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Slater R, Eccleston C, Williams A, Vincent K, Linde M, Hurley M, Laughey W. Reframing pain: the power of individual and societal factors to enhance pain treatment. Pain Rep 2024; 9:e1161. [PMID: 38655237 PMCID: PMC11037735 DOI: 10.1097/pr9.0000000000001161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/27/2024] [Indexed: 04/26/2024] Open
Abstract
The effectiveness of analgesics can be increased if synergistic behavioural, psychological, and pharmacological interventions are provided within a supportive environment.
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Affiliation(s)
- Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | - Amanda Williams
- Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
| | - Katy Vincent
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Mattias Linde
- Norwegian Centre for Headache Research (NorHEAD), Trondheim, Norway
- Regional Migraine Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Michael Hurley
- Population Health Research Institute, St George's University of London, London, United Kingdom
| | - William Laughey
- Health Professions Education Unit, Hull York Medical School, University of York, York, United Kingdom
- Reckitt Benckiser Healthcare Ltd, Dansom Lane South, Kingston Upon Hull, United Kingdom
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Bhatt A, Monk V, Bhatti A, Eiden AL, Hermany L, Hansen N, Connolly MP, Baxter L, Vanderslott S, Mitrovich R, Slater R. Identifying factors that can be used to assess a country's readiness to deploy a new vaccine or improve uptake of an underutilised vaccine: a scoping review. BMJ Open 2024; 14:e080370. [PMID: 38719292 PMCID: PMC11086410 DOI: 10.1136/bmjopen-2023-080370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/28/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVES Identifying whether a country is ready to deploy a new vaccine or improve uptake of an existing vaccine requires knowledge of a diverse range of interdependent, context-specific factors. This scoping review aims to identify common themes that emerge across articles, which include tools or guidance that can be used to establish whether a country is ready to deploy a new vaccine or increase uptake of an underutilised vaccine. DESIGN Scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines. DATA SOURCES Embase, CINAHL, Cochrane Library, Google Scholar, MEDLINE, PsycINFO and Web of Science were searched for articles published until 9 September 2023. Relevant articles were also identified through expert opinion. ELIGIBILITY CRITERIA Articles published in any year or language that included tools or guidance to identify factors that influence a country's readiness to deploy a new or underutilised vaccine. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened records and performed data extraction. Findings were synthesised by conducting a thematic analysis. RESULTS 38 articles met our inclusion criteria; these documents were created using methodologies including expert review panels and Delphi surveys and varied in terms of content and context-of-use. 12 common themes were identified relevant to a country's readiness to deploy a new or underutilised vaccine. These themes were as follows: (1) legal, political and professional consensus; (2) sociocultural factors and communication; (3) policy, guidelines and regulations; (4) financing; (5) vaccine characteristics and supply logistics; (6) programme planning; (7) programme monitoring and evaluation; (8) sustainable and integrated healthcare provision; (9) safety surveillance and reporting; (10) disease burden and characteristics; (11) vaccination equity and (12) human resources and training of professionals. CONCLUSIONS This information has the potential to form the basis of a globally applicable evidence-based vaccine readiness assessment tool that can inform policy and immunisation programme decision-makers.
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Affiliation(s)
- Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Vaneesha Monk
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Amanda L Eiden
- Center for Observational and Real-World Evidence (CORE), Merck & Co Inc, North Wales, Pennsylvania, USA
| | | | | | | | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
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Jackson SS, Lee JJ, Jackson WM, Price JC, Beers SR, Berkenbosch JW, Biagas KV, Dworkin RH, Houck CS, Li G, Smith HAB, Ward DS, Zimmerman KO, Curley MAQ, Horvat CM, Huang DT, Pinto NP, Salorio CF, Slater R, Slomine BS, West LL, Wypij D, Yeates KO, Sun LS. Sedation Research in Critically Ill Pediatric Patients: Proposals for Future Study Design From the Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research IV Workshop. Pediatr Crit Care Med 2024; 25:e193-e204. [PMID: 38059739 DOI: 10.1097/pcc.0000000000003426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES Sedation and analgesia for infants and children requiring mechanical ventilation in the PICU is uniquely challenging due to the wide spectrum of ages, developmental stages, and pathophysiological processes encountered. Studies evaluating the safety and efficacy of sedative and analgesic management in pediatric patients have used heterogeneous methodologies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) IV hosted a series of multidisciplinary meetings to establish consensus statements for future clinical study design and implementation as a guide for investigators studying PICU sedation and analgesia. DESIGN Twenty-five key elements framed as consensus statements were developed in five domains: study design, enrollment, protocol, outcomes and measurement instruments, and future directions. SETTING A virtual meeting was held on March 2-3, 2022, followed by an in-person meeting in Washington, DC, on June 15-16, 2022. Subsequent iterative online meetings were held to achieve consensus. SUBJECTS Fifty-one multidisciplinary, international participants from academia, industry, the U.S. Food and Drug Administration, and family members of PICU patients attended the virtual and in-person meetings. Participants were invited based on their background and experience. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Common themes throughout the SCEPTER IV consensus statements included using coordinated multidisciplinary and interprofessional teams to ensure culturally appropriate study design and diverse patient enrollment, obtaining input from PICU survivors and their families, engaging community members, and using developmentally appropriate and validated instruments for assessments of sedation, pain, iatrogenic withdrawal, and ICU delirium. CONCLUSIONS These SCEPTER IV consensus statements are comprehensive and may assist investigators in the design, enrollment, implementation, and dissemination of studies involving sedation and analgesia of PICU patients requiring mechanical ventilation. Implementation may strengthen the rigor and reproducibility of research studies on PICU sedation and analgesia and facilitate the synthesis of evidence across studies to improve the safety and quality of care for PICU patients.
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Affiliation(s)
- Shawn S Jackson
- Departments of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Jennifer J Lee
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - William M Jackson
- Department of Anesthesiology, Montefiore Medical Center, New York, NY
| | - Jerri C Price
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Sue R Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - John W Berkenbosch
- Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, KY
| | - Katherine V Biagas
- Department of Pediatrics, The Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Robert H Dworkin
- Departments of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY
| | - Constance S Houck
- Departments of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Heidi A B Smith
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Denham S Ward
- Departments of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY
| | | | - Martha A Q Curley
- School of Nursing, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher M Horvat
- Departments of Critical Care Medicine, Pediatrics and Biomedical Informatics, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - David T Huang
- Departments of Critical Care Medicine, Emergency Medicine, Clinical and Translational Science, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Neethi P Pinto
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cynthia F Salorio
- Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebeccah Slater
- Department of Paediatric Neuroscience, University of Oxford, Oxford, United Kingdom
| | - Beth S Slomine
- Center for Brain Injury Recovery, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Leanne L West
- International Children's Advisory Network, Atlanta, GA
| | - David Wypij
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Keith O Yeates
- Department of Psychology, University of Calgary, Calgary, AB, Canada
| | - Lena S Sun
- Departments of Pediatrics and Anesthesiology, Columbia University Irving Medical Center, New York, NY
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Hauck AGV, van der Vaart M, Adams E, Baxter L, Bhatt A, Crankshaw D, Dhami A, Evans Fry R, Freire MBO, Hartley C, Mansfield RC, Marchant S, Monk V, Moultrie F, Peck M, Robinson S, Yong J, Poorun R, Cobo MM, Slater R. Effect of parental touch on relieving acute procedural pain in neonates and parental anxiety (Petal): a multicentre, randomised controlled trial in the UK. Lancet Child Adolesc Health 2024; 8:259-269. [PMID: 38373429 DOI: 10.1016/s2352-4642(23)00340-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/08/2023] [Accepted: 12/11/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND Touch interventions such as massage and skin-to-skin contact relieve neonatal pain. The Parental touch trial (Petal) aimed to assess whether parental stroking of their baby before a clinically required heel lance, at a speed of approximately 3 cm/s to optimally activate C-tactile nerve fibres, provides effective pain relief. METHODS Petal is a multicentre, randomised, parallel-group interventional superiority trial conducted in the John Radcliffe Hospital (Oxford University Hospitals NHS Foundation Trust, Oxford, UK) and the Royal Devon and Exeter Hospital (Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK). Neonates without neurological abnormalities who were born at 35 weeks gestational age or more and required a blood test via a heel lance in the first week of life were randomly assigned (1:1) to receive parental touch for 10 s either before (intervention group) or after (control group) the clinically required heel lance. Randomisation was managed at the Oxford site using a web-based minimisation algorithm with allocation concealment. The primary outcome measure was the magnitude of noxious-evoked brain activity in response to the heel lance measured with electroencephalography (EEG). Secondary outcome measures were Premature Infant Pain Profile-Revised (PIPP-R) score, development of tachycardia, and parental anxiety score. For all outcomes, the per-protocol effect was estimated via complier average causal effect analysis on the full analysis set. The trial is registered on ISRCTN (ISRCTN14135962) and ClinicalTrials.gov (NCT04901611). FINDINGS Between Sept 1, 2021, and Feb 7, 2023, 159 parents were approached to participate in the study, and 112 neonates were included. 56 neonates were randomly assigned to the intervention group of parental stroking before the heel lance and 56 to the control group of parental stroking after the heel lance. The mean of the magnitude of the heel lance-evoked brain activity was 0·85 arbitrary units (a.u.; SD 0·70; n=39; a scaled magnitude of 1 a.u. represents the expected mean response to a heel lance in term-aged neonates) in the intervention group and 0·91 a.u. (SD 0·76; n=43) in the control group. Therefore, the primary outcome did not differ significantly between groups, with a mean difference of -0·11 a.u. (lower in intervention group; SD 0·77; 95% CI -0·42 to 0·20; p=0·38; n=82). No significant difference was observed across secondary outcomes. The PIPP-R difference in means was 1·10 (higher in intervention group, 95% CI -0·42 to 2·61; p=0·15; n=100); the odds ratio of becoming tachycardic was 2·08 (95% CI 0·46 to 9·46; p=0·34, n=105) in the intervention group with reference to the control group; and the difference in parental State-Trait Anxiety Inventory-State score was -0·44 (higher in control group; SD 6·85; 95% CI -2·91 to 2·02; p=0·72; n=106). One serious adverse event (desaturation) occurred in a neonate randomly assigned to the control group, which was not considered to be related to the study. INTERPRETATION Parental stroking delivered at an optimal speed to activate C-tactile fibres for a duration of 10 s before the painful procedure did not significantly change neonates' magnitude of pain-related brain activity, PIPP-R score, or development of tachycardia. The trial highlighted the challenge of translating an experimental researcher-led tactile intervention into a parent-led approach, and the value of involving parents in their baby's pain management. FUNDING Wellcome Trust and Bliss.
