Cancer care in a Western Indian tertiary center during the pandemic: Surgeon's perspective.

INTRODUCTION: Following the nationwide lockdown in India, most hospitals shut down elective surgeries including cancer surgeries. We continued operating on patients with cancer at a tertiary referral center in Western India, which also served as a COVID care center. We also constructed a questionnaire, exclusive to surgeons, to determine the changes in treatment strategies as well as the response to the pandemic. METHODS: The complications of all cases operated in the study period (March 22, 2020-June 30, 2020) were graded using the Clavien-Dindo classification. Also, an anonymous structured questionnaire was constructed and e-mailed to all surgical oncologists working at our institute. RESULTS: Of the 118 patients having an operation, 18 had complications. There were 12 Grade I/II and 6 Grade III complications but none of our patients had Grade-IV/V complications. When the staff of the main operating theater tested COVID positive, the complex was shut down. However surgical oncology work continued at an affiliated institute about 10 km away from the main hospital. CONCLUSION: We had favorable outcomes while operating on cancer patients in a COVID care center. The results of our questionnaire proved that surgeons were willing to risk their personal safety to provide surgical oncology care.

Health Numeracy and Relative Risk Comprehension in Perioperative Patients and Physicians.

BACKGROUND: Helping patients to understand relative risks is challenging. In discussions with patients, physicians often use numbers to describe hazards, make comparisons, and establish relevance. Patients with a poor understanding of numbers-poor "health numeracy"-also have difficulty making decisions and coping with chronic conditions. Although the importance of "health literacy" in perioperative populations is recognized, health numeracy has not been well studied. Our aim was to compare understanding of numbers, risk, and risk modification between a patient population awaiting surgery under general anesthesia and attending physicians at the same center. METHODS: We performed a single-center cross-sectional survey study to compare patients' and physicians' health numeracy. The study instrument was based on the Schwartz-Lipkus survey and included 3 simple health numeracy questions and 2 risk reduction questions in the anesthesiology domain. The survey was mailed to patients over the age of 18 scheduled for elective surgery under general anesthesia between June and September 2019, as well as attending physicians at the study center. RESULTS: Two hundred thirteen of 502 (42%) patient surveys sent and 268 of 506 (53%) physician surveys sent were returned. Median patient score was 4 of 5, but 32% had a score of ≤3. Patients significantly overestimated their total scores by an average of 0.5 points (estimated [mean ± standard deviation (SD)] = 4.3 ± 1.2 vs actual 3.8 ± 1.3; P < .001). Health numeracy was significantly associated with higher educational level (gamma = 0.351; P < .001) and higher-income level (gamma = 0.397; P < .001). Physicians' health numeracy was significantly higher than the patients' (median [interquartile range {IQR}] = 5 [4-5] vs 4 [3-5]; P < .001). There was no significant difference between physicians' self-estimated and actual total numeracy score (mean ± SD = 4.8 ± 0.6 vs 4.7 ± 0.6; P = .372). Simple health numeracy (questions 1-3) was predictive of correct risk reduction responses (questions 4, 5) for both patients (gamma = 0.586; P < .001) and physicians (gamma = 0.558; P = .006). CONCLUSIONS: Patients had poor health numeracy compared to physicians and tended to overrate their abilities. A small proportion of physicians also had poor numeracy. Poor health numeracy was associated with incomprehension of risk modification, suggesting that some patients may not understand treatment efficacy. These disparities suggest a need for further inquiry into how to improve patient comprehension of risk modification.

The influence of perioperative interventions targeting psychological distress on clinical outcome after total knee arthroplasty.

