Response to PAIN Editorial re: Boyle et al. (2006).
Explore the source record for details and available documents.
Acute Disease↗
Biomedical subjects
Neil McIntosh
Publications and source records attributed to Neil McIntosh.
Assessment of persistent pain or distress and adequacy of analgesia in preterm ventilated infants.
Indicators of persistent pain in preterm neonates are poorly defined. In the setting of a double blind, placebo-controlled trial investigating morphine use in ventilated preterm infants (NEOPAIN Trial) we aimed to identify factors that may be useful in assessing persistent pain. Twenty-two babies (morphine 12; placebo 10) were assessed for comfort, pain or distress and clinical staff described the factors they had considered. This assessment was performed during the first period of duty with the baby. Based on this, they stated which study drug they believed the infant was receiving. Eighty-nine assessments were made in total (1-14 per baby). The drug was correctly identified on 71% of occasions. Staff considered one or more of the following factors: infant activity; response to routine care; known pain-related behaviours; posture/quality of movements; respiratory effort; synchrony with ventilator; blood pressure and heart rate. Four factors most frequently identified babies receiving placebo: facial expressions of pain, high activity levels, poor response to handling and poor synchrony with ventilation. Absence of pain-related behaviour was less discriminating. Observation of a good response to handling, good synchrony with ventilation, a "settled" baby, normal blood pressure and heart rate were poor discriminators. Hypotension and poor respiratory drive were noted exclusively in babies receiving morphine infusions. Facial expressions of pain, high activity levels, poor response to routine care, and poor ventilator synchrony were associated with placebo versus morphine therapy, and may be considered useful markers for persistent pain in preterm infants.
Age Factors↗
Southall and colleagues vindicated once more.
Explore the source record for details and available documents.
Attitude of Health Personnel↗
Lack of adult-type salivary cortisol circadian rhythm in hospitalized preterm infants.
BACKGROUND/AIMS: Knowledge of the presence or absence of cortisol (F) circadian rhythm in preterm infants is important for the interpretation of F measurements made in samples taken for both clinical and research purposes. Little is known about its emergence in very preterm infants. This study examines circadian rhythm in F secretion in hospitalized infants born before 30 weeks' gestation. METHODS DESIGN: Prospective longitudinal observational study. SUBJECTS: 11 infants admitted consecutively and born before 30 completed weeks of gestation. MEASUREMENTS: F was measured by highly specific radioimmunoassay on morning and evening saliva samples gathered at weekly intervals until discharged home. Circadian rhythm was defined as > or =40% reduction from morning to evening level. RESULTS: For all data, the median salivary F was 10.3 nmol/l (range <0.5-372.8). F levels were highest in the first 3 weeks of life. No infants displayed classical circadian rhythm for 4 weeks or more prior to being discharged from hospital. The other infants showed randomly distributed morning and evening F values with a trend in 4 infants towards periods of consistently higher evening than morning values. CONCLUSION: Adult-type F circadian rhythm is rarely evident in hospitalized preterm infants born before 30 weeks' gestation.
Circadian Rhythm↗
A comparison of graphical and textual presentations of time series data to support medical decision making in the neonatal intensive care unit.
OBJECTIVE: To compare expert-generated textual summaries of physiological data with trend graphs, in terms of their ability to support neonatal Intensive Care Unit (ICU) staff in making decisions when presented with medical scenarios. METHODS: Forty neonatal ICU staff were recruited for the experiment, eight from each of five groups--junior, intermediate and senior nurses, junior and senior doctors. The participants were presented with medical scenarios on a computer screen, and asked to choose from a list of 18 possible actions those they thought were appropriate. Half of the scenarios were presented as trend graphs, while the other half were presented as passages of text. The textual summaries had been generated by two human experts and were intended to describe the physiological state of the patient over a short period of time (around 40 minutes) but not to interpret it. RESULTS: In terms of the content of responses there was a clear advantage for the Text condition, with participants tending to choose more of the appropriate actions when the information was presented as text rather than as graphs. In terms of the speed of response there was no difference between the Graphs and Text conditions. There was no significant difference between the staff groups in terms of speed or content of responses. In contrast to the objective measures of performance, the majority of participants reported a subjective preference for the Graphs condition. CONCLUSIONS: In this experimental task, participants performed better when presented with a textual summary of the medical scenario than when it was presented as a set of trend graphs. If the necessary algorithms could be developed that would allow computers automatically to generate descriptive summaries of physiological data, this could potentially be a useful feature of decision support tools in the intensive care unit.
