Evaluation of three pain assessment scales used for ventilated neonates.

AIMS AND OBJECTIVES: To compare and evaluate the reliability, validity, feasibility, clinical utility, and nurses' preference of the Premature Infant Pain Profile-Revised, the Neonatal Pain, Agitation, and Sedation Scale, and the Neonatal Infant Acute Pain Assessment Scale used for procedural pain in ventilated neonates. BACKGROUND: Procedural pain is a common phenomenon but is undermanaged and underassessed in hospitalised neonates. Information for clinician selecting pain measurements to improve neonatal care and outcomes is still limited. DESIGN: A prospective observational study was used. METHODS: A total of 1,080 pain assessments were made at 90 neonates by two nurses independently, using three scales viewing three phases of videotaped painful (arterial blood sampling) and nonpainful procedures (diaper change). Internal consistency, inter-rater reliability, discriminant validity, concurrent validity and convergent validity of scales were analysed. Feasibility, clinical utility and nurses' preference of scales were also investigated. RESULTS: All three scales showed excellent inter-rater coefficients (from 0.991-0.992) and good internal consistency (0.733 for the Premature Infant Pain Profile-Revised, 0.837 for the Neonatal Pain, Agitation, and Sedation Scale and 0.836 for the Neonatal Infant Acute Pain Assessment Scale, respectively). Scores of painful and nonpainful procedures on the three scales changed significantly across the phases. There was a strong correlation between the three scales with adequate limits of agreement. The mean scores of the Neonatal Pain, Agitation, and Sedation Scale for feasibility and utility were significantly higher than those of the Neonatal Infant Acute Pain Assessment Scale, but not significantly higher than those of the Premature Infant Pain Profile-Revised. The Neonatal Pain, Agitation, and Sedation Scale was mostly preferred by 55.9% of the nurses, followed by the Neonatal Infant Acute Pain Assessment Scale (23.5%) and the Premature Infant Pain Profile-Revised (20.6%). CONCLUSIONS: The three scales are all reliable and valid, but the Neonatal Pain, Agitation, and Sedation Scale and the Neonatal Infant Acute Pain Assessment Scale perform better in reliability. The Neonatal Pain, Agitation, and Sedation Scale appears to be a better choice for frontier nurses to assess procedural pain in ventilated neonates based on its good feasibility, utility and nurses' preference. RELEVANCE TO CLINICAL PRACTICE: Choosing a valid, reliable, feasible and practical measurement is the key step for better management of procedural pain for ventilated newborns. Using the right and suitable tool is helpful to accurately identify pain, ultimately improve the neonatal care and outcomes.

Unrelated bone marrow transplantation for beta-thalassemia major: report of the first 2 successful cases in Asia.

We report our experience in successful unrelated-donor bone marrow transplantation in 2 cases of beta-thalassemia major, which are approved to be the first 2 cases in Asia. The 2 children receiving transplantation of the bone marrow from unrelated donors were diagnosed as having beta-thalassemia major, whose gene mutation type was homozygous and double heterozygote. High-resolution HLA typing found a mismatch with 1 sub-locus in both cases, and red blood cell type was mismatched in 1 case. Pretransplant conditioning protocol contained busulfan (BU, 16 mg/kg x b.w.), cyclosphamide (CY, 200 mg/kg x b.w.), anti-thymocyte globulin (ATG, 90 mg/kg x b.w.) and fludarabine (25 mg x d-1 x m-2). To prevent graft-versus-host disease (GVHD) episodes, cyclosporine-A (Cs-A) and methotrexate (MTX) were administered. The 2 cases experienced condition resembling serum sickness during pretransplant conditioning. After bone marrow transplantation, 1 case had grade acute GVHD in the skin, another developed grade acute GVHD in both the skin and intestinal tract, but the condition was brought under control in both cases after proper treatment. The time for peripheral neutrophil granulocyte recovery to above 0.5 x 10(9)/L was 19 and 16 days postoperatively, respectively, and the time of WBC recovery to normal was 54 and 80 days postoperatively. Platelet recovery to over 50 x 10(9)/L occurred on postoperative days 61 and 90, and Hb recovered to above 100 g/L in both case on days 110 and 83 respectively. The time of final blood transfusion was 53 and 62 days postoperatively for the 2 patients. Gene mutation type in the 2 cases was switched to normal of the donors. After retrieval of relative literature, the 2 cases were approved as the first 2 successful unrelated-donor bone marrow transplantation cases in Asia. This will provide a new possibility of donor supply for hematopoietic stem cells transplantation in thalassemia.

Comparison of the intervention methods for perinatal brain injury.

OBJECTIVE: To study the effective implementation of rehabilitation therapy for nervous system impairment in neonates with perinatal brain injury. METHODS: A retrospective case study of 160 neonates with perinatal brain injury was performed. The cases were assigned into 5 groups according to different treatment modalities. Group I included 42 babies aged below 6 months who were treated at early stages with neurotrophic agents and hyperbaric oxygenation with functional habilitation for more than 10 courses. Group II consisted of 30 babies who received the same treatments at the ages of 6 to 12 months. Group III (n=30) only received single-course therapy with medicine and high baric oxygen during neonatal period. Group IV(n=30) received medication only, while group V did not receive any nervous system rehabilitation therapy. Bayley Scale was used to evaluate the effect of the therapy in the 5 groups. RESULTS: Assessment with Bayley Scale revealed significant difference in the scores of development quotient (DQ) between the 5 groups, and group I scored the highest in gross movement, fine movement, self-care ability and communication/language (P<0.01). Groups III and IV had better scores in gross movement than group II and V (P<0.05), while no significant difference was noted in respect of any other score among groups II,III,IV and V. The DQ values of the 5 groups were significantly different (X(2)=56.674, P<0.001). CONCLUSION: Perinatal administration of neurotrophic agents and hyperbaric oxygenation along with functional habilitation therapy can effectively reduce nervous system sequelae of perinatal brain injury.