Systematic review of the efficacy of pre-surgical mind-body based therapies on post-operative outcome measures

A Prospective Mixed Methods Study on Experiences of Mindfulness Intervention on Pain and Anxiety in Patients Undergoing a Colorectal Surgery

Purpose: To evaluate the effectiveness and experiences of a mindfulness intervention in colorectal surgical patients. Design of Study: Descriptive mixed methods study. Method: Sixteen participants were provided with two or three 15-20-min mindfulness sessions. Data were collected before and after each session on blood pressure, heart and respiratory rate, anxiety, and pain. The participants were interviewed before their discharge. Findings: Eight participants (n = 8) received two and eight (n = 8) three sessions. Decreasing blood pressure and lower heart rates were noted after the sessions. Also, decreasing pain scores were found, especially in participants who attended two sessions. Minor decrease in anxiety scores were noticed in participants who attended three sessions. Two major themes emerged from the interviews: healing and restoration of health and becoming in tune with self. These themes were characterized by study participants' reflections on experience of recovery, progression to physical relaxation, pathway to serenity, awareness of emotions, evolution of perceptions and experiences of mindfulness. Conclusions: The physiological changes to mindfulness intervention, composed of two or three sessions, were minor and challenging to measure to demonstrate effects. However, study participants' experiences were very positive and suggest that this intervention could prove to be beneficial for colorectal surgical patients.

Interventions to Modify Psychological Processes in Patients Undergoing Spine Surgery: A Systematic Review

OBJECTIVES

Among patients undergoing elective spine surgery, psychological processes such as kinesiophobia and pain catastrophizing are associated with postoperative disability and poor quality of life. These represent risk factors which could be modified to improve surgical outcomes. We reviewed perioperative interventions to modify psychological processes and their effects on psychological and surgery-related outcomes.

METHODS

We searched MEDLINE, EMBASE, and Cochrane databases for studies examining any interventions for modifying psychological processes in adult patients undergoing spine surgery. Two reviewers screened studies for eligibility, extracted data in duplicate, and performed risk of bias assessments. Outcomes included pain, disability, quality of life, kinesiophobia, self-efficacy, and pain catastrophizing.

RESULTS

368 titles and abstracts were retrieved, of which 27 studies underwent full-text screening. We included 12 studies which reported on 1263 patients. Eight were randomized controlled trials. Interventions included preoperative and postoperative cognitive behavioural therapy, cognitive-behavioural-based physical therapy, a web-based interactive platform, an information booklet, and music therapy. The psychological and surgery-related outcomes of interventions were variable, with some studies reporting significant benefits and others reporting no differences between groups. The greatest potential benefits were found in studies of post-operative cognitive-behavioural-based physical therapy. Risk of bias among studies was high due primarily to lack of blinding and limited standardization of interventions.

CONCLUSIONS

Several interventions to potentially modify psychological processes in patients undergoing spine surgery have been reported. Post-operative cognitive-behavioural-based physical therapy might be associated with improved outcomes, but confidence is limited by inconsistency, risk of bias, and limited long-term follow-up.

Phase 1/2 Randomized Clinical Trial of In-clinic acupuncture Prior to Bacillus Calmette-Guérin in Patients with High-risk Non-muscle-invasive Bladder Cancer

BACKGROUND

Treatment-related dose-limiting dysuria and irritative bladder symptoms are common in patients receiving intravesical bacillus Calmette-Guérin (BCG) to treat non-muscle-invasive bladder cancer (NMIBC). Acupuncture has been shown to reduce pain and urinary urgency/frequency in other patient populations.

OBJECTIVE

To evaluate the feasibility, safety, and tolerability of weekly in-clinic preprocedural acupuncture among patients receiving induction BCG.

DESIGN, SETTING, AND PARTICIPANTS

Patients with high-risk NMIBC undergoing induction BCG were randomized 2:1 to a standardized acupuncture protocol (acupuncture) versus the standard-of-care control arm.

INTERVENTION

In-office acupuncture prior to each BCG instillation.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

Feasibility was assessed via recruitment, retention, and intervention adherence. Acupuncture safety and tolerability were assessed via physician-reported Common Terminology Criteria for Adverse Events version 5.0 and adverse events (AEs). Secondary endpoints included BCG treatment adherence, patient-reported BCG-related toxicity, and bladder cancer-specific and generic (European Organisation for Research and Treatment of Cancer [EORTC]-QLQ-NMIBC-24 and EORTC-QLQ-NMIBC-C30) quality of life (QOL). Subjective assessments of acupuncture acceptability were performed through patient surveys.

RESULTS AND LIMITATIONS

A total of 43 individuals were randomized 2:1 to the acupuncture (n = 28) versus control (n = 15) group. The median age was 70.3 yr, and 76% were male. Week 7 follow-up surveys were completed by 93%; six participants withdrew early due to disease progression, refractory gross hematuria, or preference. Acupuncture was delivered successfully prior to each BCG treatment, with no acupuncture-related AEs or interruptions to induction BCG. BCG-attributed AEs were reported by 91% acupuncture and 100% control individuals, including pain (28% vs 43%, p = 0.34) and urinary symptoms (62% vs 79%, p = 0.31). Comparing acupuncture patients with controls, change in QOL over the study period demonstrated greater improvements in median urinary symptoms (9.5, interquartile range [IQR] 0.0-19.0 vs 0.0, IQR -14.3 to 7.1; p = 0.02) among patients in the acupuncture arm. Of the acupuncture patients, 96% reported that acupuncture was "very/extremely helpful," and 91% would recommend acupuncture to other patients. Limitations include modest sample size and single-institution design.

CONCLUSIONS

Acupuncture prior to induction BCG treatments is feasible and safe. In this phase 1/2 trial, improved urinary function scores were observed among patients undergoing acupuncture. Patients receiving acupuncture reported high degrees of satisfaction with treatments.

PATIENT SUMMARY

We evaluated the safety and feasibility of delivering acupuncture in a urology clinic prior to weekly intravesical bladder cancer treatments with bacillus Calmette-Guérin (BCG) in a randomized controlled trial. We found that acupuncture could be delivered safely prior to weekly BCG instillations and that the use of acupuncture was associated with high patient satisfaction and a decrease in patient-reported urinary symptoms compared with usual care.

Addressing gaps in pain research from an integrated whole person perspective

ABSTRACT

While our understanding of pain is rapidly growing, some areas of pain research are lagging behind. This article discusses two current and inter-related gaps in knowledge that are in need of addressing: first, the connections between "brain" and "body" components of pain; and second, the process of endogenous pain resolution. Historical reasons for these research gaps are discussed and solutions are outlined based on an integrative, whole person research approach. These include comprehensive mapping of the mechanosensory and nociceptive innervation of deep tissues; developing objective, non-invasive measurements to quantify the metabolic, structural and mechanical components of the peripheral tissue environment; integrating our understanding of pain pathophysiology, across whole organs and whole body, as well as across bio-psycho-social domains; and understanding the interplay of nervous system and peripheral tissue mechanisms that promote the endogenous resolution of pain and prevent its acute-to-chronic transition. Current NIH-led efforts in these areas are outlined, including several studies within the NIH HEAL (or Help End Addition Long Term) initiative and the National Center for Complementary and Integrative Health's strategic priorities in whole person research.

Effects of Intravenous Lidocaine on Quality of Recovery After Laparoscopic Bariatric Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This systematic review and meta-analysis aimed to assess the effects of pre and intraoperative lidocaine infusion on short-term recovery quality after laparoscopic bariatric surgeries. In the search across MEDLINE, Embase, and Cochrane databases, we considered randomized controlled trials comparing intravenous lidocaine vs placebo (saline) for patients with obesity undergoing laparoscopic bariatric surgery. Seven studies (640 patients) were included. The lidocaine group had a significantly higher recovery quality score, a lower morphine consumption, and a notably reduced rate of nausea and vomiting compared with the placebo group. Additionally, Lidocaine infusion was associated with a shorter hospital stay, while no significant difference was observed in the time to bowel function recovery between both groups. In conclusion, lidocaine infusion before and during laparoscopic bariatric surgery contributes to an enhanced quality of recovery.

