Managing pain medications in long-term care: nurses' views

The purpose of this study was to explore nurses' perceptions of their current practices related to administering pain medications to long-term care (LTC) residents. A cross-sectional survey design was used, including both quantitative and open-ended questions. Data were collected from 165 nurses (59% response rate) at nine LTC homes in southern Ontario, Canada. The majority (85%) felt that the medication administration system was adequate to help them manage residents' pain and 98% felt comfortable administering narcotics. In deciding to administer a narcotic, nurses were influenced by pain assessments, physician orders, diagnosis, past history, effectiveness of non-narcotics and fear of making dosage miscalculations or developing addictions. Finally, most nurses stated that they trusted the physicians and pharmacists to ensure orders were safe. These findings highlight nurses' perceptions of managing pain medications in LTC and related areas where continuing education initiatives for nurses are needed.

Supporting an ethnic minority woman's choice for pain relief in labour: a reflection

Despite professional expectations for midwives to provide care to women that is founded in equality and recognises diversity (Nursing and Midwifery Council, 2015), women from ethnic minority populations consistently suggest that they are not heard (Briscoe and Lavender, 2009; Tobin et al, 2014). This article reflects upon a situation where a Portuguese woman with limited English speaking ability was denied access to epidural anaesthesia as the midwife felt that she could not give valid consent to the procedure without the presence of an interpreter. The midwife’s role within this situation will be reflected upon and implications for midwifery practice identified.

Does video feedback analysis improve CPR performance in phase 5 medical students?

Background The use of simulation in medical education is increasing, with students taught and assessed using simulated patients and manikins. Medical students at Queen’s University of Belfast are taught advanced life support cardiopulmonary resuscitation as part of the undergraduate curriculum. Teaching and feedback in these skills have been developed in Queen’s University with high-fidelity manikins. This study aimed to evaluate the effectiveness of video compared to verbal feedback in assessment of student cardiopulmonary resuscitation performance Methods Final year students participated in this study using a high-fidelity manikin, in the Clinical Skills Centre, Queen’s University Belfast. Cohort A received verbal feedback only on their performance and cohort B received video feedback only. Video analysis using ‘StudioCode’ software was distributed to students. Each group returned for a second scenario and evaluation 4 weeks later. An assessment tool was created for performance assessment, which included individual skill and global score evaluation. Results One hundred thirty eight final year medical students completed the study. 62 % were female and the mean age was 23.9 years. Students having video feedback had significantly greater improvement in overall scores compared to those receiving verbal feedback (p = 0.006, 95 % CI: 2.8–15.8). Individual skills, including ventilation quality and global score were significantly better with video feedback (p = 0.002 and p < 0.001, respectively) when compared with cohort A. There was a positive change in overall score for cohort B from session one to session two (p < 0.001, 95 % CI: 6.3–15.8) indicating video feedback significantly benefited skill retention. In addition, using video feedback showed a significant improvement in the global score (p < 0.001, 95 % CI: 3.3–7.2) and drug administration timing (p = 0.004, 95 % CI: 0.7–3.8) of cohort B participants, from session one to session two. Conclusions There is increased use of simulation in medicine but a paucity of published data comparing feedback methods in cardiopulmonary resuscitation training. Our study shows the use of video feedback when teaching cardiopulmonary resuscitation is more effective than verbal feedback, and enhances skill retention. This is one of the first studies to demonstrate the benefit of video feedback in cardiopulmonary resuscitation teaching.

Assessing synchrony in groups:Are you measuring what you think you are measuring?

