among the isolates, the hybridization patterns demonstrated that all strains were genotypically distinct. The parallel use of at least two restriction enzymes was important for differentiating the isolates. Rapid genotypic analysis of clinical isolates from a cluster of C. albicans infections permits determination of whether a common source is probable, facilitates epidemiologic decisions and may reduce infection control measures and attendant costs.

v-src induction of the TIS10/PGS2 prostaglandin synthase gene is mediated by an ATF/CRE transcription response element

We recently reported the cloning of a mitogen-inducible prostaglandin synthase gene, TIS10/PGS2. In addition to growth factors and tumor promoters, the v-src oncogene induces TIS10/PGS2 expression in 3T3 cells. Deletion analysis, using luciferase reporters, identifies a region between -80 and -40 nucleotides 5' of the TIS10/PGS2 transcription start site that mediates pp60v-src induction in 3T3 cells. This region contains the sequence CGTCACGTG, which includes overlapping ATF/CRE (CGTCA) and E-box (CACGTG) sequences. Gel shift-oligonucleotide competition experiments with nuclear extracts from cells stably transfected with a temperature-sensitive v-src gene demonstrate that the CGTCACGTG sequence can bind proteins at both the ATF/CRE and E-box sequences. Dominant-negative CREB and Myc proteins that bind DNA, but do not transactivate, block v-src induction of a luciferase reporter driven by the first 80 nucleotides of the TIS10/PGS2 promoter. Mutational analysis distinguishes which TIS10/PGS2 cis-acting element mediates pp60v-src induction. E-box mutation has no effect on the fold induction in response to pp60v-src. In contrast, ATF/CRE mutation attenuates the pp60v-src response. Antibody supershift and methylation interference experiments demonstrate that CREB and at least one other ATF transcription factor in these extracts bind to the TIS10/PGS2 ATF/CRE element. Expression of a dominant-negative ras gene also blocks TIS10/PGS2 induction by v-src. Our data suggest that Ras mediates pp60v-src activation of an ATF transcription factor, leading to induced TIS10/PGS2 expression via the ATF/CRE element of the TIS10/PGS2 promoter. This is the first description of v-src activation of gene expression via an ATF/CRE element.

Metal-dependent binding of a nuclear factor to the rat metallothionein-I promoter

Genomic footprinting studies in vivo and experiments using synthetic metal regulatory elements (MREs) in vitro suggest protein binding to the MREs of the mouse and rat metallothionein I (MT-I) genes. Using gel-retardation assays of promoter fragments, we observe a cadmium-dependent binding factor for the rat MT-I promoter in rat hepatoma cells. This factor is present in extracts from both uninduced and cadmium-induced cells, but requires the presence of cadmium to bind to the promoter. The formation of a cadmium-dependent complex is competed by an oligonucleotide containing two MREs. This competition is lost when when one of the MREs is mutated, indicating a requirement for at least two MREs for binding of this factor. The cadmium-dependent factor dissociates more rapidly from the MT-I promoter than does a factor that binds to a consensus Sp1 site present on the same DNA fragment. UV crosslinking analysis using nuclear extracts from cadmium induced cells, in the presence of an oligonucleotide probe containing both 5-bromodeoxyuridine and 32P-deoxycytidine, identifies a 39 kDalton protein associated with the metal inducible complex.

Metal-dependent binding of a factor in vivo to the metal-responsive elements of the metallothionein 1 gene promoter

Using the technique of genomic footprinting, we demonstrate cadmium-inducible protection from dimethyl sulfate (DMS) modification of guanine residues in vivo in five metal-responsive elements (MREs) in the promoter of the rat metallothionein 1 (MT-1) gene. We also identify a site of extreme DMS hyperreactivity which, like the MRE protection, occurs only after metal ion induction. With this hyperreactive site as an indicator, we can measure the kinetics of induction and deinduction. Changes in the intracellular metal ion concentrations are reflected in alterations in the reactivity with DMS of guanine residues in the MT-1 gene promoter. Lastly, for both control and metal-induced cells, we observe DMS protection and enhancement of a binding site (located 5' of the distal MRE) which is a consensus sequence for the Sp1 transcription factor. Transfection experiments with deletion mutations of a fusion gene construct indicate both that a sequence region which includes this GC box regulates the basal level of expression of the MT-1 gene and that increasing the number of MREs in the promoter increases the induced level of transcription. Our genomic footprinting and transfection data together suggest that (i) a transcription factor, possibly Sp1, plays an important role in regulating the basal level of expression of the MT-1 gene and (ii) metal induction involves the metal-dependent binding to a sequence-specific binding factor which responds to changes in intracellular metal ion levels.

