Immunological and psychosocial functioning in parents of children with cancer.

PURPOSE: Research has shown that parents of children with cancer exhibit an altered immune profile compared to parents of healthy children, reflective of increased susceptibility to illness. These parents are also at risk for poorer psychosocial outcomes and quality of life. The current study compares peripheral blood cell analyses and psychosocial self-reports from parents of children being treated for cancer (n = 21) to parents of healthy children (n = 30). METHODS: A blood sample was drawn from parents to analyze immune profiles. Parents also completed the Perceived Stress Scale (PSS), Medical Outcomes Study Short Form-36 (MOS), and Patient-Reported Outcomes Measurement Information System Short Form v1.0 Emotional Distress-Anxiety 8a, and Emotional Distress-Depression 8a (PROMIS). Mann-Whitney U tests and independent samples t-tests were conducted to examine differences in outcomes between parent groups. RESULTS: Parents of children with cancer exhibited higher monocyte percentages in their peripheral blood compared to peers with healthy children. Parents of children with cancer also reported poorer psychosocial outcomes: higher perceived stress, higher anxiety and depression symptoms, more role disability resulting from emotional problems, poorer general and mental health, and poorer social functioning. CONCLUSION: These findings support research that has shown a direct effect of chronic stress on the immune system. Symptoms reported by parents of children with cancer indicate unmet psychosocial needs that could potentially affect long-term health. Given the central role of parents in their children's cancer care, it is compelling to address and work to improve parent immunological and psychosocial well-being.

Role of the Perioperative Surgical Home in Optimizing the Perioperative Use of Opioids.

Several federal agencies have recently noted that the United States is in the midst of an unprecedented "opioid epidemic," with an increasing number of opioid-related overdoses and deaths. Providers currently face 3 population-level, public health challenges in providing optimal perioperative pain care: (1) the continued lack of overall improvement in the excessive incidence of inadequately treated postoperative pain, (2) minimizing or preventing postoperative opioid-related side effects, and (3) addressing current opioid prescribing patterns, and the accompanying problematic surge in prescription opioid diversion, misuse, abuse, addiction, and overdose. In the Perioperative Surgical Home model, anesthesiologists and other pain medicine specialists are uniquely qualified and positioned to develop, implement, and coordinate a comprehensive perioperative analgesic plan, which begins with the formal preoperative patient assessment and continues throughout the postdischarge, convalescence period. The scope and practice of pain management within the Perioperative Surgical Home should thus (a) expand to include routine preoperative patient-level pain-risk stratification (including the chronic use of opioid and nonopioid analgesics), (b) address the multitude of biopsychosocial factors that contribute to interpatient pain variability, and (c) extend and be well coordinated across all 4 phases of the surgical pain experience (preoperative, intraoperative, postoperative, and postdischarge). Specifically, safe and effective perioperative pain management should include a plan of care that is tailored to the individual patient's underlying disease(s), presence of a chronic pain condition and preoperative use of opioids, and the specific surgical procedure-with evidence-based, multimodal analgesic regimens being applied in the vast majority of cases. An iteratively evolutionary component of an existing institutional Perioperative Surgical Home program can be an integrated Transitional Pain Service, which is modeled directly after the well-established prototype at the Toronto General Hospital in Ontario, Canada. This multidisciplinary, perioperative Transitional Pain Service seeks to modify the pain trajectories of patients who are at increased risk of (a) long-term, increasing, excessive opioid consumption and/or (b) developing chronic postsurgical pain. Like the Perioperative Surgical Home program in which it can be logically integrated, such a Transitional Pain Service can serve as the needed but missing linkage to improve the continuum of care and perioperative pain management for elective, urgent, and emergent surgery. Even if successfully and cost-efficiently embedded within an existing Perioperative Surgical Home, a new perioperative Transitional Pain Service will require additional resources.

Practice and Outcomes of the Perioperative Surgical Home in a California Integrated Delivery System.