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Affiliation(s)
| | | | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Amraj Dhami
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | | | - Roshni C Mansfield
- Department of Paediatrics, University of Oxford, Oxford, UK; Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon Marchant
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Vaneesha Monk
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Mariska Peck
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Jean Yong
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ravi Poorun
- University of Exeter Medical School, University of Exeter, Exeter, UK; Department of Paediatrics, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Maria M Cobo
- Department of Paediatrics, University of Oxford, Oxford, UK; Universidad San Francisco de Quito USFQ, Colegio de Ciencias Biologicas y Ambientales, Quito, Ecuador
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK.
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van der Vaart M, Hauck AGV, Mansfield R, Adams E, Bhatt A, Cobo MM, Crankshaw D, Dhami A, Hartley C, Monk V, Evans Fry R, Moultrie F, Robinson S, Yong J, Poorun R, Baxter L, Slater R. Parental experience of neonatal pain research while participating in the Parental touch trial (Petal). Pain 2024:00006396-990000000-00510. [PMID: 38284396 DOI: 10.1097/j.pain.0000000000003177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/10/2023] [Indexed: 01/30/2024]
Abstract
ABSTRACT Parental involvement in neonatal comfort care is a core component of family-centred care. Yet, parents experience a range of positive and negative feelings when providing pain-relieving interventions for their infants. Parents of infants who participated in the Parental touch trial (Petal), a multicentre randomised controlled trial investigating the impact of gentle parental touch on neonatal pain, were asked to complete an anonymous survey. This survey aimed to (1) explore parent-reported motivations in deciding to participate in the Petal trial; (2) understand parent-reported experiences related to trial participation; (3) understand parents' willingness to participate in future studies; and (4) evaluate parent-reported feelings while they were delivering a gentle touch intervention either before or after a clinically necessary blood test. One hundred six parents (1 parent per infant) took part in the survey. Primary motivators for participation were altruistic. Parents most frequently reported that they wanted their child to take part in the research because it has a potential benefit to babies in the future and because they wanted to improve scientific understanding. Parents reported that providing gentle touch to their children during painful procedures was associated with positive emotions, such as feeling "useful" (64%) and "reassured" (53%). Furthermore, nearly all parents (98%) were pleased to have participated in the Petal trial and would consider, or maybe consider, participating in further research studies. These results underscore the importance of structuring trials around parental involvement and providing opportunities for parents to be involved in providing comfort to their infants during necessary painful clinical procedures.
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Affiliation(s)
| | | | - Roshni Mansfield
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Maria M Cobo
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Colegio de Ciencias Biologicas y Ambientales, Universidad San Francisco de Quito USFQ, Quito, Ecuador
| | - Daniel Crankshaw
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Amraj Dhami
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Vaneesha Monk
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Shellie Robinson
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Jean Yong
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Ravi Poorun
- University of Exeter Medical School, Exeter, United Kingdom
- Children's Services, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
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Zandvoort CS, van der Vaart M, Robinson S, Usman F, Schmidt Mellado G, Evans Fry R, Worley A, Adams E, Slater R, Baxter L, de Vos M, Hartley C. Sensory event-related potential morphology predicts age in premature infants. Clin Neurophysiol 2024; 157:61-72. [PMID: 38064929 DOI: 10.1016/j.clinph.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/18/2023] [Accepted: 11/04/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE We investigated whether sensory-evoked cortical potentials could be used to estimate the age of an infant. Such a model could be used to identify infants who deviate from normal neurodevelopment. METHODS Infants aged between 28- and 40-weeks post-menstrual age (PMA) (166 recording sessions in 96 infants) received trains of visual and tactile stimuli. Neurodynamic response functions for each stimulus were derived using principal component analysis and a machine learning model trained and validated to predict infant age. RESULTS PMA could be predicted accurately from the magnitude of the evoked responses (training set mean absolute error and 95% confidence intervals: 1.41 [1.14; 1.74] weeks,p = 0.0001; test set mean absolute error: 1.55 [1.21; 1.95] weeks,p = 0.0002). Moreover, we show that their predicted age (their brain age) is correlated with a measure known to relate to maturity of the nervous system and is linked to long-term neurodevelopment. CONCLUSIONS Sensory-evoked potentials are predictive of age in premature infants and brain age deviations are related to biologically and clinically meaningful individual differences in nervous system maturation. SIGNIFICANCE This model could be used to detect abnormal development of infants' response to sensory stimuli in their environment and may be predictive of neurodevelopmental outcome.
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Affiliation(s)
- Coen S Zandvoort
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | - Shellie Robinson
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Fatima Usman
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Alan Worley
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Eleri Adams
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Maarten de Vos
- Department of Electrical Engineering (ESAT), STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Leuven, Belgium; Department of Development and Regeneration, University Hospitals Leuven, Child Neurology, KU Leuven, Leuven, Belgium
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom.
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Slater R, Iyer KK. Charting a functional brain growth curve to track early neurodevelopment. Lancet Digit Health 2023; 5:e853-e854. [PMID: 37940490 DOI: 10.1016/s2589-7500(23)00207-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/10/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Rebeccah Slater
- Department of Paediatrics and Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK.
| | - Kartik K Iyer
- Brain Modelling Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia
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Sturgess GR, Garner JP, Slater R. Abdominoperineal Resection in the United Kingdom: a Case against Centralisation. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Warrington S, Thompson E, Bastiani M, Dubois J, Baxter L, Slater R, Jbabdi S, Mars RB, Sotiropoulos SN. Concurrent mapping of brain ontogeny and phylogeny within a common space: Standardized tractography and applications. Sci Adv 2022; 8:eabq2022. [PMID: 36260675 PMCID: PMC9581484 DOI: 10.1126/sciadv.abq2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/31/2022] [Indexed: 06/16/2023]
Abstract
Developmental and evolutionary effects on brain organization are complex, yet linked, as evidenced by the correspondence in cortical area expansion across these vastly different time scales. However, it is still not possible to study concurrently the ontogeny and phylogeny of cortical areal connections, which is arguably more relevant to brain function than allometric measurements. Here, we propose a novel framework that allows the integration of structural connectivity maps from humans (adults and neonates) and nonhuman primates (macaques) onto a common space. We use white matter bundles to anchor the common space and use the uniqueness of cortical connection patterns to these bundles to probe area specialization. This enabled us to quantitatively study divergences and similarities in connectivity over evolutionary and developmental scales, to reveal brain maturation trajectories, including the effect of premature birth, and to translate cortical atlases between diverse brains. Our findings open new avenues for an integrative approach to imaging neuroanatomy.
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Affiliation(s)
- Shaun Warrington
- Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Elinor Thompson
- Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Centre for Medical Image Computing, Department of Computer Science, University College London, London, UK
| | - Matteo Bastiani
- Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jessica Dubois
- Université Paris Cité, Inserm, NeuroDiderot Unit, Paris, France
- University Paris-Saclay, CEA, NeuroSpin, Gif-sur-Yvette, France
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Saad Jbabdi
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Rogier B. Mars
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
- Donders Institute for Brain, Cognition, and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Stamatios N. Sotiropoulos
- Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Queens Medical Centre, Nottingham, UK
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Ho C, Wong S, Hatswell A, Slater R, Vioix H, Chouaid C. 1180P Treatment patterns and progression-free survival in MET exon 14 (METex14) skipping advanced non-small cell lung cancer (aNSCLC) in real-world clinical practice. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.1303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Cobo MM, Moultrie F, Hauck AGV, Crankshaw D, Monk V, Hartley C, Evans Fry R, Robinson S, van der Vaart M, Baxter L, Adams E, Poorun R, Bhatt A, Slater R. Multicentre, randomised controlled trial to investigate the effects of parental touch on relieving acute procedural pain in neonates (Petal). BMJ Open 2022; 12:e061841. [PMID: 36250332 PMCID: PMC9301810 DOI: 10.1136/bmjopen-2022-061841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Newborn infants routinely undergo minor painful procedures as part of postnatal care, with infants born sick or premature requiring a greater number of procedures. As pain in early life can have long-term neurodevelopmental consequences and lead to parental anxiety and future avoidance of interventions, effective pain management is essential. Non-pharmacological comfort measures such as breastfeeding, swaddling and sweet solutions are inconsistently implemented and are not always practical or effective in reducing the transmission of noxious input to the brain. Stroking of the skin can activate C-tactile fibres and reduce pain, and therefore could provide a simple and safe parent-led intervention for the management of pain. The trial aim is to determine whether parental touch prior to a painful clinical procedure provides effective pain relief in neonates. METHODS AND ANALYSIS This is a multicentre randomised controlled trial. A total of 112 neonates born at 35 weeks' gestation or more requiring a blood test in the first week of life will be recruited and randomised to receive parental stroking either preprocedure or postprocedure. We will record brain activity (EEG), cardiac and respiratory dynamics, oxygen saturation and facial expression to provide proxy pain outcome measures. The primary outcome will be the reduction of noxious-evoked brain activity in response to a heel lance. Secondary outcomes will be a reduction in clinical pain scores (Premature Infant Pain Profile-Revised), postprocedural tachycardia and parental anxiety. ETHICS AND DISSEMINATION The study has been approved by the London-South East Research Ethics Committee (ref: 21/LO/0523). The results will be widely disseminated through peer-reviewed publications, international conferences and via our partner neonatal charities Bliss and Supporting the Sick Newborn And their Parents (SSNAP). If the parental tactile intervention is effective, recommendations will be submitted via the National Health Service clinical guideline adoption process. STUDY STATUS Commenced September 2021. TRIAL REGISTRATION NUMBER NCT04901611; 14 135 962.
