Neonatal procedural pain exposure and pain management in ventilated preterm infants during the first 14 days of life

OBJECTIVES: Ventilated preterm infants are at high risk for procedural pain exposure. In Switzerland there is a lack of knowledge about the pain management in this highly vulnerable patient population. The aims of this study were to describe the type and frequency of procedures and to determine the amount of analgesia given to this patient group in two Swiss neonatal intensive care units. METHOD: A retrospective cohort study was performed examining procedural exposure and pain management of a convenience sample of 120 ventilated preterm infants (mean age = 29.7 weeks of gestation) during the first 14 days of life after delivery and born between May 1st 2004 and March 31st 2006. RESULTS: The total number of procedures all the infants underwent was 38,626 indicating a mean of 22.9 general procedures performed per child and day. Overall, 75.6% of these procedures are considered to be painful. The most frequently performed procedure is manipulation on the CPAP prongs. Pain measurements were performed four to seven times per day. In all, 99.2% of the infants received either non-pharmacological and/or pharmacological agents and 70.8% received orally administered glucose as pre-emptive analgesia. Morphine was the most commonly used pharmacological agent. DISCUSSION: The number of procedures ventilated preterm infants are exposed to is disconcerting. Iatrogenic pain is a serious problem, particularly in preterm infants of low gestational age. The fact that nurses assessed pain on average four to seven times daily per infant indicates a commitment to exploring a painful state in a highly vulnerable patient population. In general, pharmacological pain management and the administration of oral glucose as a non-pharmacological pain relieving intervention appear to be adequate, but there may be deficiencies, particularly for extremely low birth weight infants born <28 weeks of gestation.

Management of chronic pancreatitis

Chronic pancreatitis (CP) is an inflammatory disorder that results in permanent impairment of the glandular anatomy of the pancreas with or without functional abnormalities. The pathogenesis of CP is usually unclear, except in the case of alcohol-induced disease. The most common symptoms of CP are abdominal pain, diarrhea, and weight loss often requiring recurring hospitalization. Over time, pancreatic endocrine and exocrine dysfunction may develop as the disease progresses, and a variety of complications can occur. Among the possible complications are nutrient malabsorption and diabetes mellitus. The treatment of CP is difficult and challenging for every physician. Relieving pain is the first step in treating CP. This symptom needs to be controlled, often with narcotics, which can cause dependence. Diarrhea usually indicates the presence of steatorrhea, which is often treated with a high-calorie, high-protein, and low-fat diet to minimize symptoms of the underlying disease and to promote weight retention or gain. Pancreatic replacement therapy is used to combat maldigestion and malabsorption. Patients with diabetes may need insulin therapy for glycemic control. The use of parenteral nutrition for bowel rest is a standard approach in patients with symptomatic CP. The use of jejunal enteral feeding recently has been evaluated for efficacy in CP patients. The role of pancreatic endotherapy in the management of CP is evolving. Several reports have suggested that endoscopic therapy aimed at decompressing the obstructed pancreatic duct can be associated with pain relief in some patients. Surgery should be considered in patients who fail medical therapy.

Integration of Year-round Forage Management Systems for Spring-calving and Fall-calving Beef Cows (A Progress Report)

Animal production, hay production and feeding, winter forage composition changes, and summer pasture yields and nutrient composition of a year-round grazing system for spring-calving and fall-calving cows were compared to those of a conventional, minimal land system. Cows in the year-round and minimal land systems grazed forage from smooth bromegrassorchardgrass-birdsfoot trefoil (SB-O-T) pastures at 1.67 and 3.33 acres, respectively, per cow in the summer. During the summer, SB-O-T pastures in the year-round grazing system also were grazed by stockers at 1.67 stockers per acre, and spring-calving and fall-calving cows grazed smooth bromegrass–red clover (SB-RC) and endophyte-free tall fescue–red clover (TF-RC) at 2.5 acres per cow for approximately 45 days in midsummer. In the year-round grazing system, spring-calving cows grazed corn crop residues at 2.5 acres per cow and stockpiled SB-RC pastures at 2.5 acres per cow; fallcalving cows grazed stockpiled TF-RC pastures at 2.5 acres per cow during winter. In the minimal land system, in winter, cows were maintained in a drylot on first-cutting hay harvested from 62.5–75% of the pasture acres during summer. Hay was fed to maintain a body condition score of 5 on a 9-point scale for springcalving cows in both systems and a body condition score of 3 for fall-calving cows in the year-round system. Over 3 years, mean body weights of fall-calving cows in the year-round system did not differ from the body weights of spring-calving cows in either system, but fall-calving cows had higher (P < .05) body condition scores compared to spring-calving cows in either system. There were no differences among all groups of cows in body condition score changes over the winter grazing season (P > .05). During the summer grazing season, fall-calving cows in the year- round system and springcalving cows in the minimal land system gained more body condition and more weight (P < .05) than springcalving cows in the year-round grazing system. Fall calves in the year-round system had higher birth weights, lower weaning weights, and lower average preweaning daily gains compared to either group of spring calves (P < .05). However, there were no significant differences for birth weights, weaning weights, or average pre-weaning daily gains between spring calves in either system over the 3-year experiment (P > .05). The amount of total growing animal production (calves and stockers) per acre for each system did not differ in any year (P > .05). Over the 3-year experiment, 1.9 ton more hay was fed per cow and 1 ton more hay was fed per cow–calf pair in the minimal land system compared to the year-round grazing system (P < .05).