Effects of mindfulness-based preoperative intervention for patients undergoing elective surgery: A meta-analysis

OBJECTIVE

Patients often experience pain and psychological distress when undergoing elective surgeries. Mindfulness-based interventions have been proposed as potential strategies to address these challenges. This meta-analysis aims to evaluate the efficacy of preoperative mindfulness-based interventions on several outcomes for patients undergoing elective surgery, including preoperative anxiety/depression, postoperative anxiety/depression, postoperative pain, and quality of life (QOL).

METHODS

This meta-analysis encompassed randomized controlled trials published in the database PubMed, Cochrane, and Embase to August 2023. Mindfulness-based interventions were compared to control groups, who received treatment as usual (TAU). The RevMan software was employed to assess each outcome by using standardized mean difference based on patient-reported data. Subgroup analyses were further performed according to different categories of surgical types.

RESULTS

Eight RCTs with a total of 685 patients were identified. This meta-analysis demonstrated significant difference in preoperative anxiety (SMD:-0.36, 95% CI: -0.62 to -0.11, p = .006) and postoperative pain immediately (SMD:-0.65,95% CI: -1.09 to -0.20, p = .004), 2-3 days (SMD:-0.40, 95% CI:-0.78 to -0.02, p = .04),at 14 days (SMD:-0.48,95% CI: -0.85 to -0.12, p = .009) and 28 days (SMD:-0.89,95% CI: -1.55 to -0.23, p = .008) postoperatively. However, there were no differences between postoperative anxiety, preoperative/postoperative depression, and QOL.

CONCLUSION

Our findings suggest preoperative mindfulness-based interventions can effectively manage preoperative anxiety and postoperative pain in patients scheduled for elective surgery. Further research is warranted to explore the different timing and types of mindfulness-based intervention.

Mindfulness-Based Interventions for Surgical Patients and Impact on Postoperative Outcomes, Patient Wellbeing, and Satisfaction

Several psychosocial factors can impact surgical outcomes and overall patient wellbeing following surgery. Although advances in surgical interventions and pain management protocols can reduce surgical trauma and enhance recovery from surgery, additional intervention is warranted to optimize surgical outcomes and patient quality of life (QoL) in the short- and long-term. Research on mindfulness techniques suggests that mindfulness-based interventions (MBI) effectively promote health behaviors, reduce pain, and improve psychological wellbeing and QoL. Thus, there has been an increase in research evaluating the use of MBIs to improve postoperative outcomes and wellbeing in surgical patients. The authors provide a brief overview of psychosocial outcomes of surgery and MBIs and review the literature on the impact of MBIs on postoperative outcomes. The extant literature indicates that MBIs are feasible and acceptable for use in surgical patient populations and provides preliminary evidence of the benefits of mindfulness across a range of surgical patient populations. However, more research is needed to assess the long-term efficacy of MBIs delivered online and in-person across the perioperative continuum.

Enhancing Chronic Non-Cancer Pain Management: A Systematic Review of Mindfulness Therapies and Guided Imagery Interventions

Background and Objectives: There has been an increasing interest in the use of non-pharmacological approaches for the multidimensional treatment of chronic pain. The aim of this systematic review was to assess the effectiveness of mindfulness-based therapies and Guided Imagery (GI) interventions in managing chronic non-cancer pain and related outcomes. Materials and Methods: Searching three electronic databases (Web of Science, PubMed, and Scopus) and following the PRISMA guidelines, a systematic review was performed on Randomized Controlled Trials (RCTs) and pilot RCTs investigating mindfulness or GI interventions in adult patients with chronic non-cancer pain. The Cochrane Risk of Bias Tool was utilized to assess the quality of the evidence, with outcomes encompassing pain intensity, opioid consumption, and non-sensorial dimensions of pain. Results: Twenty-six trials met the inclusion criteria, with most of them exhibiting a moderate to high risk of bias. A wide diversity of chronic pain types were under analysis. Amongst the mindfulness interventions, and besides the classical programs, Mindfulness-Oriented Recovery Enhancement (MORE) emerges as an approach that improves interoception. Six trials demonstrated that mindfulness techniques resulted in a significant reduction in pain intensity, and three trials also reported significant outcomes with GI. Evidence supports a significant improvement in non-sensory dimensions of pain in ten trials using mindfulness and in two trials involving GI. Significant effects on opioid consumption were reported in four mindfulness-based trials, whereas one study involving GI found a small effect with that variable. Conclusions: This study supports the evidence of benefits of both mindfulness techniques and GI interventions in the management of chronic non-cancer pain. Regarding the various mindfulness interventions, a specific emphasis on the positive results of MORE should be highlighted. Future studies should focus on specific pain types, explore different durations of the mindfulness and GI interventions, and evaluate emotion-related outcomes.

Psychophysiological strategies for enhancing performance through imagery-skin conductance level analysis in guided vs. self-produced imagery

Athletes need to achieve their optimal level of arousal for peak performance. Visualization or mental rehearsal (i.e., Imagery) often helps to obtain an appropriate level of activation, which can be detected by monitoring Skin Conductance Level (SCL). However, different types of imagery could elicit different amount of physiological arousal. Therefore, this study aims: (1) to investigate differences in SCL associated with two instructional modalities of imagery (guided vs. self-produced) and six different scripts; (2) to check if SCL could differentiate respondents according to their sport expertise. Thirty participants, aged between 14 and 42 years (M = 22.93; SD = 5.24), with different sport levels took part in the study. Participants listened to each previously recorded script and then were asked to imagine the scene for a minute. During the task, SCL was monitored. We analysed the mean value, variance, slope and number of fluctuations per minute of the electrodermal signal. Unsupervised machine learning models were used for measuring the resemblance of the signal. The Wilcoxon signed-rank test was used for distinguishing guided and self-produced imagery, and The Mann-Whitney U test was used for distinguishing results of different level athletes. We discovered that among others, self-produced imagery generates lower SCL, higher variance, and a higher number of fluctuations compared to guided imagery. Moreover, we found similarities of the SCL signal among the groups of athletes (i.e. expertise level). From a practical point of view, our findings suggest that different imagery instructional modalities can be implemented for specific purposes of mental preparation.

The brief measure of preoperative emotional stress screens preoperative maladaptive psychological features and predicts postoperative opioid use: an observational study

BACKGROUND

The Brief Measure of Preoperative Emotional Stress (B-MEPS) is a suitable screening tool for Preoperative Emotional Stress (PES). However, personalized decision-making demands practical interpretation of the refined version of B-MEPS. Thus, we propose and validate cut-off points on the B-MEPS to classify PES. Also, we assessed if the cut-off points screened preoperative maladaptive psychological features and predicted postoperative opioid use.

METHODS

This observational study comprises samples of two other primary studies, with 1009 and 233 individuals, respectively. The latent class analysis derived emotional stress subgroups using B-MEPS items. We compared membership with the B-MEPS score through the Youden index. Concurrent criterion validity of the cut-off points was performed with the severity of preoperative depressive symptoms, pain catastrophizing, central sensitization, and sleep quality. Predictive criterion validity was performed with opioid use after surgery.

RESULTS

We chose a model with three classes labeled mild, moderate, and severe. The Youden index points -0.1663 and 0.7614 of the B-MEPS score classify individuals, in the severe class, with a sensitivity of 85.7% (80.1%-90.3%) and specificity of 93.5% (91.5-95.1%). The cut-off points of the B-MEPS score have satisfactory concurrent and predictive criterion validity.

CONCLUSIONS

These findings showed that the preoperative emotional stress index on the B-MEPS offers suitable sensitivity and specificity for discriminating the severity of preoperative psychological stress. They provide a simple tool to identify patients prone to severe PES related to maladaptive psychological features, which might influence the perception of pain and analgesic opioid use in the postoperative period.

Designing a Perioperative Mind-Body Intervention for Peripheral Vascular Interventions

Background

Peripheral vascular interventions (PVIs) performed under procedural sedation and analgesia (PSA) can be associated with anxiety and poor compliance with patient instructions during surgery. Mind-body interventions (MBIs) such as meditation have demonstrated the potential to decrease perioperative anxiety, though this area is understudied, and no tailored interventions have been developed for the vascular surgical patient population.

Objectives

We aimed to design a perioperative MBI that specifically targeted vascular surgical patients undergoing PVIs under PSA. We sought to perform this in a scientifically rigorous, multi-disciplinary collaborative manner.

