Nonverbal Patients Research Articles

Can Eye Tracking Help Assess the State of Consciousness in Non-Verbal Brain Injury Patients?

Background/Objectives: Developments in eye-tracking technology are opening up new possibilities for diagnosing patients in a state of minimal consciousness because they can provide information on visual behavior, and the movements of the eyeballs are correlated with the patients' level of consciousness. The purpose of this study was to provide validation of a tool, based on eye tracking by comparing the results obtained with the assessment obtained using the Coma Recovery Scale-Revised (CRS-R). Methods: The mul-ti-center clinical trial was conducted in Poland in 2022-2023. The results of 46 patients who were not able to communicate verbally due to severe brain injury were analyzed in this study. The state of consciousness of patients was assessed using the Minimally Conscious State Detection test (MCSD), installed on an eye tracker and compared to CRS-R. The examinations consisted of performing the MCSD test on patients five times (T1-T5) within 14 days. Collected data were processed based on the FDA and GCP's regulatory requirements. Depending on the nature of the data, the mean and standard deviation, median and lower and upper quartiles, and maximum and minimum values were calculated. Passing-Bablok regression analysis was used to assess the measurement equiva-lence of the methods used. Results: There was no difference between the MCSD and CRS-R in the raw change between T5 and T1 time points, as well as in the total % of points from all time points. The MCSD results from each time point show that at least the first two measurements serve to famil-iarize and adapt the patient to the measurement process, and the third and next measurement should be considered reliable. Conclusions: The results indicated a significant relationship be-tween the scores obtained with MCSD and CRS-R. The results suggest that it seems reasonable to introduce an assessment of the patient's state of consciousness based on eye-tracking technology. The use of modern technology to assess a patient's state of consciousness opens up the opportunity for greater objectivity, as well as a reduction in the workload of qualified personnel.

Diagnostic accuracy of point-of-care ultrasound (PoCUS) for the diagnosis of hip effusion in the pediatric emergency department.

A new limp or refusal to weight-bear are common symptoms in children presenting to the pediatric emergency department (ED). This poses a diagnostic challenge, particularly among toddlers and nonverbal patients. Point-of-care ultrasound (PoCUS) used by pediatric emergency medicine physicians may detect hip effusion, which dramatically aids diagnostic workup and management. There is limited literature regarding the accuracy of hip PoCUS conducted by pediatric emergency medicine physicians. This study aims to assess the diagnostic performance of pediatric emergency medicine physician-performed PoCUS in identifying hip effusion. This prospective study was conducted in a single-center pediatric ED. Children presenting with limb pain or new limp were evaluated by pediatric emergency medicine physicians who also performed hip PoCUS and categorized findings as either "effusion" or "no effusion" based on standard sonographic definitions. Patients also underwent radiology department ultrasound reviewed by a pediatric radiologist. Diagnostic test characteristics with corresponding 95% confidence intervals (CI) were calculated using radiology department ultrasound findings as the reference standard. A total of 95 patients were enrolled by 8 pediatric emergency medicine physicians. Excellent agreement was observed between PoCUS performed by pediatric emergency medicine physicians and radiology department ultrasound for the presence or absence of hip effusion (kappa = 0.81 [95% CI 0.70-0.93]). Hip effusion was identified by PoCUS in 44 out of 49 effusion-positive patients, with a sensitivity of 89.8% (95% CI 77.7-96.6%), specificity of 91.3% (95% CI 79.2%-97.5%), positive likelihood ratio of 10.33 (95% CI 4.03-26.47), and negative likelihood ratio of 0.11 (95% CI 0.05-0.26). PoCUS performed by pediatric emergency medicine physicians has reasonably high sensitivity and specificity for diagnosing hip effusion among pediatric patients presenting to the pediatric ED with a limp or leg pain. This practice may potentially expedite both diagnosis and treatment within this patient population.

