The midterm psychological effect of cast removal procedures in children.

OBJECTIVES: This study aimed to compare the course of anxiety change in children who used headphones during cast removal with controls in midterm follow-up. PATIENTS AND METHODS: Sixty-six patients who underwent forearm fracture treatment with closed reduction and long arm casting between June 2021 and March 2023 were retrospectively reviewed. Patients were divided into two groups based on the use of headphones (n=27; 21 males, 6 females; mean age: 8.0±1.8 years; range, 6 to 12 years) or not (n=39; 27 males, 12 females; mean age: 8.9±1.8 years; range, 6 to 12 years) during cast removal with an oscillating saw. Primary outcome measures included preprocedure, postprocedure, and six-month anxiety assessments with the State-Trait Anxiety Inventory. RESULTS: There was an acute increase in the mean state anxiety scores after the procedure, which returned to below baseline at the six-month follow-up in the headphone (31.4±8.3, 33.3±8.7, and 25.1±4.1, respectively) and control groups (34.9±11.1, 37.4±9.5, and 27.3±5.3, respectively). The mean trait anxiety scores before the procedure, after the procedure, and at six months remained similar in the headphone (33.6±3.0, 34.6±3.2, and 32.4±2.8; p>0.05) and control groups (34.1±2.7, 33.7±3.0, and 33.7±3.0, p>0.05). CONCLUSION: This study suggests that the acute anxiety during cast removal did not create anxiety sequelae in the sixth month regardless of headphone use.

Adjunctive Procedures and Informed Consent with Breast Implant Explantation.

BACKGROUND: The use of injectable or implantable materials or devices in the breast for augmentation or reconstruction has a history of innovation and controversy. Staying current in the field of breast implant management today means understanding not just the published literature but also its absence. Cutting edge breast implant treatment also means awareness of patient and media-driven interests and requests. METHODS: Adjuvant treatments to optimize physical and psychological well-being with breast implant explantation, without replacement, will be addressed through literature review and analysis. RESULTS: The body of literature demonstrates evidence of variable, and sometimes contradictory, methods to address adjunctive management of systemic concerns, the capsule, soft tissue of the native breast/chest, and treatment timing related to explantation. Few approaches are supported by very strong evidence. Many treatment methodologies are defensible. Any current attempts at optimizing management in patients undergoing explantation will be somewhat impaired by the ongoing nebulousness of related issues, such as breast implant illness. It seems clear, therefore, that plastic surgeons must fulfill their duty as caregivers to provide explantation surgery, either to attempt to improve physical health, mental well-being, or simply to respect patients' wishes. A well-informed surgeon will likely employ a variety of approaches, adapted to the unique patient presentations at hand. CONCLUSION: It is expected that consultations, incisions, tissue rearrangements, surgical timing, and treatment indications will continue to vary as scientific investigation strives to understand and to optimize treatment of patients experiencing difficulty with breast implants.

Subdermal Contraceptive Implant Insertion Trends and Retention in Adolescents.

STUDY OBJECTIVE: There is growing advocacy for use of long-acting reversible contraception among sexually active adolescents. Our primary aims were to evaluate the etonogestrel subdermal contraceptive implant (SCI) insertion trends among adolescents, as well as SCI retention at 1, 2, and 3 years, indications for removal, and to identify pregnancies that occurred during SCI use. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A retrospective cohort study was conducted of adolescents aged 13-19 years with SCI insertions in 2008-2014 within a large integrated health care system. Demographic and clinical characteristics included age, race/ethnicity, body mass index, gravidity, parity, insertions, reinsertions, indications for removal, and pregnancy. Electronic medical record review was conducted on a randomized sample of 540 adolescents with insertions during 2008-2011 for the retention objective to validate electronically extracted variables. Analyses included descriptive statistics, survival analysis with Kaplan-Meier estimates for implant retention and Cochran-Armitage trend test for insertions according to year during 2008-2014. RESULTS: Most adolescent SCI users were non-Hispanic white (43%), or Hispanic (34.2%) and 16 years or older (84.2%) at the time of insertion. Overall, 1-, 2-, and 3-year retention rates were 78.6%, 59.4%, and 26.2%, respectively, with retention at 44.3% at 2 years 9 months (indicative of removal of method for near expiration of 3-year device). The insertion rate trend showed statistically significant increases annually, from 0.14% in 2008 to 0.91% in 2014; P < .0001. No pregnancies were documented during implant use. The most common indication for SCI removal was device expiration. CONCLUSION: SCI insertions increased annually among adolescents, with more than a sixfold increase over the 6-year study period, and more than half of the SCIs were retained through 2 years of use. The most common indication of SCI removal was completion of Food and Drug Administration-approved duration.