BACKGROUND: In this article, we report on the implementation and impact of a Perioperative Surgical Home (PSH) model for the total knee arthroplasty at an integrated delivery system (Kaiser Permanente). METHODS: A multidisciplinary committee developed and implemented a series of PSH protocols that included the entire continuum of care from the decision for surgery until 30 days after surgery. Five hundred forty-six subjects were included in the preimplementation phase (Fast Track [T-fast]), and 518 patients were included in the postimplementation phase (PSH). The primary end points of this report are hospital length of stay (LOS), postoperative skilled nursing facility (SNF) bypass rate, and 30-day readmission rate. We used a generalized linear model to assess the effect on LOS while adjusting for potential confounding variables. RESULTS: We found that patients assigned to the PSH pathway had a significantly shorter mean LOS compared with patients in the T-fast group (2.4 ± 2.1 days [confidence interval {CI}, 2.2-2.8] vs 3.4 ± 2.9 days [CI, 2.9-3.9]). The SNF bypass rate was significantly higher in the PSH group compared with the T-fast group (94% vs 80%, P = 0.00002, CI, -0.102 to -0.036). There was no difference in the 30 readmission rates between patients managed in the PSH track and the T-fast track (1.2% vs 0.98%). CONCLUSIONS: Introduction of the PSH into an integrated delivery system resulted in a simultaneous reduction of LOS and SNF admission for total knee arthroplasty patients.

Application of continuous incisional infusion of local anesthetic after major pediatric urological surgery: prospective randomized controlled trial.

PURPOSE: The aim of the study was to determine efficacy of continuous incisional infusion of local anesthetic, ON-Q® pain relief system (Kimberly-Clark, Georgia), in improving postoperative pain, reducing narcotic requirement, and shortening recovery time after major pediatric urological surgery. MATERIAL AND METHODS: Prospective open-labeled randomized controlled trial comparing the ON-Q® pain relief system to standard of care pain management. Pain was assessed by nurses using the Visual Analog Scale or the Face, Legs, Activity, Cry, Consolability Scale depending on the child's age. Information regarding analgesic consumption and recovery parameters such as temperature, start of oral nutrition, and length of hospitalization were prospectively collected. RESULTS: Patient's demographic, clinical, and surgical characteristics were similar in both groups. The ON-Q® group experienced significantly lower scores of maximal daily pain episodes compared to the control on the day of surgery (1.9±1.8 vs. 4.2±2.2 p=0.009) and first postoperative day (2.28±3.2 vs. 5.47±2.45 p=0.004). Mean number of narcotic doses was significantly lower in treatment group compared to control [Total (2.21 vs. 4.6 p=0.02), POD0 (0.7 vs. 1.7 p=0.02) and POD1 (1.3 vs. 2.8 p=0.04)]. CONCLUSION: The ON-Q® system is a viable option for postoperative pain management in children undergoing urological surgeries. This technology significantly decreases the amount of maximal pain, and the need for systemic narcotic consumption.

Attitudes toward and use of complementary and alternative medicine among Hispanic and white mothers.

CONTEXT: Complementary and alternative medicine (CAM) use has become more prevalent in the United States. Little is known, however, regarding the ethnic and language differences of mothers as related to their beliefs about and use of CAM. OBJECTIVE: This study intended to examine the differences in CAM beliefs and use in English- and Spanish-speaking Hispanic and white mothers of children undergoing surgery. DESIGN: The research team employed a cross-sectional survey design. SETTING: Mothers were recruited from the Children's Hospital of Orange County (CHOC) in Southern California, and they completed the study's surveys on the day of their children's outpatient surgery. PARTICIPANTS: A total of 206 mothers participated: (1) 42 English-speaking, non-Hispanic white (ESW) women; (2) 92 English-speaking Hispanic (ESH) women; and (3) 72 Spanish-speaking Hispanic (SSH) women. OUTCOME MEASURES: Participants completed (1) the Holistic and Complementary and Alternative Medicine Questionnaire (HCAMQ), which captured beliefs about holistic health measures and about the validity of CAM; and (2) a checklist identifying past and present use of 27 different CAM therapies. RESULTS: The research team analyzed and controlled for demographic differences using linear regression, and the analysis revealed significant group differences in CAM use (P < .0001). ESW mothers and ESH mothers used more CAM than SSH mothers (P = .02). No significant differences were observed between groups for CAM related beliefs. CONCLUSIONS: After controlling for socioeconomic status, the research team found that SSH mothers used less CAM compared to ESH and ESW mothers. Employment of culturally specific measures of CAM use may be necessary to understand fully the differences in CAM use between Spanish- and English-speaking mothers as well as to understand the medical conditions that prompt CAM use.