Behavioural synchrony has been a popular topic of research in group living animals, but has so far lacked a standard approach. Previous studies have varied greatly in the number of behavioural states they have considered and the size of groups investigated. Here, a model of behavioural synchrony was used to test four measures of synchrony commonly used (proportion observations 100% conforming, mean proportion of conforming individuals, Ruckstuhl's group mean and the kappa coefficient). The model used scan samples of the behaviour of laying hens, originally categorised in 10 different behavioural states, as a basis for determining the agents' probability of performing behaviour states. We systematically varied the group size and the number of behavioural states in the model. The measures calculated from the behaviour of the model agents were compared against a synchrony factor that determined the 'motivation' of agents in the model to conform to the behaviour of other agents, for model runs with different group sizes and behavioural categories. The results of the model suggest that, of the measures considered, the kappa coefficient is the most suitable measure of synchrony. The kappa coefficient was the only measure of the four tested to control for expected levels of synchrony. Expected levels of synchrony are sensitive to both the number of behaviour states being examined and the size of the group, therefore observed levels of synchrony should be compared against expected levels to provide meaningful standardised measures. © 2012 Elsevier B.V.

Collective synchrony increases prosociality towards non-performers and out-group members

Previous research has found that behavioural synchrony between people leads to greater prosocial tendencies towards co-performers. In this study we investigated the scope of this prosocial effect: does it extend beyond the performance group to an extended in-group (extended parochial prosociality) or even to other people in general (generalized prosociality)? Participants performed a simple rhythmic movement either in time (synchrony condition) or out of time (asynchrony condition) with each other. Before and during the rhythmic movement, participants were exposed to a prime that made salient an extended in-group identity. After the task, half the participants had the opportunity to help an extended in-group member; the other half had the opportunity to help an out-group member. We found a main effect of our synchrony manipulation across both help targets suggesting that the prosocial effects of synchrony extend to non-performers. Furthermore, there was a significantly higher proportion of participants willing to help an out-group member after moving collectively in synchrony. This study shows that under certain intergroup contexts synchrony can lead to generalized prosociality with performers displaying greater prosociality even towards out-group members.

Recent advances in the analysis of behavioural organization and interpretation as indicators of animal welfare

While the incorporation of mathematical and engineering methods has greatly advanced in other areas of the life sciences, they have been under-utilized in the field of animal welfare. Exceptions are beginning to emerge and share a common motivation to quantify 'hidden' aspects in the structure of the behaviour of an individual, or group of animals. Such analyses have the potential to quantify behavioural markers of pain and stress and quantify abnormal behaviour objectively. This review seeks to explore the scope of such analytical methods as behavioural indicators of welfare. We outline four classes of analyses that can be used to quantify aspects of behavioural organization. The underlying principles, possible applications and limitations are described for: fractal analysis, temporal methods, social network analysis, and agent-based modelling and simulation. We hope to encourage further application of analyses of behavioural organization by highlighting potential applications in the assessment of animal welfare, and increasing awareness of the scope for the development of new mathematical methods in this area.

Long-term consequences of pain in human neonates

The low tactile threshold in preterm infants when they are in the neonatal intensive care unit (NICU), while their physiological systems are unstable and immature, potentially renders them more vulnerable to the effects of repeated invasive procedures. There is a small but growing literature on pain and tactile responsivity following procedural pain in the NICU, or early surgery. Long-term effects of repeated pain in the neonatal period on neurodevelopment await further research. However, there are multiple sources of stress in the NICU, which contribute to inducing high overall 'allostatic load', therefore determining specific effects of neonatal pain in human infants is challenging.

Let your feet do the walking: constraints on the stability of bipedal coordination

In this paper we consider whether the behaviour of the neural circuitry that controls lower limb movements in humans is shaped primarily by the spatiotemporal characteristics of bipedal gait patterns, or by selective pressures that are sensitive to considerations of balance and energetics. During the course of normal locomotion, the full dynamics of the neural circuitry are masked by the inertial properties of the limbs. In the present study, participants executed bipedal movements in conditions in which their feet were either unloaded or subject to additional inertial loads. Two patterns of rhythmic coordination were examined. In the in-phase mode, participants were required to flex their ankles and extend their ankles in synchrony. In the out-of-phase mode, the participants flexed one ankle while extending the other and vice versa. The frequency of movement was increased systematically throughout each experimental trial. All participants were able to maintain both the in-phase and the out-of-phase mode of coordination, to the point at which they could no longer increase their frequency of movement. Transitions between the two modes were not observed, and the stability of the out-of-phase and in-phase modes of coordination was equivalent at all movement frequencies. These findings indicate that, in humans, the behaviour of the neural circuitry underlying coordinated movements of the lower limbs is not constrained strongly by the spatiotemporal symmetries of bipedal gait patterns.

