Influence of depression, catastrophizing, anxiety, and resilience on postoperative pain at the first day after otolaryngological surgery: A prospective single center cohort observational study

Weak Relationships Between Psychological Factors and Experimental Pain Outcomes in Pain-Free Individuals: An Aggregate Analysis of 8 Studies

Although psychological factors such as anxiety, depression, and pain catastrophizing are known to influence pain outcomes in chronic pain populations, there are mixed results regarding whether they influence experimental pain outcomes in pain-free individuals. The objectives of this study were to determine the associations between psychological factors and experimental pain outcomes in pain-free adolescents and adults. Relationships between anxiety, depression, and pain catastrophizing and experimental pain outcomes across 8 different studies (total N = 595) were examined in different populations of pain-free adult and adolescent participants. Analyses were conducted with and without controlling for sex, age, and race. Studies were analyzed separately and as part of an aggregate analysis. Individual study analyses resulted in 136 regression models. Of these, only 8 models revealed a significant association between psychological factors and pain outcomes. The significant results were small and likely due to Type 1 error. Controlling for demographic factors had minimal effect on the results. The aggregate analyses revealed weak relationships between anxiety and pressure pain threshold (Fisher's z = -.10 [-.19, -.01]), anxiety and cold pain intensity ratings (Fisher's z = .18 [.04, .32]), and pain catastrophizing and pressure pain threshold (Fisher's z = -.14 [-.26, -.02]). Sample size calculations based on the aggregate analyses indicated that several hundred participants would be required to detect true relationships between these psychological factors and pain measures. The overall negative findings suggest that in pain-free individuals, anxiety, depression, and pain catastrophizing are not meaningfully related to experimental pain outcomes. PERSPECTIVE: Psychological variables have been shown to predict pain outcomes in chronic pain populations but these relationships may not generalize to pain-free populations. An analysis of 595 pain-free individuals across 8 studies in our lab revealed that anxiety, depression, and pain catastrophizing were not meaningfully related to experimental pain outcomes.

Increased patient resilience scores are related to positive postoperative outcomes in rotator cuff repairs

HYPOTHESIS

We sought to determine whether patients' preoperative resilience scores predict postoperative outcomes in arthroscopic rotator cuff repair surgery.

METHODS

Patients were prospectively enrolled and underwent data collection preoperatively and at 3, 6, 12, and 24 months postoperatively. Data collected included demographic characteristics and the Brief Resilience Scale (BRS) score, visual analog scale score, Veterans RAND 12-Item Health Survey scores (mental component [VR-12M] and physical component [VR-12P]), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Single Assessment Numeric Evaluation score, and Simple Shoulder Test (SST) score.

RESULTS

In total, 131 patients had complete 1- or 2-year postoperative outcome measures. Female patients comprised 56.5% of our sample, and the average age was 57.6 years. Between the low, normal, and high resilience groups, there were significant differences in the VR-12M scores at 0, 12, and 24 months postoperatively (P < .01 for all). The VR-12P scores at 12 months were 44.2, 47.4, and 49.8 in the low, normal, and high resilience groups, respectively, showing a trend upward, but this failed to reach the level of significance (P = .08). The SST scores of the low, normal, and high resilience groups at 12 months were 69.1, 79.9, and 85.1, respectively, again showing a trend upward, but this failed to reach the level of significance (P = .07). The SST scores at 0 and 24 months did not differ between groups. There were no significant differences in American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores at 0, 12, or 24 months postoperatively. We found a significant positive correlation between the BRS score and SST score at 12 months (R = 0.18), VR-12M score at 12 months (R = 0.38), VR-12M score at 24 months (R = 0.31), and VR-12P score at 12 months (R = 0.21).

CONCLUSIONS

Our study provides evidence that BRS scores in patients undergoing arthroscopic rotator cuff repair are related to postoperative outcomes, measured through the VR-12M and SST scores at 2-year follow-up.