Magnetic resonance imaging of the brain in childhood herpesvirus infections

We used magnetic resonance imaging (MRI) to evaluate nine children with neurologic disorders caused by infections with members of the herpesvirus family. MRI studies were abnormal in eight children and demonstrated a wide range of central nervous system lesions, including cystic encephalomalacia, ventricular enlargement, cerebral atrophy and focal parenchymal lesions. When compared with conventional computed tomographic scanning, MRI was more sensitive in detecting abnormalities of white matter and in defining the extent of parenchymal lesions. These studies indicate that MRI scans are highly useful in children with herpesvirus infections involving the central nervous system.

Herpes simplex virus infection of the neonatal respiratory tract

Three patients with neonatal herpes simplex virus (HSV) infection with upper or lower respiratory tract involvement are described. In all three patients, fever and respiratory tract symptoms were the presenting features and occurred in the absence of mucocutaneous lesions or maternal history of HSV Infection. In none of the children was HSV Infection considered likely at the time viral cultures were obtained. These patients demonstrate the need for consideration of HSV in the evaluation of neonatal respiratory tract disease, particularly if it is accompanied by fever and presents after the first several days of life.

Acute viral laryngotracheitis complicated by herpes simplex virus infection

We report the development of HSV-1 laryngotracheitis during the resolution phase of typical viral laryngotracheobronchitis (LTB) in an infant. This case represents an uncommon complication of viral LTB which has previously been described only at autopsy and suggests that prolonged use of systemic corticosteroids may lead to secondary infections, such as HSV-1. Therefore, we recommend that corticosteroid therapy for LTB be limited to 48 degrees in duration. This case also demonstrates that when an atypical clinical course is being followed by a patient who has LTB, then early diagnostic intervention is indicated. If HSV-1 is identified, anti-viral chemotherapy should be initiated and artificial airway management may be necessary. Tracheal intubation may be used, but, if extensive subglottic ulceration occurs, the subglottis should be bypassed in order that the chance of subglottic stenosis be minimized. In this case, early identification by bronchoscopy and viral cultures resulted in a successful combined medical-surgical management and total resolution with no sequelae.

Intrauterine herpes simplex infection resembling mechanobullous disease in a newborn infant

We present a case of transplacentally acquired intrauterine herpes simplex virus infection in a newborn delivered at 36 weeks' gestation by cesarean section because of intrauterine growth retardation and maternal preeclampsia. The mother experienced a single episode of serotype 2 herpes progenitalis at 14 weeks' gestation. At birth the infant manifested clinical findings of herpes simplex virus infection, which resembled epidermolysis bullosa and aplasia cutis congenita. Preexisting cutaneous lesions and intact fetal membranes at delivery strongly support a transplacentally acquired intrauterine herpes simplex virus infection. Repeated Tzanck smears, viral cultures, and immunohistochemical studies of the skin were required to confirm the diagnosis. Intrauterine herpes simplex virus infection is associated with significant morbidity and mortality but responds to antiviral therapy. Therefore this diagnosis must be considered in the neonate born with bullous or eroded skin lesions.