Hydrogen-bond enhanced interior charge transport and trapping in all-fiber triboelectric nanogenerators for human motion sensing and communication

Maximizing charge density output within confined tribolayer areas is crucial for advancing triboelectric nanogenerator (TENG) performance. While conventional methods primarily focus on enhancing current density by modifying the surface properties of tribo-surfaces, the impact of dipole-dipole interactions between polymer molecular chains in the fibrous tribomaterials has been underexplored. This study reveals that intermolecular dipole-dipole interactions, mediated by hydrogen bonding between chitosan and nylon66 molecular chains, serve as effective bridging mechanisms that substantially boost TENG current density. Furthermore, we developed a breathable and antibacterial electrode by depositing silver nanowires (AgNWs) on the tribolayer surfaces. To prevent air breakdown resulting from excessively high current density, multiwalled carbon nanotubes (MWCNTs) were integrated to enhance electron transfer and storage. The structure we constructed achieved an optimized performance with a high voltage of 335 V, current density of 194.5 mA m−2 and power density of 65.1 W m−2, which demonstrates outstanding performance compared to previously obtained results. Finally, the prepared SWS-TENG was attached to the fingertips, wrist, and neck to track the physiological signals of the human state during standing, walking, and running. In addition, the integration of Morse code functionality introduces new possibilities for healthcare, particularly for non-verbal patients, enabling non-invasive communication of symptoms and emotions. This technology demonstrates significant potential as a versatile and non-invasive tool for point-of-care (PoC) and biomedical applications when deployed on various parts of the human body.

Disparities in Amblyopia Treatment Outcomes: The Impact of Sociodemographic Factors, Treatment Compliance, and Age of Diagnosis

ObjectiveTo identify clinical and sociodemographic factors associated with disparities in amblyopia treatment outcomes. DesignRetrospective chart review. SubjectsChildren ≤8 years old diagnosed and treated for unilateral refractive or strabismic amblyopia at our institution from 2012-2022. MethodsChildren with amblyopia were categorized by outcome: resolved amblyopia (<0.2 logMAR interocular difference [IOD] in visual acuity, or no fixation preference in non-verbal patients) or persistent amblyopia. Demographic and clinical data were recorded from the medical record. Zip codes were used to calculate Childhood Opportunity Index (COI) scores, estimated annual household income, and distance to hospital. Main Outcome MeasuresSociodemographic and clinical factors were compared between children with resolved and persistent amblyopia. Factors significant at p<0.10 on univariate analysis were included in a multivariable regression model. Results168 patients met inclusion criteria, and 131 (78%) had resolved amblyopia. Demographic factors associated with resolution of amblyopia were younger age at diagnosis (3.3±1.7 vs. 4.5±1.9 years, p=0.0009), English as the primary language (79.4% vs. 62.2%, p=0.04), higher estimated annual income ($83,315.93±29,276.64 vs. $71,623.00±26,842.56, p=0.03), higher COI scores (50.9±27.3 vs. 40.0±26.4, p=0.03), and living further from our institution (28.6±37.6 vs. 14.9±12.7 miles, p=0.003). Patients with resolved amblyopia also had higher rates of treatment compliance (83.2±25.0% vs. 75.6±24.4%, p=0.009) and shorter delays in follow-up (40.1±76.8 vs. 61.1±90.4 days, p=0.02). Amblyopia persistence was borderline associated with governmental insurance and higher presenting IOD in visual acuity (both p=0.06). On multivariate analysis, only younger age at amblyopia diagnosis (p=0.0010) remained significantly associated with amblyopia resolution. ConclusionsOur findings suggest that disparities in amblyopia outcomes are related to differences in age at diagnosis. Interventions to lower the age at which amblyopia is diagnosed, such as programs to improve vision screening rates and access to pediatric eye care in at-risk groups, may directly address inequities in rates of amblyopia resolution.

From facial expressions to algorithms: a narrative review of animal pain recognition technologies.