Methods

Following the Obesity-Related Behavioral Intervention Trials (ORBIT) model, we designed (Phase 1a) and then refined (Phase 1b) a MBI for patients undergoing PVIs under PSA to decrease perioperative anxiety and sedation and facilitate patient intraoperative compliance. Phase 1a involved a literature review, informal information gathering and synthesis, and drafting a preliminary protocol for a perioperative MBI. Phase 1b involved assembling a multi-disciplinary expert panel of perioperative and mind-body clinicians and researchers to improve the MBI using an iterative, modified Delphi approach.

Results

The modified Delphi process was completed, and a consensus was reached after three iterations. The resulting MBI consisted of two seven-minute preoperative guided meditations on the day of surgery, including diaphragmatic breathing, body scans, and guided imagery emphasizing awareness of the ipsilateral leg where the vascular surgery was performed. A document delineating the integration of the MBI into the operating room workflow was produced, including details regarding the intervention's timing, duration, and modality.

Conclusion

Using a multi-specialty expert panel, we designed a novel MBI in the form of a guided meditation with elements of mindfulness and guided imagery to decrease anxiety and increase intraoperative compliance for patients undergoing PVIs under PSA. A prospective pilot study is being planned to test the program's feasibility.

SuRxgWell: study protocol for a randomized controlled trial of telemedicine-based digital cognitive behavioral intervention for high anxiety and depression among patients undergoing elective hip and knee arthroplasty surgery

BACKGROUND

Mood disorders (anxiety, depression), sleep disorders, and catastrophizing lead to increased post-operative pain perception, increase in postoperative opioid consumption, decreased engagement with physical activity, and increased resource utilization in surgical patients. Psychosocial disorders significantly affect postoperative outcome. Unfortunately, studies focused on perioperative psychological assessment and treatment are scarce. We propose to test whether digital cognitive behavioral intervention (dCBI) can help surgical patients. dCBI such as RxWell™ is a proven treatment for mood disorders in medical patients such as reducing depression in patients with inflammatory bowel disease. We hypothesize that RxWell™ will also be effective in surgical patients. This study aims to test whether RxWell™ can improve preoperative mood disorders and subsequently reduce postoperative pain and opioid requirement in patients scheduled for primary total hip and knee arthroplasty (THA, TKA). We named the trial as the SuRxgWell trial.

METHODS

This is a randomized, controlled trial that will enroll primary and unilateral THA or TKA patients with anxiety and/or depression symptoms before surgery to receive the SuRxgWell dCBI program and investigate its impact on postoperative outcomes including postoperative pain, anxiety, depression, sleep disorder, and catastrophizing. After signing an informed consent, subjects will be screened using the PROMIS questionnaires, and subjects with a T-score of ≥ 60 on the short Patient-Reported Outcomes Measurement Information System (PROMIS) 4a Anxiety and/or short PROMIS 4a Depression questionnaires will be randomized to either usual care (control group) or the cognitive behavioral intervention, RxWell™, plus usual care (intervention group). The control group will receive information on how to locate tools to address anxiety and depression, whereas the intervention group will have access to SuRxgWell 1 month prior to surgery and up to 3 months after surgery. The allocation will be 3:1 (intervention to control). Investigators will be blinded, but research coordinators approaching patients and research subjects will not. The primary outcome will be day of surgery anxiety or depression symptoms measured with the PROMIS Short Form v1.0 -Anxiety 4a/Depression and Generalized Anxiety Disorder Measure (GAD-7) and Patient Health Questionnaire (PHQ-8). Secondary end points include measuring other health-related quality of life outcomes including sleep disturbance, fatigue, ability to participate in social roles, pain interference, cognitive function, pain catastrophizing, and physical function. Other secondary outcomes include collecting data about preoperative and postoperative pain scores, and pain medication usage, and orthopedic functional recovery at baseline, day of surgery, and 1, 2, and 3 months after the surgery with the Pain Catastrophizing Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip injury and Osteoarthritis Outcome Score (HOOS). In addition, subjects will be asked to complete a GAD-7 and PHQ-8 questionnaires bi-weekly (via the RxWell™ app for the interventional group or REDCAP for the control group). Data about postsurgical complications, and resource utilization will also be recorded. We will also receive monthly reports measuring the usage and engagement of RxWell use for each participant randomized to that arm. The primary hypotheses will be assessed with intention-to-treat estimates, and differences in primary outcome will be tested using independent two sample t-tests. This trial is registered to the ClinicalTrials.gov database (NCT05658796) and supported by the DAPM, UPMC Health Plan, and the NIH.

DISCUSSION

Our trial will evaluate the feasibility of digital cognitive behavioral intervention as a perioperative tool to improve anxiety and depression before and after major orthopedic surgery in comparison to education. If digital cognitive behavioral intervention proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcomes.

Complementary Therapy Learning in the Setting of Lung Transplantation: A Single-Center Observational Study of Appropriation and Efficacy

Transplanted patients could benefit from complementary techniques. This prospective single-center, open study, performed in a tertiary university hospital, evaluates the appropriation and efficacy of a toolbox-kit of complementary techniques. Self-hypnosis, sophrology, relaxation, holistic gymnastics, and transcutaneous electric nerve stimulation (TENS) were taught to adult patients scheduled for double-lung transplantation. Patients were asked to use them before and after transplantation, as needed. The primary outcome was appropriation of each technique within the first three postoperative months. Secondary outcomes included efficacy on pain, anxiety, stress, sleep, and quality-of-life. Among the 80 patients included from May 2017 to September 2020, 59 were evaluated at the 4th postoperative month. Over the 4359 sessions performed, the most frequent technique used before surgery was relaxation. After transplantation, the techniques most frequently used were relaxation and TENS. TENS was the best technique in terms of autonomy, usability, adaptation, and compliance. Self-appropriation of relaxation was the easiest, while self-appropriation of holistic gymnastics was difficult but appreciated by patients. In conclusion: the appropriation by patients of complementary therapies such as mind-body therapies, TENS and holistic gymnastics is feasible in lung transplantation. Even after a short training session, patients regularly practiced these therapies, mainly TENS and relaxation.

Effect of Guided Imagery Meditation During Laparoscopic Cholecystectomy on Reducing Anxiety: A Randomized Controlled Trial

BACKGROUND

Up to 90% of patients still experience pain after abdominal surgery, which also affects their physical recovery and psychological anxiety.

AIM

To evaluate the effects of guided imagery meditation on ameliorating anxiety, improving the quality of sleep, and relieving postoperative pain in patients after laparoscopic cholecystectomy surgery.

METHOD

In the general surgical ward of a teaching hospital, patients were randomly assigned to usual care (n = 34) and guided imagery meditation intervention (n = 34) groups, using the method. The measuring outcomes included their anxiety score, quality of sleep, and pain control.

RESULTS

In terms of the anxiety difference, the experimental group scored 0.42 (standard deviation [SD] = 0.97), while the control group scored 4.79 (SD = 7.56), which indicates a statistically significant difference (F = 8.04, p = .01, partial eta² = 0.11). In terms of quality of sleep, the mean score of the experimental group was 2.67 (SD = 1.96), while the control group scored 7.55 (SD = 3.81), which indicates a significant difference (F = 39.99, p = .001, partial eta² = 0.39). The mean of the degree of postoperative pain was 2.11 points (SD = 1.39), and the score of the control group was 4.00 points (SD = 1.62), which indicates a significant difference (p = .001).

CONCLUSIONS

Guided imagery meditation is a simple, non-invasive, non-pharmacologic intervention measure. It can reduce anxiety and postoperative pain, and improve the quality of sleep. Thus, it should be promoted in clinical practice.

Evidence from Clinical Studies Related to Dermatologic Surgeries for Skin Cancer

Simple Summary

Although significant progress in pharmacotherapy for skin cancer has been made in the past several years, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgeries including lymph node dissection and skin graft can cause various complications, and these complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.