Rat metallothionein-1 structural gene and three pseudogenes, one of which contains 5'-regulatory sequences

As shown by Southern blot analysis, the metallothionein-1 (MT-1) genes in rats comprise a multigene family. We present the sequence of the MT-1 structural gene and compare its features with other metallothionein genes. Three MT-1 pseudogenes which we sequenced apparently arose by reverse transcription of processed mRNA transcripts. Two of these, MT-1 psi a and MT-1 psi c, are retrogenes which derive from the MT-1 mRNA, having diverged from the MT-1 gene 6.9 and 2.6 million years ago, respectively. The third, MT-1 psi b, differs from the MT-1 cDNA by only three nucleotide alterations. Surprisingly, MT-1 psi b also preserves sequence homology for 142 base pairs 5' to the transcription initiation site of the parent gene; it contains a promoter sequence sufficient for specifying metal ion induction. We identified, by S1 nuclease mapping, an RNA polymerase II initiation site 432 base pairs 5' of the MT-1 transcription initiation site of the MT-1 structural gene which could explain the formation of the mRNA precursor to this pseudogene. We were unable to detect MT-1 psi b transcripts, either in liver tissue or after transfection. We conclude that the absence of detectable transcripts from this pseudogene is due to either a reduced level of transcription or the formation of unstable transcripts as a consequence of the lack of a consensus sequence normally found 3' of transcription termination in the MT-1 structural gene.

Metoclopramide given pre-operatively empties the stomach

Sixty adult patients admitted for emergency major orthopedic surgery were studied according to a double-blind, randomized design in order to evaluate if a single dose of 20 mg metoclopramide given intravenously at least 90 min before premedication could evacuate the stomach before anesthesia. Three patients were excluded. X-ray examination following intake of barium sulfate before anesthesia showed 10 patients with a full stomach, all belonging to the placebo group. This study demonstrates significantly fewer (P less than 0.002) patients with a full stomach before anesthesia after metoclopramide, indicating that administration of metoclopramide reduces the risk of aspiration of gastric contents to the lungs during anesthesia.

Mycoplasma pneumoniae and Nocardia asteroides in lung biopsy tissue of an immunodeficient infant

Mycoplasma pneumoniae and Nocardia asteroides were recovered from lung tissue of an infant with an immunologic deficit. The isolate suggests a possible role of M. pneumoniae as an opportunistic pathogen. This case underscores the importance of comprehensive evaluation of lung biopsy specimens and the usefulness of Mycoplasma cultures.

Virus-induced leukopenia: Colorado tick fever as a human model

Eight patients with Colorado tick fever were studied to determine whether alterations in the production of granulopoietic stimulatory or inhibitory factors (or both) could be found in association with the leukopenic state of the disease. The studies demonstrate that in the patients with Colorado tick fever the mononuclear cell production of colony-stimulating factor is decreased and that there is an increase in circulating inhibitory factors in the serum of such patients. The depressed mononuclear cell colony-stimulating activity does not appear to be reversible by addition of either endotoxin or normal human serum. Characterization of these serum inhibitory factors may facilitate understanding of leukopenia in human disease.

Mutations affecting the regulation of transcription of the cytochrome P1-450 gene in the mouse Hepa-1 cell line

The cytochrome P1-450-dependent activity, aryl hydrocarbon hydroxylase, and cytochrome P1-450 messenger RNA levels were studied in wild-type Hepa1c1c7 cells and in aryl hydrocarbon hydroxylase-deficient mutants derived from this line. Tetrachlorodibenzo-p-dioxin (TCDD) induced both parameters approximately 50-fold in Hepa1c1c7 cells. Mutants in genes B and C that are affected in the functioning of the Ah receptor required for hydroxylase induction and dominant mutants had nondetectable or much reduced P1-450 mRNA levels and hydroxylase activities after TCDD treatment. Hybrids between wild-type cells and the dominant mutants were also deficient in these parameters. The dominant mutants therefore appear to express a trans-acting repressor of cytochrome P1-450 transcription. Mutants in gene A were heterogenous. Some lacked the mRNA completely; others were inducible for it; while still others (subgroup IV) had high levels even when they were grown without TCDD. These results suggest strongly that gene A is the structural gene for cytochrome P1-450. When subgroup IV mutants were cultured together with wild-type cells, they failed to express P1-450 mRNA in the absence of TCDD treatment. These cells probably accumulate an inducer that can be metabolized by aryl hydrocarbon hydroxylase. The inducer did not appear to be a component of the medium and therefore may be an endogenous ligand of the Ah receptor.