Facial expressions are essential for communication and emotional expression across species. Despite the improvements brought by tools like the Horse Grimace Scale (HGS) in pain recognition in horses, their reliance on human identification of characteristic traits presents drawbacks such as subjectivity, training requirements, costs, and potential bias. Despite these challenges, the development of facial expression pain scales for animals has been making strides. To address these limitations, Automated Pain Recognition (APR) powered by Artificial Intelligence (AI) offers a promising advancement. Notably, computer vision and machine learning have revolutionized our approach to identifying and addressing pain in non-verbal patients, including animals, with profound implications for both veterinary medicine and animal welfare. By leveraging the capabilities of AI algorithms, we can construct sophisticated models capable of analyzing diverse data inputs, encompassing not only facial expressions but also body language, vocalizations, and physiological signals, to provide precise and objective evaluations of an animal's pain levels. While the advancement of APR holds great promise for improving animal welfare by enabling better pain management, it also brings forth the need to overcome data limitations, ensure ethical practices, and develop robust ground truth measures. This narrative review aimed to provide a comprehensive overview, tracing the journey from the initial application of facial expression recognition for the development of pain scales in animals to the recent application, evolution, and limitations of APR, thereby contributing to understanding this rapidly evolving field.

Exploring the Experience of Patients Who Received Mechanical Ventilation Support during Their Intensive Care Unit Stay.

The objective of this study is to explore the experiences of patients who received mechanical ventilation (MV) support during their intensive care unit (ICU) stay in Jordan. A phenomenological hermeneutic approach was conducted, informed by the philosophy of Martin Heidegger. Fifteen patients participated in interviews regarding their experiences during their time in the critical care unit of three public hospitals in Jordan. Interpretive Phenomenological Analysis (IPA) was used to analyse the data. The findings of the current study indicated that patients who received MV support during their ICU stays experienced both physical and psychological suffering. A pattern of shared experiences among intensive care patients was identified. Five main themes captured the patients' experiences: (1) feeling powerless, (2) being unable to recognise time, (3) feeling dead, (4) experiencing physical pain, and (5) having future concerns. The current study found that mechanically ventilated ICU patients suffer both physically and psychologically. Nurses should use specific strategies to relieve discomfort in addition to pain treatment. This is especially essential for non-verbal patients, whose actions may resemble those of their clinicians in pain.

Virtual reality for interventional radiology patients: a preliminary study.

The aim of this prospective study was to evaluate the tolerance and feasibility of using virtual reality headsets with patients during interventional radiology procedures. In this single-center prospective study, the use of a virtual reality headset in addition to the usual analgesic and anxiolytic treatment was proposed to all patients presenting in the interventional radiology department from December 2020 to June 2022. Exclusion criteria were as follows: (1) patients with whom it was not possible to communicate (2) epileptic patients, (3) non-verbal patients, and (4) pregnant women. The main objective was to evaluate the safety of the procedure by screening complications during and after the procedure. The second objective was to evaluate feasibility, as defined by the number of patients using the helmet until the end of the procedure. Effectiveness (patient's self-evaluation of pain and anxiety), comfort, satisfaction, emotions felt, sense of security, and feeling of immersion were also evaluated. Caregivers completed a feedback questionnaire. Virtual reality headsets were offered to 100 patients, 9 of whom declined. Procedures were achieved in 93.5% of cases: 6/91 patients removed the headset before the end of the procedure. There were minor adverse events in 2/85 (2.3%) procedures (discomfort and nausea) and no major adverse events. 93.9% of patients found an overall benefit, and 90.2% would recommend virtual reality to another patient. 94.4% of caregivers were satisfied with the virtual reality equipment. The mean pain level was 2.5 ± 2.7 before the procedure, 3.3 ± 2.5 during the procedure, and 1.6 ± 2.7 after the procedure. Mean anxiety scores were 4.6 ± 2.9 before the procedure, 3.1 ± 2.7 during the procedure, and 1.1 ± 1.9 after the procedure. The use of virtual reality technology as a complement to traditional therapy for procedures under local anesthesia is feasible and safe in interventional radiology and can be beneficial for pain and anxiety management.

Management of Cerebrospinal Fluid Leak After Intrathecal Baclofen Pump Procedures in Adolescents With Cerebral Palsy: A Retrospective Study.