Computer Graphics↗
Project 27/28: inquiry into quality of neonatal care and its effect on the survival of infants who were born at 27 and 28 weeks in England, Wales, and Northern Ireland.
OBJECTIVE: To identify variations in standards of neonatal care in the first week of life that might have contributed to deaths in infants who were born at 27 and 28 weeks' gestation. METHODS: A case-control study was conducted of infants who were born at 27 and 28 weeks' gestation in England, Wales, and Northern Ireland during a 2-year period. Cases were neonatal deaths; control subjects were randomly selected survivors at day 28. Main outcome measures were failures of prespecified standards of care or deficiencies in care reported by regional panels assessing anonymized medical records. RESULTS: Failures of standards of care relating to ventilatory support (adjusted odds ratio [OR]: 3.29; 95% confidence interval [CI]: 1.97-5.49), cardiovascular support (OR: 2.37; 95% CI :1.36-4.13), and thermal care (OR: 1.71; 95% CI: 1.21-2.43) were associated with neonatal death. Frequencies of unmet resuscitation standards (range: 3%-46%) and of delays in surfactant administration (range: 38%-40%) were similar in cases and control subjects. Panels identified significantly more deficiencies in all aspects of neonatal care in cases with the exception of the management of infection. Stratification by clinical condition of infants at birth showed a stronger association between overall standard of care and death when infants were in a good condition at birth. CONCLUSIONS: Our findings suggest an association between quality of neonatal care and neonatal deaths, most marked for early thermal care and ventilatory and cardiovascular support. Poor overall quality of care was more strongly associated with deaths when the infant was in a good condition at birth.
Case-Control Studies↗
Introduction of enteral feeds in preterm infants.
Explore the source record for details and available documents.
Enteral Nutrition↗
Pain and compassion in the neonatal unit -- a neonatologist's view.
Research has shown that even extremely premature babies are sufficiently developed, anatomically and physiologically, to be capable of experiencing and responding to pain. All newborn infants and especially those who require intensive care in the first days of life are exposed to some painful procedures. Part of the neonatologist's role is the detection and management of pain in these infants. Difficult challenges come with this role. All medications carry known or potential adverse effects and limited research has been done in this vulnerable population. The benefits and risks of all available pain-relieving measures should be balanced when planning management. Compassion is no excuse for a high incidence of undesirable or dangerous side effects. We must proceed with great care.
Empathy↗
Hypoxic oxygen fluctuations produce less severe retinopathy than hyperoxic fluctuations in a rat model of retinopathy of prematurity.
The aim of this study was to investigate whether the mean around which arterial oxygen fluctuations take place was important in a unique animal model of oxygen-induced retinopathy. Retinopathy of prematurity (ROP) is associated with fluctuating arterial oxygen. A recent retrospective study suggested that management of high-risk preterm infants at lower oxygen saturations was associated with less severe ROP. Rat pups were raised in a variable oxygen environment around a high (24%), normal (21%) or low (17%) mean inspired oxygen for 14 d. Rat pups raised in the high (24%) mean variable oxygen environment had more retarded retinal vascular development than did rats raised in an environment that fluctuated around 21% mean oxygen. In contrast, rats raised in a lower mean (17%) but still variable oxygen environment had no discernible retinal differences from controls raised in constant room air. Rats raised in a relatively hypoxic but variable oxygen environment develop less severe retinal vascular abnormalities than those raised in variable oxygen around higher oxygen means.
Animals↗
Mismatched concepts in a neonatal intensive care unit (NICU): further issues for computer decision support?
BACKGROUND: Common concepts and definitions are important for the effective practice of medicine. In an intensive care unit clear understanding of terminology and communication between different staff groups may be critical for optimal care. If computerised decision support tools are to be successfully deployed in these high intensity environments, all staff must understand the concepts and information that is to be portrayed. OBJECTIVE: To examine the similarity of language and concepts related to newborn infants and their care in staff groups with different experience. METHODS: An experimental study in a tertiary regional neonatal intensive care unit involved 32 staff in 4 groups with varying experience (junior and senior / nurses and doctors). A psychologist developed a lexicon of clinical actions and a second lexicon of possible patient descriptors applicable to newborn infants receiving all degrees of neonatal care by conducting interviews with staff on the unit. Card sorting experiments were performed on the terms in the action and descriptor lexicons, the staff being asked to group words that were related to the same or similar concepts. The card sort data were analysed using conventional cluster analysis to produce tree-diagrams or dendrograms and then by distance matrix analysis to give cumulative probability plots. RESULTS: Differences were shown in the way various classes of staff and staff with different experience mentally map clinical concepts. Clinical actions were grouped more randomly by nurses and by those with less experience with a polarisation between senior doctors and junior nurses. Descriptors were classed more definitively and similarly by junior and senior nurses and senior doctors but more randomly and quite differently by junior doctors. Thus there were differences seen between nurses and doctors with different roles within the unit and differences related to experience. CONCLUSIONS: Concepts are used differently by various staff groups in a neonatal unit: this may have an impact on the effectiveness of computerised decision aids unless it is taken into account during their development.