The impact of pre-operative depression on pain outcomes after major surgery: a systematic review and meta-analysis

Symptoms of depression are common among patients before surgery. Depression may be associated with worse postoperative pain and other pain-related outcomes. This review aimed to characterise the impact of pre-operative depression on postoperative pain outcomes. We conducted a systematic review of observational studies that reported an association between pre-operative depression and pain outcomes after major surgery. Multilevel random effects meta-analyses were conducted to pool standardised mean differences and 95%CI for postoperative pain scores in patients with depression compared with those without depression, at different time intervals. A meta-analysis was performed for studies reporting change in pain scores from the pre-operative period to any time-point after surgery. Sixty studies (n = 501,962) were included in the overall review, of which 18 were eligible for meta-analysis. Pre-operative depression was associated with greater pain scores at < 72 h (standardised mean difference 0.97 (95%CI 0.37-1.56), p = 0.009, I2  = 41%; moderate certainty) and > 6 months (standardised mean difference 0.45 (95%CI 0.23-0.68), p < 0.001, I2  = 78%; low certainty) after surgery, but not at 3-6 months after surgery (standardised mean difference 0.54 (95%CI -0.06-1.15), p = 0.07, I2  = 83%; very low certainty). The change in pain scores from pre-operative baseline to 1-2 years after surgery was similar between patients with and without pre-operative depression (standardised mean difference 0.13 (95%CI -0.06-0.32), p = 0.15, I2  = 54%; very low certainty). Overall, pre-existing depression before surgery was associated with worse pain severity postoperatively. Our findings highlight the importance of incorporating psychological care into current postoperative pain management approaches in patients with depression.

Enhancing bowel preparation quality and tolerability in a low health literacy population in Western China: a multicenter randomized trial

BACKGROUND AND AIMS

Insufficient bowel preparation (BP) presents substantial challenges to the effectiveness of outpatient colonoscopy for colorectal cancer screening, particularly within populations characterized by low health literacy and poor adherence.

METHODS

We conducted a prospective, randomized, blinded, endoscopic controlled study involving 474 colonoscopy outpatients aged 18-80 years hailing from a low health literacy population with convenient access to WeChat. These patients were subsequently randomized into three groups: the control group, WeChat group, and the automatic reminder group (ARG). All people were administered 3 L of polyethylene glycol. The Boston Bowel Preparation Scale (BBPS) score of 6 or a segmental score of 2 was used as the primary outcome to evaluate BP quality. Secondary outcomes included polyp detection rate (PDR) and adverse events, etc. RESULTS: Our findings revealed that both the WeChat group (n = 158) and ARG (n = 158) exhibited significantly higher rates of adequate BP compared to the control group (n = 158) (WeChat vs. control, 79.1% vs. 61.4%; ARG vs. control, 74.7% vs. 61.4%; p < 0.001). Furthermore, these educationally reinforced groups displayed improved BP compliance (p < 0.05). According to the Hospital Anxiety and Depression Scale (HADS), patients in the reinforced education groups exhibited lower overall anxiety levels (p = 0.001) and experienced fewer adverse reactions (p = 0.019). Compared to the control group, the PDR in the right hemi-colon was significantly greater in the WeChat group (11.4%) (2.5%), and a similar trend was observed in the ARG (7.6%). Additionally, individuals in the WeChat group reported higher levels of satisfaction with their colonoscopy experience (p = 0.043). In a multivariate analysis, adjusting for potential confounding factors, WeChat-based re-education ([OR] 1.496, 95% CI 1.154-1.939; p = 0.002)) emerged as a protective factor for achieving adequate BP.

CONCLUSION

Enhanced education through WeChat can improve BP quality, and ARG applies equally to low health literacy populations.

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.

Resilience is associated with cortical gray matter of the antinociceptive pathway in people with chronic pain

Resilience is an important personal characteristic that influences health and recovery. Previous studies of chronic pain suggest that highly resilient people may be more effective at modulating their pain. Since brain gray matter in the antinociceptive pathway has also been shown to be abnormal in people with chronic pain, we examined whether resilience is related to gray matter in regions of interest (ROIs) of the antinociceptive pathway (rostral and subgenual anterior cingulate cortex (rACC, sgACC), anterior insula (aINS), dorsolateral prefrontal cortex (dlPFC)) normally and in people who are experiencing chronic pain. We extracted gray matter volume (GMV) and cortical thickness (CT) from 3T MRIs of 88 people with chronic pain (half males/females) and 86 healthy controls (HCs), who completed The Resilience Scale and Brief Pain Inventory. We found that resilience scores were significantly lower in people with chronic pain compared to HCs, whereas ROI GMV and CT were not different between groups. Resilience negatively correlated with average pain scores and positively correlated with GMV in the bilateral rACC, sgACC, and left dlPFC of people with chronic pain. Mediation analyses revealed that GMV in the right rACC and left sgACC partially co-mediated the relationship between resilience and average pain in people with chronic pain. The resilience-pain and some resilience-GMV relationships were sex-dependent. These findings suggest that the antinociceptive pathway may play a role in the impact of resilience on one's ability to modulate chronic pain. A better understanding of the brain-resilience relationship may help advance evidence-based approaches to pain management.