Epidural blood patches (EBPs) are frequently performed in children with cerebral palsy (CP) to manage post-dural puncture headache (PDPH) due to cerebrospinal fluid (CSF) leak after intrathecal baclofen pump (ITBP) placement or replacement procedures. The purpose of our study was to review the incidence and management of CSF leak following ITBPplacement or replacement procedures in children with CP. The study was a retrospective review of 245 patients representing 310 surgical cases of baclofen pump insertion (n=141) or reinsertion (n=169) conducted at a 125-bed children's hospital with prominent specialty orthopedics surgical cases. Demographic and clinical information was obtained from the anesthesia pain service database on all new ITBP placement and subsequent replacements over an eight-year period. The overall incidence of CSF leak in our population was 16% (50 of 310) and 18% (25 of 141) with a new ITBP placement.Children with diplegia were associated with a threefold risk of developing CSF leak. Of patients who developed CSF leak (n=50), 68% (n=34) were successfully treated conservatively, while 32% (n=16) required EBPs.EBPs were successful in 87.5% (14 of 16) of patients at relieving PDPH on the first attempt. Conclusions:CSF leak is a known problem after ITBP placement and replacement. Most patients were successfully treated with conservative management and EBPs were successful in patients failing conservative therapy.Diagnosing PDPH in non-verbal patients can be challenging.

Short communication: A pilot study to determine safety and feasibility of a commercial enuresis alarm to detect voiding in infants

Accurate measurement of post-void residual (PVR) volumes requires accurate determination of the timing of voiding, which is challenging in non-verbal patients. As a proof of principle, we sought to test the feasibility, safety and efficacy of using an enuresis alarm to indicate voiding in ten infants. Each infant was observed for 4h with alarm in the diaper, and diapers checked every 15-30min to confirm voiding. The alarm activated in 31 of 33 voids (93.9%). No adverse events occurred. Further work will investigate whether this approach may improve accuracy of PVR measurement.

A clinical case of an atypical clinical pattern of renal colic in a nonverbal patient

Renal colic is a condition caused by the passage of a concretion from the kidney through the ureter into the bladder, which is accompanied by a pronounced pain syndrome. Patients with renal colic often seek emergency help with complaints of severe pain, nausea, dysuria. However, there is a category of people who, for various reasons, cannot verbally express their feelings. Such patients are called nonverbal. Nonverbal patients are people with severe cognitive impairments or those who are temporarily unable to speak due to surgery or illness, but they can still demonstrate pain using nonverbal signals.In this article, we present an observation of an atypical clinical picture of renal colic in a nonverbal elderly patient. In the observed woman, an acute attack of renal colic lasted 5 days and passed first under the «mask» of acute pancreatitis. Without receiving pathogenetic therapy, the patient developed acute obstructive pyelonephritis, septic shock, which was initially mistaken for an acute violation of cerebral circulation. The performed computed tomography (CT) helped to identify a concretion in the upper third of the ureter on the left, a violation of the outflow of urine from the left kidney. The patient urgently had a stent installed in the pelvis of the left kidney, urine outflow was restored, anti-inflammatory, detoxification, litolytic therapy was prescribed. After that, the patient's condition improved significantly, and after 3 months, a decrease in the size and fragmentation of the concretion was observed during the control CT scan.Conclusion. Nonverbal patients are a special group of patients whose clinical picture may be blurred or atypical. Assessment of pain symptoms in nonverbal patients is difficult, which can lead to an incorrect diagnosis and lengthen the period of diagnosis of the disease. The timely diagnosis of renal colic in nonverbal patients is also affected by the localization of pain, since its irradiating nature can direct the diagnostic search «on the wrong track».