The impact of major life events on the use of complementary and alternative medicine among individuals with chronic pain: a cross-sectional study.

CONTEXT: Chronic pain affects millions of Americans. Treating chronic pain can be difficult because it is a complex condition influenced by genetic makeup and physiological and psychological factors. The experience of major life events has also been found to affect the psychosocial functioning, health, and health behaviors of patients. Whereas the impact of major life events on the use of traditional medical practices has been explored, only one study to date has examined the relationship between major life events and use of complementary and alternative medicine (CAM). OBJECTIVE: This study examined the impact of major life events on the use of CAM among patients with chronic pain syndromes. DESIGN: Participants were consecutive patients seeking treatment at a pain clinic. SETTING: The study occurred at a tertiary center for pain management in Southern California. PARTICIPANTS: Participants were adult patients experiencing chronic pain for at least 6 mo, seeking treatment at a pain center. OUTCOME MEASURES: Participants completed a measure assessing their use of CAM modalities as well as their receptiveness to using previously unused CAM modalities, and they provided demographic information, including the occurrence of major life events, such as a job loss. RESULTS: A total of 199 adults with chronic pain participated in the study. The majority (91.6%) of chronic pain patients in the study reported using at least one form of CAM, with an average of at least five different forms of CAM. Individuals reported receptiveness to CAM modalities that they had not previously used (P < .05). Rates of CAM use were greater among those that had experienced a major life event in the prior 6 mo (P < .05). The most common major life events for this group included a compromised medical status, death of a loved one, financial hardship, a major geographical move, and altered family relationships. CONCLUSIONS: The study found that individuals with chronic pain frequently use CAM therapies, especially those who had recently experienced a major life event. Major life events may motivate patients with chronic pain to seek out different forms of CAM as a way to manage their pain.

Effects of therapeutic suggestion in children undergoing general anesthesia: a randomized controlled trial.

OBJECTIVES AND AIM: The goal of this randomized controlled trial was to examine the effect of intraoperative positive therapeutic suggestion on postoperative nausea and vomiting (PONV) in children undergoing general anesthesia and otolaryngological surgery. BACKGROUND: Because of the high incidence of PONV following otolaryngological surgery and its negative impact on recovery, researchers have examined various nonpharmacological interventions to target this phenomenon. To date, the effectiveness of therapeutic suggestion has not been studied in children. METHODS: Participants were 67 children undergoing tonsillectomy and adenoidectomy and their mothers. Children received a standardized anesthetic procedure and were randomly assigned to one of three interventions administered under general anesthesia: therapeutic suggestion, story (prosody control), or standard operating room noise. Children, parents, and healthcare personnel were blinded to group assignment. Nausea and vomiting were recorded in the postanesthesia care unit (PACU) and for the first 3 days at home. RESULTS: Results demonstrated a decrease in nausea severity across the first 3 days, F(2,49) = 10.37, P < 0.001, but no group differences in nausea severity in the PACU (F(2,49) = 0.87, P = 0.43) or at home (F(2,49) = 0.80, P = 0.46). There were also no group differences in vomiting episodes in the PACU (chi(2) (2) = 1.25, P > 0.05) or at home (F(2,49) = 1.59, P = 0.21). CONCLUSIONS: In this blinded controlled trial, therapeutic suggestion delivered intraoperatively did not impact children's PONV. However, because this is the first study of this kind, replication may be needed.

Hemispheric synchronized sounds and perioperative analgesic requirements.

BACKGROUND: Data on the effect of Hemisync sounds on perioperative analgesic requirements are scant. METHODS: We randomized surgical outpatients into a treatment group that received Hemisync sounds (n = 20), a music group that received music (n = 20), and a control group that had a blank cassette tape (n = 20). All subjects underwent a controlled standardized propofol-nitrous-vecuronium and fentanyl general anesthesia. RESULTS: The treatment group had significantly reduced intraoperative fentanyl consumption (P < 0.05). Postoperatively, pain visual analog scale scores were significantly lower in the Hemisync group at 1 h (P = 0.02) and 24 h (P = 0.005). Subjects in the Hemisync group were also discharged earlier (P = 0.048). CONCLUSION: The use of Hemisync sounds before and during general anesthesia reduces intraoperative analgesic requirements, postoperative pain scores, and discharge time.