Our aim was to assess the effect of perioperative interventions targeting psychological distress on clinical outcome after total knee arthroplasty (TKA). We searched studies on the effect of perioperative interventions focused on psychological distress used in conjunction with TKA on pain, function, and quality of life (QoL) on PubMed, Embase.com, PsycINFO/OVID, CENTRAL, the Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We included 40 studies (22 RCTs, ten cohort studies, and eight quasi-experimental studies) with a total of 3846 patients. We graded the quality of evidence as low for pain and function and as moderate for QoL. Patients receiving music, education, cognitive behavioural therapy, guided imagery, pain coping skills training, Reiki, occupational therapy with self-monitoring, and biofeedback-assisted progressive muscles relaxing training had lower pain scores or declined opioid prescriptions after TKA. Pain coping skills training, audio recording-guided imagery scripts, video promoting self-confidence, psychological therapies by video, Reiki, music, occupational therapy with self-monitoring, education, and psychotherapy improved postoperative functional outcome. Education through an app improved QoL after TKA. The studies in our systematic review show that perioperative interventions targeting psychological distress for patients receiving TKA seem to have a positive effect on postoperative pain, function, and QoL. RCTs with strict methodological safeguards are still needed to determine if perioperative interventions focused on psychological distress should be used in conjunction with TKA. These studies should also assess which type of intervention will be most effective in improving patient-reported outcome measures and declining opioid prescriptions.

Perioperative Considerations for Patients With Major Depressive Disorder Undergoing Surgery.

In the United States, approximately 15% of adults suffer from major depressive disorder (MDD), which results in an annual cost of over $200 billion per year. In the perioperative setting, MDD is associated with increased morbidity and mortality. The exact causes of the increase in adverse outcomes are unknown. Major depression affects virtually all major systems in the human body, and most antidepressants affect dopamine, norepinephrine, and serotonin levels or alter their target receptors. Unfortunately, anesthesia and medications used in the perioperative period affect the same neurotransmitters. As a result, patients with MDD are at an increased risk for cardiovascular effects, altered thermoregulation, and postoperative cognitive dysfunction. To determine when to continue or hold antidepressants preoperatively and avoid potential drug interactions, perioperative providers must understand the pharmacological action of antidepressants. This article reviews the pathophysiology of MDD, mechanism of action of antidepressants, and perioperative considerations for patients on antidepressant medications.

Feasibility of a Perioperative Text Messaging Smoking Cessation Program for Surgical Patients.

Although surgical patients who smoke could benefit from perioperative abstinence, few currently receive support. This pilot study determined the feasibility and acceptability of a perioperative text messaging smoking cessation program. One hundred patients (73% of eligible patients approached) enrolled in a surgery-specific messaging service, receiving 1-3 daily messages about smoking and surgical recovery for 30 days. Only 17 patients unenrolled, the majority responded to prompting messages, and satisfaction with the program was high. Surgical patients are amenable to text message-based interventions; a future efficacy trial of text messaging smoking cessation support in surgical patients is warranted.

Perioperative Management of Women Undergoing Risk-reducing Surgery for Hereditary Breast and Ovarian Cancer.

Carriers of genetic mutations that predispose to cancer syndromes are often faced with complex decisions. For women with hereditary breast and ovarian cancer in particular, the decision to undergo risk-reducing mastectomy or bilateral salpingo-oophorectomy is burdensome from a physical and psychological perspective. Although risk-reducing surgery is the most effective preventative measure in reducing a genetic mutation carrier's risk of breast or ovarian cancer, the success of these procedures requires a multidisciplinary approach that centers on careful counseling regarding the risks and benefits of risk-reducing surgery. The physical and psychological distress associated with risk-reducing surgery often makes a combined surgical approach attractive to some patients. In this review, we present the evidence surrounding the comprehensive surgical care of women with hereditary breast and ovarian cancer syndromes and evaluate the perioperative factors that influence surgical management.

A prospective study on elective surgical inpatient satisfaction with perioperative anaesthesia service at Ayder comprehensive specialized hospital, Mekelle, Ethiopia.