Comparative assessment of pupillary oscillation and blinking rate between emmetropes and myopes

Aim of this study was to investigate for a relationship between pupillary oscillations (PO) and blinking rate (B) in various vision deprived states such as in refractive errors (Myopes).: A case control descriptive study with 340 individuals, including 220 myopes and 120 emmetropes were compared for pupillary oscillation rate (PO), blinking rate (B) and Pupillary oscillation/blinking rate (PO/B) ratio bilaterally in normal as well as in individual subgroups of decreasing visual acuity, done under slit lamp in dim diffuse illumination. The pupillary oscillation rate (PO) was 49.23± 8.80 in right eye (POR) and 56.44 ±8.95 in left eye (POL) in the control group whereas it was 46.28 ±11.55 and 52.79 ±11.22 in the right and left eyes respectively of the cases. While PO/B ratio was 12.41±14.11 in the right eye and 14.33±15.9 in the left eye in control group, it was 7.13 ± 7.86 in the right and 8.18 ±9.07 in the left eye of the cases respectively. The blinking rate (B) was 8.62 ±6.06 in the control eyes and in the cases it was 11.69 ±7.91. The comparative analysis of all of the above parameters were statistically significant with p &amp;#60; 0.001 between cases and controls. POR = POL in 5.0%, POR &amp;#62; POL in 7.50% and POR &amp;#60; POL in 87.50%.: This study could be useful in non-verbal patients and comatose patients as diagnostic and prognostic tool, having an implication in different refractive errors and neurological diseases.

Behavioral pain scale may not be reliable in awake non-verbal intensive care patients: a case control study

BackgroundThe evaluation of pain in patients, unable of oral communication, often relies on behavioral assessment. However, some critically ill patients, while non-verbal, are awake and have some potential for self-reporting. The objective was to compare the results of a behavioral pain assessment with self-reporting in awake, non-verbal, critically ill patients unable to use low-tech augmentative and alternative communication tools.MethodsProspective cohort study of intubated or tracheotomized adult, ventilated patients with a RASS (Richmond Agitation Sedation Scale) of -1 to + 1 and inadequate non-verbal communication skills in a surgical intensive care unit of a tertiary care university hospital. For pain assessment, the Behavioral Pain Scale (BPS) was used. Self-reporting of pain was achieved by using an eye tracking device to evaluate the Numeric Rating Scale (NRS) and the pain/discomfort item of the EuroQol EQ-5D-5 L (EQ-Pain). All measurements were taken at rest.ResultsData was collected from 75 patients. Neither the NRS nor the EQ-Pain (r < .15) correlated with the BPS. However, NRS and EQ-Pain were significantly correlated (r = .78, p = < 0.001), indicating the reliability of the self-reporting by these patients. Neither the duration of intubation/tracheostomy, nor cause for ICU treatment, nor BPS subcategories had an influence on these results.ConclusionsBehavioral pain assessment tools in non-verbal patients who are awake and not in delirium appear unreliable in estimating pain during rest. Before a behavioral assessment tool such as the BPS is used, the application of high-tech AACs should be strongly considered.Trial registrationGerman Clinical Trials Register, Registration number: DRKS00021233. Registered 23 April 2020 - Retrospectively registered, https://drks.de/search/en/trial/DRKS00021233.

Empirical comparison of deep learning models for fNIRS pain decoding.

Pain assessment is extremely important in patients unable to communicate and it is often done by clinical judgement. However, assessing pain using observable indicators can be challenging for clinicians due to the subjective perceptions, individual differences in pain expression, and potential confounding factors. Therefore, the need for an objective pain assessment method that can assist medical practitioners. Functional near-infrared spectroscopy (fNIRS) has shown promising results to assess the neural function in response of nociception and pain. Previous studies have explored the use of machine learning with hand-crafted features in the assessment of pain. In this study, we aim to expand previous studies by exploring the use of deep learning models Convolutional Neural Network (CNN), Long Short-Term Memory (LSTM), and (CNN-LSTM) to automatically extract features from fNIRS data and by comparing these with classical machine learning models using hand-crafted features. The results showed that the deep learning models exhibited favourable results in the identification of different types of pain in our experiment using only fNIRS input data. The combination of CNN and LSTM in a hybrid model (CNN-LSTM) exhibited the highest performance (accuracy = 91.2%) in our problem setting. Statistical analysis using one-way ANOVA with Tukey's (post-hoc) test performed on accuracies showed that the deep learning models significantly improved accuracy performance as compared to the baseline models. Overall, deep learning models showed their potential to learn features automatically without relying on manually-extracted features and the CNN-LSTM model could be used as a possible method of assessment of pain in non-verbal patients. Future research is needed to evaluate the generalisation of this method of pain assessment on independent populations and in real-life scenarios.

