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Background: Pain is the main complaint felt by mothers during childbirth. Pain management can be done with non-pharma-cological techniques, one of which is using the Rebozo technique. Objective(s): This study aimed to determine the effectiveness of the rebozo technique for active phase 1 labour pain in primipa-rous women. Method(s): The study used a quasi-experimental design with a pretest and posttest control group. An accidental sampling technique divided a sample of 30 people into control and intervention groups. The intervention group received Rebozo therapy, a therapy using a traditional cloth wrapped around the pelvis and buttocks with the mother kneeling, then shaking it slowly. The pain was measured using the Visual Analogue Scale (VAS), ranging from 0-10. Bivariate test using Wilcoxon. Result(s): The majority of respondents were aged 21-29 years (56.7%), had high school education (83.3%) and were house-wives (50%). The majority of the control group showed moderate pain (53.3%), while the intervention group showed severe (60%). The reduction in pain in the intervention group was more significant than in the control group (2.27 > 0.73). Both the control group and the intervention group showed p < 0.001. Conclusion(s): The Rebozo technique effectively reduces labour pain in the active phase of the first stage in primiparous women. This technique is easy and inexpensive, so it can be an option for non-pharmacological therapy to treat labour pain.Copyright © 2023 Japan University of Health Sciences.
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Pulmonary parenchymal involvement secondary to the subcutaneous injection of silicone gels is an unusual condition which occurs more frequently in women aged between 22 and 55 years. Although different theories have been put forward about its etiology, it is unknown and the condition may cause local and systemic complications and even have a fatal outcome. Few cases have been reported in South America and there is no report of this unique entity in Peru. We present the case of a previously healthy 28-year-old male transgender patient who, after an illegal subcutaneous injection of silicone gels in the gluteal region given by a non-healthcare professional, showed progressive respiratory distress and stabbing chest pain of approximately 7 out of 10 on the pain scale within the first 24 hours. Upon admission to the emergency room, respiratory failure was objectively evidenced since the patient had an oxygen saturation of 72 % at a FiO2 of 21 %, as well as pulmonary parenchymal involvement both in the CT scan and chest X-ray with signs highly suggestive of this pathology. Using a SARS-CoV-2 RNA real-time RT-PCR test performed on a respiratory specimen, COVID pneumonia, immunodeficiency disorders and pulmonary embolism were ruled out. Since there is no standard treatment, the patient was given relevant support measures such as the administration of supplemental oxygen at a low flow rate by binasal cannula, intravenous systemic corticosteroids and antibiotic therapy, thus achieving good progress with resolution of the initial clinical presentation. Then, after 10 days of intrahospital treatment, the patient was discharged.Copyright © La revista. Publicado por la Universidad de San Martin de Porres, Peru.
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A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.
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Purpose: The aim of this study was to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on children and adolescents with migraine. Method(s): This longitudinal cohort study enrolled children and adolescents with migraine from the Department of Pediatric Neurology at our hospital from January 2017 to June 2021. Self-re-ported data from individual headache diaries were used. The patients were questioned about their headache frequency and intensity, stress, physical activity, changes in mood and sleep, and their school and home lives during the COVID-19 pandemic. The Pediatric Migraine Disability Assessment (Ped-MIDAS) scoring system was applied to assess headache-related disability. Result(s): In total, 325 pediatric migraine patients (mean age 12.8+/-5.6 years, 62.5% female) were included in this study. The average monthly frequency of migraine headaches was 2.17+/-1.32 and 4.62+/-3.29 before and during the COVID-19 pandemic (P<0.001), respectively. The Ped-MIDAS score was obtained for 207 patients both before and during the pandemic, and the total score slightly increased from 13.8 to 14.7 points (P=0.295). Sixty patients (18.5%) showed significantly worsening migraine headaches. Younger age (P=0.017), mood deterioration (P<0.001), sleep problems (P<0.001), increased acute medication use (P=0.010), and larger changes in the Ped-MIDAS score (P=0.002) were significantly associated with worsening headache in the logis-tic regression analysis. Conclusion(s): Headache attacks in children and adolescents with migraine were more frequent during the COVID-19 pandemic than before it. Worsening headaches could be independently at-tributed to younger age, mood deterioration, and poor sleep during the COVID-19 pandemic.Copyright © 2022 Korean Child Neurology Society.