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Affiliation(s)
- Maria M Cobo
- Department of Paediatrics, University of Oxford, Oxford, UK
- Colegio de Ciencias Biologicas y Ambientales, Universidad San Francisco de Quito USFQ, Quito, Ecuador
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | | | - Vaneesha Monk
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | | | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ravi Poorun
- Children's Services, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
- College of Medicine & Health, University of Exeter, Exeter, UK
| | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford, UK
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12
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Geller M, Slater R, Graham‐Williams E, Wolf T, Spriet M, Berryhill E, Skipper L, Aleman M. Imaging of equine septic discospondylitis using MRI, CT and post‐mortem radiographs. EQUINE VET EDUC 2022. [DOI: 10.1111/eve.13620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M. Geller
- University of California Davis California USA
- The William R. Pritchard Veterinary Medical Teaching Hospital Davis California USA
| | - R. Slater
- University of California Davis California USA
- The William R. Pritchard Veterinary Medical Teaching Hospital Davis California USA
| | - E. Graham‐Williams
- University of California Davis California USA
- The William R. Pritchard Veterinary Medical Teaching Hospital Davis California USA
| | - T. Wolf
- University of California Davis California USA
- The William R. Pritchard Veterinary Medical Teaching Hospital Davis California USA
| | - M. Spriet
- University of California Davis California USA
- The William R. Pritchard Veterinary Medical Teaching Hospital Davis California USA
| | - E. Berryhill
- University of California Davis California USA
- The William R. Pritchard Veterinary Medical Teaching Hospital Davis California USA
| | - L. Skipper
- University of California Davis California USA
- The William R. Pritchard Veterinary Medical Teaching Hospital Davis California USA
| | - M. Aleman
- University of California Davis California USA
- The William R. Pritchard Veterinary Medical Teaching Hospital Davis California USA
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13
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van der Vaart M, Hartley C, Baxter L, Mellado GS, Andritsou F, Cobo MM, Fry RE, Adams E, Fitzgibbon S, Slater R. Premature Infants Display Discriminable Behavioral, Physiological, and Brain Responses to Noxious and Nonnoxious Stimuli. Cereb Cortex 2021; 32:3799-3815. [PMID: 34958675 PMCID: PMC9433423 DOI: 10.1093/cercor/bhab449] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 11/14/2022] Open
Abstract
Pain assessment in preterm infants is challenging as behavioral, autonomic, and neurophysiological measures of pain are reported to be less sensitive and specific than in term infants. Understanding the pattern of preterm infants’ noxious-evoked responses is vital to improve pain assessment in this group. This study investigated the discriminability and development of multimodal noxious-evoked responses in infants aged 28–40 weeks postmenstrual age. A classifier was trained to discriminate responses to a noxious heel lance from a nonnoxious control in 47 infants, using measures of facial expression, brain activity, heart rate, and limb withdrawal, and tested in two independent cohorts with a total of 97 infants. The model discriminates responses to the noxious from the nonnoxious procedure with an overall accuracy of 0.76–0.84 and an accuracy of 0.78–0.79 in the 28–31-week group. Noxious-evoked responses have distinct developmental patterns. Heart rate responses increase in magnitude with age, while noxious-evoked brain activity undergoes three distinct developmental stages, including a previously unreported transitory stage consisting of a negative event-related potential between 30 and 33 weeks postmenstrual age. These findings demonstrate that while noxious-evoked responses change across early development, infant responses to noxious and nonnoxious stimuli are discriminable in prematurity.
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Affiliation(s)
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | | | | | - Maria M Cobo
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK.,Colegio de Ciencias Biologicas y Ambientales, Universidad San Francisco de Quito USFQ, Quito EC170901, Ecuador
| | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Sean Fitzgibbon
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
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14
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Adjei T, Purdy R, Jorge J, Adams E, Buckle M, Evans Fry R, Green G, Patel C, Rogers R, Slater R, Tarassenko L, Villarroel M, Hartley C. New method to measure interbreath intervals in infants for the assessment of apnoea and respiration. BMJ Open Respir Res 2021; 8:8/1/e001042. [PMID: 34893521 PMCID: PMC8666899 DOI: 10.1136/bmjresp-2021-001042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/18/2021] [Indexed: 11/23/2022] Open
Abstract
Background Respiratory disorders, including apnoea, are common in preterm infants due to their immature respiratory control compared with term-born infants. However, our inability to accurately measure respiratory rate in hospitalised infants results in unreported episodes of apnoea and an incomplete picture of respiratory activity. Methods We develop, validate and use a novel algorithm to identify interbreath intervals (IBIs) and apnoeas in preterm infants. In 42 preterm infants (1600 hours of recordings), we assess IBIs from the chest electrical impedance pneumograph using an adaptive amplitude threshold for the detection of breaths. The algorithm is refined by comparing its accuracy with clinically observed breaths and pauses in breathing. We develop an automated classifier to differentiate periods of true apnoea from artefactually low amplitude signal. We assess the performance of this algorithm in the detection of morphine-induced respiratory depression. Finally, we use the algorithm to investigate whether retinopathy of prematurity (ROP) screening alters the IBI distribution. Results Individual breaths were detected with a false-positive rate of 13% and a false-negative rate of 12%. The classifier identified true apnoeas with an accuracy of 93%. As expected, morphine caused a significant shift in the IBI distribution towards longer IBIs. Following ROP screening, there was a significant increase in pauses in breathing that lasted more than 10 s (t-statistic=1.82, p=0.023). This was not reflected by changes in the monitor-derived respiratory rate and no episodes of apnoea were recorded in the medical records. Conclusions We show that our algorithm offers an improved method for the identification of IBIs and apnoeas in preterm infants. Following ROP screening, increased respiratory instability can occur even in the absence of clinically significant apnoeas. Accurate assessment of infant respiratory activity is essential to inform clinical practice.
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Affiliation(s)
- Tricia Adjei
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ryan Purdy
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - João Jorge
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Miranda Buckle
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Chetan Patel
- Department of Ophthalmology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Rogers
- Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Lionel Tarassenko
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Mauricio Villarroel
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
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15
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Schmidt Mellado G, Pillay K, Adams E, Alarcon A, Andritsou F, Cobo MM, Evans Fry R, Fitzgibbon S, Moultrie F, Baxter L, Slater R. The impact of premature extrauterine exposure on infants' stimulus-evoked brain activity across multiple sensory systems. Neuroimage Clin 2021; 33:102914. [PMID: 34915328 PMCID: PMC8683775 DOI: 10.1016/j.nicl.2021.102914] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/10/2021] [Accepted: 12/09/2021] [Indexed: 11/03/2022]
Abstract
Prematurity can result in widespread neurodevelopmental impairment, with the impact of premature extrauterine exposure on brain function detectable in infancy. A range of neurodynamic and haemodynamic functional brain measures have previously been employed to study the neurodevelopmental impact of prematurity, with methodological and analytical heterogeneity across studies obscuring how multiple sensory systems are affected. Here, we outline a standardised template analysis approach to measure evoked response magnitudes for visual, tactile, and noxious stimulation in individual infants (n = 15) using EEG. By applying these templates longitudinally to an independent cohort of very preterm infants (n = 10), we observe that the evoked response template magnitudes are significantly associated with age-related maturation. Finally, in a cross-sectional study we show that the visual and tactile response template magnitudes differ between a cohort of infants who are age-matched at the time of study but who differ according to whether they are born during the very preterm or late preterm period (n = 10 and 8 respectively). These findings demonstrate the significant impact of premature extrauterine exposure on brain function and suggest that prematurity can accelerate maturation of the visual and tactile sensory system in infants born very prematurely. This study highlights the value of using a standardised multi-modal evoked-activity analysis approach to assess premature neurodevelopment, and will likely complement resting-state EEG and behavioural assessments in the study of the functional impact of developmental care interventions.
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Affiliation(s)
| | - Kirubin Pillay
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ana Alarcon
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Department of Neonatology, Hospital Sant Joan de Deu, Institut de Recerca Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | | | - Maria M Cobo
- Department of Paediatrics, University of Oxford, Oxford, UK; Universidad San Francisco de Quito USFQ, Colegio de Ciencias Biologicas y Ambientales, Quito, Ecuador
| | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sean Fitzgibbon
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK.
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK.
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16
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Baxter L, Moultrie F, Fitzgibbon S, Aspbury M, Mansfield R, Bastiani M, Rogers R, Jbabdi S, Duff E, Slater R. Functional and diffusion MRI reveal the neurophysiological basis of neonates' noxious-stimulus evoked brain activity. Nat Commun 2021; 12:2744. [PMID: 33980860 PMCID: PMC8115252 DOI: 10.1038/s41467-021-22960-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/05/2021] [Indexed: 11/20/2022] Open
Abstract
Understanding the neurophysiology underlying neonatal responses to noxious stimulation is central to improving early life pain management. In this neonatal multimodal MRI study, we use resting-state and diffusion MRI to investigate inter-individual variability in noxious-stimulus evoked brain activity. We observe that cerebral haemodynamic responses to experimental noxious stimulation can be predicted from separately acquired resting-state brain activity (n = 18). Applying this prediction model to independent Developing Human Connectome Project data (n = 215), we identify negative associations between predicted noxious-stimulus evoked responses and white matter mean diffusivity. These associations are subsequently confirmed in the original noxious stimulation paradigm dataset, validating the prediction model. Here, we observe that noxious-stimulus evoked brain activity in healthy neonates is coupled to resting-state activity and white matter microstructure, that neural features can be used to predict responses to noxious stimulation, and that the dHCP dataset could be utilised for future exploratory research of early life pain system neurophysiology.
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Affiliation(s)
- Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sean Fitzgibbon
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | | | | | - Matteo Bastiani
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
- Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - Saad Jbabdi
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Eugene Duff
- Department of Paediatrics, University of Oxford, Oxford, UK
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK.
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17
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Cobo MM, Hartley C, Gursul D, Andritsou F, van der Vaart M, Schmidt Mellado G, Baxter L, Duff EP, Buckle M, Evans Fry R, Green G, Hoskin A, Rogers R, Adams E, Moultrie F, Slater R. Quantifying noxious-evoked baseline sensitivity in neonates to optimise analgesic trials. eLife 2021; 10:e65266. [PMID: 33847561 PMCID: PMC8087440 DOI: 10.7554/elife.65266] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/17/2021] [Indexed: 01/18/2023] Open
Abstract
Despite the high burden of pain experienced by hospitalised neonates, there are few analgesics with proven efficacy. Testing analgesics in neonates is experimentally and ethically challenging and minimising the number of neonates required to demonstrate efficacy is essential. EEG (electroencephalography)-derived measures of noxious-evoked brain activity can be used to assess analgesic efficacy; however, as variability exists in neonate's responses to painful procedures, large sample sizes are often required. Here, we present an experimental paradigm to account for individual differences in noxious-evoked baseline sensitivity which can be used to improve the design of analgesic trials in neonates. The paradigm is developed and tested across four observational studies using clinical, experimental, and simulated data (92 neonates). We provide evidence of the efficacy of gentle brushing and paracetamol, substantiating the need for randomised controlled trials of these interventions. This work provides an important step towards safe, cost-effective clinical trials of analgesics in neonates.