Adult↗
The pain of heel prick and its measurement in preterm infants.
Variability of physiological parameters was used as a measure of stress in the newborn infant. There was a significant increase in variability of the heart rate (P < 0.01) when the stab of the heel prick occurred in addition to the other elements of the procedure (positioning, warming, alcohol swab cleansing and squeezing). This dummy procedure itself caused some increase in variability although this was not significant at the 5% level. There were similar significant increases in variability of the respiratory rate and O2 and CO2 tensions in the blood (P < 0.05) during the stab procedure.
Carbon Dioxide↗
Cutaneous hypersensitivity following peripheral tissue damage in newborn infants and its reversal with topical anaesthesia.
The flexion reflex threshold has been used as a measure of sensation in a group of premature infants born at 27-32 weeks postmenstrual age. The threshold in an area of local tissue damage created by routine heel lances was half the threshold on the intact heel on the other side. This indicated a hypersensitivity to tissue damage analogous to tenderness or hyperalgesia reported in adults. In a double-blind study, treatment of the damaged area with the topical anaesthetic cream, EMLA, was found to reverse this hypersensitivity or in other words increase the flexion reflex threshold. Treatment with placebo had no effect. The results show that the newborn infant central nervous system is capable of mounting a chronic pain response to local injury which can be reduced by local anaesthetic.
Anesthetics, Local↗
Role and experience determine decision support interface requirements in a neonatal intensive care environment.
The aim of this paper is to describe a novel approach to the analysis of data obtained from card-sorting experiments. These experiments were performed as a part of the initial phase of a project, called NEONATE. One of the aims of the project is to develop decision support tools for the neonatal intensive care environment. Physical card-sorts were performed using clinical "action" and patient "descriptor" words. Thirty-two staff (eight junior nurses, eight senior nurses, eight junior doctors, and eight senior doctors) participated in the actions card-sorts and the same number of staff participated in separate descriptors card-sorting experiments. To check for consistency, the card-sorts were replicated for nurses during the action card-sorts. The card-sort data were analysed using hierarchical cluster analysis to produce tree-diagrams or dendrograms. Differences were shown in the way various classes of staff with different levels of experience mentally map clinical concepts. Clinical actions were grouped more loosely by nurses and by those with less experience, with a polarisation between senior doctors and junior nurses. Descriptors were classed more definitively and similarly by nurses and senior doctors but in a less structured way and quite differently by junior doctors. This paper presents a summary of the differences in the card-sort data for the various staff categories. It is shown that concepts are used differently by various staff groups in a neonatal unit and that this may diminish the effectiveness of computerised decision aids unless it is explored during their development.
Computational Biology↗
Practicalities of consent.
Explore the source record for details and available documents.
Hearing Tests↗
Restoring high neonatal autopsy rates.
Explore the source record for details and available documents.
Autopsy↗
Intensive care monitoring: past, present and future.
Monitoring is the serial evaluation of time-stamped data, and the volume of such data in an intensive care unit is huge. Clinical and biochemical data may be available at hourly or more frequent intervals but physiological data are 'continuous'. Although sophisticated monitors display the physiological data in multiple and varied combinations, staff are challenged by the frequency of the false alarms and lack of knowledge of the patterns from which they could predict problems. All these data, together with large amounts of clinical data, lead to information overload. In this paper, the case is made for the development of automatic decision-support system based on statistical and probabilistic analysis of data patterns appropriate for the level of cognition of the user (nurses and juniors at the bedside rather than consultants). Such decision support could both reduce the false-positive alarms that frustrate clinical staff, and improve the early detection of pathophysiological events. We have used the development of a pneumothorax as our paradigm. Our data indicate that the clinical diagnosis of pneumothorax takes a median of 127 minutes, but using short decision algorithms based on routinely available monitoring data, most can be detected within 10-15 minutes of occurrence.
Algorithms↗