Evaluation of Year-round Forage Management Systems for Spring- and Fall-Calving Beef Cows (A Progress Report)

A year-round grazing system for spring- and fall-calving cows was developed to compare animal production and performance, hay production and feeding, winter forage composition changes, and summer pasture yield and nutrient composition to that from a conventional, or minimal land system. Systems compared forage from smooth bromegrass-orchardgrass-birdsfoot trefoil pastures for both systems in the summer and corn crop residues and stockpiled grass-legume pastures for the year-round system to drylot hay feeding during winter for the minimal land system. The year-round grazing system utilized 1.67 acres of smooth bromegrassorchardgrass- birdsfoot trefoil (SB-O-T) pasture per cow in the summer, compared with 3.33 acres of (SB-O-T) pasture per cow in the control (minimal land) system. In addition to SB-O-T pastures, the year-round grazing system utilized 2.5 acres of tall fescue-red clover (TFRC) and 2.5 acres of smooth bromegrass-red clover (SBRC) per cow for grazing in both mid-summer and winter for fall- and spring-calving cows, respectively. First-cutting hay was harvested from the TF-RC and SB-RC pastures, and regrowth was grazed for approximately 45 days in the summer. These pastures were then fertilized with 40 lbs N/acre and stockpiled for winter grazing. Also utilized during the winter for spring-calving cows in the year-round grazing system were corn crop residue (CCR) pastures at an allowance of 2.5 acres per cow. In the minimal land system, hay was harvested from three-fourths of the area in SB-O-T pastures and stored for feeding in a drylot through the winter. Summer grazing was managed with rotational stocking for both systems, and winter grazing of stockpiled forages and corn crop residues by year-round system cows was managed by strip-stocking. Hay was fed to maintain a body condition score of 5 on a 9 point scale for spring-calving cows in both systems. Hay was supplemented as needed to maintain a body condition score of 3 for fall-calving cows nursing calves through the winter. Although initial condition scores for cows in both systems were different at the initiation of grazing for both winter and summer, there were no significant differences (P > .05) in overall condition score changes throughout both grazing seasons. In year 1, fall-calving cows in the year-round grazing system lost more (P < .05) body weight during winter than spring-calving cows in either system. In year 2, there were no differences seen in weight changes over winter for any group of cows. Average daily gains of fall calves in the yearround system were 1.9 lbs/day compared with weight gains of 2.5 lbs/day for spring calves from both systems. Yearly growing animal production from pastures for both years did not differ between systems when weight gains of stockers that grazed summer pastures in the year-round grazing system were added to weight gains of suckling calves. Carcass characteristics for all calves finished in the feedlot for both systems were similar. There were no significant differences in hay production between systems for year 1; however, amounts of hay needed to maintain cows were 923, 1373, 4732 lbs dry matter/cow for year-round fall-calving, year-round spring-calving, and minimal land spring-calving cows, respectively. In year 2, hay production per acre in the minimal land system was greater (P < .05) than for the year-round system, but the amounts of hay required per cow were 0, 0, and 4720 lbs dry matter/cow for yearround fall-calving, year-round spring-calving, and minimal land spring-calving cows, respectively.

Safe refeeding management of anorexia nervosa inpatients: an evidence-based protocol.

OBJECTIVE Anorexia nervosa is associated with several serious medical complications related to malnutrition, severe weight loss, and low levels of micronutrients. The refeeding phase of these high-risk patients bears a further threat to health and potentially fatal complications. The objective of this study was to examine complications due to refeeding of patients with anorexia nervosa, as well as their mortality rate after the implementation of guidelines from the European Society of Clinical Nutrition and Metabolism. METHODS We analyzed retrospective, observational data of a consecutive, unselected anorexia nervosa cohort during a 5-y period. The sample consisted of 65 inpatients, 14 were admitted more than once within the study period, resulting in 86 analyzed cases. RESULTS Minor complications associated with refeeding during the first 10 d (replenishing phase) were recorded in nine cases (10.5%), four with transient pretibial edemas and three with organ dysfunction. In two cases, a severe hypokalemia occurred. During the observational phase of 30 d, 16 minor complications occurred in 14 cases (16.3%). Six infectious and 10 non-infectious complications occurred. None of the patients with anorexia nervosa died within a follow-up period of 3 mo. CONCLUSIONS Our data demonstrate that the seriousness and rate of complications during the replenishment phase in this high-risk population can be kept to a minimum. The findings indicate that evidence-based refeeding regimens, such as our guidelines are able to reduce complications and prevent mortality. Despite anorexia nervosa, our sample were affected by serious comorbidities, no case met the full diagnostic criteria for refeeding syndrome.