BACKGROUND: Patient satisfaction is a subjective and challenging perception, linking physical, expressive, psychological, societal, and cultural factors. Dissatisfaction arises if the patient feels an inconsistency between expected and delivered care. Usually health care satisfactions are very high and according to many studies levels of satisfaction are above 85% and patient's satisfaction in terms of anesthesia is not very different. The aim of this study was to assess patient's satisfaction with perioperative anesthesia service and associated factors. METHODS: Institution-based cross-sectional study was conducted from December to January, 2017/8 at the Ayder Comprehensive Specialize Hospital. The data were collected using structured interviewer-administered questionnaire prepared to collect data on demographic character of the patients, determinant factors which could affect the patient satisfaction level on anesthesia service. Epi Info version 6 was used to record the data and SPSS version 20 was used for the analysis. Descriptive statistics were used to explore the socio-demographic characteristics of patients; factors possibly related to satisfaction level and overall satisfaction were summarized as frequencies and percentages. RESULTS: One hundred twenty consecutive patients were originally enrolled in the study that took over 1 Month. The overall proportion of patients who satisfied with anaesthesia services was 88.33%. Nausea and vomiting, pain, shortness of breath and cold were factors which affected patient satisfaction negatively. CONCLUSION AND RECOMMENDATION: Compared with the other studies done at home and abroad; the overall proportion of patients, in Ayder comprehensive specialized hospital, who responded for satisfaction with perioperative anesthesia service is low. Patient satisfaction level should be determined regularly and all bodies should work to decrease the factors which decrease the satisfaction level.

Perioperative Anxiety and Stress in Children Undergoing Congenital Cardiac Surgery and Their Parents: Effect of Brief Intervention-A Randomized Control Trial.

OBJECTIVE: To know the effects of psychological preparation on perioperative stress, anxiety, and mood in children undergoing cardiac surgery and their parents. DESIGN: Prospective randomized control nonblinded trial. SETTING: Single-center tertiary teaching hospital. PARTICIPANTS: A total of 60 children aged 5 to 15 years undergoing cardiac surgery were included in the study. One of the parents, preferably the father, was selected from the respective children. INTERVENTIONS: Subjects were randomized into 2 groups: noninterventional (group 1) and interventional (group 2). Intervention was in the form of toys and video games in children, and counseling and information in parents. Preoperative and postoperative anxiety in parents was measured using the State-Trait Anxiety Inventory (STAI), stress using the Index of Clinical Stress (ICS) scale by Abell, and the Ottawa mood scale. In children, the STAI-C (child version of STAI), Ottawa mood and Ottawa stress scales, and Wong-Baker faces pain scale were applied and serum cortisol was measured. MEASUREMENTS AND MAIN RESULTS: Group 2 children had significantly less (p < 0.001) stress, anxiety, and pain and improved mood. Group 2 parents had a significant reduction in state anxiety (42 ± 4.4 v 54.5 ± 7.8; p < 0.001) and ICS score (68.1±9.6 v 84.2 ± 9.2; p < 0.001) and an improvement in mood (7.5 ± 0.7 v 5.9 ± 1; p < 0.001) compared with group 1. Postoperatively, cortisol levels in group 2 were lower than group 1 (571.3 nmol/L [123.3 -1247.14] v 718.9 nmol/L [53-1642.0]). CONCLUSION: Providing video games and toys preoperatively reduced postoperative stress and anxiety and improved mood in children undergoing congenital cardiac surgery. Parents were relieved of anxiety and stress with proper counseling and information.

Surgical perioperative pathways-Patient experiences of unmet needs show that a person-centred approach is needed.

AIM: To explore patients' and healthcare professionals' experiences of patients' surgical pathways in a perioperative setting. BACKGROUND: Elective surgical pathways have improved over the past decades due to fast-track programmes, but patients desire more personalised and coordinated care and treatment. There is little knowledge of how healthcare professionals' collaboration and communication affect patients' pathways. DESIGN: The overall framework was complex intervention method. A phenomenological-hermeneutic approach was used for data analyses. COREQ checklist was used as a guideline to secure accurate and complete reporting of the study. METHODS: Field observations (120 hr) and semi-structured interviews (24 patients) were undertaken during 2016-2017. Healthcare professionals involved in the pathways were interviewed: (a) 13 single interviews and (b) 13 focus group interviews (37 healthcare professionals) were conducted. The Consolidated Criteria for Reporting Qualitative Research checklist was used. RESULTS: Patients asked for individualised information adapted to their life and illness experiences. Furthermore, healthcare professionals need access to a quick overview of individual patients and their perioperative pathway in the electronic patient journal (EPJ). Agreements made with patients did not always reach the right receiver, there was poor interpersonal communication and the complex teamwork between many healthcare professionals made pathways incoherent and uncoordinated. Healthcare professionals who had the time to talk about other subjects than the disease with smiles and good humour gave patients a feeling of security. CONCLUSION: Patients wanted to be treated as individuals, but often they received standard treatment. Healthcare professionals had the intention of treating patients individually, but the EPJ and information provided to patients were not easy to access. RELEVANCE TO CLINICAL PRACTICE: Visible information about the patient's whole pathway could improve healthcare professionals' care and treatment. In addition, systematic feedback from patients' could make it possible to adjust information, care and treatment to achieve a more coherent pathway. Particular attention needs to be paid to how electronic healthcare systems can underpin relational coordination in pathways.