Twelve-month Continuation of the Etonogestrel Implant in Adolescents With Polycystic Ovary Syndrome.

STUDY OBJECTIVE: To identify why adolescents with polycystic ovary syndrome (PCOS) chose the etonogestrel (ENG) contraceptive implant, to determine the 12-month continuation rate, and to characterize factors related to discontinuation. DESIGN, SETTING, AND PARTICIPANTS: Retrospective chart review of adolescents seen at a tertiary care children's hospital between July 1, 2008, and August 30, 2019, with PCOS diagnosis confirmed per National Institutes of Health criteria and ≥12-month ENG follow-up. INTERVENTIONS AND MAIN OUTCOME MEASURES: Demographic characteristics, reasons for ENG insertion and removal, and information on other hormonal/contraceptive therapies were collected. Patients were categorized as ENG continuers (use ≥12 months) or discontinuers (removal at <12 months), and groups were compared. RESULTS: A total of 96 patients met inclusion criteria (age 17.7 ± 2.2 years, body mass index 34.8 ± 8 kg/m2). Reasons for ENG were documented in 74% (51% contraception, 32% ease of use, 15% other, 13% estrogen avoidance). In all, 27% had never been sexually active, and 67% had had prior sexual activity. Treatments prior to ENG placement included 74% combined hormonal contraception, 20% medroxyprogesterone acetate withdrawal, and 17% depot medroxyprogesterone. A total of 77% continued ENG at 12 months. The main reasons for discontinuation were bleeding (41%), concern about weight gain (23%), and mood changes (18%). No preimplantation characteristics were independently predictive of continuation, although 100% of patients with type 2 diabetes (n = 11) continued. Patients who sought additional care, including telephone calls (41% vs 12%, P = .006) and clinic visits (64% vs 20%, P < .001) were more likely to discontinue. CONCLUSIONS: The ENG implant was well tolerated in adolescents with PCOS and similar to published 12-month continuation rates.

Sensitivity to Change of Subdomain Question 6 of the Urogenital Distress Inventory Short Form After Sling Removal for Pain.

OBJECTIVE: To determine the sensitivity to change of question 6 (Q6) of the modified short form version of the Urogenital Distress Inventory (UDI-6) before and after synthetic sling removal (SSR). METHODS: Following IRB approval, a prospectively maintained database of mid-urethral sling (MUS) complications identified women with UDI-6 Q6 data before and after SSR. Q6 were compared pre- and postoperatively and against patient self-report of pain in women undergoing -SSR for pain (SSR-P) and in a control group when pain was not the primary indication for SSR (SSR-C). Women with missing pre-SSR or insufficient (<6 months) follow-up measures of pain were excluded. Three hypotheses were tested. (1) Correlation of Q6 scores with patients' self-reported pain pre- and post-SSR, (2) Higher pre-SSR Q6 scores in the SSR-P group than in the SSR-C group, and (3) Decrease in Q6 scores in the SSR-P group. RESULTS: Between 2005 and 2017, 116 of 435 women referred to our institution met study criteria. Q6 scores were significantly (P <.0001) associated with self-reported pain with increasing likelihood of self-reporting pain as Q6 score increased. Mean pre-SSR Q6 scores in SSR-C (n = 42) was 1.0 ± 1.2 while mean pre-SSR Q6 scores in SSR-P (n = 74) was 2.3 ± 1.1 (P <.0001). Mean improvement in Q6 score after SSR was -0.19 ± 1.2 (P = 0.3) in SSR-C and -0.88 ± 1.4 (P <0.0001) in SSR-P. CONCLUSION: In women undergoing SSR for MUS-related complications, Q6 scores were correlated to self-reported pain and responsive to surgical intervention for pain relief.

Effect of Spiritual Care on Chest Tube Removal Anxiety and Pain in Heart Surgery in Muslim Patients (Shia and Sunni).

The process of removal of a chest tube can cause pain and anxiety. Spiritual care can be considered as a component of nursing care, especially in the pain and anxiety relating to such procedures. This study was a randomized clinical trial. Eighty patients completed the study. The findings showed significant differences in anxiety and pain between groups (p = 0.001). Spiritual care reduced anxiety and pain caused by chest tube removal in patients (Shia and Sunni Islam) undergoing heart surgery.

Pacemaker implantation in patients with major depression, should it be of concern? A case report and literature review.