Telemedicine-Based Digital Cognitive Behavioral Intervention for Perioperative Anxiety and Depression for Total Knee Arthroplasty

Introduction

Preoperative anxiety and depression have been shown to increase postoperative pain and opioid consumption by up to 50% in patients undergoing primary unilateral Total Knee Arthroplasty (TKA). We hypothesized that the use of a telemedicine-based digital Cognitive Behavioral Intervention program (RxWell®) started one month prior to surgery would control anxiety and depression prior to surgery.

Materials and methods

This was a randomized, controlled trial that enrolled patients undergoing primary unilateral TKA. At least a month prior to surgery, patients who gave consent to participate were asked to complete PROMIS® (Patient-Reported Outcomes Measurement Information System) emotional anxiety short form 8a and PROMIS® emotional depression short form-8a questionnaires. Patients with T-scores of ≥ 57 were randomized to either a no intervention (control group) or a RxWell® program (treatment group) for a month prior to surgery. The primary outcome of this proof-of-concept study was the ability of the RxWell® to normalize patients' PROMIS anxiety T scores.

Results

T scores for anxiety and depression among patients randomized to the RxWell® group significantly decreased from 64.3 ± 3.0 at the time of randomization to 58.5 ± 2.6 prior to surgery (n=5, p=0.006), whereas no changes in T scores were recorded in the control group (59.4 ± 4.2 at the time of randomization vs. 57.7 ± 6.2; n=6, p=0.559).

Conclusion

These preliminary data suggest that the use of a RxWell® program represents an effective approach to control anxiety and depression prior to surgery. In contrast, it seems that in the absence of treatment, anxiety level remains similar over a month prior to surgery.

Association between preoperative serum C-reactive protein level and leukocyte count and postoperative pain after otolaryngological surgery

PURPOSE

To determine whether the preoperative inflammatory serum C-reactive protein (CRP) and leukocyte count (LEUK) are associated with postoperative pain and complaints after otolaryngological surgery.

METHODS

Retrospective evaluation of 680 patients (33% female, median age 50 years) receiving otolaryngological surgery between November 2008 and March 2017 in a tertiary university hospital. Postoperative pain on the first postoperative day was assessed using the validated questionnaire of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including a numeric rating scale for assessment of postoperative pain (NRS, 0-10). The influence of preoperative parameters including CRP and LEUK on patients' postoperative pain was estimated.

RESULTS

Mean CRP value was 15.6 ± 34.6 mg/l and mean LEUK value 7.8 ± 3.2 Gpt/l. Patients with pharyngeal surgery had the highest CRP values (34.6 ± 52.9 mg/l), highest LEUK values (9.2 ± 4.2 Gpt/l) and the highest pain levels (3.1 ± 2.4 NRS) compared to all other surgical procedures (all p < 0.05). Higher postoperative pain was associated with LEUK values > 11.3 Gpt/l (r = 0.093, p = 0.016) and higher preoperative chronic pain (r = 0.127, p = 0.001). Multivariate analysis confirmed younger age, female gender, duration of surgery, preoperative chronic pain, type of surgery, and higher LEUK values > 11.3 as independent factors for postoperative pain. Perioperative antibiotics had no effect on the postoperative pain.

CONCLUSION

Beyond known factors, preoperative LEUK as inflammation marker is an independent predictor for pain on the first postoperative day.

Virtual reality psychological intervention helps reduce preoperative anxiety in patients undergoing carotid artery stenting: a single-blind randomized controlled trial

Objective

This study aimed to explore the effectiveness and applicability of a psychological intervention using virtual reality (VR) to reduce preoperative anxiety in patients undergoing carotid artery stenting (CAS).