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Affiliation(s)
- Maria M Cobo
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
- Universidad San Francisco de Quito USFQ, Colegio de Ciencias Biologicas y AmbientalesQuitoEcuador
| | - Caroline Hartley
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Deniz Gursul
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | | | | | | | - Luke Baxter
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Eugene P Duff
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
- Wellcome Centre for Integrative Neuroimaging, University of OxfordOxfordUnited Kingdom
| | - Miranda Buckle
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Ria Evans Fry
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Gabrielle Green
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Amy Hoskin
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Richard Rogers
- Department of Anaesthetics, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Fiona Moultrie
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom
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18
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Eccleston C, Fisher E, Howard RF, Slater R, Forgeron P, Palermo TM, Birnie KA, Anderson BJ, Chambers CT, Crombez G, Ljungman G, Jordan I, Jordan Z, Roberts C, Schechter N, Sieberg CB, Tibboel D, Walker SM, Wilkinson D, Wood C. Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission. Lancet Child Adolesc Health 2021; 5:47-87. [PMID: 33064998 DOI: 10.1016/s2352-4642(20)30277-7] [Citation(s) in RCA: 103] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/30/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Christopher Eccleston
- Centre for Pain Research, University of Bath, Bath, UK; Cochrane Pain, Palliative, and Supportive Care Review Groups, Churchill Hospital, Oxford, UK; Department of Clinical-Experimental and Health Psychology, Ghent University, Ghent, Belgium.
| | - Emma Fisher
- Centre for Pain Research, University of Bath, Bath, UK; Cochrane Pain, Palliative, and Supportive Care Review Groups, Churchill Hospital, Oxford, UK
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK; Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Paula Forgeron
- School of Nursing, Faculty of Health Sciences, University of Ottawa, ON, Canada
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Kathryn A Birnie
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, AB, Canada
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Christine T Chambers
- Department of Psychology and Neuroscience, and Department of Pediatrics, Dalhousie University, Halifax, NS, Canada; Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada
| | - Geert Crombez
- Department of Clinical-Experimental and Health Psychology, Ghent University, Ghent, Belgium
| | - Gustaf Ljungman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | | | - Neil Schechter
- Division of Pain Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anesthesiology, Harvard Medical School, Boston, MA, USA
| | - Christine B Sieberg
- Division of Pain Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Suellen M Walker
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK; John Radcliffe Hospital, Oxford, UK; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Chantal Wood
- Department of Spine Surgery and Neuromodulation, Poitiers University Hospital, Poitiers, France
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19
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Hartley C, Baxter L, Moultrie F, Purdy R, Bhatt A, Rogers R, Patel C, Adams E, Slater R. Predicting severity of adverse cardiorespiratory effects of morphine in premature infants: a post hoc analysis of Procedural Pain in Premature Infants trial data. Br J Anaesth 2020; 126:e133-e135. [PMID: 33309053 PMCID: PMC8767644 DOI: 10.1016/j.bja.2020.10.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/29/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ryan Purdy
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Richard Rogers
- Department of Anaesthetics, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Chetan Patel
- Department of Ophthalmology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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20
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Affiliation(s)
- Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK.
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Ralph Bax
- Paediatric Medicines Office, Scientific Evidence Generation Department, European Medicines Agency, Amsterdam, Netherlands
| | - John van den Anker
- Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA; Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
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21
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Duff EP, Moultrie F, van der Vaart M, Goksan S, Abos A, Fitzgibbon SP, Baxter L, Wager TD, Slater R. Inferring pain experience in infants using quantitative whole-brain functional MRI signatures: a cross-sectional, observational study. Lancet Digit Health 2020; 2:e458-e467. [PMID: 32954244 PMCID: PMC7480713 DOI: 10.1016/s2589-7500(20)30168-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background In the absence of verbal communication, it is challenging to infer an individual's sensory and emotional experience. In communicative adults, functional MRI (fMRI) has been used to develop multivariate brain activity signatures, which reliably capture elements of human pain experience. We aimed to translate whole-brain fMRI signatures that encode pain perception in adults to the newborn infant brain, to advance understanding of functional brain development and pain perception in early life. Methods In this cross-sectional, observational study, we recruited adults at the University of Oxford (Oxford, UK) and infants on the postnatal wards of John Radcliffe Hospital (Oxford, UK). Healthy full-term infants were eligible for inclusion if they were clinically stable, self-ventilating in air, and had no neurological abnormalities. Infants were consecutively recruited in two cohorts (A and B) due to the installation of a new fMRI scanner using the same recruitment criteria. Adults (aged ≥18 years) were eligible if they were postgraduate students or staff at the University of Oxford. Participants were stimulated with low intensity nociceptive stimuli (64, 128, 256, and 512 mN in adults; 64 and 128 mN in infants) during acquisition of fMRI data. fMRI pain signatures (neurologic pain signature [NPS] and stimulus intensity independent pain signature-1 [SIIPS1]), and four control signatures (the vicarious pain signature, the picture-induced negative emotion signature [PINES], the social rejection signature, and a global signal signature) were applied directly to the adult data and translated to the infant brain. We assessed the concordance of the signatures with the brain responses of adults and infants using cosine similarity scores, and we assessed stimulus intensity encoding of the signature responses using a Spearman rank correlation test. We also assessed brain activity in pro-pain and anti-pain components of the signatures. Findings Between May 22, 2013, and Jan 29, 2018, we recruited ten healthy participants to the adult cohort (five women and five men; mean age 28·3 years [range 23-36]), 15 infants to infant cohort A (six girls and nine boys; mean postnatal age 4 days [range 1-11]), and 22 infants to infant cohort B (11 girls and 11 boys; mean postnatal age 3 days [range 1-10]). The NPS was activated in both the adults and infants, and reliably encoded stimulus intensity. The NPS was activated in the adult cohort (p<0·0001) and both infant cohorts (p=0·048 for infant cohort A; p=0·001 for infant cohort B). The SIIPS1 was only expressed in adults. Pro-pain brain regions showed similar activation patterns in adults and infants, whereas responses in anti-pain brain regions were divergent. Interpretation Basic intensity encoding of nociceptive information is similar in adults and infants. However, translation of adult brain signatures to infants indicated substantial differences in infant cerebral processing of nociceptive information, which might reflect their absence of expectation, motivation, and contextualisation associated with pain. This study expands the use of brain activity pain signatures to non-verbal patients and provides a potential research approach to assess the impact of analgesic interventions on brain function in infants. Funding Wellcome Trust, Supporting the Sick Newborn and their Parents Medical Research Fund.
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Affiliation(s)
- Eugene P Duff
- Department of Paediatrics, University of Oxford, Oxford, UK
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Sezgi Goksan
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Alexandra Abos
- Laboratory of Neuroimaging and Cognition, Medical Psychology Unit, Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Sean P Fitzgibbon
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Tor D Wager
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, NH, USA
- Department of Psychology and Neurosciences, University of Colorado, Boulder, CO, USA
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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22
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Hill RM, Boto E, Holmes N, Hartley C, Seedat ZA, Leggett J, Roberts G, Shah V, Tierney TM, Woolrich MW, Stagg CJ, Barnes GR, Bowtell R, Slater R, Brookes MJ. A tool for functional brain imaging with lifespan compliance. Nat Commun 2019; 10:4785. [PMID: 31690797 PMCID: PMC6831615 DOI: 10.1038/s41467-019-12486-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 09/05/2019] [Indexed: 02/04/2023] Open
Abstract
The human brain undergoes significant functional and structural changes in the first decades of life, as the foundations for human cognition are laid down. However, non-invasive imaging techniques to investigate brain function throughout neurodevelopment are limited due to growth in head-size with age and substantial head movement in young participants. Experimental designs to probe brain function are also limited by the unnatural environment typical brain imaging systems impose. However, developments in quantum technology allowed fabrication of a new generation of wearable magnetoencephalography (MEG) technology with the potential to revolutionise electrophysiological measures of brain activity. Here we demonstrate a lifespan-compliant MEG system, showing recordings of high fidelity data in toddlers, young children, teenagers and adults. We show how this system can support new types of experimental paradigm involving naturalistic learning. This work reveals a new approach to functional imaging, providing a robust platform for investigation of neurodevelopment in health and disease. Magnetoencephalography (MEG) recordings are sensitive to movement and therefore are especially challenging with young participants. Here the authors develop a wearable MEG system based on a modified bicycle helmet, which enables reliable recordings in toddlers, children, teenagers and adults.
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Affiliation(s)
- Ryan M Hill
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Elena Boto
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Niall Holmes
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom
| | - Zelekha A Seedat
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - James Leggett
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Gillian Roberts
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Vishal Shah
- QuSpin Inc., 2011 Cherry Street, Unit 112, Louisville, CO, 80027, USA
| | - Tim M Tierney
- Wellcome Centre for Human Neuroimaging, UCL Institute of Neurology, University College London, 12 Queen Square, London, WC1N 3AR, United Kingdom
| | - Mark W Woolrich
- Oxford Centre for Human Brain Activity (OHBA), Wellcome Centre for Integrative Neuro-Imaging, Department of psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, United Kingdom
| | - Charlotte J Stagg
- Oxford Centre for Human Brain Activity (OHBA), Wellcome Centre for Integrative Neuro-Imaging, Department of psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, United Kingdom
| | - Gareth R Barnes
- Wellcome Centre for Human Neuroimaging, UCL Institute of Neurology, University College London, 12 Queen Square, London, WC1N 3AR, United Kingdom
| | - Richard Bowtell
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom
| | - Matthew J Brookes
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom.
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23
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Vaart M, Duff E, Raafat N, Rogers R, Hartley C, Slater R. Multimodal pain assessment improves discrimination between noxious and non‐noxious stimuli in infants. ACTA ACUST UNITED AC 2019; 1:21-30. [PMID: 35546868 PMCID: PMC8974881 DOI: 10.1002/pne2.12007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/25/2019] [Accepted: 08/07/2019] [Indexed: 11/30/2022]
Abstract
Infants in neonatal intensive care units frequently experience clinically necessary painful procedures, which elicit a range of behavioral, physiological, and neurophysiological responses. However, the measurement of pain in this population is a challenge and no gold standard exists. The aim of this study was to investigate how noxious‐evoked changes in facial expression, reflex withdrawal, brain activity, heart rate, and oxygen saturation are related and to examine their accuracy in discriminating between noxious and non‐noxious stimuli. In 109 infants who received a clinically required heel lance and a control non‐noxious stimulus, we investigated whether combining responses across each modality, or including multiple measures from within each modality improves our ability to discriminate the noxious and non‐noxious stimuli. A random forest algorithm was used to build data‐driven models to discriminate between the noxious and non‐noxious stimuli in a training set which were then validated in a test set of independent infants. Measures within each modality were highly correlated, while different modalities showed less association. The model combining information across all modalities had good discriminative ability (accuracy of 0.81 in identifying noxious and non‐noxious stimuli), which was higher than the discriminative power of the models built from individual modalities. This demonstrates the importance of including multiple modalities in the assessment of infant pain.