Simplified gentamicin dosing in neonates: a time- and cost-efficient approach

A nomogram-based method for monitoring gentamicin therapy in neonates was developed and evaluated prospectively. Gentamicin dosage adjustment, based on analysis of a single blood sample collected between 8 and 12 hours after dose administration, resulted in satisfactory serum levels in 79% of the neonates. When compared to dosage adjustment methods requiring multiple blood samples, the nomogram method is a cost-effective and time-efficient technique for screening the appropriateness of gentamicin dosages in neonates.

Herpes simplex virus adsorption to and survival within placental lymphoid populations

Neonatal herpes simplex virus (HSV) infections are frequently characterized by widespread dissemination and high morbidity and mortality. To assess the potential role of the lymphocyte in permitting or promoting dissemination of HSV, we studied lymphoid populations of placental and adult blood with respect to HSV survival. Adsorption of HSV to the lymphocyte surface did not differ between placental and adult cells. Placental blood permitted greater survival of HSV than adult lymphocytes. T-cell-enriched lymphocytes appeared to be slightly more permissive than T-cell-depleted lymphocytes, but these differences were not statistically significant and apparently less than adult-placental blood differences. These findings lend support to the hypothesis that intracellular changes common to various neonatal lymphoid populations may permit or promote dissemination of HSV in the neonate.

Synthesis and degradation of hepatic metallothionein in mice differing in susceptibility to cadmium mortality

We have confirmed the observations of Tsunoo et al. (Toxicol. Lett. 4:253, 1979) that (a) DBA/2 mice are resistant to cadmium mortality than C3H mice and (b) DBA/2 mice accumulate more 109Cd into hepatic metallothionein than do C3H mice in response to an injection of 30 mumol CdCl2/kg, a dose of CdCl2 which is lethal to C3H mice. We now report, using a nonlethal dose of 8 mumol CdCl2/kg, that the rates of both the synthesis and the degradation of cadmium-induced hepatic metallothionein are increased in C3H mice. The rate of metallothionein synthesis, measured 6 hr after cadmium administration and expressed as the percentage of injected [35S]cysteine incorporated into metallothionein/g liver, was 0.33 +/- 0.04% (SD) in C3H mice, compared to 0.19 +/- 0.06% in DBA/2 mice (significantly different rates by Students' t test. P less than 0.01). Also, at this dose, hepatic 35S-labeled metallothionein was degraded with a half-life of 22.5 +/- 0.7 hr in C3H mice, compared to 30.1 +/- 2.5 hr in DBA/2 mice (significantly different half-lives by F test, within 95% confidence limits). The increased accumulation of metallothionein in resistant DBA/2 mice compared to sensitive C3H mice after cadmium exposure appears to be due primarily to a difference in metallothionein degradation, rather than metallothionein synthesis.

Metallothionein synthesis in foetal, neonatal and maternal rat liver

The synthesis of hepatic metallothionein relative to other cytosol proteins was measured by [35S]cysteine incorporation in foetal, neonatal and pregnant rats. The relative rate of hepatic metallothionein synthesis reached a maximum in foetal liver on days 18-21 of gestation. Metallothionein synthesis then declined until weaning, when adult levels were established. The rate of metallothionein synthesis was greater in pregnant rats at term than in nulliparous rats. To determine if circulating inducing agents could play a role in the regulation of metallothionein synthesis in foetal liver we treated pregnant rats with inducers at a time prior to the normal rise in foetal liver metallothionein synthesis. Injections of copper, cadmium or hydrocortisone to 17-day-pregnant dams failed to induce foetal metallothionein synthesis. In contrast, zinc injection to the dam was an effective inducer in the foetuses. Maternal laparotomy (performed to expose the foetus for direct injection of inducers) induced foetal metallothionein synthesis. Metallothionein synthesis in the livers of 17-day-gestation dams was induced by all metal injections and laparotomy but, surprisingly, not by hydrocortisone injection. Maternal adrenalectomy did not influence the subsequent normal elevation in foetal or maternal metallothionein synthesis. These results, in conjunction with previous reports, suggest that mobilization of zinc in serum during late gestation may regulate foetal and maternal changes in metallothionein synthesis.