Methods

A total of 114 patients aged 18-86 years who were scheduled to undergo CAS were randomized to the VR and control groups. Patients in the VR group used a VR headset to view a 16-min psychological intervention video, while those in the control group used a tablet for viewing. The primary assessment instrument was the State Anxiety Inventory (S-AI), which was given 20 min before and after the intervention and 24 h after surgery. Secondary assessment tools were the Self-efficacy for Managing Chronic Disease (SEMCD-6) scale, which was completed before the intervention and 24 h after the operation, a smart bracelet to assess sleep quality, monitored in the evening before the operation, and the VR Suitability and Satisfaction Questionnaire, completed 24 h after the operation.

Results

The two groups were similar in terms of demographic information, preintervention STAI scores and preintervention SEMCD-6 scores (p > 0.05). S-AI scores were lower in both groups after the intervention and surgery, and the scores of the VR group were lower than those of the control group (p = 0.036, p = 0.014). SEMCD-6 scores post-surgery had improved in both groups, but the VR group had significantly higher scores than the control group (p = 0.005). Smart bracelet measurements showed no significant differences in postintervention sleep quality between the two groups (p = 0.540). For satisfaction, the VR group scored higher in all aspects except scheduling. A total of 47 (85.45%) patients reported having a comfortable experience, and only 5 (9.09%) experienced mild adverse effects.

Conclusion

The use of a virtual reality psychological intervention was beneficial to reduce the anxiety of patients before CAS and improved their self-efficacy. As virtual reality devices evolve and demonstrate better comfort and safety, more comprehensive and in-depth research of the use of VR to reduce patient anxiety should be performed in the future.Clinical trial registration:https://www.chictr.org.cn/showproj.aspx?proj=186412, identifier ChiCTR2200066219.

Feasibility of Prospectively Comparing Opioid Analgesia With Opioid-Free Analgesia After Outpatient General Surgery: A Pilot Randomized Clinical Trial

IMPORTANCE

The overprescription of opioids to surgical patients is recognized as an important factor contributing to the opioid crisis. However, the value of prescribing opioid analgesia (OA) vs opioid-free analgesia (OFA) after postoperative discharge remains uncertain.

OBJECTIVE

To investigate the feasibility of conducting a full-scale randomized clinical trial (RCT) to assess the comparative effectiveness of OA vs OFA after outpatient general surgery.

DESIGN, SETTING, AND PARTICIPANTS

This parallel, 2-group, assessor-blind, pragmatic pilot RCT was conducted from January 29 to September 3, 2020 (last follow-up on October 2, 2020). at 2 university-affiliated hospitals in Montreal, Quebec, Canada. Participants were adult patients (aged ≥18 years) undergoing outpatient abdominal (ie, cholecystectomy, appendectomy, or hernia repair) or breast (ie, partial or total mastectomy) general surgical procedures. Exclusion criteria were contraindications to drugs used in the trial, preoperative opioid use, conditions that could affect assessment of outcomes, and intraoperative or early complications requiring hospitalization.

INTERVENTIONS

Patients were randomized 1:1 to receive OA (around-the-clock nonopioids and opioids for breakthrough pain) or OFA (around-the-clock nonopioids with increasing doses and/or addition of nonopioid medications for breakthrough pain) after postoperative discharge.

MAIN OUTCOMES AND MEASURES

Main outcomes were a priori RCT feasibility criteria (ie, rates of surgeon agreement, patient eligibility, patient consent, treatment adherence, loss to follow-up, and missing follow-up data). Secondary outcomes included pain intensity and interference, analgesic intake, 30-day unplanned health care use, and adverse events. Between-group comparison of outcomes followed the intention-to-treat principle.

RESULTS

A total of 15 surgeons were approached; all (100%; 95% CI, 78%-100%) agreed to have patients recruited and adhered to the study procedures. Rates of patient eligibility and consent were 73% (95% CI, 66%-78%) and 57% (95% CI, 49%-65%), respectively. Seventy-six patients were randomized (39 [51%] to OA and 37 [49%] to OFA) and included in the intention-to-treat analysis (mean [SD] age, 55.5 [14.5] years; 50 [66%] female); 40 (53%) underwent abdominal surgery, and 36 (47%) underwent breast surgery. Seventy-five patients (99%; 95% CI, 93%-100%) adhered to the allocated treatment; 1 patient randomly assigned to OFA received an opioid prescription. Seventeen patients (44%) randomly assigned to OA consumed opioids after discharge. Seventy-three patients (96%; 95% CI, 89%-99%) completed the 30-day follow-up. The rate of missing questionnaires was 37 of 3724 (1%; 95% CI, 0.7%-1.4%). All the a priori RCT feasibility criteria were fulfilled.