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Affiliation(s)
- Marianne Vaart
- Department of Paediatrics University of Oxford Oxford UK
| | - Eugene Duff
- Department of Paediatrics University of Oxford Oxford UK
| | - Nader Raafat
- Department of Paediatrics University of Oxford Oxford UK
| | - Richard Rogers
- Nuffield Department of Anaesthesia John Radcliffe Hospital Oxford UK
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24
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Abstract
Measuring brain activity in infants provides an objective surrogate approach with which to infer pain perception following noxious events. Here we discuss different approaches which can be used to measure noxious-evoked brain activity, and discuss how these measures can be used to assess the analgesic efficacy of pharmacological and non-pharmacological interventions. We review factors that can modulate noxious-evoked brain activity, which may impact infant pain experience, including gestational age, sex, prior pain, stress, and illness.
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Affiliation(s)
- Deniz Gursul
- Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom.
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25
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Slater R. The challenge of distinguishing pain from distress in young children. The Lancet Child & Adolescent Health 2019; 3:367-368. [DOI: 10.1016/s2352-4642(19)30118-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 11/26/2022]
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26
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Liow N, Montaldo P, Lally PJ, Teiserskas J, Bassett P, Oliveira V, Mendoza J, Slater R, Shankaran S, Thayyil S. Preemptive Morphine During Therapeutic Hypothermia After Neonatal Encephalopathy: A Secondary Analysis. Ther Hypothermia Temp Manag 2019; 10:45-52. [PMID: 30807267 DOI: 10.1089/ther.2018.0052] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although therapeutic hypothermia (TH) improves outcomes after neonatal encephalopathy (NE), the safety and efficacy of preemptive opioid sedation during cooling therapy is unclear. We performed a secondary analysis of the data from a large multicountry prospective observational study (Magnetic Resonance Biomarkers in Neonatal Encephalopathy [MARBLE]) to examine the association of preemptive morphine infusion during TH on brain injury and neurodevelopmental outcomes after NE. All recruited infants had 3.0 Tesla magnetic resonance imaging and spectroscopy at 1 week, and neurodevelopmental outcome assessments at 22 months. Of 223 babies recruited to the MARBLE study, the data on sedation were available from 169 babies with moderate (n = 150) or severe NE (n = 19). Although the baseline characteristics and admission status were similar, the babies who received morphine infusion (n = 141) were more hypotensive (49% vs. 25%, p = 0.02) and had a significantly longer hospital stay (12 days vs. 9 days, p = 0.009) than those who did not (n = 28). Basal ganglia/thalamic injury (score ≥1) and cortical injury (score ≥1) was seen in 34/141 (24%) and 37/141 (26%), respectively, of the morphine group and 4/28 (14%) and 3/28 (11%) of the nonmorphine group (p > 0.05). On regression modeling adjusted for potential confounders, preemptive morphine was not associated with mean (standard deviation [SD]) thalamic N-acetylaspartate (NAA) concentration (6.9 ± 0.9 vs. 6.5 ± 1.5; p = 0.97), and median (interquartile range) lactate/NAA peak area ratios (0.16 [0.12-0.21] vs. 0.13 [0.11-0.18]; p = 0.20) at 1 week, and mean (SD) Bayley-III composite motor (92 ± 23 vs. 94 ± 10; p = 0.98), language (89 ± 22 vs. 93 ± 8; p = 0.53), and cognitive scores (95 ± 21 vs. 99 ± 13; p = 0.56) at 22 months. Adverse neurodevelopmental outcome (adjusted for severity of encephalopathy) was seen in 26 (18%) of the morphine group, and none of the nonmorphine group (p = 0.11). Preemptive morphine sedation during TH does not offer any neuroprotective benefits and may be associated with increased hospital stay. Optimal sedation during induced hypothermia requires further evaluation in clinical trials.
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Affiliation(s)
- Natasha Liow
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom.,Neonatal Unit, Università degli Studi della Campania, "Luigi Vanvitelli," Italy
| | - Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Justinas Teiserskas
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | | | - Vânia Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Josephine Mendoza
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Rebeccah Slater
- Department of Pediatrics, University of Oxford, Oxford, United Kingdom
| | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, Michigan
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
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27
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Baxter L, Fitzgibbon S, Moultrie F, Goksan S, Jenkinson M, Smith S, Andersson J, Duff E, Slater R. Optimising neonatal fMRI data analysis: Design and validation of an extended dHCP preprocessing pipeline to characterise noxious-evoked brain activity in infants. Neuroimage 2019; 186:286-300. [PMID: 30414984 PMCID: PMC6347570 DOI: 10.1016/j.neuroimage.2018.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/16/2018] [Accepted: 11/06/2018] [Indexed: 11/21/2022] Open
Abstract
The infant brain is unlike the adult brain, with considerable differences in morphological, neurodynamic, and haemodynamic features. As the majority of current MRI analysis tools were designed for use in adults, a primary objective of the Developing Human Connectome Project (dHCP) is to develop optimised methodological pipelines for the analysis of neonatal structural, resting state, and diffusion MRI data. Here, in an independent neonatal dataset we have extended and optimised the dHCP fMRI preprocessing pipeline for the analysis of stimulus-response fMRI data. We describe and validate this extended dHCP fMRI preprocessing pipeline to analyse changes in brain activity evoked following an acute noxious stimulus applied to the infant's foot. We compare the results obtained from this extended dHCP pipeline to results obtained from a typical FSL FEAT-based analysis pipeline, evaluating the pipelines' outputs using a wide range of tests. We demonstrate that a substantial increase in spatial specificity and sensitivity to signal can be attained with a bespoke neonatal preprocessing pipeline through optimised motion and distortion correction, ICA-based denoising, and haemodynamic modelling. The improved sensitivity and specificity, made possible with this extended dHCP pipeline, will be paramount in making further progress in our understanding of the development of sensory processing in the infant brain.
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Affiliation(s)
- Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Sean Fitzgibbon
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, United Kingdom
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Sezgi Goksan
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Mark Jenkinson
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, United Kingdom
| | - Stephen Smith
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, United Kingdom
| | - Jesper Andersson
- FMRIB, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, United Kingdom
| | - Eugene Duff
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom.
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28
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Green G, Hartley C, Hoskin A, Duff E, Shriver A, Wilkinson D, Adams E, Rogers R, Moultrie F, Slater R. Behavioural discrimination of noxious stimuli in infants is dependent on brain maturation. Pain 2019; 160:493-500. [PMID: 30422872 PMCID: PMC6343955 DOI: 10.1097/j.pain.0000000000001425] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/03/2018] [Accepted: 09/04/2018] [Indexed: 11/26/2022]
Abstract
Changes in facial expression are an essential form of social communication and in nonverbal infants are often used to alert care providers to pain-related distress. However, studies of early human brain development suggest that premature infants aged less than 34 weeks' gestation do not display discriminative brain activity patterns to equally salient noxious and innocuous events. Here we examine the development of facial expression in 105 infants, aged between 28 and 42 weeks' gestation. We show that the presence of facial expression change after noxious and innocuous stimulation is age-dependent and that discriminative facial expressions emerge from approximately 33 weeks' gestation. In a subset of 49 infants, we also recorded EEG brain activity and demonstrated that the temporal emergence of facial discrimination mirrors the developmental profile of the brain's ability to generate discriminative responses. Furthermore, within individual infants, the ability to display discriminative facial expressions is significantly related to brain response maturity. These data demonstrate that the emergence of behavioural discrimination in early human life corresponds to our brain's ability to discriminate noxious and innocuous events and raises fundamental questions as to how best to interpret infant behaviours when measuring and treating pain in premature infants.
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Affiliation(s)
- Gabrielle Green
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Eugene Duff
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Adam Shriver
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, United Kingdom
| | - Dominic Wilkinson
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, United Kingdom
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Richard Rogers
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, United Kingdom
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
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29
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Moultrie F, Shriver A, Hartley C, Wilkinson D, Ewer AK, Rogers R, Adams E, Slater R. A universal right to pain relief: balancing the risks in a vulnerable patient population. The Lancet Child & Adolescent Health 2019; 3:62-64. [DOI: 10.1016/s2352-4642(18)30269-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 08/06/2018] [Indexed: 01/10/2023]
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30
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Gursul D, Goksan S, Hartley C, Mellado GS, Moultrie F, Hoskin A, Adams E, Hathway G, Walker S, McGlone F, Slater R. Stroking modulates noxious-evoked brain activity in human infants. Curr Biol 2018; 28:R1380-R1381. [PMID: 30562526 PMCID: PMC6303187 DOI: 10.1016/j.cub.2018.11.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A subclass of C fibre sensory neurons found in hairy skin are activated by gentle touch [1] and respond optimally to stroking at ∼1-10 cm/s, serving a protective function by promoting affiliative behaviours. In adult humans, stimulation of these C-tactile (CT) afferents is pleasant, and can reduce pain perception [2]. Touch-based techniques, such as infant massage and kangaroo care, are designed to comfort infants during procedures, and a modest reduction in pain-related behavioural and physiological responses has been observed in some studies [3]. Here, we investigated whether touch can reduce noxious-evoked brain activity. We demonstrate that stroking (at 3 cm/s) prior to an experimental noxious stimulus or clinical heel lance can attenuate noxious-evoked brain activity in infants. CT fibres may represent a biological target for non-pharmacological interventions that modulate pain in early life.
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Affiliation(s)
- Deniz Gursul
- Department of Paediatrics, University of Oxford, Oxford, OX3 9DU, UK
| | - Sezgi Goksan
- Department of Paediatrics, University of Oxford, Oxford, OX3 9DU, UK
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, OX3 9DU, UK
| | | | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, OX3 9DU, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, OX3 9DU, UK
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, OX3 9DU, UK
| | - Gareth Hathway
- School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Susannah Walker
- Department of Natural Sciences and Psychology, Liverpool John Moores University, Liverpool, L3 3AF, UK
| | - Francis McGlone
- Department of Natural Sciences and Psychology, Liverpool John Moores University, Liverpool, L3 3AF, UK; Institute of Psychology, Health and Society, University of Liverpool, Liverpool, L69 3BX, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, OX3 9DU, UK.