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This article considers current contemporaneous practical issues of delirium care in nursing homes with reference to a hypothetical case study B.M. I introduce the diagnosis and management of delirium-superim-posed-on-dementia (DSD), being relatively common in patients in advanced phases of illness of many nursing home residents. General principles are discussed, although this article applies mainly to higher income countries. There is inevitably much palliative and end-of-life care in nursing homes, necessitating rigorous advance care planning. Nursing home residents are especially prone to acquiring infections. Urinary tract infections (UTIs) are traditionally the most commonly treat-ed infection among nursing home residents and, indeed, the accurate diagnosis of a UTI poses significant and distinctive challenges in the nursing home setting. There is no denying, however, that recently the global coronavirus (SARS-CoV-2) pandemic has posed an existential threat to both staff and residents of nursing homes. Resident-focused factors are striking. Psychotropic drugs are the most frequently prescribed medications in European nursing homes, but medication errors in nursing homes in general are relatively prevalent. Contributing factors to a high burden from pain for residents include residents belief set that age-related pain is inevitable, as well as un-der-recognition of pain and inappropriate pain assessment by clini-cians. Dehydration is associated with frailty, poor cognition, falls, de-lirium, disability, and mortality. Issues relating to the environment also matter. It is also impossible to ignore the organisational constraints on the provision of high quality care. Faced with widespread staffing short-ages, and many economies in financial distress, one partial solution is to retain current staff longer in nursing homes. Research on nursing home staffing has expanded beyond just staffing levels to include mul-tiple other staffing issues of concern.Copyright © by Societa Italiana di Gerontologia e Geriatria (SIGG).
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Aim: The COVID-19 pandemic has seen hospitals isolating suspect cases. Geriatric populations are at a risk of severe COVID-19 disease and often present with concomitant geriatric syndromes requiring holistic interdisciplinary care. However, isolation of older people poses challenges to care delivery. This study shares the experience of Singapore's first acute geriatric isolation facility geriatric PARI (Pneumonia-Acute Respiratory Infection) ward and describes the geriatric-related outcomes and pitfalls in care delivery. Method(s): This is a retrospective cross-sectional study performed in 7 negative pressure isolation rooms in an acute care public hospital in Singapore. 100 patients admitted consecutively to the geriatric PARI ward were included. Patient demographics, presenting symptoms and geriatric-related adverse outcomes associated with hospitalisation were collected and analysed. Result(s): Patients' mean age was 86.4 years (standard deviation [SD]: 6.8) with significant comorbidities being hypertension (81%), hyperlipidaemia (74%) and renal disease (70%). 51% of patients had dementia and 24% had behaviour and psychological symptoms of dementia (BPSD). 27% of patients presented atypically with delirium and 15% presented with a fall. Delirium was associated with restraint use (OR: 3.88;p-value 0.01). Falls rate was 1.64 per 1000 occupied bed. 1 patient screened positive for COVID-19. Conclusion(s): The geriatric PARI ward is essential for curbing nosocomial transmission of COVID-19. This is important in the older people with comorbidities who are more likely to develop morbidity and mortality. Our study reveals challenges in delivering person-centred care to the older patients in isolation rooms, especially in the management of delirium and falls prevention. Innovative strategies should be developed to minimise isolation-related adverse outcome.Copyright © The Author(s) 2022.
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Pain in children is frequent. Parents evaluate their children's pain to decide how to manage it or to share information with caregivers. This qualitative descriptive study aims to identify elements influencing the evaluation and management of pain in children from a parent's perspective. Participants were recruited through a pediatric center and university family medicine clinic. Participants had to have used medication for their child that was prescribed "as needed" to manage their child's pain in the month preceding the interview, whether it was a prescription-strength medication or an over-the-counter strength prescription. Semi-directed interviews 30-45 min in duration were conducted with 16 parents in the Outaouais region of Quebec (Canada), either at the participant's home or by phone (after the declaration of the COVID-19 pandemic). A thematic analysis was completed to identify themes in the data from these individual interviews. The evaluation of children's pain by their parents is influenced by the parents' experience with pain and the expression of the pain by the children, whereas the actions to relieve the pain are based on the beliefs surrounding pain management in children. Evaluation of pain is complex since many parents' beliefs influence this evaluation and the subsequent pain management. The study results raise healthcare professionals' awareness regarding several elements which influence the evaluation of children's pain and its management by their parents.