CONCLUSIONS AND RELEVANCE

The findings of this pilot RCT support the feasibility of conducting a robust, full-scale RCT to inform evidence-based prescribing of analgesia after outpatient general surgery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04254679.

Predictive Factors for Postoperative Opioid Use in Elective Skull Base Craniotomies

Objective In 2017, the United States officially declared opioid overuse a public health emergency. Due to a paucity of published benchmark data in skull base neurosurgery, we quantified postoperative opioid use in patients undergoing skull base craniotomies and identified factors that influence postoperative opioid use.

Setting Tertiary academic medical center.

Participants Patients who underwent elective craniotomies by two skull base neurosurgeons between January 2015 and May 2020.

Main Outcome Measures Demographic and perioperative data were retrospectively extracted from the electronic medical record. Surgical approaches were categorized as having either “significant” or “minimal” muscle dissection. Univariate and multivariate linear regression analyses were performed to identify predictors of postoperative opioid use at 24, 48, and 72 hours.

Results We included 300 craniotomies, 206 were supratentorial and 94 were infratentorial. This included 195 women and 105 men, with a mean age of 54.9 years. In multivariable analysis, a history of anxiety or depression, preoperative opioid use, and a history of migraines independently predicted a significantly greater opioid use at 24, 48, and 72 hours. Increased age and minimal muscle dissection independently predicted lower opioid consumption. Sex, infratentorial versus supratentorial approach, length of surgery, and postoperative steroid use did not impact total opioid use.

Conclusion Younger age, history of anxiety or depression, preoperative opioid consumption, preexisting history of migraines, and significant intraoperative muscle dissection were associated with higher postoperative opioid consumption. These risk factors provide insight on potential targets for minimizing postoperative opioids in craniotomies.

Is There a Neuropathic-Like Component to Endometriosis-Associated Pain? Results From a Large Cohort Questionnaire Study

Background: Pain is one of the primary symptoms of endometriosis, a chronic inflammatory condition characterised by the presence of endometrial tissue outside the uterus. Endometriosis-associated pain is commonly considered as nociceptive in nature, but its clinical presentation suggests that it might have neuropathic-like properties in a subgroup of patients.

Methods: This is a cross sectional study using an online survey. The survey was distributed by patient support websites. The survey was composed of validated questionnaires assessing pain symptoms, psychological measures and questions about number of surgeries.

Main Results: We had 1,417 responses which met the inclusion criteria. Using standard painDETECT cut-off scores, we found that pain was classified as neuropathic in 40% of patients and as mixed neuropathic/nociceptive in a further 35%. In line with observations in other neuropathic conditions, the neuropathic subgroup reported higher pain intensities, greater psychological distress and cognitive impairment. Neuropathic pain was also more likely in those with more surgeries to the abdomen and a longer history of pain. As revealed by a cluster analysis, those with a neuropathic pain component could further be divided into two subgroups based on their sensory profile.

Conclusions: The data presented here indicate that endometriosis-associated pain includes a neuropathic-like component in a substantial proportion of women. Although further investigation is required, our finding challenges the current conceptualisation of endometriosis-associated pain as nociceptive and advocates for a new perspective on this type of pain, which is so debilitating to a large number of women.

State-of-the-Art Review on Immersive Virtual Reality Interventions for Colonoscopy-Induced Anxiety and Pain

BACKGROUND

Colonoscopy related fear impairs the current gold standard screening of colorectal cancer. Compared to other minimally invasive procedures for cancer screening, colonoscopy-induced anxiety exceeds the procedure through bowel preparation. Immersive virtual reality's (iVR) role in alleviating the complex stress-pain relationship encountered during medical procedures is directly proportional to the rising affordability of state-of-the-art Head-Mounted-Displays (HMDs).

OBJECTIVE

to assess the effect of iVR on patients' colonoscopy-induced anxiety and pain.

MATERIALS AND METHODS

A systematic search was conducted in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, Embase and Scopus databases up to January 2022. Clinical trials evaluating anxiety as an outcome were included without language restriction.