Implementation of Perioperative Music Using the Consolidated Framework for Implementation Research.

BACKGROUND: Complementary integrative health therapies have a perioperative role in the reduction of pain, analgesic use, and anxiety, and increasing patient satisfaction. However, long implementation lags have been quantified. The Consolidated Framework for Implementation Research (CFIR) can help mitigate this translational problem. METHODS: We reviewed evidence for several nonpharmacological treatments (CFIR domain: characteristics of interventions) and studied external context and organizational readiness for change by surveying providers at 11 Veterans Affairs (VA) hospitals (domains: outer and inner settings). We asked patients about their willingness to receive music and studied the association between this and known risk factors for opioid use (domain: characteristics of individuals). We implemented a protocol for the perioperative use of digital music players loaded with veteran-preferred playlists and evaluated its penetration in a subgroup of patients undergoing joint replacements over a 6-month period (domain: process of implementation). We then extracted data on postoperative recovery time and other outcomes, comparing them with historic and contemporary cohorts. RESULTS: Evidence varied from strong and direct for perioperative music and acupuncture, to modest or weak and indirect for mindfulness, yoga, and tai chi, respectively. Readiness for change surveys completed by 97 perioperative providers showed overall positive scores (mean >0 on a scale from -2 to +2, equivalent to >2.5 on the 5-point Likert scale). Readiness was higher at Durham (+0.47) versus most other VA hospitals (range +0.05 to +0.63). Of 3307 veterans asked about willingness to receive music, approximately 68% (n = 2252) answered "yes." In multivariable analyses, a positive response (acceptability) was independently predicted by younger age and higher mean preoperative pain scores (>4 out of 10 over 90 days before admission), factors associated with opioid overuse. Penetration was modest in the targeted subset (39 received music out of a possible 81 recipients), potentially reduced by device nonavailability due to diffusion into nontargeted populations. Postoperative recovery time was not changed, suggesting smooth integration into workflow. CONCLUSIONS: CFIR-guided implementation of perioperative music was feasible at a tertiary VA hospital, with moderate penetration in a high-risk subset of patients. Use of digital music players with preferred playlists was supported by strong evidence, tension for change, modest readiness among providers, good acceptability among patients (especially those at risk for opioid overuse), and a protocolized approach. Further study is needed to identify similar frameworks for effective knowledge-translation activities.

Parental satisfaction of child's perioperative care.

BACKGROUND: Satisfaction in the hospital setting is an important component of both hospital funding and patient experience. When it comes to a child's hospital experience, parent satisfaction of their child's perioperative care is also necessary to understand. However, little research has been conducted on the predictors of this outcome. Therefore, the purpose of this current study was to validate a priori selected predictors for parental satisfaction in their child's perioperative process. METHODS: Eight hundred and ten pediatric patients who underwent tonsillectomy and adenoidectomy surgery and their parents were included in this study. The primary outcome was assessed using a 21-item parent satisfaction questionnaire resulting in three satisfaction scores: overall care satisfaction, OR/induction satisfaction, and total satisfaction. RESULTS: Descriptive statistics and correlational analysis found that sedative-premedication, parental presence at anesthesia induction, child social functioning, parental anxiety, and language were all significant predictors of various components of the satisfaction score. Regression models, however, revealed that only parent anxiety and child social functioning remained significant predictors such that parents who reported lower state anxiety (OR/induction satisfaction: OR = 0.975, 95% CI [0.957, 0.994]; total satisfaction: OR = 0.968, 95% CI [0.943, 0.993]) and who had higher socially functioning children (overall care satisfaction: OR = 1.019, 95% CI [1.005, 1.033]; OR/induction satisfaction: OR = 1.011, 95% CI [1.000, 1.022]) were significantly more satisfied with the perioperative care they received. CONCLUSION: Lower parent anxiety and higher child social functioning were predictive of higher parental satisfaction scores.