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Background: Complex regional pain syndrome type-1 (CRPS-1) is a severely disabling pain syndrome characterized by sensory and vasomotor disturbance, swelling, and functional impairment. Persistence of signs and symptoms has been observed in up to 64% of cases until 5.8 yrs after the onset of manifestations. Long-term disability, such as irreversible functional limitation, has been reported in up to 28% of cases with severe consequences on workability. No scores are validated to evaluate residual disability. Bisphosphonates have the best efficacy profile, compared with other therapeutic approaches, but data on long-term effectiveness are lacking. Objectives: To retrospectively evaluate long-term residual disability in patients with CRPS-1 of hand or foot after treatment with IV Neridronate (IVNer). To identify predictors of residual disability. To quantify disease outcomes, such as patient's subjective perception and residual pain. To assess long-term safety profile. Methods: We retrospectively collected data of patients affected by CRPS-1, treated with IVNer, referred to a tertiary Rheumatology Centre between Feb 2013 and Dec 2020. Visual analogue scale (VAS) and McGill Questionnaire (McGQ) were used for pain assessment. Disabilities of the Arm, Shoulder and Hand (DASH) and American Orthopaedic Foot and Ankle Society's (AOFAS) ankle-hindfoot scale for hand and foot involvement, respectively, were administered to explore disability through a phone survey. This kind of investigation was preferred for Covid pandemic. Results: 106 patients with definite diagnosis of CRPS-1 were included, mean age±standard deviation 55.6±13 yrs, 67% females, mean follow up duration 56.3 months (range 14-94), 46.2% with hand involvement. The mean VAS score before treatment onset was 55.8±23.4mm, while the McGQ was 12.9±6.7 in the sensory domain, 4.9±3.3 in the affective domain and 17.8±9.2 on the total score. Based on the patient's subjective perception and the proposed semi-quantitative scale, 77.4% described themselves as fully recovered (FR), 15% partially recovered (PR), and 7.6% with persistent disease (PD). Comparison between baseline and follow-up VAS shows a significant reduction (55.8±23.4 vs 15.1±26.4, p<0.00001). Pain assessment by McGQ showed a significant improvement in global score (baseline vs follow-up 17.8±9.2 vs 3.9±7.8, p<0.00001), sensory (12.9±6.7 vs 2.7±5.7, p<0.00001) and affective (4.9±3.3 vs 1.2±2.3, p<0.00001) domains. According to DASH score, 79.2% of the patients were FR, 3.8% had some difficulties, but with overall preserved use of the upper limb, and 17.0% had permanent functional disability. According to AOFAS ankle-hindfoot scale 76.4% of patients were FR, 16.0% had partial recovery, and 7.6% had severe functional impairment. Percentages of DASH and AOFAS scores showed a complete accordance with patients' subjective perception (Figure 1a and b). The only predictor of long-term functional impairment for CRPS-1 in the hand was a delayed treatment compared to symptoms onset (p=0.02). No predictors were found for foot localization. No patients reported the occurrence of osteonecrosis of the jaw or atraumatic fractures/atypical fracture features. Conclusion: IVNer maintained a good long-term effectiveness and safety profile in the treatment of CRPS-1. The effectiveness of IVNer is maintained on both pain symptoms and function, in terms of reductions in the VAS, McGQ and in hand and foot disability scores.
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Background: According to the recent medical literature, COVID-19 disease can lead to a constellation of clinical syndromes lasting well beyond the frst 30 days of infection. The most common post COVID sequalae includes pulmonary, nervous system and neurocognitive, mental, metabolic, cardiovascular, gastrointestinal and several other clinical manifestations. Regarding joint involvement and particularly reactive arthritis (ReA), literature data is limited and describes case reports or series of cases of patients diagnosed with this condition following COVID-19 disease. Objectives: To describe the pattern and the management of post-COVID reactive arthritis. Methods: We have conducted a descriptive study of consecutive adult patients who presented to rheumatology outpatient clinic for joint or peri-articular pain/swelling/stiffness and received a diagnosis of post-COVID 19 reactive arthritis, by excluding other types of rheumatological conditions. The assessed clinical variables were: visual analogue scale (VAS) pain, swollen joint count (SJC), tender joint count (TJC), duration of morning stiffness, presence of enthesitis/tendinitis and axial involvement. Biochemistry and serology was performed: rheumatoid factor, ACPA, ANA, HLA B27, antiChlamydia Trachomatis, Ureaplasma Urealyticum and Mycoplasma Hominis Ab, anti HBs and HBc Ab, and anti HCV. COVID-19 disease prior to diagnosis of ReA was confrmed by PCR test. Results: In the study were included 16 patients with confrmed post COVID-19 ReA. The mean age of the study group was 43.5±10.8 (range 21-60), the female: male ratio was 4:1 and the duration of joint symptoms was 10.4±11.8 (range 1-42) weeks. The severity of COVID-19 disease was mild in 68.7% cases, moderate in 18.7% and severe in only 6.2% of the cases. The duration between COVID-19 diagnosis and ReA varied between cases, with a mean value of 4.3±4.2 (range 1-12) weeks. In 43.7% of the cases patients had peripheral joint involvement (synovitis), in 37.5%-periarticular involvement (enthesitis), 6.25%-isolate axial involvement (sacroiliac joints), 6.25% enthesitis and axial involvement (cervical spine) and 6.25% synovitis and enthesitis. In patients with peripheral joint pattern, the distribution of pain was symmetric (71.4%). The pattern of synovitis was determined by a TJC of 6.25±5.2 (range 1-16) joints and SJC 1.6±2.4 (range 0-7) joints. Both TJC and SJC correlated positively with the duration of morning stiffness (r=0.9 and r=0.6), but did not correlate with the VAS pain scale. In most of the cases synovitis affected the hand (wrist, MCP and PIP) 62.5% and the knee, feet and ankles-50%. Two patients presented with monoarthritis, 1 with oligoarthritis and 5 with polyarthritis, in the majority of cases, involvement being symmetric (75%). Periarticular pattern was determined by enthesi-tis, affecting the elbow and shoulder (50%), costo-sternal enthesitis (25%) and trochanteritis (25%). From the entire study group, 31.2% had elevated serum infammatory markers (ESR and/or CRP). Patients responded well to NSAIDs alone in 68.7% cases, local (intra-articular or peri-articular infltrations) or and systemic corticoids (5 mg Prednisolone equivalent) were administered in 5.3% and 12.5% cases respectively, in 12.5% cases (two patients) Methotrexate was administered. Conclusion: Reactive arthritis represents a post COVID-19 sequelae. The time of onset of ReA varied between 1 and 12 weeks after COVID-19 diagnosis. The clinical pattern of the disease was expressed by joint or periarticular involvement, mainly affecting the hand, feet and knee symmetrically. Cases of axial manifestations were less common. Most of the patients responded well to NSAIDs, only in a few particular cases, low doses of corticoids and/or Methotrexate were recommended.