RESULTS

Four clinical trials were included: three on the patients' intraprocedural anxiety and one on patient education. Intraprocedural iVR interventions for colonoscopy-induced anxiety and pain revealed a similar effect as conventional sedation, while a statistically significant reduction was reported for non-sedated patients. iVR patient education improved the quality of bowel preparation and reduced patient anxiety before colonoscopy.

CONCLUSIONS

The current research highlights the need to use high-end HMDs and appropriate interactive iVR software content for colonoscopy-induced anxiety. Methodological frameworks regarding the eligibility of participants, double-blinding and randomization of iVR studies can facilitate the development of iVR implementation for anxiety and pain management.

Preoperative Anxiety and Postoperative Pain in Patients With Laparoscopic Hysterectomy

Objective: This study was designed to investigate preoperative anxiety situations and postoperative pain degree in Chinese patients undergoing laparoscopic hysterectomy and to analyze the related factors of preoperative anxiety and the correlation between preoperative anxiety and postoperative pain to provide a reference for effective postoperative analgesia management.

Methods: A total of 100 female patients undergoing laparoscopic hysterectomy were enrolled in this study and randomly divided into two groups (n = 50, each). In group A, the patients were treated with dexmedetomidine and sufentanil for postoperative analgesia. In group B, the patients were treated with sufentanil alone for postoperative analgesia. All patients were evaluated with a self-rating anxiety scale (SAS) 1 day before the operation. The patients’ pain was evaluated using the numerical rating scale (NRS) 1 day after the operation, and data were recorded.

Results: In these 100 patients, the highest preoperative SAS score was 48, and the average score was 40.99 ± 4.55 points, which is higher than the norm in China. There were significant differences in preoperative SAS scores among patients with different occupations and previous surgical experience (P < 0.05). There was no significant difference in SAS scores among patients with different education levels (P > 0.05). The postoperative NRS score of group A was significantly higher than that of group B, and the difference was statistically significant (P < 0.05). The correlation coefficients between SAS scores and NRS scores in groups A and B were 0.836 and 0.870, respectively, presenting with a significantly positive correlation.

Conclusion: Preoperative anxiety is an important predictor of postoperative pain. Patients undergoing laparoscopic hysterectomy have preoperative anxiety. The degree of anxiety is influenced by the occupation and previous operation experience of the patients, and patients with higher preoperative anxiety have greater postoperative pain. In addition, we should not neglect the management of postoperative pain because of the small trauma of laparoscopic surgery, and dexmedetomidine combined with sufentanil can improve the postoperative analgesic effect.

Opioid and/or Psychotropic Use Increases Intraprocedural Sedation Drug Requirements

Objectives Acute pain management in opioid users can be challenging in the perioperative period. This study focuses on whether use of opioids increases sedation medication requirements in patients undergoing port placement under moderate sedation.

Materials and Methods A retrospective review was performed on all patients undergoing port placement between June 1, 2017, and June 30, 2019. Exclusion criteria included receiving general anesthesia, no sedation, and errors in data entry. Data collection included demographics, use of opioids, benzodiazepines, antidepressants, tobacco, alcohol, and sedation data.

Results Opioid, benzodiazepine, and selective serotonin reuptake inhibitors (SSRIs)/serotonin-norepinephrine reuptake inhibitors (SNRIs) use was significantly associated with higher sedation drug dose requirements. Patients using opioids required 10.5% higher doses of midazolam compared with nonusers. Benzodiazepine users required 16.3% additional dosage of midazolam than nonusers. Finally, patients on SSRIs/SNRIs medications required 11.8% higher midazolam dosing when compared with nonusers.

Conclusion Anticipating higher needs of sedation medications during procedures in patients with history of psychotropic agents use can allow for more effective sedation and patient satisfaction. More patient and provider awareness is needed on this topic, as health care policy is moving toward value-based healthcare, with patient satisfaction surveys being one of its indicators.

Resilience and pain catastrophizing among patients with total knee arthroplasty: a cohort study to examine psychological constructs as predictors of post-operative outcomes

Background

Patients’ psychological health may influence recovery and functional outcomes after total knee arthroplasty (TKA). Pain catastrophizing, known to be associated with poor function following TKA, encompasses rumination, magnification, and helplessness that patients feel toward their pain. Resilience, however, is an individual's ability to adapt to adversity and may be an important psychological construct that supersedes the relationship between pain catastrophizing and recovery. In this study we sought to identify whether pre-operative resilience is predictive of 3-month postoperative outcomes after adjusting for pain catastrophizing and other covariates.

