Touch and massage for medically fragile infants.

Research investigating the efficacy of infant massage has largely focused on premature and low birth weight infants. The majority of investigations have neglected highly acute patients in academic neonatal intensive care units (NICUs). The current study was developed with two aims: (Phase 1) to develop, implement and demonstrate the feasibility and safety of a parent-trained compassionate touch/massage program for infants with complex medical conditions and (Phase 2) to conduct a longitudinal randomized control trial (RCT) of hand containment/massage versus standard of care in a level III academic Center for Newborn and Infant Critical Care (CNICC). Certified infant massage instructors (CIMIs) taught parents to massage their hospitalized infants. Massage therapy and instruction were performed for seven consecutive days and health outcomes were collected for up to 1 month following treatment. Caregivers, nurses and certified infant massage therapists indicated moderate to high levels of satisfaction and feasibility with the implementation of hand containment/massage in a level III academic center CNICC. In addition, infant behavioral and physiological measures were within safe limits during the massage sessions. All caregivers participating in the massage group reported high levels of satisfaction 7 days into the intervention and at the 1-month follow-up with regards to their relationship with their infant, the massage program's impact on that relationship and the massage program. Due to unequal and small sample sizes, between group analyses (control versus massage) were not conducted. Descriptive infant characteristics of health outcomes are described. Preliminary data from this study indicates feasibility and safety of infant massage and satisfaction among the caregivers, CIMIs and the nurses in the CNICC. An important contribution from this study was the demonstration of the infants' safety based on physiological stability and no change in agitation/pain scores of the infants receiving massage. Massage in a tertiary urban academic NICU continues to be an area of needed study. Future studies examining infant health outcomes, such as weight gain, decreased length of hospitalization and caregiver-infant bonding, would provide greater insight into the impact of massage for medically fragile infants.

Chronic osteomyelitis: results obtained by an integrated team approach to management.

BACKGROUND: The pathology of chronic osteomyelitis suggests that thorough debridement of bone and soft tissue, with closure of dead space, supported by appropriate antibiotics would be the optimal therapeutic strategy. METHODS: In 1993, we formed a multidisciplinary Bone Infection Team (orthopaedic surgeon, infectious diseases specialist, plastic surgeon, and nurse practitioner) to apply those principles to the treatment of chronic osteomyelitis. We present the outcomes of such therapy in 82 patients treated by the Team in the first seven years. All patients underwent surgical debridement with other procedures including bone distraction, muscle flap implantation and bone grafts as necessary to foster restoration of bone and soft-tissue integrity. Antibiotic choice was based on sensitivity data, with a short course of intravenous antibiotics and a prolonged course of oral antibiotics being the usual therapy. RESULTS: During the first seven years, we treated 82 patients for chronic osteomyelitis. Most patients required multiple surgical procedures (mean = 2.2), with 10 patients requiring five or more operations. Staphylococcus aureus was the single most common pathogen, although the majority (57%) of the infections were polymicrobial. Intravenous antibiotics were administered for a median of 16 days; 16 patients received intravenous antibiotics only during the immediate perioperative period. Oral antibiotics were administered for a median of 59 days. The infection was cured in all but one patient in our clinic; the remaining patient had definitive surgical repair at another clinic and is now infection free. In 77/82 patients, the limb afflicted with chronic osteomyelitis was salvaged. Because of extensive damage to bones and surrounding soft tissues, amputation was necessary in five patients. Five patients required internal fixation 12 or more months after the infection was controlled for nonunion; all such procedures were successful. No patient whose infection remained inactive for six or more months after surgical debridement has reactivated the infection during a median follow-up of 56 months (range: 23-89 months). CONCLUSIONS: Management of chronic osteomyelitis requires thorough debridement of infected bone and soft tissues coupled with rigid stabilization with external fixators, elimination of dead space, often requiring soft-tissue flap coverage, and staged bone reconstruction. When such a surgical approach is accompanied by appropriate antibiotics based on the sensitivity of the microbes isolated from the infected site, the infected focus is eliminated and bone length and integrity are restored.

Assisting older adults to communicate their postoperative pain.

An intervention assisting older adults to communicate their pain was tested in a posttest-only experiment. Thirty-eight preoperative older adults were randomly assigned to a communication group watching a videotape about communicating and managing postoperative pain or a comparison group watching a videotape about managing postoperative pain only. Pain was measured on Postoperative Days 1 and 2, and 1 and 7 days after hospital discharge by a data collector blind to the condition. The communication group reported greater pain relief and less pain interference on Postoperative Day 1. The comparison group reported greater pain relief on Postoperative Day 2 after attaining a pain interference level similar to the pain communication group. The pain communication intervention had modest effects for reducing pain interference with activities on Postoperative Day 1. Greater pain relief might be achieved when older adults and their health care providers are more knowledgeable about both pain communication and pain management.