BACKGROUND: Psychological adaptation after cardiac pacemaker implantation is a challenge for patients with mental illness. CASE PRESENTATION: Here we report a self-harming patient with a psychiatric disorder. A 73-year-old female patient with 16-year coronary heart disease and a 4-year depression was admitted to our hospital for a coma. Two months earlier, the local hospital confirmed that the patient had a second-degree sinoatrial (SA) block (type 2) as well as basal septal hypertrophy with the left ventricular outflow obstruction. Therefore, metoprolol sustained-release tablets 95 mg QD and diltiazem sustained-release tablets 90 mg QD was given as treatment after a pacemaker was implanted. However, the patient had continued complaining about discomfort due to the pacemaker implanted after being discharged from the hospital. Two months later, she attempted to commit suicide by removing her pacemaker and taking 80 sleeping pills. After a series of treatments, the patient improved and was discharged without a pacemaker re-implantation. With continued anti-depression treatment and strengthen family supervision, the patient's condition is stable now. CONCLUSIONS: A suicide attempt by intentionally removing the permanent pacemaker system was rarely reported. In bradycardia patients with a history of psychological or psychiatric disease, careful evaluation should be done before and after implantation of the pacemaker.

Reducing urinary catheter use using an electronic reminder system in hospitalized patients: A randomized stepped-wedge trial.

OBJECTIVE: To determine the effectiveness and ease of use of an electronic reminder device in reducing urinary catheterization duration. DESIGN: A randomized controlled trial with a cross-sectional anonymous online survey and focus group. SETTING: Ten wards in an Australian hospital. PARTICIPANTS: All hospitalized patients with a urinary catheter. INTERVENTION: An electronic reminder system, the CATH TAG, applied to urinary catheter bags to prompt removal of urinary catheters. OUTCOMES: Catheterization duration and perceptions of nurses about the ease of use. METHODS: A Cox proportional hazards model was used to assess the rate of removal of catheters. A phenomenological approach underpinned data collection and analysis methods associated with the focus group. RESULTS: In total, 1,167 patients with a urinary catheter were included. The mean durations in control and intervention phases were 5.51 days (95% confidence interval [CI], 4.9-6.2) and 5.08 days (95% CI, 4.6-5.6), respectively. For patients who had a CATH TAG applied, the hazard ratio (HR) was 1.02 (95% CI, 0.91-1.14; P = .75). A subgroup analysis excluded patients in an intensive care unit (ICU), and the use of the CATH TAG was associated with a 23% decrease in the mean, from 5.00 days (95% CI, 4.44-5.56) to 3.84 days (95% CI, 3.47-4.21). Overall, 82 nurses completed a survey and 5 nurses participated in a focus group. Responses regarding the device were largely positive, and benefits for patient care were identified. CONCLUSION: The CATH TAG did not reduce the duration of catheterization, but potential benefits in patients outside the ICU were identified. Electronic reminders may be useful to aid prompt removal of urinary catheters in the non-ICU hospital setting.

The use of cold therapy, music therapy and lidocaine spray for reducing pain and anxiety following chest tube removal.

AIM: To determine the effect of cold therapy, music therapy and lidocaine spray on pain and anxiety following chest tube removal (CTR). METHODS: This study was a randomized clinical trial. The participants were randomly assigned either one of four groups: control group, cold therapy, music therapy, and lidocaine spray. The primary outcome of the study was to measure pain using Visual Analog Scale. Anxiety was used as secondary outcome. RESULTS: Thirty patients in each arm completed the study. There was no difference in pain scores between groups immediately after and 20 min after CTR (F = 2.06, p = 0.108). However, there was a significant difference between the anxiety scores of control and intervention groups 20 min after CTR (p < 0.05). CONCLUSIONS: Cold therapy reduced anxiety levels after the procedure. A multimodal approaches, such as the administration of pharmacologic agents in conjunction with non-pharmacological interventions including cold therapy may also be suggested.

Taking the provider "out of the loop:" patients' and physicians' perspectives about IUD self-removal.

OBJECTIVE: This study describes the perspectives of patients and providers about intrauterine device (IUD) self-removal. STUDY DESIGN: This qualitative study is a subanalysis of two datasets from a single project, which included semistructured individual interviews with 15 patients and 12 physicians. We derived the data for this analysis from portions of the interviews pertaining to IUD self-removal and provider removal. We analyzed data using deductive and inductive techniques to perform content and thematic analyses. RESULTS: The majority of patients and physicians cited both concerns about and potential benefits of IUD self-removal. Patients cited concerns about safety as the reason they did not wish to remove their own IUD, but physicians did not share these concerns; instead, physicians were apprehensive about not being involved in the discussion to remove the IUD. Both patients and physicians valued having the provider "in the loop" and reported fears about hasty or coerced removal. CONCLUSIONS: IUD self-removal is an option that some patients may be interested in. Addressing concerns about safety may make self-removal more appealing to some patients. Addressing physicians' concern about "hasty" removal may require additional training so that providers are better able to support patients' decision making around contraceptive use. IMPLICATIONS: The option of self-removal could have a positive impact on reproductive autonomy and patient decision making.

