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LO57: Pain associated with investigations and procedural interventions commonly administered in the emergency department in older adults: a prospective cohort study
- L. Baril, L. Baril, E. Nguyen, L. Santerre, V. Émond, M. Émond, S. Berthelot, É. Mercier
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 22 / Issue S1 / May 2020
- Published online by Cambridge University Press:
- 13 May 2020, p. S28
- Print publication:
- May 2020
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Introduction: Acute pain is frequent among patients visiting the emergency department (ED). In addition to the acute discomfort, pain has been linked to adverse events and poorest outcomes in older adults. However, pain is frequently overlooked by emergency clinicians, particularly in older adults. Advanced age has been linked to poor recognition and under treatment of pain. The contribution of ED investigations and procedures to the patient's pain is unknown. This study aims to determine the intensity of the pain induced by the investigations and procedures commonly performed in the ED. Methods: In two EDs, a convenience sample of older adults (≥ 65 years old) with at least two investigations or procedures performed during their ED visit were eligible. Patients were excluded if they were hemodynamically unstable, in palliative care or not oriented in time and space. The pain intensity was assessed at bedside by a research assistant for the following investigations or procedures: blood sampling, intravenous catheter, electrocardiogram, X-rays, computed tomography, beside ultrasound, urinary catheter, cervical collar and prehospital immobilization mattress. The predetermined sample size was 50 pain assessment per investigation or procedure. The pain intensity was assessed using a numerous rating scale (NRS) ranging from 0 (no pain) to 10 (most severe pain), for each investigation or procedure received. NRS results are presented using median (med) and interquartile range (IQR) and classified as followed: no pain (0), mild pain (1-3), moderate pain (4-6) and severe pain (7-10). Results: Between June 2018 and December 2019, 494 patients were screened of which 318 were finally included (exclusion: not oriented (n = 113), refusal (n = 27), palliative care (n = 34), other reasons (n = 12)). The mean age of included patients was 77.8 years old (standard deviation = 8.0), 54.4% were female and 78.6% were living in the community. Only 15 patients (4.7%) were known to have cognitive impairment or dementia and 23 patients (7.2%) were on regular or PRN opioid medication at home. The expected sample size of at least 50 pain score assessment per investigation or procedure was obtained for all interventions with the exception of urinary catheter (n = 23) and immobilization mattress (n = 35). For the other investigations or procedures, the number of pain assessment ranged between 51 (cervical collar) and 231 (blood sampling). All investigations and procedures were associated with a median pain score of 0 with the exception of blood sampling (n = 231, med NRS 1 (IQR 0;3)), intravenous catheter (n = 241, med NRS 1 (IQR 0;4)), urinary catheter (n = 23, med NRS 4 (IQR 1;6)), cervical collar (n = 51, med NRS 5 (IQR 0;8)) immobilisation mattress (n = 35, med NRS 3 (IQR 0;8)). Moderate or severe pain (NRS 4-10) was infrequently reported following most investigations or procedures with the exception of urinary catheter (60.8%), cervical collar (54.9%) and immobilization mattress (48.5%). Cervical collar induced severe pain in 41.8% of the patients. Conclusion: Most investigations and procedures commonly administered in the ED to older adults are associated with no pain or low intensity of pain. Severe pain is also infrequently induced by these interventions for most older adults. However, urinary catheter, cervical collar and immobilization mattress are associated with a higher intensity of pain and more than 40% of patients suffering from severe pain following the application of cervical collar. Considering the potential adverse effects of pain and the lack of evidence-based data to support the use of some interventions such as the cervical collar, the decision to use these interventions should be carefully weighted and could include a shared-decision making process. The generalizability of those findings to older adults with cognitive impairment is unknown. Future studies should focus on circumstances in which these procedures are beneficial to the patient to limit the unnecessary pain associated with their use.