Abstract

Despite the significant progress made in the past several years in pharmacotherapies for skin cancer, such as BRAF/MEK inhibitors, immune checkpoint inhibitors, and Hedgehog pathway inhibitors, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In cases of lymph node metastases with clinically palpable lymphadenopathy, lymph node dissection (LND) is typically performed for most skin cancers. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgery can cause various complications. Although skin graft is frequently used for reconstruction of the surgical defect, extensive graft necrosis may develop if optimal stabilization of the graft is not obtained. LND also sometimes causes complications such as intraoperative or postoperative bleeding and postoperative lymphoceles. Moreover, as in other types of surgery, surgical site infection, intraoperative anxiety, and intraoperative and postoperative pain may also develop. These complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.

The influence of psychological interventions on surgical outcomes: a systematic review

BACKGROUND

An amplified and/or prolonged surgical stress response might overcome the organs' functional reserve, thus leading to postoperative complications. The aim of this systematic literature review is to underline how specific psychological interventions may contribute to improve surgical outcomes through the positive modulation of the surgical stress response in surgical patients.

METHODS

We conducted a comprehensive literature search in the Cochrane Register of Controlled Trials, PubMed, EMBASE, Scopus, PsycINFO, and CINAHL databases. Only studies published in English from Jan 2000 to Apr 2022 and reporting pain and/or anxiety among outcome measures were included in the review. The following psychological interventions were considered: (1) relaxation techniques, (2) cognitive-behavioral therapies, (3) mindfulness, (4) narrative medicine, (5) hypnosis, and (6) coping strategies.

RESULTS

Among 3167 records identified in the literature, 5 papers were considered eligible for inclusion in this review because reporting the effects that psychological features have on neurochemical signaling during perioperative metabolic adaptation and those metabolic and clinical effects that the psychological interventions had on the observed population.

CONCLUSION

Our findings confirm that psychological interventions may contribute to improve surgical outcomes via the positive influence on patients' metabolic surgical stress response. A multidisciplinary approach integrating physical and non-physical therapies can be considered a good strategy to successfully improve surgical outcomes in the perioperative period.

Can perioperative psychological interventions decrease the risk of postsurgical pain and disability? A systematic review and meta-analysis of randomized controlled trials

ABSTRACT

Many patients experience pain after surgery. Psychological factors such as emotion and cognition are shown to be associated with the development of acute and chronic postsurgical pain (CPSP). Therefore, the question arises whether targeting these psychological factors can reduce negative postsurgical outcomes. The aim of the current review was to investigate the efficacy of perioperative psychological interventions in reducing (sub)acute postsurgical pain and CPSP and disability in adults. Randomized controlled trials were identified through 4 databases (Web of Science, PsychINFO, PubMed, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]). The outcomes of interest were (sub)acute (ie, within 3 months after surgery) and chronic (>3 months after surgery) pain and disability. After screening, 21 studies were included in the final analyses. It was found that psychological interventions significantly reduced (sub)acute pain (d = -0.26, 95% confidence interval [CI] [-0.48 to -0.04]) and disability (d = -0.43, 95% CI [-0.84 to -0.03]) as well as CPSP (d = -0.33, 95% CI [-0.61 to -0.06]) and disability (d = -0.43, 95% CI [-0.68 to -0.18]). In addition, interventions delivered after surgery and interventions delivered by a psychologist tended to be more effective than interventions delivered before surgery and interventions delivered by another healthcare provider. Furthermore, the current review points to the need for more research to determine which specific type of intervention may be most beneficial for surgical patients. Finally, the current review identified that research in this domain has concerns regarding bias in missing outcome data due to withdrawal and drop out.

Exploring Non-pharmacological Methods for Pre-operative Pain Management

The management of pain is an essential aspect of surgical care, and pain levels in post-operative patients vary case by case. Treating postoperative pain is crucial as it leads to better outcomes and reduces risk of long term pain. While post-operative analgesics has been the mainstay of treatment, this mini-review explores an emerging concept which is preoperative pain management, with promising potential. Such interventions include educating patients on the expected pain outcomes and available pain medications. Non-pharmacological methods such as relaxation exercises have also proven to be effective after abdominal surgery, and educating patients on the existence of such methods pre-operatively encourages them to make use of available therapies. A major area of importance is the pre-operative psychological and emotional wellbeing of patients, as it is a strong predictor of pain and pain prognosis. Cognitive Behavioral Therapy can be effectively used to tackle preoperative anxiety and reduce pain levels. Hypnosis is another developing modality for decreasing stress. Lastly, long term pre-operative opioid use has been linked with higher pain scores and longer pain duration. This provides the basis on which pre-operative opioid weaning can lead to favorable post-operative pain outcomes.

While many of these methods have not been experimented on recipients of abdominal surgery in specific, it still paves the path for newer pain control strategies that can eventually be adopted for visceral surgery patients. This review points the reader and researchers to new and developing areas that hold the potential to revolutionize current established pain management guidelines.

The Efficacy of Psychological Care and Chinese Herbal Decoction in Postoperative Chemotherapy Patients with Endometrial Cancer

Background. In recent years, the incidence of endometrial cancer (EC) has been on the rise worldwide. The purpose of this study was to investigate the efficacy of psychological care and Chinese herbal decoction in EC patients with postoperative chemotherapy. Methods. 80 EC patients with postoperative chemotherapy were randomly divided into the observation group and control group. The control group was given psychotherapy. The observation group was given psychological care plus Chinese herbal decoction treatment. HE4, CA125, traditional Chinese medicine (TCM) syndrome scores, toxic and side effects, and quality of life scores before and after treatment were observed. Results. After treatment, the total effective rate of the observation group was higher than that of the control group. After treatment, serum HE4 and CA125 levels in the observation group were lower than those in the control group. In addition, CD3+ and CD4+ levels in the observation group were higher than those in the control group. Meanwhile, the CD8+ level in the observation group was lower than that in the control group. Compared with the control group, the quality of life in the observation group was significantly improved, and the incidence of adverse reactions was reduced. Conclusion. Chinese herbal decoction combined with psychological care can improve the clinical symptoms, alleviate the toxic and side effects, and improve the life quality of EC patients with postoperative chemotherapy.

The unseen pandemic: treatment delays and loss to follow-up due to fear of COVID

BACKGROUND

Fear of contracting SARS-CoV-2 has transformed public interaction with healthcare professionals and hospitals alike. In turn, this has resulted in a collateral impact on patients' health across medical and surgical paradigms. Understanding the causative factors of this fear, and tackling it head on, is vital to return to pre-pandemic levels of healthcare.

MAIN BODY

In this editorial, we explore the evidence base behind the fear of healthcare professionals and facilities that has developed during the course of the SARS-CoV-2pandemic. We also reflect on the ways in which these fears have affected the general public. In so doing, we review a recent article from Montalto et al. that has explored fear of SARS-CoV-2 among patients undergoing surgery in Italy.

CONCLUSION

While fear of SARS-CoV-2 is uncommon among surgical patients, there are still those who delay or avoiding seeking medical care due to fear of transmission. Physicians must lead the fight against this fear in a hope to regain the trust of the public.

Targeting Coping to Improve Surgical Outcomes in Pediatric Patients With Median Arcuate Ligament Syndrome: Feasibility Study

Background: Median arcuate ligament syndrome (MALS) is a vascular compression syndrome leading to postprandial epigastric pain, nausea, and weight loss; it can be treated surgically. While most patients report improved quality of life following surgical intervention, 30% continue to experience chronic abdominal pain. Pre-surgical diagnoses of depression and/or anxiety have been found to significantly predict post-surgical: quality of life, highest experience of pain, anxiety, and parent- and self-reported coping strategies. As such, increasing the coping strategies of pediatric patients with MALS may impact their post-surgical outcomes. The purpose of the current study was to: (1) implement a pre-operative cognitive behavioral therapy protocol with a focus on psychoeducation and coping strategies; and (2) determine feasibility of a pre-surgical intervention for this population. Method: Children (<18 years of age) with a diagnosis of MALS who were eligible for surgical intervention were invited to participate in a 7-week in-person or video-based pre-surgical cognitive behavioral therapy intervention. Psychiatric comorbidities were assessed at baseline and post-surgery; patient-reported distress, pain interference and intensity, health-related quality of life, and health status were assessed at four time points (baseline, week 4, week 7, and post-surgery). Descriptive analyses were used to characterize the sample, assess feasibility outcomes (i.e., attrition rates), and explore symptom-based outcomes across time. Results: Twelve pediatric patients (M age = 15.2 ± 1.7; 91.7% female) and their parents (91.7% mothers) participated. Feasibility metrics based on protocol completion were exceeded for engagement at the stages of consent (68.4% vs. goal of ≥50%), treatment initiation (92.3% vs. 85%), and treatment completion (84.6% vs. 75%). Out of the 12 participants, nine (75%) met criteria for at least one comorbid psychiatric diagnosis at baseline and nine (75%) elected to undergo MALS surgery after completing the intervention. Conclusion: The intervention implementation was feasible, despite chronic pain symptoms experienced by the sample, a high prevalence of psychiatric diagnoses, and an international pandemic, suggesting that it would be beneficial to further evaluate the efficacy of the intervention. Future research should include stakeholder input in the design, deployment, and evaluation of a pilot efficacy trial of pre-surgical cognitive behavioral therapy for pediatric patients with MALS.