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Background: Prior studies have demonstrated improved accuracy and efficacy when Intra-articular (IA) therapeutics are injected using ultrasound (US) guidance. There is also growing evidence that many patients with knee oste-oarthritis (OA) exhibit a pro-infammatory catabolic synovial fuid (SF) profile. However, it is not known if temporary clinical improvement in pain and function after IA Hyaluronic acid (HA) injections is associated with changes in SF volumes. Objectives: The purpose of this study was to determine if IA HA injections delivered using US directed needle visualization with an external pneumatic compression device would result in improved clinical outcomes for knee OA at 3 and 6 months, and if this was associated with a reduction in the amount of knee synovial fuid (SF) measured on US. Methods: 49 eligible subjects with symptomatic Knee OA, BMI < 40 and KL radiographic rating of II or III OA were consented for this open label prospective IRB approved Investigator Initiated SF OA biomarker study (HS 3179, NCT 04093232). All standing radiographs were reviewed by a fellowship-trained MSK radiologist. 36 subjects had adequate aspirated SF volumes of > 500 mcl for biomarker analysis and therefore were eligible to receive two IA injections of HYADD4, 24 mg/3ml (Fidia Farmaceutici S.p.A. Italy) 7 days apart by a MSK US certifed Rheumatologist. An external pneumatic compression device and US visualized needle insertion ensured injections were delivered into the intra-syn-ovial space. Despite COVID-19 restrictions, 34 patients (17 women and 17 men) between 35 and 78 years of age returned for 3 month evaluations and 30 had evaluations at 6 months. The following clinical variables were measured: Western Ontario and McMaster Universities Index (WOMAC) total scores, Visual Analog Pain Scale (VAS, 0-10), PCS scores on the SF-36 health survey questionnaires (physical function/bodily pain and general health), 6-min-ute walking distance in meters (6 MWD), and measured SF depth before and after an external pneumatic compression device was infated to 100 mmHg to facilitate aspiration by increasing available SF volumes under positive presure. The SF depth was measured on the recorded US image (GE logiq e) as the largest anechoic region selected for aspiration on either the lateral (n= 30) or medial (n=4) compartment. SF and simultaneous peripheral blood samples were centrifuged and cryopreserved at-80 o C within 45 minutes of aspiration for future analysis. Statistical differences between baseline values compared to those levels at 3 and 6 months were determined using a paired ANOVA test with p <0.05 signifcance. Results: Improvements over baseline values were observed at 3 and 6 months respectively, after IA HA injections in WOMAC (40%, 40%), VAS (45%, 51%) and PCS (15%, 18%) all p< 0.0001. The 6 WWD improved by 7 % at 3 months (p< 0.007) but was not statistically improved at 6 months. US measured SF depth at baseline was 3.2 ± 2.2 mm before infation and 6.4 + 3.7 mm after infation of the pneumatic external compressioin device but statistical differences in SF depth were not observed at 3 and 6 months. Conclusion: Despite improvements in WOMAC, VAS scores, and PCS scores on the SF 36 at 3 and 6 months after US guided knee injections with an HA product, a statistically signifcant reduction in the amount of US measured SF was not observed. The 6 MWD improved at 3 months but was not statistically different from the baseline distance by 6 months. IA injections using US needle visualization confrmed that the product was delivered into the synovial space with 100 % accuracy which might have resulted in improved efficacy results in this study compared to prior IA HA studies injected without US or using different HA products. In the future, we hope SF biomarkers may identify which individual OA patients will likely achieve the greatest beneft with IA HA injections and to determine if this is associated with a reduction in catabolic pro-infammatory proteins.