Efficiency to reach age of puberty and behaviour of buffalo heifers (Bubalus bubalis) kept on pasture or in confinement
- E. Sabia, F. Napolitano, G. De Rosa, G. M. Terzano, V. L. Barile, A. Braghieri, C. Pacelli
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In order to evaluate the influence of rearing system (free-ranging (FR) v. confinement (C)) on buffalo heifer efficiency to reach age of puberty and on behavioural and immune functions, two experiments were conducted from September 2010 to October 2011. In Experiment I, 32 subjects aged 8 to 9 months at the start of experiment were used. A total of 16 animals (group C) were group housed in an indoor slatted floor pen (4 m2/animal) with an outdoor paddock (4 m2/animal); 16 others grazed on a Mediterranean natural pasture of 40 ha (group FR). Behavioural data were collected and organic matter digestibility, blood metabolites and progesterone were determined. At the end of the experiment, a novel object test and a skin test were conducted, and the avoidance distance (AD) at the manger was measured. Free-ranging animals were able to express natural behaviours such as wallowing and grazing. C animals devoted more time to the novel object than FR animals, whereas AD at manger was lower in group FR than in group C (P<0.01). Cellular immune response was higher in FR heifers than in C animals (P<0.01). FR animals also showed a higher digestibility of organic matter (P<0.01). Heifers from group FR had higher plasma concentrations of non-esterified fatty acids (P<0.001) and lower concentrations of glucose than heifers from group C (P<0.001). C animals showed higher daily weight gains (P<0.01) and weight at the puberty (P<0.05), but there were no differences in terms of age of puberty between the two groups. The intakes of dry matter (DM), CP and energy to reach the age of puberty were similar in both groups. In order to verify whether the results obtained in Experiment I could be replicated in different rearing conditions (reduced pasture availability, different location and altitude), a second experiment was conducted on 26 animals, where only onset of age of puberty and metabolic profile were monitored. In Experiment II, 13 heifers grazed on a natural pasture of 5 ha, other 13 received the same space as indicated for Experiment I. Results from Experiment II generally confirmed those of Experiment I. Only the intakes of DM and energy to reach the age of puberty were higher in group C than in FR (P<0.001). A lower competition with human nutrition, reproductive performances similar to those shown by confined animals and the indications given by immune and behavioural variables, suggest that a free-range-based system may be conveniently used for buffalo heifer farming purposes.
Patterns of oestrus, time of LH release and ovulation and effects of time of artificial insemination in Mediterranean buffalo cows
- B. M. Moioli, F. Napolitano, S. Puppo, V. L. Barile, G. M. Terzano, A. Borghese, A. Malfatti, A. Catalano, A. M. Pilla
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- Journal:
- Animal Science / Volume 66 / Issue 1 / February 1998
- Published online by Cambridge University Press:
- 02 September 2010, pp. 87-91
- Print publication:
- February 1998
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Thirty-two post-partum Mediterranean river buffalo cows were continuously observed for signs of oestrus from September to December with the aid of two vasectomized bulls. Symptoms of oestrus among female Mediterranean buffaloes are weak, therefore oestrus was assessed based on bull behaviour (following and licking a cow and trying to mount her). Oestrus was divided into three phases based on the bull behaviour assessment. Status of the uterus and ovarian follicles were checked rectally every day for each cow which was detected by a teaser bull to be in oestrus. All cows in oestrus were bred twice by artificial insemination (AI), the first at ovulation and the second (using a different bull) 22 h later.
The average duration of interest shown by the bull towards a cow (from the very first to the last sign of interest) was 68 h and the average length of the three phases was: phase 1 = 21 (s.d. 29) h, phase II = 32 (s.d. 24) h and phase III = 15 (s.d. 15) h. Fifteen buffaloes were bled during oestrus, and LH profiles were determined. No differences were evident among oestruses followed by pregnancy (no. = 18) and the others (no. = 26) for the variables describing behavioural events. Neither intensity of the bull courtship, presence or clarity of mucous discharge, or housing system affected the success of AI. The only differences between pregnant and non-pregnant cows were in the timing between the LH peak and the end of phase II (2·4 v. 14·7 h, P < 0·001), end of phase III (22 v. 40 h, P > 0·05) and ovulation (25 v. 46 h, P < 0·05). Successful pregnancies occurred 34 (s.d. 14) h after the end of phase II. The endocrinology and behavioural patterns of buffalo reproduction need further research to clarify the reasons for non-optimal pregnancy rates after AI.