Methods

Patients undergoing TKA between January 2019 and November 2019 were included in this longitudinal cohort study. Demographics and questionnaires [Brief Resilience Scale (BRS), Pain Catastrophizing Scale (PCS), Knee injury and Osteoarthritis Outcome Score, Junior (KOOS, JR.) and Patient-Reported Outcomes Measurement Information System Physical and Mental Health (PROMIS PH and MH, respectively)] were collected preoperatively and 3 months postoperatively. Multivariable regression was used to test associations of preoperative BRS with postoperative outcomes, adjusting for PCS and other patient-level sociodemographic and clinical characteristics.

Results

The study cohort included 117 patients with a median age of 67.0 years (Q1–Q3: 59.0–72.0). Fifty-three percent of patients were women and 70.1% were white. Unadjusted analyses identified an association between resilience and post-operative outcomes and the relationship persisted for physical function after adjusting for PCS and other covariates; in multivariable linear regression analyses, higher baseline resilience was positively associated with better postoperative knee function (β = 0.24, p = 0.019) and better general physical health (β = 0.24, p = 0.013) but not general mental health (β = 0.04, p = 0.738).

Conclusions

Our prospective cohort study suggests that resilience predicts postoperative knee function and general physical health in patients undergoing TKA. Exploring interventions that address preoperative mental health and resilience more specifically may improve self-reported physical function outcomes of patients undergoing TKA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01772-2.

'Desire for more analgesic treatment': pain and patient-reported outcome after paediatric tonsillectomy and appendectomy

BACKGROUND

Insufficiently treated pain after paediatric appendectomy and tonsillectomy is frequent. We aimed to identify variables associated with poor patient-reported outcomes.

METHODS

This analysis derives from the European PAIN OUT infant registry providing information on perioperative pharmacological data and patient-reported outcomes 24 h after surgery. Variables associated with the endpoint 'desire for more pain treatment' were evaluated by elastic net regularisation (odds ratio [95% confidence interval]).

RESULTS

Data from children undergoing appendectomy (n=472) and tonsillectomy (n=466) between 2015 and 2019 were analysed. Some 24.8% (appendectomy) and 20.2% (tonsillectomy) wished they had received more pain treatment in the 24 h after surgery. They reported higher composite pain scores (5.2 [4.8-5.5] vs 3.6 [3.5-3.8]), more pain-related interference, and more adverse events than children not desiring more pain treatment, and they received more opioids after surgery (morphine equivalents (81 [60-102] vs 50 [43-56] μg kg^-1). Regression analysis revealed that pain-related sleep disturbance (appendectomy odds ratio: 2.8 [1.7-4.6], tonsillectomy 3.7 [2.1-6.5]; P<0.001) and higher pain intensities (1.5-fold increase) increased the probability of desiring more pain treatment. There was an inverse association between the number of different classes of non-opioids administered preventively, and the desire for more analgesics postoperatively. Children not receiving any non-opioid analgesics before the end of a tonsillectomy had a 3.5-fold (2.1-6.5-fold) increase in the probability of desiring more pain treatment, compared with children receiving at least two classes of different non-opioid analgesics.

CONCLUSIONS

Preventive administration of at least two classes of non-opioid analgesics is a simple strategy and may improve patient-reported outcomes.

A prospective cohort register-based study of chronic postsurgical pain and long-term use of pain medication after otorhinolaryngological surgery

Data on chronic postsurgical pain (CPSP) after otorhinolaryngological surgery are sparse. Adult in-patients treated in 2017 were included into the prospective PAIN OUT registry. Patients’ pain on the first postoperative day (D1), after six months (M6) and 12 months (M12) were evaluated. Determining factor for CPSP was an average pain intensity ≥ 3 (numeric rating scale 0–10) at M6. Risk factors associated with CPSP were evaluated by univariate and multivariate analyses. 10% of 191 included patients (60% male, median age: 52 years; maximal pain at D1: 3.5 ± 2.7), had CPSP. Average pain at M6 was 0.1 ± 0.5 for patients without CPSP and 4.2 ± 1.2 with CPSP. Average pain with CPSP still was 3.7 ± 1.1 at M12. Higher ASA status (Odds ratio [OR] = 4.052; 95% confidence interval [CI] = 1.453–11.189; p = 0.007), and higher minimal pain at D1 (OR = 1.721; CI = 1.189–2.492; p = 0.004) were independent predictors of CPSP at M6. Minimal pain at D1 (OR = 1.443; CI = 1.008–2.064; p = 0.045) and maximal pain at M6 (OR = 1.665; CI = 1.340–2.069; p < 0.001) were independent predictors for CPSP at M12. CPSP is an important issue after otorhinolaryngological surgery. Better instrument for perioperative assessment should be defined to identify patients at risk for CPSP.