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Background: Nowadays, noninvasive ventilation is the mainstay of the ventilation strategy in the neonatal intensive care units (NICUs) and most of infants, especially preterm infants, having respiratory problems, are provided noninvasive ventilation (NIV) upon their demands. Nevertheless, complication of NIV device-related pressure injury was common, the incidence of nasal injury ranged from 20% to 60%. Limited studies were found evaluating the nursing care of preterm infants receiving NIV. Aims: This study aimed to develop an evidence-based clinical practice guideline for preterm infants receiving NIV, implement the guideline in a NICU of a regional hospital, and evaluate infant outcomes including comfort, incidence of NIV device-related pressure injury. Besides, improvement on nurse's knowledge and practice for caring infants under NIV were assessed. Study Design and Methods: The Iowa Model-Revised was adopted as the theoretical framework to guide the study process. A multidisciplinary workgroup consists of eight stakeholders in NICU was formed for the process and acted as the champions for the new practice. A before and after study design was adopted and included the preimplementation and post-implementation phases. An integrative review was conducted to identify relevant studies from eight electronic databases before the study. All eligible studies were appraised using the Johns Hopkins University's evidence appraisal tool. Neonatal Pain, Agitation and Sedation Scale (N-PASS) for pain assessment and two self-developed NIV care bundle knowledge test and audit tool were used for the study. Results: Due to the COVID-19 pandemic in 2020, the study was extended for a month and ended in January 2021. A total of 74 infants in Pre-implementation phase (before group) and 67 infants in Post-implementation phase (after group) were recruited. Logistic regression model was used to compare the incidence of pressure injury between groups after adjusted for all substantial covariates in the study. Infants in after group had an 84% decreased odds of acquiring pressure injury (adjusted OR=0.149, 95% CI 0.045-0.495, p=0.002). Infant's comfort level whilst receiving NIV was not determined in the study as the after group having a significantly lesser mean time (p<0.001) in calm state but lower N-PASS score. Regarding nurse participants, 71 nurses received the training programme on NIV care bundle, and overall nurses' knowledge level improved immediately (adjusted p<0.001) and at 12 weeks after the programme. Three audits were conducted to evaluate nurses' practice, nurses' compliance rate to the care bundle significantly improved at 12 (p<0.001) and 24 weeks (p<0.001) in comparison with baseline compliance rate in the pre-implementation phase. However, nurses' knowledge retention at 12-week and compliance rate at 24-week after the training programme declined. Conclusion: The evidence-based clinical practice guideline aims to promote comfort and prevent injury in infants receiving NIV, and outcomes of the infants depend on vigilant nursing care and compliance to this clinical practice guideline. Declining of nurse's knowledge level and practice compliance found in the study indicates the needs of continuous education and audit on the practice to sustain the service quality and patient's safety.
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Introduction: Pain following caesarean section (CS) may hinder recovery and ability to care for the newborn. NICE [1] and PROSPECT [2] suggest analgesia be individualised. Regular paracetamol and NSAID should be co-prescribed. NICE advise adding regular dihydrocodeine where required. PROSPECT advise opioids for breakthrough where other techniques (e.g. regional) are contraindicated. Our protocol is PR diclofenac 100 mg in theatre, regular oral paracetamol 1 g + ibuprofen 400 mg, breakthrough dihydrocodeine 30 mg and oramorph 5 mg. The NHSL pain scale is a 0–4 numeric patientreported score, with >2 and <3 representing high and low scores. A CS audit in 2019–20 demonstrated 95% of patients being satisfied/very satisfied with pain relief, but 42% and 31% reported high pain scores on movement and rest, respectively. Only 28% received PR diclofenac, 85% paracetamol + ibuprofen, and 86% breakthrough dihydrocodeine. This re-audit assessed dynamic pain scores following introduction of regular dihydrocodeine 30 mg. Methods: After hospital clinical audit team approval, a prospective reaudit of postoperative CS pain and analgesia following neuraxial anaesthesiawas performed using a standardised patient questionnaire conducted on postoperative day 1 or 2 in Sep–Oct 2021. Participation was voluntary, occurring contemporaneously with routine postneuraxial anaesthesia follow-up. The NHSL pain scale was used. Elective and emergency patients were included. Cases under general anaesthetic were excluded. Results: The main outcomes are reported in the Table. (Table Presented) Discussion: Following introduction of regular dihydrocodeine, pain scores on movement did not improve. Use of breakthrough analgesia reduced. Time taken to receive breakthrough analgesia increased. The COVID-19 pandemic impacted staff absence rates. Telephone reviews post-discharge were not evaluated for the re-audit, which may skew results, with confounding factors contributing to pain. Future work will include midwife education, review opioid protocol prescribing and introduction of routine regional anaesthetic techniques (e.g. TAP block), followed by re-audit.