Rhythm and orthopedics: The effect of music therapy in cast room procedures, a prospective clinical trial.

INTRODUCTION: Cast room procedures generally cause anxiety in patients. Anxiety complicates the procedure as well as increases the risk of a complication. Listening to music was found to be the safest and most common non-drug treatment method. The aim of this study is to evaluate the effect of listening to music on adult patients in cast room procedures. This study points out the relation between anxiety and anxiety relevant cardiac arrhythmia. MATERIALS AND METHODS: The study was performed on 199 patients with stable general condition, aged above 18. The patients were divided into two groups. Randomization method used in the study was coin flip. The first group (Group 1) listened to music during cast room procedures whereby the second group (Group 2) did not listen to music. Length of the procedure, complication, blood pressure and heart rate evaluations before and after the procedure, Visual Analogue Scale (VAS scores for pain), State-Trait Anxiety Inventory (STAI) anxiety score, patient satisfaction, willingness of the patient to repeat the procedure, P wave dispersion (Pd) and corrected QT interval dispersion (QTcd) as electrocardiographic arrhythmia predictors were evaluated. The Clinical Research Ethics Committee approval was obtained for this study. RESULTS: Significant difference was shown between the two groups for the following criteria: VAS scores (p = 0.005), anxiety scores (p = 0.032), processing time (p = 0.027), and QTcd values (p = 0.031). Patient satisfaction (p < 0.001) and willingness to repeat the procedure (p < 0.001) were higher for the group who listened to music. No significant difference in Pd values, blood pressure and heart rate was reported within the groups. CONCLUSION: Music therapy is a non-invasive, safe, nonpharmacologic, anxiolytic, and analgesic treatment. Music therapy should become standard protocol in cast room procedures. One of the most important achievements of this study was the fact that music decreases anxiety and anxiety-related cardiac arrhythmia. Therefore, conducting further prospective studies including high cardiac risk patients especially with arrhythmia is crucial.

Medical and bioethical considerations in elective cochlear implant array removal.

OBJECTIVE: Cochlear explantation for purely elective (e.g. psychological and emotional) reasons is not well studied. Herein, we aim to provide data and expert commentary about elective cochlear implant (CI) removal that may help to guide clinical decision-making and formulate guidelines related to CI explantation. DATA SOURCES: We address these objectives via three approaches: case report of a patient who desired elective CI removal; review of literature and expert discussion by surgeon, audiologist, bioethicist, CI user and member of Deaf community. REVIEW METHODS: A systematic review using three scientific online databases was performed. Included articles addressed the benefits and/or complications of cochlear implantation in young children, CI explantation with or without revision surgery and the ethical debate between the medical and Deaf communities on cochlear implantation and explantation. CONCLUSIONS: The medical and audiological perspectives identify a host of risks related to implant removal without reimplantation, including risk from surgery, general anaesthesia, cochlear ossification and poor audiometric outcomes. The member of the deaf community and bioethicist argue that physicians need to guide the principles of beneficence, non-maleficence and patient autonomy. Taken together, patient desires should be seen as paramount, if the patient is otherwise fit for surgery and well informed. IMPLICATIONS FOR PRACTICE: Similar to the case of device implantation, device explantation should be a multidisciplinary and collaborative decision with the patient and the family's desires at the centre. While every case is different, we offer a CI explantation discussion to assist in clinical decision-making, patient counselling and education.

User perspectives on Implanon NXT in South Africa: A survey of 12 public-sector facilities