Effects of a training program in medical hypnosis on burnout in anesthesiologists and other healthcare providers: A survey study

OBJECTIVE

To determine whether the participation to a medical hypnosis training program reduces the levels of burnout in healthcare providers.

DESIGN

Survey study.

SETTINGS

Study conducted from 2014 to 2018 using the MBI-HSS questionnaire assessing three dimensions of burnout: emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA).

PARTICIPANTS

Healthcare providers in particular anesthesiologists participating to a one-year medical hypnosis training program.

INTERVENTION

All participants were asked to fill the MBI-HSS on the first day before the training program had begun, then on the last day of the program once the entire training was completed.

PRIMARY AND SECONDARY OUTCOME MEASURES

The EE, DP and PA scores and their grade (high, average and low) were compared before and after training and between physicians and caregivers.

RESULTS

In total, 1850 persons participated to the training sessions, with 1366 participants enrolled before the first session (74%) and 1407 (76%) after the fourth. On the 1366 persons enrolled before training, 1139 (83%) completed the survey and on the 1407 enrolled after training, 1194 (85%) completed the survey. The scores were significantly smaller after training for EE and DP and significantly greater for PA. Before training, EE was significantly greater in physicians than in caregivers as well as DP, with no difference for PA. After training, DP was significantly greater in physicians than in caregivers and PA was smaller, with no difference for EE. Before training, there was high rates of burnout in both healthcare providers but there was a significant trend to smaller rates of burnout after training.

CONCLUSIONS

This study shows that healthcare providers who participated to a medical hypnosis training program presented improvements in the three dimensions of burnout. Further study is required to investigate and recommend this type of continuous medical education to improve professional satisfaction and wellbeing in healthcare providers.

Predictors of one year chronic post-surgical pain trajectories following thoracic surgery

PURPOSE

Chronic post-surgical pain (CPSP) is a highly prevalent complication following thoracic surgery. This is a prospective cohort study that aims to describe the pain trajectories of patients undergoing thoracic surgery beginning preoperatively and up to 1 year after surgery METHODS: Two hundred and seventy nine patients undergoing elective thoracic surgery were enrolled. Participants filled out a preoperative questionnaire containing questions about their sociodemographic information, comorbidities as well as several psychological and pain-related statuses. They were then followed-up during their immediate postoperative period and at the three, six and 12 month time-points to track their postoperative pain, complications and pain-related outcomes. Growth mixture modeling was used to construct pain trajectories.

RESULTS

The first trajectory is characterized by 185 patients (78.1%) with mild pain intensity across the 12 month period. The second is characterized by 32 patients (7.5%) with moderate pain intensity immediately after surgery which decreases markedly by 3 months and remains low at the 12 month follow-up. The final trajectory is characterized by 20 patients (8.4%) with moderate pain intensity immediately after surgery which persists at 12 months. Patients with moderate to severe postoperative pain intensity were much more likely to develop CPSP compared to patients with mild pain intensity. Initial pain intensity levels immediately following surgery as well as levels of pain catastrophizing at baseline were predicting pain trajectory membership. None of the surgical or anesthetic-related variables were significantly associated with pain trajectory membership.

CONCLUSION

Patients who undergo thoracic surgery can have postoperative pain that follows one of the three different types of trajectories. Higher levels of immediate postoperative pain and preoperative pain catastrophizing were associated with moderately severe CPSP.

[Contribution of respiratory relaxation techniques during intravitreal injections: A pilot study]

PURPOSE

To study the effects of breathing techniques for anxiety, perceived pain, and patient satisfaction while receiving intravitreal injections.

METHOD

This prospective, randomized clinical study included patients admitted for intravitreal anti-VEGF injections. They were randomized into two groups: a relaxation group who listened to a prerecorded relaxation breathing session before and during the injection, and a control group who received the injection without a relaxation session. Statistical analysis was then performed to assess the factors influencing satisfaction, anxiety, and perceived pain.

RESULTS

We included one-hundred four patients in total: 52 in the relaxation group versus 52 in the control group. The relaxation group had a greater decrease in anxiety than the control group (P=0.03) but similar levels of pain (P=0.86). In total, 80.76% of patients in the relaxation group expressed the wish to have a relaxation session during their next injection. Multivariate analysis showed that the patient's usual level of stress as well as the relaxation session affected the level of anxiety experienced before the injection.

CONCLUSION

Relaxation techniques before and during intravitreal injections decrease anxiety in patients without decreasing pain during IVT. Prerecorded relaxation breathing sessions are non-invasive, inexpensive, easy to set up, and reduce anxiety during intravitreal injections on an outpatient basis.

The Impact of Guided Imagery on Pain and Anxiety in Hospitalized Adults

BACKGROUND

The use and impact of guided imagery in the acute care setting is limited.

AIMS

The purpose of this quality improvement project was to evaluate the feasibility of a guided imagery intervention to change pain scores, anxiety scores, and opioid analgesia usage among hospitalized adults in an acute care setting.

DESIGN

Quality improvement project using three measurements (baseline, 24 hours, and 48 hours).

SETTINGS

Acute care hospital.

PARTICIPANTS/SUBJECTS

Adult inpatients referred to an APRN-led pain management service.

METHODS

The intervention was the use of a 30-minute guided imagery recording delivered via MP3 player which patients used twice daily.

RESULTS

Limited changes were seen in pain scores, with no statistically significant results (p = .449). Statistically significant reductions were found in both anxiety scores (p < .001) and opioid analgesia usage (p = .043).

CONCLUSIONS

Findings from this quality improvement project support the impact of guided imagery on anxiety and opioid analgesia use. Changes in pain scores were not demonstrated in this project. Additional research with a rigorous design is needed to determine cause and effect conclusions.

CLINICAL IMPLICATIONS

The use of guided imagery as an adjunctive intervention for pain control may engage and empower the patient in self-care activities, which may have an impact on how care is perceived. Guided imagery is a low-cost, easily implemented approach that can be incorporated into patient care to reduce anxiety and, potentially, opioid analgesia use.

Effects of psychological interventions on anxiety and pain in patients undergoing major elective abdominal surgery: a systematic review

A maladaptive response to surgical stress might lead to postoperative complications. A multidisciplinary approach aimed at controlling the surgical stress response may reduce procedural complications and improve patients’ quality of life in the short and long term. Several studies suggest that psychological interventions may interact with the pathophysiology of surgical stress response, potentially influencing wound repair, innate and adaptive immunity, inflammation, perception of pain, and patients’ mood. The aim of this systematic review is to summarise the effects of perioperative psychological interventions on surgical pain and/or anxiety in adult patients scheduled for elective general abdominal and/or urologic surgery.

We conducted a systematic review of controlled clinical trials and observational studies involving psychological interventions for adult patients scheduled for elective general abdominal and/or urologic surgery. Only studies reporting pain and/or anxiety among outcome measures were included in the systematic review. The following psychological interventions were considered: (1) relaxation techniques, (2) cognitive-behavioural therapies, (3) mindfulness, (4) narrative medicine, (5) hypnosis and (6) coping strategies.

We examined 2174 papers. Among these, 9 studies were considered eligible for inclusion in this systematic review (1126 patients cumulatively): 8 are randomised controlled trials and 1 is an observational prospective pre/post study.