Perioperative Interdisciplinary Intervention Contributes to Improved Outcomes of Adolescents Treated With Hip Preservation Surgery.

BACKGROUND: Adolescent hip preservation surgery (HPS) candidates typically present with chronic pain, which can negatively affect psychological function and surgical outcomes. A previous study demonstrated high rates of psychological symptoms and maladaptive behaviors in this population. This study quantified psychological and functional improvements in these patients from preoperative presentation to postoperative follow-up. An integrated interdisciplinary approach is also described. METHODS: A total of 67 patients undergoing HPS were evaluated preoperatively and postoperatively at 1 year by staff psychologists. Perioperative psychological intervention consisted of education, counseling, and administration of self-report measures. Self-report measure scores were compared preoperatively and postoperatively, grouped by orthopaedic diagnoses. Frequency analysis, correlational analysis, and analysis of variance were conducted. RESULTS: Psychological function improved significantly at follow-up: decreased emotional symptomatology (46.1 to 43.6, P=0.013), anxiety (49.6 to 45.8, P<0.001), school problems (46.6 to 44.7, P=0.035), internalizing problems (46.3 to 44.1, P=0.015), social stress (44.5 to 42.3, P=0.024), sense of inadequacy (49.0 to 46.0, P=0.004), and increased self-concept (51.1 to 54.1, P=0.003). Resiliency factors also significantly improved: increased mastery (50.3 to 52.9, P=0.001) and resourcefulness (49.7 to 52.0, P=0.046), decreased emotional reactivity (46.3 to 42.9, P=0.001), and vulnerability (47.7 to 44.7, P=0.011). Physical function and return to activity also significantly improved (University of California-Los Angeles: 7.1 to 8.7, P=0.017; modified Harris Hip Score: 67.3 to 83.8, P<0.001). Return to activity positively correlated with optimism and self-efficacy (P=0.041). Femoroacetabular impingement and hip dysplasia patients consistently reported feeling less depressed (P=0.036), having fewer somatic complaints (P=0.023), fewer internalized problems (P=0.037), and exhibiting fewer atypical behaviors (P=0.036) at follow-up. Slipped capital femoral epiphysis patients did not demonstrate improvements in psychological functioning postoperatively. CONCLUSIONS: Perioperative psychological education and counseling, in combination with HPS, improved postoperative psychological and physical function. Patients reported reduced anxiety, school problems, and social stress, with marked increase in resilience. Increased mobility and return to activity significantly correlated with improved optimism and self-efficacy. LEVEL OF EVIDENCE: Level II-therapeutic studies-investigating the results of treatment.

Perioperative cognitive evaluation.

PURPOSE OF REVIEW: This article reviews the recent clinical evidence published between January 2017 and June 2018 - related to perioperative cognitive evaluation. Namely, new insights into risk factors, prevention, diagnosis and diagnostic tools and treatment. RECENT FINDINGS: Several risk factors (preoperative, intraoperative and postoperative) have been found to be associated with the development of postoperative delirium (POD) and/or postoperative cognitive dysfunction (POCD). Short-term and long-term postoperative consequences can be reduced by targeting risk factors, introducing preventive strategies and including frequent cognitive monitoring. Administration of medications such as ketamine, opioids and benzodiazepines are associated with increased cognitive dysfunction. Prevention of POD/POCD starts with creating an environment, which promotes return to preoperative baseline functioning. This includes frequent monitoring of cognitive status, access to rehabilitation and psychological and social supports, and avoiding polypharmacy. In addition, patients should have early access to their sensory aids and maintain normal circadian rhythm. Treatment of POD/POCD has pharmacological and nonpharmacological approaches. SUMMARY: Clinical evidence on POD/POCD is continuously evolving, which is essential in guiding clinical management to provide the highest quality of clinical care.