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31
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Hartley C, Moultrie F, Hoskin A, Green G, Monk V, Bell JL, King AR, Buckle M, van der Vaart M, Gursul D, Goksan S, Juszczak E, Norman JE, Rogers R, Patel C, Adams E, Slater R. Analgesic efficacy and safety of morphine in the Procedural Pain in Premature Infants (Poppi) study: randomised placebo-controlled trial. Lancet 2018; 392:2595-2605. [PMID: 30509743 PMCID: PMC6294828 DOI: 10.1016/s0140-6736(18)31813-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/16/2018] [Accepted: 08/01/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Infant pain has immediate and long-term effects but is undertreated because of a paucity of evidence-based analgesics. Although morphine is often used to sedate ventilated infants, its analgesic efficacy is unclear. We aimed to establish whether oral morphine could provide effective and safe analgesia in non-ventilated premature infants for acute procedural pain. METHODS In this single-centre masked trial, 31 infants at the John Radcliffe Hospital, Oxford, UK, were randomly allocated using a web-based facility with a minimisation algorithm to either 100 μg/kg oral morphine sulphate or placebo 1 h before a clinically required heel lance and retinopathy of prematurity screening examination, on the same occasion. Eligible infants were born prematurely at less than 32 weeks' gestation or with a birthweight lower than 1501 g and had a gestational age of 34-42 weeks at the time of the study. The co-primary outcome measures were the Premature Infant Pain Profile-Revised (PIPP-R) score after retinopathy of prematurity screening and the magnitude of noxious-evoked brain activity after heel lancing. Secondary outcome measures assessed physiological stability and safety. This trial is registered with the European Clinical Trials Database (number 2014-003237-25). FINDINGS Between Oct 30, 2016, and Nov 17, 2017, 15 infants were randomly allocated to morphine and 16 to placebo; one infant assigned placebo was withdrawn from the study before monitoring began. The predefined stopping boundary was crossed, and trial recruitment stopped because of profound respiratory adverse effects of morphine without suggestion of analgesic efficacy. None of the co-primary outcome measures differed significantly between groups. PIPP-R score after retinopathy of prematurity screening was mean 11·1 (SD 3·2) with morphine and 10·5 (3·4) with placebo (mean difference 0·5, 95% CI -2·0 to 3·0; p=0·66). Noxious-evoked brain activity after heel lancing was median 0·99 (IQR 0·40-1·56) with morphine and 0·75 (0·33-1·22) with placebo (median difference 0·25, 95% CI -0·16 to 0·80; p=0·25). INTERPRETATION Administration of oral morphine (100 μg/kg) to non-ventilated premature infants has the potential for harm without analgesic efficacy. We do not recommend oral morphine for retinopathy of prematurity screening and strongly advise caution if considering its use for other acute painful procedures in non-ventilated premature infants. FUNDING Wellcome Trust and National Institute for Health Research.
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Affiliation(s)
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Vaneesha Monk
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Jennifer L Bell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew R King
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Miranda Buckle
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Deniz Gursul
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sezgi Goksan
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane E Norman
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Richard Rogers
- Department of Anaesthetics, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Chetan Patel
- Department of Ophthalmology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK.
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Goksan S, Baxter L, Moultrie F, Duff E, Hathway G, Hartley C, Tracey I, Slater R. The influence of the descending pain modulatory system on infant pain-related brain activity. eLife 2018; 7:37125. [PMID: 30201093 PMCID: PMC6133549 DOI: 10.7554/elife.37125] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/15/2018] [Indexed: 12/13/2022] Open
Abstract
The descending pain modulatory system (DPMS) constitutes a network of widely distributed brain regions whose integrated function is essential for effective modulation of sensory input to the central nervous system and behavioural responses to pain. Animal studies demonstrate that young rodents have an immature DPMS, but comparable studies have not been conducted in human infants. In Goksan et al. (2015) we used functional MRI (fMRI) to show that pain-related brain activity in newborn infants is similar to that observed in adults. Here, we investigated whether the functional network connectivity strength across the infant DPMS influences the magnitude of this brain activity. FMRI scans were collected while mild mechanical noxious stimulation was applied to the infant's foot. Greater pre-stimulus functional network connectivity across the DPMS was significantly associated with lower noxious-evoked brain activity (p = 0.0004, r = -0.86, n = 13), suggesting that in newborn infants the DPMS may regulate the magnitude of noxious-evoked brain activity.
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Affiliation(s)
- Sezgi Goksan
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Eugene Duff
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Gareth Hathway
- School of Life Sciences, The University of Nottingham, Nottingham, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Irene Tracey
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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Hartley C, Duff EP, Green G, Mellado GS, Worley A, Rogers R, Slater R. Nociceptive brain activity as a measure of analgesic efficacy in infants. Sci Transl Med 2018; 9:9/388/eaah6122. [PMID: 28469039 DOI: 10.1126/scitranslmed.aah6122] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 11/30/2016] [Accepted: 03/21/2017] [Indexed: 01/08/2023]
Abstract
Pain in infants is undertreated and poorly understood, representing a major clinical problem. In part, this is due to our inability to objectively measure pain in nonverbal populations. We present and validate an electroencephalography-based measure of infant nociceptive brain activity that is evoked by acute noxious stimulation and is sensitive to analgesic modulation. This measure should be valuable both for mechanistic investigations and for testing analgesic efficacy in the infant population.
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Affiliation(s)
- Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Eugene P Duff
- Functional Magnetic Resonance Imaging of the Brain Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Gabrielle Green
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | | | - Alan Worley
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Richard Rogers
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK.
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Macdonald J, Heaton D, Slater R, Orlowski A. 69Identifying opportunities to prevent AF-related stroke through better access to NHS primary and secondary care data. Europace 2017. [DOI: 10.1093/europace/eux283.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Slater R, Hartley C, Moultrie F, Adams E, Juszczak E, Rogers R, Norman JE, Patel C, Stanbury K, Hoskin A, Green G. A blinded randomised placebo-controlled trial investigating the efficacy of morphine analgesia for procedural pain in infants: Trial protocol. Wellcome Open Res 2016; 1:7. [PMID: 28066825 PMCID: PMC5218543 DOI: 10.12688/wellcomeopenres.10005.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infant pain has both immediate and long-term negative consequences, yet in clinical practice it is often undertreated. To date, few pain-relieving drugs have been tested in infants. Morphine is a potent analgesic that provides effective pain relief in adults, but there is inconclusive evidence for its effectiveness in infants. The purpose of this study is to establish whether oral morphine provides effective analgesia for procedural pain in infants. A blinded, placebo-controlled, parallel-group randomized, phase II, clinical trial will be undertaken to determine whether morphine sulphate administered orally prior to clinically-required retinopathy of prematurity (ROP) screening and heel lancing provides effective analgesia.
156 infants between 34 and 42 weeks' gestational age who require a clinical heel lance and ROP screening on the same test occasion will be included in the trial. Infants will be randomised to receive either a single dose of morphine sulphate (100 μg/kg) or placebo. Each infant will be monitored for 48 hours and safety data will be collected during the 24 hours following drug administration. The primary outcome will be the Premature Infant Pain Profile-revised (PIPP-R) score 30 seconds after ROP screening. The co-primary outcome will be the magnitude of nociceptive-specific brain activity evoked by a clinically-required heel lance. Infant clinical stability will be assessed by comparing the number of episodes of bradycardia, tachycardia, desaturation and apnoea, and changes in respiratory support requirements in the 24-hour periods before and after the clinical intervention. In addition, drug safety will be assessed by considering the occurrence of apnoeic and hypotensive episodes requiring intervention in the 24-hour period following drug administration. This study has been published as an Accepted Protocol Summary by The Lancet.
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Affiliation(s)
| | | | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ed Juszczak
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - Jane E Norman
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh, UK
| | - Chetan Patel
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, UK
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Slater R, Hartley C, Moultrie F, Adams E, Juszczak E, Rogers R, Norman JE, Patel C, Stanbury K, Hoskin A, Green G. A blinded randomised placebo-controlled trial investigating the efficacy of morphine analgesia for procedural pain in infants: Trial protocol. Wellcome Open Res 2016. [PMID: 28066825 DOI: 10.12688/wellcomeopenres.10005.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infant pain has both immediate and long-term negative consequences, yet in clinical practice it is often undertreated. To date, few pain-relieving drugs have been tested in infants. Morphine is a potent analgesic that provides effective pain relief in adults, but there is inconclusive evidence for its effectiveness in infants. The purpose of this study is to establish whether oral morphine provides effective analgesia for procedural pain in infants. A blinded, placebo-controlled, parallel-group randomized, phase II, clinical trial will be undertaken to determine whether morphine sulphate administered orally prior to clinically-required retinopathy of prematurity (ROP) screening and heel lancing provides effective analgesia.
156 infants between 34 and 42 weeks' gestational age who require a clinical heel lance and ROP screening on the same test occasion will be included in the trial. Infants will be randomised to receive either a single dose of morphine sulphate (100 μg/kg) or placebo. Each infant will be monitored for 48 hours and safety data will be collected during the 24 hours following drug administration. The primary outcome will be the Premature Infant Pain Profile-revised (PIPP-R) score 30 seconds after ROP screening. The co-primary outcome will be the magnitude of nociceptive-specific brain activity evoked by a clinically-required heel lance. Infant clinical stability will be assessed by comparing the number of episodes of bradycardia, tachycardia, desaturation and apnoea, and changes in respiratory support requirements in the 24-hour periods before and after the clinical intervention. In addition, drug safety will be assessed by considering the occurrence of apnoeic and hypotensive episodes requiring intervention in the 24-hour period following drug administration. This study has been published as an Accepted Protocol Summary by The Lancet.
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Affiliation(s)
| | | | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ed Juszczak
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - Jane E Norman
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh, UK
| | - Chetan Patel
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford, UK
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Goksan S, Hartley C, Hurley SA, Winkler AM, Duff EP, Jenkinson M, Rogers R, Clare S, Slater R. Optimal echo time for functional MRI of the infant brain identified in response to noxious stimulation. Magn Reson Med 2016; 78:625-631. [PMID: 27654315 PMCID: PMC5516146 DOI: 10.1002/mrm.26455] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/14/2016] [Accepted: 08/15/2016] [Indexed: 12/17/2022]
Abstract
Purpose Blood oxygen level dependent (BOLD) brain activity, measured using functional MRI (fMRI), is dependent on the echo time (TE) and the reversible spin–spin relaxation time constant (
T2*) that describes the decay of transverse magnetization. Use of the optimal TE during fMRI experiments allows maximal sensitivity to BOLD to be achieved. Reports that
T2* values are longer in infants (due to higher water concentrations and lower lipid content) have led to the use of longer TEs during infant fMRI experiments; however, the optimal TE has not been established. Methods In this study, acute experimental mildly noxious stimuli were applied to the heel in 12 term infants (mean gestational age = 40 weeks, mean postnatal age = 3 days); and the percentage change in BOLD activity was calculated across a range of TEs, from 30 to 70 ms, at 3 Tesla. In addition,
T2* maps of the whole brain were collected in seven infants. Results The maximal change in BOLD occurred at a TE of 52 ms, and the average
T2* across the whole brain was 99 ms. Conclusion A TE of approximately 50 ms is recommended for use in 3T fMRI investigations in term infants. Magn Reson Med 78:625–631, 2017. © 2016 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine.