Factors influencing the accuracy of fetal weight estimation with a focus on preterm birth at the limit of viability: a systematic literature review

BACKGROUND Fetal weight estimation (FWE) is an important factor for clinical management decisions, especially in imminent preterm birth at the limit of viability between 23(0/7) and 26(0/7) weeks of gestation. It is crucial to detect and eliminate factors that have a negative impact on the accuracy of FWE. DATA SOURCES In this systematic literature review, we investigated 14 factors that may influence the accuracy of FWE, in particular in preterm neonates born at the limit of viability. RESULTS We found that gestational age, maternal body mass index, amniotic fluid index and ruptured membranes, presentation of the fetus, location of the placenta and the presence of multiple fetuses do not seem to have an impact on FWE accuracy. The influence of the examiner's grade of experience and that of fetal gender were discussed controversially. Fetal weight, time interval between estimation and delivery and the use of different formulas seem to have an evident effect on FWE accuracy. No results were obtained on the impact of active labor. DISCUSSION This review reveals that only few studies investigated factors possibly influencing the accuracy of FWE in preterm neonates at the limit of viability. Further research in this specific age group on potential confounding factors is needed.

Management of Home Parenteral Nutrition: A Prospective Multicenter Observational Study

BACKGROUND There are no specific Swiss home parenteral nutrition (HPN) data showing patient characteristics, quality of life (QoL) and complications. The goal of this study was to collect representative nationwide data on current adult HPN patients in Switzerland for international comparability and benchmarking. METHODS This was a multicenter, nationwide, observational study. We conducted interviews for demographics, PN characteristics, QoL and complications. The data were assessed at baseline and after a follow-up of 3 months using a questionnaire. RESULTS Thirty-three adult patients were included. The most common underlying diseases were cancer, radiation enteritis and state after bariatric surgery, and the most prevalent indication was short bowel syndrome. During the 3-month observation period, significant increase or stabilization of body weight occurred in the patients, physical activity scores improved from 34.0 to 39.4 and mental scores improved from 41.9 to 46.4. HPN dependency and traveling restrictions were of the greatest concern. Diarrhea, xerostomia and/or thirst were frequent complaints. CONCLUSION Anthropometric parameters and QoL improved during the observational period in this HPN cohort. These Swiss HPN data are prerequisite for evaluation and comparison of HPN recommendations and best clinical practice, status of professional care instructions related to HPN effectiveness, quality of treatment and patient safety.

Anticoagulation Management Practices and Outcomes in Elderly Patients with Acute Venous Thromboembolism: A Clinical Research Study.

Whether anticoagulation management practices are associated with improved outcomes in elderly patients with acute venous thromboembolism (VTE) is uncertain. Thus, we aimed to examine whether practices recommended by the American College of Chest Physicians guidelines are associated with outcomes in elderly patients with VTE. We studied 991 patients aged ≥65 years with acute VTE in a Swiss prospective multicenter cohort study and assessed the adherence to four management practices: parenteral anticoagulation ≥5 days, INR ≥2.0 for ≥24 hours before stopping parenteral anticoagulation, early start with vitamin K antagonists (VKA) ≤24 hours of VTE diagnosis, and the use of low-molecular-weight heparin (LMWH) or fondaparinux. The outcomes were all-cause mortality, VTE recurrence, and major bleeding at 6 months, and the length of hospital stay (LOS). We used Cox regression and lognormal survival models, adjusting for patient characteristics. Overall, 9% of patients died, 3% had VTE recurrence, and 7% major bleeding. Early start with VKA was associated with a lower risk of major bleeding (adjusted hazard ratio 0.37, 95% CI 0.20-0.71). Early start with VKA (adjusted time ratio [TR] 0.77, 95% CI 0.69-0.86) and use of LMWH/fondaparinux (adjusted TR 0.87, 95% CI 0.78-0.97) were associated with a shorter LOS. An INR ≥2.0 for ≥24 hours before stopping parenteral anticoagulants was associated with a longer LOS (adjusted TR 1.2, 95% CI 1.08-1.33). In elderly patients with VTE, the adherence to recommended anticoagulation management practices showed mixed results. In conclusion, only early start with VKA and use of parenteral LMWH/fondaparinux were associated with better outcomes.