Participation in paediatric perioperative care: 'what it means for parents'.

AIMS AND OBJECTIVES: To explore what it means for parents to participate in their children's paediatric perioperative care. BACKGROUND: Allowing parents to participate in paediatric perioperative care can make a major difference for children in terms of their well-being, a decreased need for painkillers, fewer sleeping disorders and a more positive experience for both parties. The nurse anaesthetist should have a holistic view and develop a shared vision for the child, the parents and for themselves to perform successful paediatric perioperative care. DESIGN: Descriptive qualitative study. METHODS: The study was conducted in 2014. Data were collected in 20 narrative interviews with 15 mothers and five fathers who had experience of participating in their child's paediatric perioperative day surgery. The analysis was carried out with qualitative content analysis to describe the variations, differences and similarities in the experiences. RESULTS: The analysis revealed a main category that describes that parental participation in the context of paediatric perioperative care in day surgery meant 'having strength to participate despite an increased vulnerability'. Three generic categories with additional subcategories explained what was essential for the parents to be able to preserve this strength and participate in their child's care despite their increased vulnerability. The generic categories were named, 'gaining information about what will happen', 'being seen as a resource' and 'gaining access to the environment'. CONCLUSION: Efforts should be made to improve parents' roles and opportunities to participate in paediatric perioperative care. RELEVANCE TO CLINICAL PRACTICE: Nurse anaesthetists have a crucial role in enabling parents' participation and need knowledge to develop strategies and nursing interventions that meet parents' needs.

A qualitative study of patient and provider experiences during preoperative care transitions.

AIMS AND OBJECTIVES: To explore the issues and challenges of care transitions in the preoperative environment. BACKGROUND: Ineffective transitions play a role in a majority of serious medical errors. There is a paucity of research related to the preoperative arena and the multiple inherent transitions in care that occur there. DESIGN: Qualitative descriptive design was used. METHODS: Semistructured interviews were conducted in a 975-bed academic medical centre. RESULTS: A total of 30 providers and 10 preoperative patients participated. Themes that arose were as follows: (1) need for clarity of purpose of preoperative care, (2) care coordination, (3) interprofessional boundaries of care and (4) inadequate time and resources. CONCLUSION: Effective transitions in the preoperative environment require that providers bridge scope of practice barriers to promote good teamwork. Preoperative care that is a product of well-informed providers and patients can improve the entire perioperative care process and potentially influence postoperative patient outcomes. RELEVANCE TO CLINICAL PRACTICE: Nurses are well positioned to bridge the gaps within transitions of care and accordingly affect health outcomes.

Patient experiences of perioperative nutrition within an Enhanced Recovery After Surgery programme for colorectal surgery: a qualitative study.

AIM: Nutrition is an important element of the Enhanced Recovery After Surgery (ERAS) programme. Patients have previously indicated that nutrition is a key component of ERAS that requires improvement. Our aim was to explore the perioperative nutrition experiences of colorectal surgical patients to identify barriers and facilitators to the integration of nutrition within ERAS. METHOD: Sixteen individuals undergoing colorectal surgery participated in a semi-structured interview between postoperative day three and hospital discharge. The topic guide was developed iteratively throughout the study; topics included preoperative counselling, carbohydrate loading, fasting and postoperative nutrition. A constant comparison technique was employed during coding, and an inductive thematic analysis was used. Validity was ensured by double coding a sample of transcripts. RESULTS: Findings are presented in the context of the following clinical themes: preoperative information, preoperative fasting, carbohydrate loading and nutritional drinks, postoperative diet and discharge. Individuals received too much general information which was repetitive, contradictory and not disease specific; this formed a key barrier affecting nutrition. Other barriers were negative experiences of nutritional drinks, stoma management, nausea and vomiting, and challenges from the hospital environment. Facilitators included interactions with staff, food accessibility and choice, and motivation for discharge. CONCLUSION: The key barrier to adherence of perioperative nutrition protocols was poor provision of information. Targeted information regarding postoperative diet, stoma management and coping with nausea and vomiting would be beneficial for colorectal surgical patients. Easily accessible food provided by ward staff was considered a facilitator.