The impact of asynchronous electroacupuncture stimulation duration on cold thermal pain threshold.

The durations of asynchronous electroacupuncture can affect the resultant hypoalgesia. Healthy volunteers were randomized to receive different durations (0 min, 20 min, 30 min, or 40 min) of asynchronous electroacupuncture stimulations (alternating low/high [2/100 Hz] frequency at 5 mA). Using a human experimental cold thermal pain threshold model, we found that 30 min of asynchronous 2/100 Hz stimulation resulted in the most significant hypoalgesic effect that was sustained for at least 60 min after stimulation compared with 0-, 20-, or 40-min stimulations (P < 0.05). We conclude that the most optimal duration for asynchronous electroacupuncture stimulation is 30 min.

Auricular acupuncture as a treatment for pregnant women who have low back and posterior pelvic pain: a pilot study.

OBJECTIVE: The primary aim of this study was to examine whether 1 week of continuous auricular acupuncture could reduce low back and posterior pelvic pain associated with pregnancy. STUDY DESIGN: A randomized controlled trial was conducted on pregnant women who have lower back and posterior pelvic pain. These women were randomly assigned into an acupuncture group, a sham acupuncture group, or a waiting list control group. All participants were monitored for 2 weeks. RESULTS: Baseline and day 7 showed significant group differences in pain (F = 15; P < .0001) and in the disability rating index score (F = 7; P < .0001). The participants in the acupuncture group reported a significant reduction of pain and improvement of functional status as compared with those in the sham acupuncture and control groups. CONCLUSION: One week of continuous auricular acupuncture decreases the pain and disability experienced by women with pregnancy-related low back and posterior pelvic pain.

Extra-1 acupressure for children undergoing anesthesia.

BACKGROUND: Acupuncture and related techniques have been used as adjuncts for perioperative anesthesia management. We examined whether acupressure in the Extra-1 (Yin-Tang) point would result in decreased preprocedural anxiety and reduced intraprocedural propofol requirements in a group of children undergoing endoscopic procedures. METHODS: Fifty-two children were randomized to receive acupressure bead intervention either at the Extra-1 acupuncture point or at a sham point. A Bispectral Index (BIS) monitor was applied to all children before the onset of the intervention. Anxiety was assessed at baseline and before entrance to the operating room. Anesthetic techniques were standardized and maintained with IV propofol infusion titrated to keep BIS values of 40-60. RESULTS: We found that after the intervention, children in the Extra-1 group experienced reduced anxiety whereas children in the sham group experienced increased anxiety (-9% [-3 to -15] vs 2% [-6 to 7.4], P = 0.012). In contrast, no significant changes in BIS values were observed in the preprocedural waiting period between groups (P = ns). We also found that total intraprocedural propofol requirements did not differ between the two study groups (214 +/- 76 microg x kg(-1) x min(-1) vs 229 +/- 95 microg x kg(-1) x min(-1), P = 0.52). CONCLUSIONS: We conclude that acupressure bead intervention at Extra-1 acupoint reduces preprocedural anxiety in children undergoing endoscopic procedures. This intervention, however, has no impact on BIS values or intraprocedural propofol requirements.

Acupuncture analgesia: I. The scientific basis.

Acupuncture has been used in China and other Asian countries for the past 3000 yr. Recently, this technique has been gaining increased popularity among physicians and patients in the United States. Even though acupuncture-induced analgesia is being used in many pain management programs in the United States, the mechanism of action remains unclear. Studies suggest that acupuncture and related techniques trigger a sequence of events that include the release of neurotransmitters, endogenous opioid-like substances, and activation of c-fos within the central nervous system. Recent developments in central nervous system imaging techniques allow scientists to better evaluate the chain of events that occur after acupuncture-induced stimulation. In this review article we examine current biophysiological and imaging studies that explore the mechanisms of acupuncture analgesia.

Acupuncture analgesia: II. Clinical considerations.