Physician Communication Behaviors on Patient Satisfaction in Primary Care Medical Settings in Bangladesh.

This study aims at exploring the effects of physicians' communication behaviors on patients' satisfaction in primary care medical consultations in Chattogram, Bangladesh. The study used a quantitative research approach designed with a cross-sectional survey. Data were collected using post-consultation and facilitator administered questionnaire from the patients who visited the physician for medical consultation in different hospitals and clinics in Chattogram city. Seven hundred patients were included as the study participants. A hierarchical linear regression analysis was performed to examine the factors contributing to the outcome variables. A statistically significant difference (P < .001) appeared regarding patients' perception of adequate consultation, physicians' nonverbal behavior, inhibiting behavior and patients' participating behavior in private and public settings. However, R2 value shows that physicians' patient-centered behaviors appeared as the stronger predictors of patient satisfaction toward medical interviews, followed by socioeconomic variables of patients and physicians and patients' participation during the consultation. Presence of a third person with patients during consultation (β = -.05, P = .040), physicians' private setting of consultation (β = .16, P < .001), physicians' seniority (β = .05, P = .042), patients' participating behavior during consultation (β = .20, P < .001), physicians' nonverbal behavior (β = .10, P < .001), physicians' inhibiting behavior (β = -.39, P < .001), and physicians' facilitating behavior with patients (β = .32, P < .001) were reported as the influencing factors of patients' satisfaction with medical consultation. This study suggests the profound impact of physicians' patient-centered communication behaviors on patient satisfaction in primary care settings, overshadowing even socioeconomic factors and patient participation.

2020 Improving pain management in non-verbal patients

Abstract Introduction Identification of pain generally relies on patient self-reporting of symptoms. Patients with limited communication, advanced dementia or learning disabilities are unable to self-report pain. This results in pain being under-recognised and under-treated. Consequences of this are serious and include physical and psychological distress, longer length of stay and worse outcomes.1 Methods Abbey Pain Score (APS) [Figure 1] was introduced on a single Healthcare of the Older Person ward.2,3 It was used as the primary means of assessing pain in non-verbal patients (NVP) in place of the usual verbal pain scale (scored 0-10). [Figures 2 and 3] Ward-based teaching for all doctors, nurses and healthcare assistants was conducted before introduction of the APS. Data was collected for 20 consecutive NVP. Figure 1: Abbey Pain Score (Six items observed &amp; Score) Vocalisation: 0-3; Facial expression: 0-3; Change in body language: 0-3; Behavioural change: 0-3; Physiological change: 0-3; Physical changes: 0-3. Scoring scale: No Pain (0-2); Mild Pain (3-7); Moderate Pain (8-13); Severe (14+). Results At baseline we identified that pain as a symptom was missed in 54 % of NVP using the verbal pain score. With introduction of APS this dropped only slightly at 3 months but there was an increased uptake in scoring NVP on APS. With persistent engagement there was a significant decline in number of patients with un-managed pain needs. Figure 3: Abbey pain score (All patients with any pain) Baseline Pre-intervention: 21 / 39 (54 %); Post-intervention (3 months): 10 / 20 (50 % Post-intervention (12 months): 1 / 19 (5 %) Conclusion ABP is an effective means of addressing pain in NVP. It is simple to implement and can lead to significant improvements in patient care.

Multilevel Pain Assessment with Functional Near-Infrared Spectroscopy: Evaluating ΔHBO2 and ΔHHB Measures for Comprehensive Analysis.