Treatment intensification with insulin glargine in patients with inadequately controlled type 2 diabetes improves glycaemic control with a high treatment satisfaction and no weight gain

PRINCIPLES We aimed to evaluate the efficacy of, and treatment satisfaction with, insulin glargine administered with SoloSTAR® or ClikSTAR® pens in patients with type 2 diabetes mellitus managed by primary care physicians in Switzerland. METHODS A total of 327 patients with inadequately controlled type 2 diabetes were enrolled by 72 physicians in this prospective observational study, which aimed to evaluate the efficacy of a 6-month course of insulin glargine therapy measured as development of glycaemic control (glycosylated haemoglobin [HbA1c] and fasting plasma glucose [FPG]) and weight change. We also assessed preference for reusable or disposable pens, and treatment satisfaction. RESULTS After 6 months, the mean daily dose of insulin glargine was 27.7±14.3 U, and dose titration was completed in 228 (72.4%) patients. Mean HbA1c decreased from 8.9%±1.6% (n=327) to 7.3%±1.0% (n=315) (p<0.0001), and 138 (43.8%) patients achieved an HbA1c≤7.0%. Mean FPG decreased from 10.9±4.5 to 7.3±1.8 mmol/l (p<0.0001). Mean body weight did not change (85.4±17.2 kg vs 85.0±16.5 kg; p=0.11). Patients' preference was in favour of the disposable SoloStar® pen (80%), as compared with the reusable ClickStar® pen (20%). Overall, 92.6% of physicians and 96.3% of patients were satisfied or very satisfied with the insulin glargine therapy. CONCLUSIONS In patients with type 2 diabetes insulin glargine administered by SoloSTAR® or ClikSTAR® pens, education on insulin injection and on self-management of diabetes was associated with clinically meaningful improvements in HbA1c and FPG without a mean collective weight gain. The vast majority of both patients and primary care physicians were satisfied with the treatment intensification.

Use of a modified Delphi panel to identify and weight criteria for prioritization of zoonotic diseases in Switzerland

Zoonotic diseases have a significant impact on public health globally. To prevent or reduce future zoonotic outbreaks, there is a constant need to invest in research and surveillance programs while updating risk management strategies. However, given the limited resources available, disease prioritization based on the need for their control and surveillance is important. This study was performed to identify and weight disease criteria for the prioritization of zoonotic diseases in Switzerland using a semi-quantitative research method based on expert opinion. Twenty-eight criteria relevant for disease control and surveillance, classified under five domains, were selected following a thorough literature review, and these were evaluated and weighted by seven experts from the Swiss Federal Veterinary Office using a modified Delphi panel. The median scores assigned to each criterion were then used to rank 16 notifiable and/or emerging zoonoses in Switzerland. The experts weighted the majority of the criteria similarly, and the top three criteria were Severity of disease in humans, incidence and prevalence of the disease in humans and treatment in humans. Based on these weightings, the three highest ranked diseases were Avian Influenza, Bovine Spongiform Encephalitis, and Bovine Tuberculosis. Overall, this study provided a preliminary list of criteria relevant for disease prioritization in Switzerland. These were further evaluated in a companion study which involved a quantitative prioritization method and multiple stakeholders.

Food intake in nonpurging obese women who binge eat before and after a behavioral weight loss program

Little is known about the impact of behavioral programs to decrease binge eating in obese persons who do not purge. This study was conducted to compare the amount of change in the reduction of binge days and selected nutrients in women who had joined a behavioral weight loss program. Forty-six women in the behavioral self management (BSM) group and thirty-six women in the Wait List Control (WLC) groups completed seven day food records at baseline and six months. These records were analyzed for calories, percentage of calories from protein, carbohydrate, fat and dietary fiber/ 1000 calories and were marked as "binge" or "nonbinge" days. Foods were also divided into 12 food groups but only six contributing to fat intake were chosen for analysis: dairy; fat; grains and starchy vegetables; meat, fish, and poultry; meat, fish, and poultry combinations; snacks and desserts. At six months, there was no difference in the amount of change in any of the selected nutrients between the BSM and WLC groups or in the amount of change within each food group except in the meat, fish, and poultry combination and in the snacks and desserts groups because both groups experienced similar changes at six months. Binge and nonbinge day nutrient analysis by BSM and WLC showed that at baseline and six months within the BSM group, calories increased significantly on binge days. Within the WLC group at six months, percentage of calories from protein was significantly decreased on binge days.^ The significant finding of this study was the reduction in the amount of change in the number of binge days at six months between the BSM and WLC groups ($-$2.2 versus $-$1.1 respectively). These data suggest that behavioral programs can successful reduce binge days, but that significant change in food intake may require more intensive treatment. ^