A Phase I Clinical Study of Cisplatin-Incorporated Polymeric Micelles (NC-6004) in Patients with Solid Tumors

BACKGROUND: On the basis of preclinical studies of NC-6004, a cisplatin-incorporated micellar formulation, we hypothesised that NC-6004 could show lower toxicity than cisplatin and show greater anti-tumour activity in phase I study. METHODS: A total of 17 patients were recruited in a range of advanced solid tumour types. NC-6004 was administered intravenously (i.v.) every 3 weeks. The dose escalation started at 10?mg?m(-2) and was increased up to 120?mg?m(-2) according to the accelerated titration method and modified Fibonacci method. RESULTS: One dose-limiting toxicity (DLT) occurred in a patient who was given 90?mg?m(-2) of NC-6004, otherwise any significant cisplatin-related toxicity was not observed or generally mild toxicity was observed. Despite the implementation of post-hydration and pre-medication regimen, renal impairment and hypersensitivity reactions still developed at 120?mg?m(-2), which led to the conclusion that the maximum tolerated dose was 120?mg?m(-2), and the recommended dose was 90?mg?m(-2), although DLT was not defined as per protocol. Stable disease was observed in seven patients. The maximum concentration and area under the concentration-time curve of ultrafilterable platinum at 120?mg?m(-2) NC-6004 were 34-fold smaller and 8.5-fold larger, respectively, than those for cisplatin. CONCLUSION: The delayed and sustained release of cisplatin after i.v. administration contributes to the low toxicity of NC-6004.

No evidence of morphine analgesia to noxious shock in the shore crab, Carcinus maenas

A number of criteria have been suggested for testing if pain occurs in animals, and these include an analgesic effect of opiates (Bateson, 1991). Morphine reduces responses to noxious stimuli in crustaceans but also reduces responsiveness in a non-pain context. Here we use a paradigm in which shore crabs receive a shock in a preferred dark shelter but not if they remain in an unpreferred light area. Analgesia should thus enhance movement to the preferred dark area because they should not experience 'pain'. However, morphine inhibits rather than enhances this movement even when no shock is given. Morphine produces a general effect of non-responsiveness rather than a specific analgesic effect and this could also explain previous studies claiming analgesia. However, we question the utility of this criterion of pain and suggest instead that behavioural criteria be employed. (C) 2011 Published by Elsevier B.V.

International Association for Hospice and Palliative Care (IAHPC) List of Essential Practices in Palliative Care

The objective of this study was to identify, through a consensus process, the essential practices in primary palliative care. A three-phase study was designed. Phase 1 methods included development of a working group; a literature review; development of a baseline list of practices; and identification of levels of intervention. In Phase 2, physicians, nurses, and nurse aides (n = 425) from 63 countries were asked in three Delphi rounds to rate the baseline practices as essential or nonessential and select the appropriate levels of intervention for each. In Phase 3, representatives of 45 palliative care organizations were asked to select and rank the 10 most important practices resulting from Phase 2. Scores (1-10) were assigned to each, based on the selected level of importance. Results of Phase 1 were a baseline list of 140 practices. Three levels of intervention were identified: Identification/Evaluation; Diagnosis; and Treatment/Solution measures. In Phase 2, the response rates (RR) for the Delphi rounds were 96.5%, 73.6%, and 71.8%, respectively. A consensus point (=80% agreement) was applied, resulting in 62 practices. In Phase 3, RR was 100%. Forty-nine practices were selected and ranked. "Evaluation, Diagnosis and Treatment of Pain" scored the highest (352 points). The working group (WG) arranged the resulting practices in four categories: Physical care needs, Psychological/Emotional/Spiritual care needs, Care Planning and Coordination, and Communication. The IAHPC List of Essential Practices in Palliative care may help define appropriate primary palliative care and improve the quality of care delivered globally. Further studies are needed to evaluate their uptake and impact.