Psychological characteristics widely influence the pathophysiological mechanisms underlying the neuroendocrine and inflammatory response to surgical stress, potentially interfering with surgical outcomes. Psychological interventions are technically feasible and realistically applicable perioperatively during abdominal and/or urologic surgery; they influence the pathophysiological mechanisms underlying maladaptive surgical stress response and might have positive effects on patients’ surgical outcomes, such as pain and anxiety.

Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons

Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.

Mind-body practices in U.S. adults: Prevalence and correlates

OBJECTIVES

Mind-body practices (MBP), such as Yoga or Tai-Chi, have increased in popularity in the past 25 years in the US. These activities may help promote a less sedentary lifestyle and may have positive effects on health. The objective of the present study is to understand the prevalence and trends of MBP in US adults and the factors associated with their use in a population-based adult lifespan sample.

METHODS

We used data from three waves of the Midlife in the United States (MIDUS) survey (1995, 2005, and 2015), a population-based longitudinal study of community-dwelling adults. Only data from participants with valid observations across three waves (N = 2262) aged 24-74 years at baseline (M = 46; SD = 11) were used. We examined the prevalence of MBP, longitudinal patterns, and correlates of MBP use over 20 years.

RESULTS

Rates of MBP use were relatively stable over time in this sample, with 20%, 17%, and 18% of participants using MBP at wave 1, 2, and 3, respectively. A number of sociodemographic and health variables were independently related to frequency of MBP use over 20 years: Women, participants with higher levels of education, never married participants, and participants who suffered from multiple chronic health conditions were more likely to use MBP.

DISCUSSION

Our findings suggest that MBP may provide an opportunity for physical activity for individuals suffering from chronic health conditions. More research is needed to understand whether this, in turn, results in better health outcomes for these individuals.

The impact of preoperative pain-related psychological factors on pain intensity post-surgery in Jordan

This study aimed to investigate the impact of preoperative psychological factors on postoperative pain. We included 300 postoperative patients who underwent open reduction and internal fixation surgery. Pain Scale, Pain Catastrophizing Scale, and Depression, Anxiety, and Stress Scale were completed by patients preoperatively and at 24 hours after surgery. Clinical characteristics were obtained from medical records. Data were analyzed using multiple linear regression. Postoperative pain was predicted by pain catastrophizing and anxiety symptoms. High preoperative catastrophizing and anxiety levels were associated with increased pain postoperatively. However, the relationships between preoperative depressive and stress symptoms and postoperative pain were not significant.

Effect of preoperative psychological interventions on elective orthopaedic surgery outcomes: a systematic review and meta-analysis

BACKGROUND

Orthopaedic surgery is largely successful; however, a proportion of patients are dissatisfied and report pain and poor function. Psychological factors have been shown to influence orthopaedic surgical outcomes. This systematic review and meta-analysis investigates the types and effectiveness of preoperative psychological interventions in elective orthopaedic surgery.

METHODS

A registered systematic review (PROSPERO CRD42017073833) was performed on literature (1960-January 2018) using eight databases. Prospective controlled clinical trials involving adult and adolescent elective orthopaedic surgery were included. Interventions examined included relaxation, cognitive behavioural therapy, hypnosis, emotional counselling and mixed psychotherapies; general procedural education was excluded. Outcomes extracted included pain, anxiety, quality of life and disability.

RESULTS

A total of 19 studies met the inclusion criteria (n = 1893 patients). Meta-analyses were performed for pain, anxiety and quality of life. Analysis did not find enough evidence to confirm reduction in post-operative pain (seven studies, 666 patients; g = -0.15 (95% CI -0.42, 0.13), P = 0.305). Pooled data from six studies on acute post-operative anxiety (589 patients) showed a moderate statistically significant benefit (g = -0.26 (-0.49, -0.03), P = 0.024). There was an improved quality of life (mental component) at longer term follow-up (g = 0.25 (0.02, 0.49), P = 0.034).

CONCLUSIONS

These studies provide evidence that psychological interventions have a positive effect on anxiety in the acute post-operative period, and on mental components of quality of life at longer term follow-up.

The effects of preoperative guided imagery interventions on preoperative anxiety and postoperative pain: A meta-analysis

INTRODUCTION

Preoperative anxiety and postoperative pain are common problems in patients undergoing surgery. The aim of this study is to analyse the effect of using guided imagery prior to surgery in adults and children to reduce preoperative anxiety and acute postoperative pain, compared with conventional preoperative nursing care.

METHODS

A systematic review and meta-analysis were conducted. We searched randomised clinical trials in databases and search engines.

RESULTS

A total of 1101 records were identified, of which 21 were included in the qualitative synthesis. Two random model meta-analysis were performed with eight trials. Guided imagery preoperatively was shown to be effective in relieving preoperative state anxiety in children (d = -3.71), preoperative trait anxiety in adults (d = -0.64) and postoperative pain in adults (d = -0.24). Postoperative pain in children and preoperative state anxiety in adults was reduced but without significant difference.

CONCLUSION

Guided imagery preoperatively is an effective, easy and low-cost intervention.

Effectiveness and reporting standards of psychological interventions for improving short-term and long-term pain outcomes after total knee replacement: a systematic review

OBJECTIVES

To assess the effectiveness and reporting standards of psychological interventions for improving outcomes after total knee replacement (TKR).

DESIGN

Medline, Embase, and PsycINFO were searched from inception to up to 9 May 2019 with no language restrictions applied. Randomised controlled trials (RCTs) assessing the effectiveness of psychological interventions for short-term and long-term postoperative pain after TKR were included. Screening, data extraction, and assessment of methodological quality were performed in duplicate by two reviewers. The primary effectiveness outcome was postoperative pain severity and the primary harm outcome was serious adverse events. Secondary outcomes included function, quality of life, and psychological well-being. Reporting standards were assessed using the Template for Intervention Description and Replication (TIDieR) checklist for intervention reporting.

RESULTS

12 RCTs were included, with a total of 1299 participants. Psychological interventions comprised music therapy (five studies), guided imagery and music (one study), hypnosis (one study), progressive muscle relaxation with biofeedback (one study), pain coping skills programme (one study), cognitive-behavioural therapy (two studies), and a postoperative management programme (one study). Due to the high heterogeneity of interventions and poor reporting of harms data, it was not possible to make any definitive statements about the overall effectiveness or safety of psychology interventions for pain outcomes after TKR.

CONCLUSION

Further evidence about the effectiveness of psychological interventions for improving pain outcomes after TKR is needed. The reporting of harm outcomes and intervention fidelity is currently poor and could be improved. Future work exploring the impact of intervention timing on effectiveness and whether different psychological approaches are needed to address acute postoperative pain and chronic postoperative pain would be of benefit.

PROSPERO REGISTRATION NUMBER

CRD42018095100.

The effect of mindfulness training prior to total joint arthroplasty on post-operative pain and physical function: A randomised controlled trial

OBJECTIVE

To evaluate the efficacy of Mindfulness-Based Stress Reduction (MBSR) in improving pain and physical function following total joint arthroplasty (TJA).

DESIGN

Two-group, parallel-group, randomised controlled trial, conducted between September 2012 and May 2017.

SETTING

Single centre study conducted at a University-affiliated, tertiary hospital.

INTERVENTION

People with arthritis scheduled for TJA, with a well-being score <40 (Short Form-12 Survey) were randomly allocated to a pre-surgery eight-week MBSR program or treatment as usual (TAU).

OUTCOME MEASURES

Self-reported joint pain and function at 12 months post-surgery, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were knee stiffness and global improvement (WOMAC); physical and psychological well-being (Veterans RAND 12-item Health Survey); self-efficacy (Arthritis Self-Efficacy Scale); and mindfulness (5-Factor Mindfulness Questionnaire).

RESULTS

127 participants were randomised; 65 to MBSR and 62 to TAU, of which 45 participants allocated to the intervention and 56 participants allocated to usual care proceeded to surgery and 100 (99%) completed primary outcome measures. Greater improvements in knee pain (mean difference, -10.3 points, 95% CI -19.0 to -1.6; P = 0.021) and function (mean difference, -10.2 points, 95% CI -19.2 to -1.3; P = 0.025) at 12 months post-surgery were observed in the MBSR group compared to the TAU group. A between group difference in global scores (-9.5 points, 95% CI -17.9 to -1.1; P = 0.027) was also observed. No other differences in secondary outcomes were observed.