Medical clowns reduce pre-operative anxiety, post-operative pain and medical costs in children undergoing outpatient penile surgery: A randomised controlled trial.

AIM: The aim of this paper is to investigate prospectively the potential benefits of the participation of the medical clowns in the outpatient paediatric penile surgery programme. METHODS: Eighty children undergoing meatotomy, age 2 to 16 years, were randomised into two groups (40 each). In the first group, the medical clown was an integral part of the medical team, and in the second group, the treatment was given without participation of the medical clown. The following parameters were measured: the level of pre-operative anxiety, the level of the post-operative pain, the amount of pain medication use in the first 24 h after surgery and the time needed to return to normal activities. The operating room time and hospital costs were calculated. RESULTS: The patients from the first group demonstrated a lower pre-operative anxiety index upon (P = 0.0319) and after surgery (P = 0.0042), required less induction time for anaesthesia (P < 0.001), spent overall less time in the operating room (P < 0.0001) and required less time to recover from the surgery and to be discharged (P = 0.0172). The overall OR time and post-operative unit care savings of 20 and 155 min, respectively, led to the cost savings of $467. CONCLUSION: Our data demonstrated that the use of the medical clown functioning as an integral part of the operating team reduces children pre-operative anxiety and leads to a shortening of the overall time in the hospital thereby reducing the overall medical cost justifying the participation of medical clown as an integral part of the health team in a paediatric urology outpatient surgical unit.

Managing adolescent obesity and the role of bariatric surgery.

PURPOSE OF REVIEW: This update explores the current management options for adolescent obesity with a specific focus on bariatric surgery. RECENT FINDINGS: Research has highlighted the serious health complications associated with adolescent obesity and thus emphasized the need for effective interventions. With the increasing severity of obesity seen in younger populations, coupled with the modest effects of most behavioral and even pharmacologic interventions, there has been increased interest in, and attention on, bariatric surgery in younger populations. Recent adult-focused guidelines regarding the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient outline the importance of careful patient selection, in addition to close monitoring, with a particular focus on preventing nutritional deficiencies. Several recent publications have focused on issues specific to bariatric surgery in the adolescent patient including the relationship between a patient's physical and emotional maturity and timing of surgery. SUMMARY: Adolescent obesity is prevalent with increasing severity and long-term health implications. To date nonsurgical interventions have had modest effects. Bariatric surgery is becoming more common and has been shown to be well tolerated and effective in adolescents, but requires careful preoperative screening and postoperative monitoring.

Autistic children and anesthesia: is their perioperative experience different?

BACKGROUND: Children with autism spectrum disorders (ASD) are an increasingly common patient population in the perioperative setting. Children with ASD present with abnormal development in social interaction, communication, and stereotyped patterns of behavior and may be more prone to elevated perioperative anxiety. The perioperative experience for these patients is complex and presents a unique challenge for clinicians. AIM: The aim of the current study was to provide a further understanding of the premedication patterns and perioperative experiences of children with ASD in comparison to children without ASD. METHODS: Using a retrospective cohort study design, medical records were evaluated for patients with and without ASD undergoing general anesthesia for dental rehabilitation from 2006-2011. The following objectives were measured and compared: (i) premedication patterns and (ii) complications, pain, anesthetic type, PACU time, and time to discharge. To compare categorical variables, the chi-square test was used. Bivariate and multivariable analyses were performed to control for potential confounding as a result of baseline differences between the two groups. RESULTS: A total of 121 ASD patients and 881 non-ASD patients were identified. When controlling for age, weight, and gender, children in the ASD group were more likely to have nonstandard premedication types (P < 0.0001), while children without ASD were more likely to have standard premedication types (P < 0.0001). No significant group differences were identified in regards to the other outcome measures. CONCLUSIONS: Other than a significant difference in the premedication type and route, we found that children with ASD seemed to have similar perioperative experiences as non-ASD subjects. It was especially interesting to find that their postoperative period did not pose any special challenges. There is much to be learned about this unique patient population, and a more in-depth prospective evaluation is warranted to help better delineate the best approach to caring for these patients.