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Affiliation(s)
- Sezgi Goksan
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Samuel A Hurley
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Anderson M Winkler
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Eugene P Duff
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Mark Jenkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Richard Rogers
- Nuffield Department of Anaesthetics, University of Oxford, Oxford, United Kingdom
| | - Stuart Clare
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
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Hartley C, Moultrie F, Gursul D, Hoskin A, Adams E, Rogers R, Slater R. Changing Balance of Spinal Cord Excitability and Nociceptive Brain Activity in Early Human Development. Curr Biol 2016; 26:1998-2002. [PMID: 27374336 PMCID: PMC4985558 DOI: 10.1016/j.cub.2016.05.054] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/25/2016] [Accepted: 05/24/2016] [Indexed: 01/28/2023]
Abstract
In adults, nociceptive reflexes and behavioral responses are modulated by a network of brain regions via descending projections to the spinal dorsal horn [1]. Coordinated responses to noxious inputs manifest from a balance of descending facilitation and inhibition. In contrast, young infants display exaggerated and uncoordinated limb reflexes [2]. Our understanding of nociceptive processing in the infant brain has been advanced by the use of electrophysiological and hemodynamic imaging [3, 4, 5, 6]. From approximately 35 weeks’ gestation, nociceptive-specific patterns of brain activity emerge [7], whereas prior to this, non-specific bursts of activity occur in response to noxious, tactile, visual, and auditory stimulation [7, 8, 9, 10]. During the preterm period, refinement of spinal cord excitability is also observed: reflex duration shortens, response threshold increases, and improved discrimination between tactile and noxious events occurs [2, 11, 12]. However, the development of descending modulation in human infants remains relatively unexplored. In 40 infants aged 28–42 weeks’ gestation, we examined the relationship between nociceptive brain activity and spinal reflex withdrawal activity in response to a clinically essential noxious procedure. Nociceptive-specific brain activity increases in magnitude with gestational age, whereas reflex withdrawal activity decreases in magnitude, duration, and latency across the same developmental period. By recording brain and spinal cord activity in the same infants, we demonstrate that the maturation of nociceptive brain activity is concomitant with the refinement of noxious-evoked limb reflexes. We postulate that, consistent with studies in animals, infant reflexes are influenced by the development of top-down inhibitory modulation from maturing subcortical and cortical brain networks. Noxious-evoked brain activity increases in magnitude across the preterm period Maturation of nociceptive brain activity coincides with reflex activity refinement This may relate to the emergence of top-down inhibition in human infants
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Affiliation(s)
- Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Deniz Gursul
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Amy Hoskin
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK.
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Poorun R, Hartley C, Goksan S, Worley A, Boyd S, Cornelissen L, Berde C, Rogers R, Ali T, Slater R. Electroencephalography during general anaesthesia differs between term-born and premature-born children. Clin Neurophysiol 2015; 127:1216-1222. [PMID: 26589678 PMCID: PMC4725254 DOI: 10.1016/j.clinph.2015.10.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/10/2015] [Accepted: 10/14/2015] [Indexed: 11/28/2022]
Abstract
Noxious stimulation during anaesthesia evokes a significant increase in delta activity that does not differ between term-born and premature-born children. Background EEG activity recorded during anaesthesia is different in premature-born and term-born children. EEG-derived measures that can be used to titrate anaesthetic depth may be influenced by premature birth.
Objectives Premature birth is associated with a wide range of complications in later life, including structural and functional neurological abnormalities and altered pain sensitivity. We investigated whether during anaesthesia premature-born children display different patterns of background EEG activity and exhibit increased responses to nociceptive stimuli. Methods We examined background EEG and time-locked responses to clinical cannulation in 45 children (mean age (±SD) at study: 4.9 (± 3.0) years) under sevoflurane monoanaesthesia maintained at a steady-state end-tidal concentration of 2.5%. 15 were born prematurely (mean gestational age at birth: 29.2 ± 3.9 weeks) and 30 were age-matched term-born children. Results Background levels of alpha and beta power were significantly lower in the premature-born children compared to term-born controls (p = 0.048). Clinical cannulation evoked a significant increase in delta activity (p = 0.032), which was not significantly different between the two groups (p = 0.44). Conclusions The results indicate that whilst under anaesthesia premature-born children display different patterns of background brain activity compared to term-born children. Significance As electrophysiological techniques are increasingly used by anaesthetists to gauge anaesthetic depth, differences in background levels of electrophysiological brain activity between premature and term-born children may be relevant when considering titration of anaesthetic dose.
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Affiliation(s)
- Ravi Poorun
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Sezgi Goksan
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Alan Worley
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Stewart Boyd
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Laura Cornelissen
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA 02115, USA
| | - Charles Berde
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA 02115, USA
| | - Richard Rogers
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Tariq Ali
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK.
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Hartley C, Goksan S, Poorun R, Brotherhood K, Mellado GS, Moultrie F, Rogers R, Adams E, Slater R. The relationship between nociceptive brain activity, spinal reflex withdrawal and behaviour in newborn infants. Sci Rep 2015; 5:12519. [PMID: 26228435 PMCID: PMC4521152 DOI: 10.1038/srep12519] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/22/2015] [Indexed: 11/17/2022] Open
Abstract
Measuring infant pain is complicated by their inability to describe the experience. While nociceptive brain activity, reflex withdrawal and facial grimacing have been characterised, the relationship between these activity patterns has not been examined. As cortical and spinally mediated activity is developmentally regulated, it cannot be assumed that they are predictive of one another in the immature nervous system. Here, using a new experimental paradigm, we characterise the nociceptive-specific brain activity, spinal reflex withdrawal and behavioural activity following graded intensity noxious stimulation and clinical heel lancing in 30 term infants. We show that nociceptive-specific brain activity and nociceptive reflex withdrawal are graded with stimulus intensity (p < 0.001), significantly correlated (r = 0.53, p = 0.001) and elicited at an intensity that does not evoke changes in clinical pain scores (p = 0.55). The strong correlation between reflex withdrawal and nociceptive brain activity suggests that movement of the limb away from a noxious stimulus is a sensitive indication of nociceptive brain activity in term infants. This could underpin the development of new clinical pain assessment measures.
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Affiliation(s)
| | - Sezgi Goksan
- Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK
| | - Ravi Poorun
- Nuffield Department of Clinical Neurosciences, University of Oxford, OX3 9DU, UK
| | | | | | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, OX3 9DU, UK
| | - Richard Rogers
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, OX3 9DU, UK
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, OX3 9DU, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, OX3 9DU, UK
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Goksan S, Hartley C, Emery F, Cockrill N, Poorun R, Moultrie F, Rogers R, Campbell J, Sanders M, Adams E, Clare S, Jenkinson M, Tracey I, Slater R. Correction: fMRI reveals neural activity overlap between adult and infant pain. eLife 2015; 4. [PMID: 26020290 PMCID: PMC4446667 DOI: 10.7554/elife.08663] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Goksan S, Hartley C, Emery F, Cockrill N, Poorun R, Moultrie F, Rogers R, Campbell J, Sanders M, Adams E, Clare S, Jenkinson M, Tracey I, Slater R. fMRI reveals neural activity overlap between adult and infant pain. eLife 2015; 4. [PMID: 25895592 PMCID: PMC4402596 DOI: 10.7554/elife.06356] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/11/2015] [Indexed: 12/15/2022] Open
Abstract
Limited understanding of infant pain has led to its lack of recognition in clinical practice. While the network of brain regions that encode the affective and sensory aspects of adult pain are well described, the brain structures involved in infant nociceptive processing are less well known, meaning little can be inferred about the nature of the infant pain experience. Using fMRI we identified the network of brain regions that are active following acute noxious stimulation in newborn infants, and compared the activity to that observed in adults. Significant infant brain activity was observed in 18 of the 20 active adult brain regions but not in the infant amygdala or orbitofrontal cortex. Brain regions that encode sensory and affective components of pain are active in infants, suggesting that the infant pain experience closely resembles that seen in adults. This highlights the importance of developing effective pain management strategies in this vulnerable population. DOI:http://dx.doi.org/10.7554/eLife.06356.001 Doctors long believed that infants do not feel pain the way that older children and adults do. Instead, they believed that the infants' responses to discomfort were reflexes. Based on these beliefs, it was a routine practice to perform surgery on infants without suitable pain relief up until the late 1980s. Even now, infants may receive less than ideal pain relief. For example, a review found that although newborns in intensive care units undergo 11 painful procedures per day on average, more than half of the babies received no pain medications. Some guidelines continue to emphasize that for infants cuddling and feeding are more important sources of comfort than pain-relieving drugs. There is growing support for better pain control for infants. Doctors and nurses now routinely observe behaviour and physiological responses—such as heart rate—to assess whether infants are experiencing pain. When an infant shows signs of pain, medical staff may give the infant sugar water or other interventions aimed at reducing their distress. However, recordings of brain activity suggest that infants may experience pain without exhibiting physical signs and that sugar water may reduce the behaviours associated with pain but not the pain itself. More objective measurements of infant pain would be useful, but to create such measurements scientists must first understand how infants experience pain. So Goksan et al. used a technique called functional magnetic resonance imaging (fMRI) to compare the brain responses of adults and newborns to the same stimulus—a sharp poke of the foot. The adults were also asked about the pain they experienced, and whether the infants pulled their foot away when poked was documented. The fMRI results revealed that pain increased activity in 20 regions in the adults' brains, and 18 of the same regions in the infants' brains. The brain regions activated in the infants' brains in response to a poke on the foot are involved in processing sensations and emotions. The two regions that did not activate in the infant brains—the amygdala and the orbitofrontal cortex—help individuals interpret the stimuli. Goksan et al. therefore conclude that infants experience pain in similar ways to adults, though they may not experience all the emotions that adults have when they are in pain. It is, therefore, important to give infants suitable pain relief during potentially painful procedures. DOI:http://dx.doi.org/10.7554/eLife.06356.002
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Affiliation(s)
- Sezgi Goksan
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Faith Emery
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Naomi Cockrill
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Ravi Poorun
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Fiona Moultrie
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Richard Rogers
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Jon Campbell
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Michael Sanders
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Eleri Adams
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Stuart Clare
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Mark Jenkinson
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Irene Tracey
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Rebeccah Slater
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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Scott DA, Slater R, Duffy M. Limitations of ultrasound-guided central venous cannulation. Anaesth Intensive Care 2015; 43:273-274. [PMID: 25735699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Williams G, Fabrizi L, Meek J, Jackson D, Tracey I, Robertson N, Slater R, Fitzgerald M. Functional magnetic resonance imaging can be used to explore tactile and nociceptive processing in the infant brain. Acta Paediatr 2015; 104:158-66. [PMID: 25358870 PMCID: PMC4463763 DOI: 10.1111/apa.12848] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 10/21/2014] [Accepted: 10/29/2014] [Indexed: 01/29/2023]
Abstract
Aim Despite the importance of neonatal skin stimulation, little is known about activation of the newborn human infant brain by sensory stimulation of the skin. We carried out functional magnetic resonance imaging (fMRI) to assess the feasibility of measuring brain activation to a range of mechanical stimuli applied to the skin of neonatal infants. Methods We studied 19 term infants with a mean age of 13 days. Brain activation was measured in response to brushing, von Frey hair (vFh) punctate stimulation and, in one case, nontissue damaging pinprick stimulation of the plantar surface of the foot. Initial whole brain analysis was followed by region of interest analysis of specific brain areas. Results Distinct patterns of functional brain activation were evoked by brush and vFh punctate stimulation, which were reduced, but still present, under chloral hydrate sedation. Brain activation increased with increasing stimulus intensity. The feasibility of using pinprick stimulation in fMRI studies was established in one unsedated healthy full-term infant. Conclusion Distinct brain activity patterns can be measured in response to different modalities and intensities of skin sensory stimulation in term infants. This indicates the potential for fMRI studies in exploring tactile and nociceptive processing in the infant brain.