CONCLUSION

MBSR improves post-surgery pain and function in people with psychological distress undergoing TJA. Further research is required to examine potential barriers to broader implementation and uptake.

Development of the Mind-Body-Spiritual (MBS) Nursing Care Model for Coronary Heart Disease Patients

Introduction: Patients with coronary heart disease (CHD) may experience various physical, psychological or spiritual issues. A holistic mind-body spiritual nursing care (MBS) model is needed to help patients' cope with the issues. This study aimed to develop an MBS nursing care model for CHD patients.Method: The study employed a crossectional design with 110 CHD patients participated in the study. Respondents were asked to fill out questionnaires to gather the required data. Criteria for respondent selection were Moslem, aged 40-75 year, medical diagnosis of CHD, and haemodynamically stable. The independent variables were focal, contextual and residual stimuli, while the dependent variables were coping and spirituality. Data were analyzed using partial least square.Results: The results show that the mind-body-spiritual nursing care formed focal stimuli. Spirituality is formed by focal, contextual, residual stimuli and coping style. Nursing care significantly affects spirituality, shown by T-statistics of 6.795. Spirituality can be explained by patience, endeavour toward wellness, and offer the results only to God by 72%, while the rest is explained by other factors.Conclusion: MBS nursing care model has a strong relationship with spirituality. This model needs to be applied in a further research to see its effectiveness in improving spirituality and expression of cardiovascular risk inflammatory markers.

Guided meditation as an adjunct to enhance postoperative recovery after cardiac surgery: study protocol for a prospective randomized controlled feasibility trial

BACKGROUND

Cardiac surgical procedures are associated with postoperative neurological complications such as cognitive decline and delirium, which can complicate recovery and impair quality of life. Perioperative depression and anxiety may be associated with increased mortality after cardiac surgeries. Surgical prehabilitation is an emerging concept that includes preoperative interventions to potentially reduce postoperative complications. While most current prehabilitation interventions focus on optimizing physical health, mind-body interventions are an area of growing interest. Preoperative mind-body interventions such as Isha Kriya meditation, may hold significant potential to improve postsurgical outcomes.

METHODS

This is a prospective, randomized controlled feasibility trial. A total of 40 adult patients undergoing cardiac surgery will be randomized to one of three study groups. Participants randomized to either of the two intervention groups will receive meditative intervention: (1) commencing two weeks before surgery; or (2) commencing only from the day after surgery. Meditative intervention will last for four weeks after the surgery in these groups. Participants in the third control group will receive the current standard of care with no meditative intervention. All participants will undergo assessments using neurocognitive, sleep, depression, anxiety, and pain questionnaires at various time points in the perioperative period. Blood samples will be collected at baseline, preoperatively, and postoperatively to assess for inflammatory biomarkers. The primary aim of this trial is to assess the feasibility of implementing a perioperative meditative intervention program. Other objectives include studying the effect of meditation on postoperative pain, sleep, psychological wellbeing, cognitive function, and delirium. These will be used to calculate effect size to design future studies.

DISCUSSION

This study serves as the first step towards understanding the feasibility of implementing a mind-body intervention as a prehabilitative intervention to improve postoperative surgical outcomes after cardiac surgery.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03198039 . Registered on 23 June 2017.

Maternal and Child Acceptability of a Proposed Guided Imagery Therapy Mobile App Designed to Treat Functional Abdominal Pain Disorders in Children: Mixed-Methods Predevelopment Formative Research

BACKGROUND

Functional abdominal pain disorders are chronic abdominal pain conditions, which affect up to 20% of children worldwide. Of the various functional abdominal pain disorder treatment modalities, psychological therapies such as guided imagery therapy appear most effective. However, there are significant barriers to receiving psychological therapies, including access to trained therapists. Alternatively, remotely delivered psychological therapies for functional abdominal pain disorders have been efficacious.

OBJECTIVE

The objective of our study was to assess acceptability of a proposed guided imagery therapy app designed to treat functional abdominal pain disorders through remote delivery of prerecorded audio sessions and to evaluate user preferences for using such an app.

METHODS

Using a mixed-methods approach, we conducted a predevelopment formative study among children aged 7 to 12 years with a functional abdominal pain disorder and their parents. The parents completed our modified Technology Acceptance Model (TAM) questionnaire, which quantified behavioral intention and related factors for using a guided imagery therapy app. Dyads participated in separate in-person semistructured interviews to assess their attitudes toward and preferences for a guided imagery therapy app. Questionnaire and interview findings were collected concurrently, analyzed separately, and then integrated through methods triangulation.

RESULTS

Among the 15 participating parent-child dyads, 5 (33%) children were Hispanic and 11 (73%) had irritable bowel syndrome. They had diverse socioeconomic status. All parent participants were mothers. The TAM questionnaire indicated that mothers scored favorably on behavioral intention to use a guided imagery therapy app (mean score 12.0, SD 2.6, possible range 3-15). Scores for the TAM factors perceived usefulness, perceived ease of use, hedonic motivation, compatibility, and habit also were favorable. Maternal interviews confirmed positive attitudes toward the proposed app. They advocated a visual component to hold their child's attention during the guided imagery therapy sessions; recommended incorporating background sounds into the sessions; favored session reminder notifications from the app; and thought the best time for their child to listen to the sessions would be in the evening or before bed. The child interviews also confirmed positive attitudes toward the proposed app. They suggested guided imagery therapy session topics such as sports and adventures; listening to sessions in their bedroom; and the need for parental supervision to install the app on their mobile device. Integration of the quantitative and qualitative methods findings complimented one another on acceptability. The favorable behavioral intention TAM score aligned well with expressed positive maternal and child attitudes toward the app and can be explained by the desire to avoid medications. The questionnaire and interviews also confirmed therapeutic benefit as an intrinsic motivator to promote routine use.

CONCLUSIONS

A guided imagery therapy app designed to treat pediatric patients with functional abdominal pain disorders appears to be acceptable to both mothers and children. Incorporating parent and child preferences into a guided imagery therapy app could promote therapeutic compliance and increase access to optimal care.

A systematic review of psychological interventions in total hip and knee arthroplasty

BACKGROUND

The current practice in elective orthopaedics does not routinely include psychological interventions despite evidence that psychological factors such as personality, anxiety, depression and negative thinking styles can influence outcomes and recovery from surgery. The objective of this paper was to review the effectiveness of psychological interventions used in conjunction with total hip (THA) and knee arthroplasty (TKA), in improving patient reported joint outcomes.

METHODS

An extensive literature search was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Search terms included psychology, interventions, and orthopaedics. Articles were included if they were randomised controlled trials (RCTs) of psychological interventions involving active patient participation measured with patient reported joint outcomes in patients undergoing hip or knee arthroplasty.

RESULTS

A total of 19,489 titles were screened. Seven studies met the inclusion criteria and were included. Five of seven studies did not show improvements in patient reported outcomes after surgery. Specifically, psycho-education alone was not effective at improving patient reported joint outcomes in two out of two studies.

CONCLUSION

The current literature does not support routine psychological interventions for TKA and THA. However, it should be noted that the literature for psychological interventions in conjunction with TKA and THA is still in its infancy. This gap in the literature is surprising, considering the importance of the role of psychological factors in recovery. Further RCTs with long term follow ups, multidisciplinary involvement, and more comprehensive and focused interventions that go beyond educating patients are needed. Future studies should account for the demand effect, include measures of psychological variables to determine whether psychological interventions are more beneficial for some patients compared to others, and compare the different modes of delivery and timing of interventions to determine the optimal nature and duration of psychological interventions for TKA and THA.

Utilization and Perception of Integrative Medicine Among Plastic Surgery Patients

BACKGROUND

Integrative medicine (IM) is currently used by 40% of Americans. Our objective is to examine the prevalence and perception of IM utilization in patients being evaluated for elective plastic surgery.

METHODS

In July 2014, 402 consecutive patients presenting to plastic surgery clinics at the University of Florida, Veterans Affairs (VA), and Private Practices in Gainesville, Florida were requested to complete a survey regarding utilization of and attitudes towards IM.