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Background and objectives: Healthcare workers (HCWs) are at significant risk of exposure to COVID-19 virus during this pandemic period. As part of healthcare protocol and staff risk assessment in Brunei Darussalam, all emergency department (ED) staff underwent periodical COVID-19 surveillance nasopharyngeal (NP) swabbing. This study was performed to evaluate the experience and comfort level of HCWs toward COVID-19 NP swab. Methodology: All HCWs (n=151) based in the ED, Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Brunei Darussalam, underwent COVID-19 surveillance NP swabbing followed by voluntary basis of completing an anonymous perception questionnaire form. The perception scale used in this study was adopted from numeric pain scale (0-10) with additional input of comfort level description. Data were analyzed using Excel software for demography profile, median perception scale, perception of comfort level, and correlation between the variables. Result: The HCWs (n=138) who completed the form consisted of nurses (52%), doctors (27%), support staffs (14%), and cleaners (7%);56% were male gender;61% were in the 20-to 40-year-old age group, and only 11% were in the >51-year-old age group. For the majority of the participants, this was their first time undergoing an NP swab (86%), and those who had previous swab experience accounted for 14%. The overall median perception scale was 3 (scale 0-10). In all, 26% reported that they were comfortable with the procedure, 29% were mild uncomfortable, 33% moderate uncomfortable, 10% severe uncomfortable, and 2% reported this was their worst ever experience. Some participants reported tearing eyes (n=4), runny nose (n=2), pain (n=3), and mild bleeding (n=1) as side effects. There was no correlation between gender, age, profession, or previous swab experience and the perception scale of NP swab. Conclusion: NP swab test procedure is well tolerated by the majority of HCWs. The perception scale could be affected by type of specimen, type and size of swab kit, and sampling procedure technique. Further comparison study is needed to determine the factors that may contributes to the level of comfort perception.
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Purpose/Background: With ERAS protocols advocating for multi-modal non-opiate options, amongst a surging opiate crisis, we reviewed published data to create our own protocol for non-narcotic colorectal surgery. Hypothesis/Aim: Non narcotic options in the perioperative period of colectomy is a viable, safe management plan Methods/Interventions: Our institution implemented an updated ERAS protocol beginning 1/1/2020. Our study was conducted from 7/1/19- 6/30/20. There were two groups, the prior ERAS protocol (p-ERAS) and the current non opiate (c-ERAS) group. Data was collected from 1/1/2019- 6/1/2020, acknowledging the decreased colectomies performed during the Coronavirus pandemic. Any patient during that time who was scheduled for surgery with a preoperative ERAS designation was included. Pain control was reviewed by comparing nursing reported pain scales. Other compared end points between the two groups included: length of stay (LOS), return of bowel function, and outpatient pain control based on the discharge medication orders and the number of patients who requested additional medications. Results/Outcome(s): 134 patients were studied with 25 patients (18.7%) c-ERAS compliant, compared to 109 patients (81.3%) who received opiates. Mean pain scores were reported by nursing as no pain (0), mild (1-3), moderate (4-6), or severe (7-10). A distribution of the duration of time (calculated in hours spent during the different pain levels) was determined for each of the four levels. The c-ERAS group was found to have a significantly longer duration with no pain, 34 vs 23 hours, (p = 0.062). The p-ERAS group was found to have elevated duration of moderate pain, 23.2 hours, in contrast to spending 17.7 and 14.1 hours with mild and severe pain, respectively. Overall, there was a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain. There was no statistically significant difference in the average length of stay. Limitations: Small population, only some of the recommended non - narcotic therapy options were available, analyzed pain scales were subjective findings reported to the staff and retrospectively reviewed. Conclusions/Discussion: In 2015, our community-based teaching institution implemented a colorectal ERAS protocol, which was later recognized to be dated. In 2019, a resident driven revision of the ERAS protocol was performed. This resulted in the implementation of a non-opiate colectomy regimen. Aside from immediate pre-operative opiate use by Anesthesia, no other peri-operative opiate medications were routinely ordered. Our regimen included preoperative celecoxib, tylenol, and pregabalin, intraoperative lidocaine infusion, and a postoperative rotation of toradol and IV tylenol, then transition to oral tylenol, and no narcotics prescribed on discharge. With this protocol, we have found a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain.
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AIM: The aim of the study was to analyze whether a patient's opinion is related to the effect of analgesic treatment. METHODS: The study was conducted using a survey questionnaire among adult patients admitted to the hospital emergency department in March 2021. The Numerical Rating Scale (NRS) was used to assess pain. Patients were asked to rate the intensity of pain during their stay in the emergency department in three situations: (1) at admission; (2) during the stay; and (3) upon discharge. The relationships between qualitative variables were assessed by the chi-squared test. Significance was set at p < 0.05. RESULTS: There was no statistical dependence between the patient's opinion about the medical institution and results of the effectiveness of analgesic treatments (p = 0.056). The highest percentage of patients satisfied with the received treatment were those who did not feel pain during ED discharge (94.12%), and the lowest were those who complained of severe pain during ED discharge (63.91%). The average mark for the functioning and organization of the emergency department was 7.44 (±2.04). Only 54 patients (29.83%) had taken pain medication before deciding to visit ED. CONCLUSIONS: No statistical dependency between the effect of the analgesic treatment and the patient's opinion has been observed. The majority of patients with pain discomfort visit emergency departments without looking for consultation in other locations or without taking analgesics. In the considered institution, patients were satisfied with the analgesic treatment, staff performance, and with the organization of the department.