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Affiliation(s)
- Gemma Williams
- UCL Department of Neuroscience, Physiology & Pharmacology; University College London; London UK
| | - Lorenzo Fabrizi
- UCL Department of Neuroscience, Physiology & Pharmacology; University College London; London UK
| | - Judith Meek
- Elizabeth Garrett Anderson Obstetric Wing; University College Hospital; London UK
| | - Deborah Jackson
- UCL Department of Neuroscience, Physiology & Pharmacology; University College London; London UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences; Oxford Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB); University of Oxford; Oxford UK
| | - Nicola Robertson
- Elizabeth Garrett Anderson Obstetric Wing; University College Hospital; London UK
| | - Rebeccah Slater
- UCL Department of Neuroscience, Physiology & Pharmacology; University College London; London UK
| | - Maria Fitzgerald
- UCL Department of Neuroscience, Physiology & Pharmacology; University College London; London UK
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Hartley C, Poorun R, Goksan S, Worley A, Boyd S, Rogers R, Ali T, Slater R. Noxious stimulation in children receiving general anaesthesia evokes an increase in delta frequency brain activity. Pain 2014; 155:2368-76. [PMID: 25218826 PMCID: PMC4247379 DOI: 10.1016/j.pain.2014.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 08/22/2014] [Accepted: 09/03/2014] [Indexed: 12/21/2022]
Abstract
More than 235,000 children/year in the UK receive general anaesthesia, but it is unknown whether nociceptive stimuli alter cortical brain activity in anaesthetised children. Time-locked electroencephalogram (EEG) responses to experimental tactile stimuli, experimental noxious stimuli, and clinically required cannulation were examined in 51 children (ages 1–12 years) under sevoflurane monoanaesthesia. Based on a pilot study (n = 12), we hypothesised that noxious stimulation in children receiving sevoflurane monoanaesthesia would evoke an increase in delta activity. This was tested in an independent sample of children (n = 39), where a subset (n = 11) had topical local anaesthetic applied prior to stimulation. A novel method of time-locking the stimuli to the EEG recording was developed using an event detection interface and high-speed camera. Clinical cannulation evoked a significant increase (34.2 ± 8.3%) in delta activity (P = 0.042), without concomitant changes in heart rate or reflex withdrawal, which was not observed when local anaesthetic was applied (P = 0.30). Experimental tactile (P = 0.012) and noxious (P = 0.0099) stimulation also evoked significant increases in delta activity, but the magnitude of the response was graded with stimulus intensity, with the greatest increase evoked by cannulation. We demonstrate that experimental and clinically essential noxious procedures, undertaken in anaesthetised children, alter the pattern of EEG activity, that this response can be inhibited by local anaesthetic, and that this measure is more sensitive than other physiological indicators of nociception. This technique provides the possibility that sensitivity to noxious stimuli during anaesthesia could be investigated in other clinical populations.
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Affiliation(s)
| | - Ravi Poorun
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sezgi Goksan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Alan Worley
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, UK
| | - Stewart Boyd
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, UK
| | - Richard Rogers
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - Tariq Ali
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK.
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Abstract
Infants within neonatal intensive care units can receive multiple medically essential painful procedures per day. How they respond to these events, how best to alleviate the negative effects, and the long-term consequences for the infant are all significant questions that have yet to be fully answered. In recent years, several studies have examined cortical responses to noxious stimuli in the neonate through the use of near-infrared spectroscopy (NIRS) and electroencephalography (EEG). These investigations dispel any notion that the newborn infant does not process noxious stimuli at a cortical level and open the way for future research. In this Viewpoint Article, we review these studies and discuss key clinical challenges which may be elucidated with the use of these techniques. Conclusion Simultaneously measuring the changes that are evoked in behaviour, physiology and the cortex following noxious events will provide the best approach to understanding the neonate's experience of pain.
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Cornelissen L, Fabrizi L, Patten D, Worley A, Meek J, Boyd S, Slater R, Fitzgerald M. Postnatal temporal, spatial and modality tuning of nociceptive cutaneous flexion reflexes in human infants. PLoS One 2013; 8:e76470. [PMID: 24124564 PMCID: PMC3790695 DOI: 10.1371/journal.pone.0076470] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 08/28/2013] [Indexed: 12/22/2022] Open
Abstract
Cutaneous flexion reflexes are amongst the first behavioural responses to develop and are essential for the protection and survival of the newborn organism. Despite this, there has been no detailed, quantitative study of their maturation in human neonates. Here we use surface electromyographic (EMG) recording of biceps femoris activity in preterm (<37 weeks gestation, GA) and term (≥ 37 weeks GA) human infants, less than 14 days old, in response to tactile, punctate and clinically required skin-breaking lance stimulation of the heel. We show that all infants display a robust and long duration flexion reflex (>4 seconds) to a single noxious skin lance which decreases significantly with gestational age. This reflex is not restricted to the stimulated limb: heel lance evokes equal ipsilateral and contralateral reflexes in preterm and term infants. We further show that infant flexion withdrawal reflexes are not always nociceptive specific: in 29% of preterm infants, tactile stimulation evokes EMG activity that is indistinguishable from noxious stimulation. In 40% of term infants, tactile responses are also present but significantly smaller than nociceptive reflexes. Infant flexion reflexes are also evoked by application of calibrated punctate von Frey hairs (vFh), 0.8-17.2 g, to the heel. Von Frey hair thresholds increase significantly with gestational age and the magnitude of vFh evoked reflexes are significantly greater in preterm than term infants. Furthermore flexion reflexes in both groups are sensitized by repeated vFh stimulation. Thus human infant flexion reflexes differ in temporal, modality and spatial characteristics from those in adults. Reflex magnitude and tactile sensitivity decreases and nociceptive specificity and spatial organisation increases with gestational age. Strong, relatively non-specific, reflex sensitivity in early life may be important for driving postnatal activity dependent maturation of targeted spinal cord sensory circuits.
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Affiliation(s)
- Laura Cornelissen
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, United Kingdom
| | - Lorenzo Fabrizi
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, United Kingdom
| | - Deborah Patten
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, United Kingdom
| | - Alan Worley
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Judith Meek
- Elizabeth Garrett Anderson Obstetric Wing, University College Hospital, London, United Kingdom
| | - Stewart Boyd
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Rebeccah Slater
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, United Kingdom
| | - Maria Fitzgerald
- Department of Neuroscience, Physiology & Pharmacology, University College London, London, United Kingdom
- * E-mail:
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Abstract
A 60-year-old man with chronic obstructive pulmonary disease and a heavy smoker and drinker presented to the emergency department with left-sided thoracoabdominal pain after falling down the stairs. Initial clinical findings were left-sided chest tenderness with no clinical evidence of subcutaneous emphysema. Twenty-four hours later the patient's respiratory distress increased-repeat chest X-ray showed a left gastrothorax indicative of a ruptured left hemi diaphragm. Diagnostic laparoscopy in the supine position via an umbilical port confirmed the presence of the stomach, spleen and splenic flexure of the colon in the left chest. Laparoscopic reduction of the stomach and colon was performed, but a small upper midline incision was required to reduce the spleen without injury. The diaphragmatic tear was repaired by direct open suture. The patient required a brief period of postoperative ventilation via a tracheostomy. The patient remained well at a 3-month follow-up visit.
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Affiliation(s)
- G Safdar
- Department of General Surgery, The Rotherham NHS Foundation Trust, Rotherham, UK.
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Fabrizi L, Williams G, Lee A, Meek J, Slater R, Olhede S, Fitzgerald M. Cortical activity evoked by an acute painful tissue-damaging stimulus in healthy adult volunteers. J Neurophysiol 2013; 109:2393-403. [PMID: 23427303 PMCID: PMC3652217 DOI: 10.1152/jn.00990.2012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 02/18/2013] [Indexed: 12/25/2022] Open
Abstract
Everyday painful experiences are usually single events accompanied by tissue damage, and yet most experimental studies of cutaneous nociceptive processing in the brain use repeated laser, thermal, or electrical stimulations that do not damage the skin. In this study the nociceptive activity in the brain evoked by tissue-damaging skin lance was analyzed with electroencephalography (EEG) in 20 healthy adult volunteers (13 men and 7 women) aged 21-40 yr. Time-frequency analysis of the evoked activity revealed a distinct late event-related vertex potential (lance event-related potential, LERP) at 100-300 ms consisting of a phase-locked energy increase between 1 and 20 Hz (delta-beta bands). A pairwise comparison between lance and sham control stimulation also revealed a period of ultralate stronger desynchronization after lance in the delta band (1-5 Hz). Skin application of mustard oil before lancing, which sensitizes a subpopulation of nociceptors expressing the cation channel TRPA1, did not affect the ultralate desynchronization but reduced the phase-locked energy increase in delta and beta bands, suggesting a central interaction between different modalities of nociceptive inputs. Verbal descriptor screening of individual pain experience revealed that lance pain is predominantly due to Aδ fiber activation, but when individuals describe lances as C fiber mediated, an ultralate delta band event-related desynchronization occurs in the brain-evoked activity. We conclude that pain evoked by acute tissue damage is associated with distinct Aδ and C fiber-mediated patterns of synchronization and desynchronization of EEG oscillations in the brain.
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Affiliation(s)
- Lorenzo Fabrizi
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom.
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