Behavioural skeletons in GCM: autonomic management of grid components

Autonomic management can be used to improve the QoS provided by parallel/distributed applications. We discuss behavioural skeletons introduced in earlier work: rather than relying on programmer ability to design “from scratch” efficient autonomic policies, we encapsulate general autonomic controller features into algorithmic skeletons. Then we leave to the programmer the duty of specifying the parameters needed to specialise the skeletons to the needs of the particular application at hand. This results in the programmer having the ability to fast prototype and tune distributed/parallel applications with non-trivial autonomic management capabilities. We discuss how behavioural skeletons have been implemented in the framework of GCM(the Grid ComponentModel developed within the CoreGRID NoE and currently being implemented within the GridCOMP STREP project). We present results evaluating the overhead introduced by autonomic management activities as well as the overall behaviour of the skeletons. We also present results achieved with a long running application subject to autonomic management and dynamically adapting to changing features of the target architecture.
Overall the results demonstrate both the feasibility of implementing autonomic control via behavioural skeletons and the effectiveness of our sample behavioural skeletons in managing the “functional replication” pattern(s).

Prenatal alcohol exposure alters biobehavioral reactivity to pain in newborns

To examine biobehavioral responses to an acute pain event in a Cape Town, South Africa, cohort consisting of 28 Cape Colored (mixed ancestry) newborns (n = 14) heavily exposed to alcohol during pregnancy (exposed), and born to abstainers (n = 14) or light (<or = 0.5 oz absolute alcohol/d) drinkers (controls).

Neonatal procedural pain exposure predicts lower cortisol and behavioral reactivity in preterm infants in the NICU

Data from animal models indicate that neonatal stress or pain can permanently alter subsequent behavioral and/or physiological reactivity to stressors. However, cumulative effects of pain related to acute procedures in the neonatal intensive care unit (NICU) on later stress and/or pain reactivity has received limited attention. The objective of this study is to examine relationships between prior neonatal pain exposure (number of skin breaking procedures), and subsequent stress and pain reactivity in preterm infants in the NICU. Eighty-seven preterm infants were studied at 32 (+/-1 week) postconceptional age (PCA). Infants who received analgesia or sedation in the 72 h prior to each study, or any postnatal dexamethasone, were excluded. Outcomes were infant responses to two different stressors studied on separate days in a repeated measures randomized crossover design: (1) plasma cortisol to stress of a fixed series of nursing procedures; (2) behavioral (Neonatal Facial Coding System; NFCS) and cardiac reactivity to pain of blood collection. Among infants born

Are there developmentally distinct motor indicators of pain in preterm infants?

The aims of this study were to examine preterm infant reactions to pain in detail over prolonged time periods using multiple measures, and to assess the value of including specific body movements of the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP) system to evaluate pain. Ten preterm infants born at 31 weeks mean gestational age (GA) and mean birth weight 1676 g were studied during a routine blood collection in a Level III neonatal intensive care unit (NICU). At 32-week post-conceptional age, computerized physiologic and video recordings were obtained continuously for 60 min (prior to, during and after lance). Motor and facial behaviors were coded independently, using the NIDCAP and the NFCS (Neonatal Facial Coding System), respectively, and compared with heart rate (HR) and oxygen saturation responses. Of the movements hypothesized to be stress cues in the NIDCAP model, extension of arms and legs (80%) and finger splay (70%) were the most common following lance. Contrary to the model, most infants (70%) had lower incidence of twitches and startles post-lance compared to baseline. Whereas all infants showed some NFCS response to lance, for three infants, the magnitude was low. HR increased and oxygen saturation decreased post-lance. Infants with more prior pain exposure, lower Apgar, and lower GA at birth, displayed more motor stress cues but less facial activity post-lance. Extension of extremities and finger splay, but not twitches and startles, from the NIDCAP, appear to be stress cues and show promise as clinical pain indicators to supplement facial and physiological pain measures in preterm infants.