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Purpose: Osteoarthritis (OA) is a chronic and disabling condition affecting morbidity and mortality. Despite its high prevalence and the availability of international management guidelines, nearly half of patients do not receive recommended treatments. OA Management Programs (OAMPs) are an alternative care model to reduce barriers and enhance the receipt of evidence-based care. This study was designed to evaluate the fidelity and feasibility of an OAMP in a United States academic medical center and understand its patients' baseline characteristics. Methods: The OAMP, which opened on July 1, 2017, is focused on knee and hip osteoarthritis. A multi-disciplinary group, including patients with OA, designed the clinic model and operations based on international OAMP implementation recommendations considering local factors. The intended treatment dose was 1-6 appointments over 4-12 months with no more than two months between visits. At each appointment, patients had the opportunity to meet with a care team comprised of a medical provider (physician or advanced practice provider), registered dietitian, physical therapist, and mental health counselor. All providers had completed OA clinical competency training. Telemedicine video visits were also available after June 2020 due to the COVID-19 pandemic. Patients are asked to complete the patient questionnaires before their visit through a patient portal in the electronic health record. They are also provided with a tablet computer to complete the VR-12 and the HOOS and/or KOOS while in the clinic waiting room. For this study, a database was created for all adult patients who had at least one clinic visit from July 1, 2017, to January 15, 2021. Data was collected by an electronic health record data pull and a manual audit of visit notes. Primary outcomes related to clinic feasibility and fidelity included clinic operations and expansion, treatment duration, and number and type of appointments attended. Secondary outcomes included patients' baseline characteristics. Results: The 938 eligible patients attended an average of 2.7 visits over a mean of 114.4 days (±5.9). Patients utilized the OAMP differently: 371 (39.5%) of patients attended 1 visit, 348 (37.1%) attended 2-3, and 232 (24.7%) attended 4 or more. A total of 175 (18.66%) completed at least one telemedicine visit. Patient referrals came predominantly from primary care (61%%) and orthopedics (20.3%);8.6% were self-referred. The average time between seeking care and the first appointment is just over six weeks. Due to patient demand, the program has expanded from seeing six patients per week to seeing more than 40 patients per week. The expansion has required hiring and training an increased number of clinicians, starting with four clinicians in different specialties to 11 clinicians. The average patient was 62.2 years (±10.2), and most were female (72%). Nearly all were Caucasian (91.3%). Medicare (51.4%) was the most common type of insurance, followed by commercial insurance (38.3%). Half of the patients were employed (49%), while 32% were retired. At the initial visit, the average BMI was 40.9 (±10). The average Charlson Comorbidity Index score (CCI) was 2.1 (±1.3), indicating moderate severity of comorbid conditions. The baseline pain rating was moderate at 4.44 (±2.37) on a 1-10 pain scale. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Hip Injury and Osteoarthritis Outcome Score (HOOS) pain scores were 47.9 (±18) and 44.9 (±23.6), respectively showing moderate baseline levels of pain. Veterans-Rand 12 scores were low at the initial visit. The VR-12 physical and mental subscales were 25.66 (±7.35) and 48.15 (±10.76) lower than expected for an adult population. The average number of repetitions obtained from the 30-second chair rise test was 10.65 (±3.49), which is lower than age and gender norms. The completion rate of self-administered patient questionnaires was low, with less than half of patients completing all questionnaires at the initial visit. Conclusions: Baseline data reveals patie ts with high levels of pain, low function, and multiple comorbid conditions who are willing to attend multiple visits. The program has continued to expand to meet increased patient demand. Patient utilization of the clinic varied, with some patients attending only one appointment and others returning numerous times. Despite being invited back within two months, a subset of patients returned for a second appointment more than six months after their initial appointment. Completion rates of the self-questionnaires (HOOS/KOOS, VR-12) were low despite having options of how to complete these. The low completion rate indicates that instruments should be selected judiciously with careful consideration for which should be administered at every clinic visit. Clinic operations and growth are feasible with variable fidelity. The next steps will be an evaluation of patient utilization of the clinic and its impact on patients outcomes.