Assessing pain in non-verbal patients is challenging, often depending on clinical judgment which can be unreliable due to fluctuations in vital signs caused by underlying medical conditions. To date, there is a notable absence of objective diagnostic tests to aid healthcare practitioners in pain assessment, especially affecting critically-ill or advanced dementia patients. Neurophysiological information, i.e., functional near-infrared spectroscopy (fNIRS) or electroencephalogram (EEG), unveils the brain's active regions and patterns, revealing the neural mechanisms behind the experience and processing of pain. This study focuses on assessing pain via the analysis of fNIRS signals combined with machine learning, utilising multiple fNIRS measures including oxygenated haemoglobin (ΔHBO2) and deoxygenated haemoglobin (ΔHHB). Initially, a channel selection process filters out highly contaminated channels with high-frequency and high-amplitude artifacts from the 24-channel fNIRS data. The remaining channels are then preprocessed by applying a low-pass filter and common average referencing to remove cardio-respiratory artifacts and common gain noise, respectively. Subsequently, the preprocessed channels are averaged to create a single time series vector for both ΔHBO2 and ΔHHB measures. From each measure, ten statistical features are extracted and fusion occurs at the feature level, resulting in a fused feature vector. The most relevant features, selected using the Minimum Redundancy Maximum Relevance method, are passed to a Support Vector Machines classifier. Using leave-one-subject-out cross validation, the system achieved an accuracy of 68.51%±9.02% in a multi-class task (No Pain, Low Pain, and High Pain) using a fusion of ΔHBO2 and ΔHHB. These two measures collectively demonstrated superior performance compared to when they were used independently. This study contributes to the pursuit of an objective pain assessment and proposes a potential biomarker for human pain using fNIRS.

Evidence-Based Pain Assessment in Nonverbal Palliative Care Patients

BackgroundCentral to palliative care is the early assessment and treatment of pain, whether physical, psychosocial, or spiritual. Nonverbal palliative care patients are at risk for inadequate pain assessment leading to prolonged suffering. AimsThe purpose of this project was to implement and evaluate an evidence-based pain assessment tool for nonverbal palliative care patients. DesignThe Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare and the Implementation Strategies for Evidence-Based Practice Guide provided the guiding frameworks. SettingsOn a six-bed adult inpatient Palliative Care Unit (PCU). Participants/SubjectsNonverbal palliative care patients. MethodsEvidence supported use of the Multidimensional Objective Pain Assessment Tool (MOPAT) for nonverbal patients receiving palliative care. During an eight-week pilot, nurses recorded pain assessments on a paper form and trended pain scores over a 24-hour period. Evaluation included knowledge, attitudes, and behaviors pre- and post-pilot and was subsequently used in a Precision Implementation Approach to promote adoption. ResultsNurses’ attitudes toward palliative care pain assessment improved in all items on the evaluation tools. Pain was assessed using MOPAT for 74% of nonverbal palliative care patients and 88% of patients had linked pain interventions to MOPAT scores. ConclusionsMOPAT is the only valid evidence-based pain assessment tool for nonverbal patients receiving palliative care. This project led to successful adoption of the MOPAT within the PCU.

Tell Me More® As A Tool for Provider Connectedness With Hospitalized Patients: A Mixed-Methods Study.

Rates of burnout and compassion fatigue in healthcare professionals have remained high since the beginning of the pandemic with adverse implications for patient care. Tell Me More® (TMM) is a tool licensed by the Gold Foundation, which was created with the purpose of helping patients, caregivers, and hospital staff to connect with each other on a humanistic level. Research has shown the benefits of the TMM with students and anecdotally with patients. This mixed-method study, which consisted of surveys and semistructured interviews with healthcare professionals (n = 72), sought out to understand the impact of implementation of TMM on a hospital floor. Surveys were distributed before and after the occurrence of TMM with interviews only occurring afterward. Three out of 8 survey items were found to be significant. Content analysis from interviews generated 4 themes from participants which included "Connectedness to Patient," "Separation of Person and Illness," "Communication with Patient's Support Network," and "Connectedness with Non-Verbal Patients." TMM is a useful tool for strengthening provider-patient relationships in hospital settings and may therefore lessen compassion fatigue and burnout.