BACKGROUND: Acupuncture and related percutaneous neuromodulation therapies can be used to treat patients with both acute and chronic pain. In this review, we critically examined peer-reviewed clinical studies evaluating the analgesic properties of acupuncture modalities. METHODS: Using Ovid and published medical databases, we examined prospective, randomized, sham-controlled clinical investigations involving the use of acupuncture and related forms of acustimulation for the management of pain. Case reports, case series, and cohort studies were not included in this analysis. RESULTS: Peer-reviewed literature suggests that acupuncture and other forms of acustimulation are effective in the short-term management of low back pain, neck pain, and osteoarthritis involving the knee. However, the literature also suggests that short-term treatment with acupuncture does not result in long-term benefits. Data regarding the efficacy of acupuncture for dental pain, colonoscopy pain, and intraoperative analgesia are inconclusive. Studies describing the use of acupuncture during labor suggest that it may be useful during the early stages, but not throughout the entire course of labor. Finally, the effects of acupuncture on postoperative pain are inconclusive and are dependent on the timing of the intervention and the patient's level of consciousness. CONCLUSIONS: Current data regarding the clinical efficacy of acupuncture and related techniques suggest that the benefits are short-lasting. There remains a need for well designed, sham-controlled clinical trials to evaluate the effect of these modalities on clinically relevant outcome measures such as resumption of daily normal activities when used in the management of acute and chronic pain syndromes.

Acupuncture-induced blood oxygenation level-dependent signals in awake and anesthetized volunteers: a pilot study.

BACKGROUND: There are conflicting data regarding clinical efficacy of acupuncture applied while patients are under general anesthesia. We hypothesize that these conflicting data are a result of the inhibitory effect of anesthesia on acupuncture-induced central nervous system activity that can be demonstrated using magnetic resonance imaging. METHODS: Using a crossover study design, volunteers received standardized Stomach 36 manual acupuncture in two experimental conditions: while undergoing a propofol-based general anesthetic, and while awake. Functional magnetic resonance imaging was conducted during both experimental sessions. Paired-t-test analyses were performed to examine the differences in acupuncture-induced blood oxygenation level-dependent (BOLD) signals between awake and anesthesia conditions. A secondary analysis was performed to account for the changes in regional cerebral blood flow at six regions of interest (thalamus, red nucleus, insula, periaqueductal gray, retrosplenial cingular gyri, and the inferior temporal region). RESULTS: Using BOLD, we found significant differences between the two experimental sessions in brain areas, including postcentral gyri, retrosplenial cingular area, left posterior insula, bilateral precuneus, thalamus, red nuclei, and substantia nigra (cluster 100, P < 0.01). A secondary analysis correcting for background cerebral blood flow found that BOLD signal differences between experimental conditions were not directly caused by changes in regional blood flow. DISCUSSION: Propofol-based anesthesia reduces the neurophysiological response to acupuncture stimulation as measured by acupuncture-induced BOLD signals. Further work should be conducted to determine the clinical significance of these findings.

Acupuncture as an adjunct for sedation during lithotripsy.

OBJECTIVE: To determine whether a combination of auricular and body acupuncture is effective as an adjunct for the preprocedural anxiety and pain management in patients undergoing lithotripsy procedures. DESIGN: Randomized controlled study. SETTING AND LOCATION: Lithotripsy suite located at the Yale New Haven Hospital, New Haven CT. SUBJECTS: Adult patients who were scheduled to receive elective lithotripsy procedures. INTERVENTIONS: Acupuncture group: Preprocedural auricular acupuncture intervention combined with intraprocedural electroacupuncture stimulation (n = 29); Sham control group: Preprocedural sham auricular acupuncture intervention combined with intraprocedural sham electroacupuncture stimulation (n = 27). OUTCOMES MEASUREMENT: Preprocedural anxiety, intraprocedural alfentanil consumption, visual analogue scale for pain. RESULTS: Patients in the acupuncture group were less anxious preprocedure than those in the Sham Control Group 32 (29-34) versus 40 (35-45) (p = 0.029). Similarly, patients in the Acupuncture Group used a lesser amount of alfentanil than those in the sham control group (p = 0.040). The adjustable alfentanil consumption as expressed by median rate of alfentanil consumption of 1 (0.6-1.6) microg kg(-1) minute(-1) in the acupuncture group was lower than that of 1.5 (0.9-2.3) microg kg(-1) minute(-1) in the sham control group. Patients in the Acupuncture group also reported lower pain scores on admission to the recovery room (p = 0.014). CONCLUSIONS: A combination of auricular and body acupuncture can be used as an adjunct treatment to decrease preprocedural anxiety and intraprocedural analgesia in patients undergoing lithotripsy.