ABSTRACT
INTRODUCTION/HYPOTHESIS: Analgosedation is standard of care in management of patients on mechanical ventilation. Drug shortages before and during the COVID-19 pandemic presented unique challenges, particularly during surges. The purpose of this study was to evaluate the impact of a structured, daily huddle report on analgosedative medication use in mechanically ventilated MICU patients. METHODS: This retrospective, single-center analysis included 3 two-month epochs before (E1), during (E2) and after (E3) initiation of an interprofessional pre-round huddle. Two metrics presented included continuous infusion (CI) analgosedation and drug shortages in effort to identify opportunities for scheduled enteral or parenteral therapies to aid CI weaning. Adult patients admitted to the MICU and on CI analgosedation were included. The primary endpoint compared daily and cumulative scheduled parenteral, enteral, and CI analgosedation administered between epochs. Secondary endpoints included percent-time in goal RASS, Objective Pain Assessment Scale (OPAS), time without delirium, evaluation of drug costs, and effect on ICU outcomes between epochs. RESULTS: A total of 81 patients (E1: 27;E2: 23;E3: 31) were included. Mean age (E1, 65.9±15.4 vs E2, 59.7±10.3 vs E3, 56.3±12.6 years;p=0.021) and proportion COVIDpositive (E1, 0 [0%] vs E2, 6 [26.1%] vs E3, 3 [9.7%];p=0.013) were different between groups. Cumulative CI opioid requirements (E1, 719.5 (214.4-1874.5) vs E2, 641.9 (503.7-1675.9) vs E3, 430.4 (247.2-856.5) mg morphine equivalents;p=0.029) were significantly different. Time on CI fentanyl (E1, 85.9 (46.1-170.5) vs E2, 95.3 (47.2-161.7) vs E3, 41.4 (12.4-67.2) hours;p=0.003) was also decreased. Percent-time in goal OPAS, RASS, without delirium were similar between epochs. Drug cost for CI fentanyl (E1, 3842.1 [1144.9-100009.83] vs E2, 4019.7 [2607.3-8954.4] vs E3, 2208.1 [1321.7-4451.4];p=0.023) was reduced. CONCLUSIONS: This exploratory analysis of a structured approach in scheduling enteral and parenteral agents to wean off CI analgosedation during drug shortages may be effective. Time on, overall CI fentanyl requirements, and costs were significantly reduced while maintaining adequate analgesia and sedation. These results may introduce novel strategies to mitigate drug shortages while maintaining clinical outcomes.
ABSTRACT
The COVID-19 pandemic can be attributed as a main factor to accelerate the current digital transformation and to encourage innovation and technological adoption. Consequently, the care provided to our children, one of the significant aspects of life, needs to be adapted with the life’s changes. Children are our future and our most precious resources. They need our attention in all life domains including health, education, safety and social interaction. Nowadays, technologies have been incorporated with machine learning and it has been proven that they are more powerful, reliable and profitable. Machine learning methods have been applied by many children-related studies to generate predictive models for different applications. The efficacy of the generated models mainly rely on the constructed databases. This article carries out a comprehensive survey on available children’s databases constructed for machine-learning-based solutions with their methodologies, characteristics, challenges, and applications. First, it provides an overview of the available studies and classifies them based on their applications. Next, it defines a set of attributes and evaluates them while also shedding light on their pros and cons. The primary concerns related to collection, development and distribution of children’s databases are also discussed. This study can be considered as a guideline for researchers in multidisciplinary fields to construct reliable databases and to develop more advanced techniques. Author
ABSTRACT
The coronavirus disease 2019 (COVID-19) pandemic imposes an unprecedented lifestyle, dominated by social isolation. In this frame, the population to pay the highest price is represented by demented patients. This group faces the highest risk of mortality, in case of severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection, and they experience rapid cognitive deterioration, due to lockdown measures that prevent their disease monitoring. This complex landscape mirrors an enhancement of neuropsychiatric symptoms (NPSs), with agitation, delirium and reduced motor performances, particularly in non-communicative patients. Due to the consistent link between agitation and pain in these patients, the use of antipsychotics, increasing the risk of death during COVID-19, can be avoided or reduced through an adequate pain treatment. The most suitable pain assessment scale, also feasible for e-health implementation, is the Mobilization-Observation-Behaviour-Intensity-Dementia (MOBID-2) pain scale, currently under validation in the Italian real-world context. Here, we report the case of an 85-year-old woman suffering from mild cognitive impairment, subjected to off-label treatment with atypical antipsychotics, in the context of undertreated pain, who died during the pandemic from an extensive brain hemorrhage. This underscores the need for appropriate assessment and treatment of pain in demented patients.
ABSTRACT
Background and Aim: Coronavirus pandemic has led to new issues in infective disease management, risk management and staffing. The purpose of this work is to demonstrate that the newly adopted strategies of the hospital ward Medicina II are effective, without compromising the standard of nursing care that were in place before the pandemic. Methods: We identified all the problems regarding infective disease management, risk management and staffing, highlighting all the actions taken to mitigate them. We selected three Nursing Sensitive Outcomes (NSO) to serve as a baseline from which we could proceed with a before and after qualitative comparison. Results: Of the 3 NSOs chosen (fall risk, alcohol-based hand gel consumption rate and pain assessment), both fall risk and hand gel consumption rate showed that the standards were maintained or were improved upon after the adoption of the new strategies. Pain assessment initially showed signs of a decline when compared to the standard. As such, after an analysis of the causes, the according action were taken to rectify this. Conclusions: While the changes applied showed signs of an increase in effectiveness, more researches must be conducted to corroborate these findings and identify among all the actions taken the most incisive. This could aid in identifying and reducing health and safety restrictions that have been put in place, as these would no longer be required, thus leading to also a better acceptance from the general population.