Investigating Nurses’ Knowledge, Attitude, and Performance Regarding Pain Management of Non-verbal Critically-Ill Patients in Tanzania Intensive Care Units

Background: Although patients› self-report is the gold standard for pain, many patients admitted to the intensive care units are unable to communicate and express their pain. Accordingly, the nurse must have special abilities to diagnose and manage pain in such conditions. This study assesses nurses’ knowledge, attitude, and performance regarding pain management of non-verbal critically ill adult patients in intensive care units. Methods: This cross-sectional descriptive study was conducted from February to May 2020 among nurses working in four national referral hospitals in Dar es Salaam, Tanzania. The study sample included 202 intensive care unit nurses who were recruited by the census. The data was collected using pre-validated questionnaires, including the knowledge and attitudes survey regarding pain tools, and a performance tool by Eunkyoung. The data were analyzed using the chi-square test, one sample t-test, and Spearman correlation coefficient in the SPSS software, version 20. The significance level was set at P&lt;0.05. Results: The mean knowledge and attitude score was 13.26±2.75, indicating inadequate knowledge and negative attitude. The mean performance score was 2.08±0.16, indicating low performance. No significant relationship was detected between nurses’ knowledge and attitude and their performance according to the t-test (t=2.84, P=0.09) and the Spearman correlation coefficient (r=0.12, P=0.102). Meanwhile, no significant relationships were found between the nurses’ knowledge, attitude, and performance and their demographic characteristics. Conclusion: Planning to increase knowledge and improve the attitude and performance of ICU nurses for better pain management of non-verbal patients is necessary. It is recommended to evaluate the pain of these patients based on the observation of behavioral indicators of pain and choose the appropriate tool for pain assessment.

Caregiver-reported outcomes with real-world use of cannabidiol in Lennox-Gastaut syndrome and Dravet syndrome from the BECOME survey

PurposePlant-derived highly purified cannabidiol (CBD) reduced the frequency of seizures associated with Lennox-Gastaut syndrome (LGS) and Dravet syndrome (DS) and improved the overall condition of patients in placebo-controlled phase 3 clinical trials. Anecdotal reports also suggest a positive effect on nonseizure outcomes. In this study, we aimed to identify, through a caregiver survey which nonseizure outcomes were most likely to change in these patients. MethodsThe BEhavior, COgnition, and More with Epidiolex® (BECOME) was a 20-minute, cross-sectional, online survey that was developed with extensive input from caregivers, healthcare professionals, and epilepsy researchers, and was based on questions from validated measures and previously published caregiver reports. US-based caregivers (from Jazz Pharmaceuticals patient/caregiver database) of people with LGS or DS who were treated with CBD (Epidiolex®, 100 mg/mL oral solution) for ≥3 months were asked to compare the past month to the period before CBD initiation and rate their impression of changes using symmetrical Likert scales. ResultsA total of 498 caregivers (97% parents) of patients with LGS (80%) or DS (20%) completed the survey. Mean (range) age of patients was 16 (1−73) years, and 52% were male. Patients were taking a median CBD dose of 14 mg/kg/d and median 4 concomitant antiseizure medications. A large proportion of respondents reported improvements in ≥1 survey question for all nonseizure-related domains: alertness, cognition, and executive function (85%); emotional functioning (82%); language and communication (79% in nonverbal patients and 74% in verbal); activities of daily living (51%); sleep (51%); and physical functioning (46%). Respondents reported improvements in seizure-related domains, including overall seizure frequency (85%), overall seizure severity (76%), seizure-free days per week for ≥1 seizure type (67%), and seizure freedom during the past month (16%). The majority of respondents who reported reduction in seizure frequency also reported improvements in nonseizure outcomes domains (51–80%). However, improvements in nonseizure outcomes (18–56%) were also reported in patients who either had no change or worsening of seizure frequency. ConclusionsThis survey characterized and quantified caregiver impression of changes in the seizure and nonseizure outcomes in patients taking add-on CBD treatment. Overall, 93% of caregivers reported planning to continue CBD treatment, primarily because of reduced seizure burden but also because of improvements in nonseizure-related outcomes. Despite the limitations that are associated with a retrospective survey-based study design, these results support further evaluation of the effect of CBD treatment on nonseizure outcomes among patients with LGS or DS.