RESULTS

The survey completion rate was 75.5% (n = 331). The respondents' mean age was 48.5 years, and they were primarily white (75%), married (48%), and educated with at least a college degree (58%). The respondents were distributed between the university (74%), VA (15%), and private practice (11%). There was an equal mix of reconstructive (52%) and cosmetic (48%) visits. Overall IM utilization was 80.0%. Integrative medicine use correlated with having a college degree (P = 0.0002) and being middle age (40-64 years, P < 0.005). A higher utilization rate of IM in the private sector (87.0%) compared with the university (76.1%) and VA (71.0%) was not statistically significant (P = 0.17). Similarly, higher IM utilization in cosmetic patients compared with reconstructive patients (81% vs 74%) was not statistically significant (P = 0.56). The majority of patients stated a strong belief in self-healing techniques (71%, P < 0.005), and they desired (61%) that their physician should be familiar with these techniques (P < 0.005).

CONCLUSIONS

The IM utilization is highly prevalent among plastic surgery patients regardless of reason for visit (cosmetic versus reconstruction) or practice setting (private versus academic versus VA). Increasing awareness of IM usage and potential impact on outcomes is especially important for academic and VA plastic surgeons. Moreover, an opportunity exists to study how certain aspects of IM can positively impact plastic surgery care.

The effects of psychological interventions on wound healing: A systematic review of randomized trials

PURPOSE

Psychological stress has been shown to delay wound healing. Several trials have investigated whether psychological interventions can improve wound healing, but to date, this evidence base has not been systematically synthesized. The objective was to conduct a systematic review of randomized controlled trials in humans investigating whether psychological interventions can enhance wound healing.

METHODS

A systematic review was performed using PsychINFO, CINAHL, Web of Science, and MEDLINE. The searches included all papers published in English up until September 2016. The reference lists of relevant papers were screened manually to identify further review articles or relevant studies. Nineteen studies met inclusion criteria and were included in the review.

RESULTS

Fifteen of nineteen studies were of high methodological quality. Six studies were conducted with acute experimentally created wounds, five studies with surgical patients, two studies with burn wounds, two studies with fracture wounds, and four studies were conducted with ulcer wounds. Post-intervention standardized mean differences (SMD) between groups across all intervention types ranged from 0.13 to 3.21, favouring improved healing, particularly for surgical patients and for relaxation interventions. However, there was some evidence for publication bias suggesting negative studies may not have been reported. Due to the heterogeneity of wound types, population types, and intervention types, it is difficult to pool effect sizes across studies.

CONCLUSIONS

Current evidence suggests that psychological interventions may aid wound healing. Although promising, more research is needed to assess the efficacy of each intervention on different wound types. Statement of contribution What is already known on this subject? Psychological stress negatively affects wound healing. A number of studies have investigated whether psychological interventions can improve healing. However, no systematic reviews have been conducted. What does this study add? Synthesis and review of 19 trials conducted on psychological interventions and wound healing. Most evidence supports improved healing, particularly for surgical wounds and relaxation interventions. More research is needed on different intervention types with clinical wounds and into mechanisms of action.

Acceptability of a Guided Imagery Intervention for Persons Undergoing a Total Knee Replacement

BACKGROUND

Guided imagery (GI) has been recommended as a mind-body therapy for pain relief following orthopaedic surgery, but little is known about the acceptability of the intervention.

PURPOSE

Describe the perceptions of patients undergoing total knee replacement (TKR) surgery regarding the acceptability of a customized GI intervention to promote TKR outcomes.

METHODS

Narrative and survey data collected during a randomized controlled trial of the GI intervention were analyzed to assess the acceptability of the intervention.

RESULTS

Most participants were satisfied with and actively engaged in the intervention, and they perceived it to be helpful. For the smaller group of participants who did not find the intervention to be acceptable, reasons for dissatisfaction and barriers to engagement were identified.

CONCLUSIONS

Guided imagery is an acceptable intervention for many persons undergoing TKR surgery. The results of this study can provide information to further develop a targeted and customized GI intervention for this population.

The Feasibility and Effectiveness of Online Guided Imagery Training for Health Professionals

This study evaluated the feasibility and impact of brief online guided imagery training (up to 3 hours) for health professionals. Paired t tests were used to measure pre-to-post-training changes in stress (Perceived Stress Scale,), anxiety (Patient Reported Outcomes Measurement Information System-Anxiety Scale), empathy (Empathic Concern Scale, and Perspective-taking Scale), and self-efficacy (Self-Efficacy in providing Non-Drug Therapies Scale). Online guided imagery training attracted diverse health professionals and trainees (n = 273; 14% trainees; 34% registered nurses, 20% physicians, 14% social workers, 5% registered dititians, and 27% others). Participants reported small but significant pre-to-post-module improvements in stress (17.8 to 13.5), anxiety (T-scores 56.4 to 54.3), empathy (both empathic concern, 29.8 to 30.7, and perspective taking, 28.0 to 29.4), and self-efficacy in providing nondrug therapies for common symptoms (58.5 to 77.0) (P < .001 for all). Future studies will need to examine the clinical impact of online guided imagery training for health professionals.

Guided Imagery for Total Knee Replacement: A Randomized, Placebo-Controlled Pilot Study

OBJECTIVES

To determine the effect of guided imagery (GI) on functional outcomes of total knee replacement (TKR), explore psychological and neuroimmune mediators, and assess feasibility of study implementation.

DESIGN

Investigator-blinded, randomized, placebo-controlled pilot study.

SETTINGS

Hospital, surgeon's office, participant's home.

PARTICIPANTS

82 persons undergoing TKR.

INTERVENTIONS

Audiorecordings of TKR-specific GI scripts or placebo-control audiorecordings of audiobook segments.

OUTCOME MEASURES

Gait velocity and Western Ontario and McMaster Universities Arthritis Index (WOMAC) Function scale.

RESULTS

Outcomes for 58 participants (29 receiving GI and 29 controls) were analyzed at 6 months after surgery. The most frequent reason for noncompletion was protocol-driven exclusion at 6 months for having the contralateral knee replaced before the study endpoint (n = 15). With imaging ability as a moderator, gait velocity, but not WOMAC Function score, was significantly improved at 6 months in the GI group. Participants in the GI group, but not the control group, had lower WOMAC Pain scores at 3 weeks after surgery than at baseline. Hair cortisol concentration was significantly lower at 6 months after surgery than at baseline in the GI group but not the control group. GI group participants had lower treatment adherence but greater treatment credibility than the control group.

CONCLUSION

Randomized controlled trials of GI in the TKR population are feasible, but inclusion/exclusion criteria influence attrition. Further studies are needed to elaborate this study's findings, which suggest that guided imagery improves objective, but not patient-reported, outcomes of TKR. Hair cortisol concentration results suggest that engagement in a time-limited guided imagery intervention may contribute to stress reduction even after the intervention is terminated. Further investigation into optimal content and dosing of GI is needed.

Are Anesthesia Providers Ready for Hypnosis? Anesthesia Providers' Attitudes Toward Hypnotherapy

This study sought to measure current attitudes toward hypnosis among anesthesia providers using an in-person survey distributed at a single grand rounds at a single academic teaching hospital. One hundred twenty-six anesthesia providers (anesthesiologists and nurse anesthetists) were included in this study. A 10-question Institutional Review Board (IRB)-approved questionnaire was developed. One hundred twenty-six (73% of providers at the meeting) anesthesia providers completed the survey. Of the respondents, 54 (43%) were anesthesiologists, 42 (33%) were trainees (interns/residents/fellows) in anesthesia, and 30 (24%) were nurse anesthetists. Over 70% of providers, at each level of training, rated their knowledge of hypnosis as either below average or having no knowledge. Fifty-two (42%) providers agreed or strongly agreed that hypnotherapy has a place in the clinical practice of anesthesia, while 103 (83%) believed that positive suggestion has a place in the clinical practice of anesthesia (p < .0001). Common reasons cited against using hypnosis were that it is too time consuming (41%) and requires special training (34%). Only three respondents (2%) believed that there were no reasons for using hypnosis in their practice. These data suggest that there is a self-reported lack of knowledge about hypnosis among anesthesia providers, although many anesthesia providers are open to the use of hypnosis in their clinical practice. Anesthesia providers are more likely to support the use of positive suggestion in their practice than hypnosis. Practical concerns should be addressed if hypnosis and therapeutic verbal techniques are to gain more widespread use.