Abstract: Background. Implanon NXT, a long-acting reversible contraceptive, was introduced in South Africa (SA) in early 2014, aiming to expand the method mix and increase its effectiveness. Initial uptake was high, but has since declined considerably. In these early years after the implant's introduction, it is important to identify reasons for the decline, and remedy gaps in services. Objectives. To determine periods of use, reasons for the use and early removal of the implant Implanon NXT. Methods. In 2016, we recruited 152 women from six clinics in the City of Johannesburg, and six in North West Province, SA. A semistructured interview was administered to 91 women currently using the implant and 61 previous users. We examined user perspectives, factors influencing women's experiences with the implant and reasons for discontinuation. Results. The participants' mean age was 30 years, with only 15% aged <25. Implant uptake was motivated by convenience (less frequent visits required than for short-acting methods) and by favourable views of the method among friends, family and healthcare providers. Only about a quarter of women recalled being counselled pre-insertion about implant effectiveness, and half about side-effects pre-insertion. Among discontinuers, the median time to device removal was 8 months (interquartile range 6 - 12), and this was primarily as a result of side-effects (90%), especially bleeding-pattern changes and headaches. Removals were most common among married and cohabiting women, often ascribed to the effects of bleeding on their sexual relationships. Rumours and misinformation contributed to some removals. Overall, women's experiences with the implant were rated 'good' or 'very good' by 74% of those continuing use, many of whom reported not having experienced any side-effects or that these had diminished over time. Conclusion. Levels of acceptability among continuing users were high, mainly linked to the method's convenience. While early favourable views drove uptake, negative perceptions, if unaddressed, may now undermine services. Deficiencies in counselling around effectiveness and side-effects may extend to contraceptive services more generally. Women require more intensive support when experiencing sideeffects, including effective systematic approaches to ameliorating bleeding and headaches. Implant services could specifically target young women and first-time contraceptive users. These actions together could reverse the persistent decline in implant use in SA.

Patients' perspectives about why they have their contraceptive Implanon NXT device removed early.

BACKGROUND: Women with long-acting, reversible contraceptive devices inserted may choose to remove them prior to their planned expiry dates. OBJECTIVE: The objective of this study was to explore Australian women's experiences with the etonogestrel subdermal contraceptive implant (Implanon NXT) and why they had it removed early. METHODS: Semi-structured interviews were conducted with 18 women between June 2013 and January 2014. Transcriptions of the audio-taped interviews were analysed using a constant comparative analysis framework. RESULTS: Two core themes of participants' responses that were identified in this study were influences on choice of contraception, which included convenience and information sources; and influences on removal of contraception, which included side effects and their negative impacts on relationships and financial costs. DISCUSSION: This study highlights that women's experiences with side effects contribute to the early removal of long-acting contraceptive devices such as Implanon NXT. This study emphasises the importance of general practitioners (GPs) in providing comprehensive information about the benefits and potential side effects associated with using these implants.

"She just told me to leave it": Women's experiences discussing early elective IUD removal.

OBJECTIVE: The objective of this study is to describe the thoughts and experiences of women who report discussing intrauterine device (IUD) removal within 9 months of insertion. STUDY DESIGN: This is a qualitative study, consisting of semistructured individual interviews with 16 women who considered early elective IUD removal. We identified eligible participants via chart review. We analyzed interviews using a modified grounded theory approach. RESULTS: While pain and bleeding were prominent reasons for removal, women also discussed many other symptoms and concerns. Most women reported a strong desire to have a successful IUD experience, and all reported waiting for symptoms to resolve prior to their visit. Some women reported that providers supported their choice, while others reported that providers preferred that they continue the IUD despite symptoms and concerns. Some women reported providers' resistance or refusal to remove the IUDs. The women who reported that their providers were neutral about IUD removal more frequently expressed satisfaction with the visit. When the provider resisted removal, women felt frustrated, even as they acknowledged their doctor's good intentions. In several cases, this may have hurt the doctor-patient relationship. CONCLUSIONS: When physicians resist early elective IUD removal, it may impact patient satisfaction and even jeopardize the doctor-patient relationship. IMPLICATIONS: Though IUDs are highly effective and well-liked contraceptives, some patients choose to discontinue the method. Because provision of patient-centered contraceptive care includes IUD removal when requested, providers must ensure that their counseling is unbiased and that they do not place perceived or real barriers to IUD removal.

Reasons for Intrauterine Device Use, Discontinuation and Non-Use in Malawi: A Qualitative Study of Women and their Partners.

The copper intrauterine device (IUD) is a safe, long-acting, and effective method of contraception that is under-utilized in many countries, including Malawi. A unique cohort of women who had enrolled in a trial of postpartum IUD use one year earlier gave insights into reasons for using, discontinuing, or not using the IUD. We conducted in-depth interviews with 18 women one year after they participated in a pilot study of a randomized controlled trial of postpartum IUD insertion, and 10 of their male partners. Women and their partners expressed a strong desire for family planning, and perceived numerous benefits of the IUD. However, fear of the IUD was common among successful users and non-users alike. This fear arose from rumours from friends and neighbors who were non-users. How women and their partners responded to this fear affected IUD adoption and continuation. Key themes included (1) Trust in information received from health care providers versus rumours from community members; (2) Partner involvement in IUD decision-making; and (3) Experience with side effects from short-term hormonal contraceptive methods. Broad community education about the IUD's benefits and safety, and proactive counseling to address couples' specific fears, may be needed to increase uptake of the method.