Levels of metallothionein messenger RNA in foetal, neonatal and maternal rat liver

We have used translation in vitro of hepatic polyadenylated RNA to characterize the levels of metallothionein mRNA in foetal, neonatal, pregnant and nulliparous rats. The translation products of foetal hepatic metallothionein mRNA increased relative to other mRNA translation products from day 18 of gestation to birth and attained a maximum, maintained throughout suckling, which is tenfold above 17-day foetal hepatic levels and fourfold above adult levels. Maternal liver metallothionein mRNA decreased fivefold between 17 days and 20 days of gestation, rose sharply immediately before birth, and was low throughout lactation.

Molecular cloning of the rat metallothionein 1 (MT-1) mRNA sequence

Starting with liver mRNA from cadmium chloride-treated rats, we constructed a cDNA library. A mouse metallothionein 1 (MT-1) cDNA restriction fragment (Durnam et al. 1980) was used as a hybridization probe to isolate from this library a cDNA (p2A10) which is a nearly complete copy of the rat MT-1 mRNA sequence. Southern analysis of rat DNA, using p2A10 as a probe, together with the screening of a rat genomic library, reveal that the rat MT-1 gene belongs to a family of related sequences. The rat MT-1 gene is inducible both by glucocorticoids and by metals.

Induction of metallothionein mRNA in HeLa cells by dexamethasone and by heavy metals

Synthesis of metallothionein, a cysteine-rich heavy metal binding protein, is induced in cultured HeLa cells both by the heavy metals Cd2+, Zn2+ and Cu2+, and by the glucocorticoid hormone dexamethasone. The accumulation of [35S]cysteine-labeled metallothionein and the amount of translatable metallothionein mRNA show identical concentration dependences in response to dexamethasone treatment and in response to zinc exposure. Induction of translatable metallothionein mRNA is rapid in response to both the metal and glucocorticoid inducers. Increased synthesis and accumulation of metallothionein in response to either metal or glucocorticoid exposure is regulated by the level of translatable metallothionein mRNA in HeLa cells.

Infections with Legionella pneumophila in children

To learn the role of Legionella pneumophila, the agent of Legionnaires' disease, in childhood illness, a prospective study was conducted among 52 children younger than four years of age with acute disease of the lower respiratory tract. Viral, mycoplasmal, and bacterial cultures and acute- and convalescent-phase sera were obtained during 64 episodes of acute illness; additional sera were drawn annually for three to five years. On the basis of serologic evidence, none of the acute episodes appeared to be due to L. pneumophila serogroup 1 or 2. However, examination of annual serum specimens showed that 27 (52%) of the children had rises in titer of indirect immunofluorescent antibody (a fourfold or greater rise to a reciprocal titer of greater than or equal to 128). Most rises in titer were in response to the serogroup 2 antigen. These results suggest that L. pneumophila is not a common cause of acute respiratory disease in early childhood in the study area but that children are frequently exposed to the organism. Alternatively, the serologic responses might be to unrelated cross-reacting microorganisms.

Metallothionein mRNA induction in HeLa cells in response to zinc or dexamethasone is a primary induction response

Metallothioneins (MTs) are low molecular weight, heavy metal binding proteins unique in their high cysteine content and high affinity for Zn2+, Cd2+, Hg2+, Ag2+ and Cu2+ (refs 1--3). The synthesis of MTs is induced by zinc or cadmium in the liver and kidney and in cultured cells. More recently MT induction by the steroid hormone dexamethasone (Dex) has been demonstrated in HeLa cells and adrenalectomized rats. Because glucocorticoid hormones lead to an intracellular accumulation of zinc, the question arises of whether the induction of MT gene expression by steroids is a 'primary induction response' (ref. 18), or due to elevated intracellular Zn2+. The glucocorticoid-induced transport of Zn2+ is dependent on concurrent protein synthesis. We now show that, in contrast to glucocorticoid-stimulated Zn2+ transport, the Zn2+ and Dex induction of translatable MT-mRNA is independent of concomitant protein synthesis but not RNA synthesis; that is, MT induction by either agent is a primary induction response.

Partial purification, characterization and translation in vitro of rat liver metallothionein messenger ribonucleic acid

Poly(A)+ (polyadenylated) mRNA coding for metallothioneins was purified 13-fold from rat liver polyribosomes and was identified by its ability to direct the biosynthesis of these proteins in a wheat-germ cell-free system. The carboxymethylated products of the protein-synthesizing system in vitro were analysed with sodium dodecyl sulphate/20% polyacrylamide-gel electrophoresis. The labelled compounds [3H]serine and [35S]cysteine were incorporated at high specific radioactivity into proteins that co-migrated with authentic metallothioneins. No [3H]leucine incorporation was found, in agreement with the amino acid composition of the metallothioneins. Metallothionein mRNA had a sedimentation coefficient of 9 S and carried a maximum of four ribosomes. At 5 h after a subcutaneous injection of ZnCl2 or CdCl2 (10 mumol/kg body wt.), the amount of this mRNA increased approx. 2- and 4-fold respectively, on the basis of translation in vitro. The increase in metallothionein mRNA (defined by translation in the wheat-germ system) was transient and, after CdCl2 treatment, fell back to control values by 17 h. Metallothioneins constituted a maximum of 0.8% of the total protein products synthesized in the wheat-germ system by total mRNA isolated from rat liver after CdCl2 treatment.

Turnover of metallothioneins in rat liver

Two electrophoretically distinguishable metallothioneins were isolated from the livers of Cd2+-treated rats and had thiol group/metal ratios of 3:1, a total metal content, in each of these proteins, of 3.6 atoms of Cd2+ + 2.4 atoms of Zn2+/molecule and 4.2 atoms of Cd2+ + 2.8 atoms of Zn2+/molecule and respective apoprotein mol.wts. of 5844 and 6251. Studies with 1 h pulse labels of [3H]cysteine, given after a single injection of ZnCl2 or CdCl2, showed that these metals stimulated radioactive isotope incorporation into the metallothioneins over the control value by 10- and 15-fold respectively. This stimulation was maximal at 4 h after a single CdCl2 injection and decreased to control values by 16 h, suggesting that either a translational event is responding to free intracellular Cd2+ or a short-lived mRNA is being produced or stabilized in response to the metal treatment. In rats chronically exposed to CdCl2, the metallothioneins increased to 0.2% of the liver wet weight from a control value of 2--4 mumol/kg of liver, with a maximum rate of accumulation of 2--3 mumol/h per kg of liver. The turnover of these proteins in control animals was 0.3--0.6 mumoles/h per kg of liver, measured by the rate of disappearance of 203Hg2+, which binds irreversibly to the metallothioneins. Pretreatment with CdCl2 completely stopped the rapid 203Hg turnover observed in untreated animals. Unlike CdCl2, treatment with ZnCl2 increased the concentration of metallothioneins to a new steady-state pool, 11 mumole/kg of liver, after 10 h. The increase in the zinc-thionein pool by exposure to ZnCl2 in vivo was determined to be primarily due to a stimulation of metallothionein biosynthesis.

Optical spectra and electronic structure of flavine mononucleotide in flavodoxin crystals

The polarized single-crystal absorption spectra of the oxidized and semiquinone forms of flavodoxin from Clostridium MP have been measured with a double beam recording microspectrophotometer. The spectra establish that the radical species in the crystal is the neutral (blue) falvine semiquinone. Combination of the spectra reported here with polarization data from previous fluorescence and stretched-film studies provides transition moment directions for the first two phi-phi transitions of the oxidized form. Predictions of molecular orbital theory are in good agreement with these experimental directions. The crystal spectra of the semiquinone indicate that the two lowest frequency transitions have the same detailed orbital origin as the corresponding transitions of the oxidized form; in the semiquinone these transitions appear at lower frequency, are closer together, and, as predicted from detailed considerations of transition probabilities, exhibit approximately half the absorption intensity. Our hypothesis of a common orbital origin suggests that semiquinone formation takes place by the addition of an electron to the lowest empty phi orbital of the oxidized form without any gross electronic rearrangement.