Ultrasound-Guided Thoracic Paravertebral Nerve Block on Postoperative Pain, Quality of Life, and Recovery in Patients with Non-Small-Cell Lung Cancer

Objectives

Our study will investigate the effect of ultrasound-guided thoracic paravertebral block (UG-TPVB) on postoperative pain, quality of life, and enhanced recovery in patients with non-small-cell lung cancer (NSCLC) undergoing lobectomy surgery.

Methods

Our study included 100 patients aged 52 to 75 years who underwent lobectomy surgery with pathological diagnosis of NSCLC. Patients received ultrasound-guided thoracic paravertebral block or general anesthesia with tracheal intubation. Patients' pain score was recorded on a numeric rating scale (NRS) 24 hours post operation. The total postoperative dosage of tramadol hydrochloride, length of hospitalization, quality of life (QoL), and inflammation levels were recorded.

Results

Compared with patients who received general anesthesia with tracheal intubation, patients in the UG-TPVB group had lower postoperative NRS scores at 24 h (1.8 vs. 3.5, P = 0.035); the average 24 h postoperative NRS score of the UG-TPVB group is lower than that of the general anesthesia with tracheal intubation (4.6 vs. 5.3, P = 0.012), thus receiving less dosage of tramadol hydrochloride (221 ± 45 vs. 250 ± 38 mg, P < 0.01). Patients in the UG-TPVB group had better EORTC QLQ-C30 scores compared with patients in the general anesthesia with tracheal intubation group. The difference of length of hospitalization, hs-CRP, and IL-6 between two groups did not reach statistical difference (length of hospitalization 6.2 vs. 6.9 days, P = 0.055; hs-CRP: 7.1 ± 1.9 vs. 10.4 ± 6.6, P = 0.095; and IL-6: 71.3 ± 7.2 vs. 68.9 ± 8.7, P = 0.529). Discussion. NSCLC patients undergoing lobectomy surgery who received UG-TPVB had less postoperative pain, used less dosage of tramadol hydrochloride, and had better QoL.

The use of pre-operative virtual reality to reduce anxiety in women undergoing gynecological surgeries: a prospective cohort study

BACKGROUND

Pre-operative anxiety is common and is associated with negative surgical outcomes. Virtual reality (VR) is a promising new technology that offers opportunities to modulate patient experience and cognition and has been shown to be associated with lower levels of anxiety. In this study, we investigated changes in pre-operative anxiety levels before and after using VR in patients undergoing minor gynecological surgery.

METHODS

Patients who underwent elective minor gynecological surgeries in KK Women's and Children's hospital, Singapore were recruited. The VR intervention consisted of 10-min exposure via a headset loaded with sceneries, background meditation music and breathing exercises. For the primary outcome of pre-operative anxiety, patients were assessed at pre- and post-intervention using the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes of self-reported satisfaction scores and EuroQol 5-dimension 3-level (EQ-5D-3L) were also collected.

RESULTS

Data analysis from 108 patients revealed that HADS anxiety scores were significantly reduced from 7.2 ± 3.3 pre-intervention to 4.6 ± 3.0 post-intervention (p < 0.0001). Furthermore, HADS depression scores were significantly reduced from 4.7 ± 3.3 pre-intervention to 2.9 ± 2.5 post-intervention (p < 0.0001). Eighty-two percent of the patients self-reported VR intervention as 'Good' or 'Excellent'. EQ-5D-3L showed significant changes in dimensions of 'usual activities' (p = 0.025), 'pain/discomfort' (p = 0.008) and 'anxiety/ depression' (p < 0.0001).

CONCLUSIONS

For patients undergoing minor gynecological procedures, the VR intervention brought about a significant reduction in pre-operative anxiety. This finding may be clinically important to benefit patients with high pre-operative anxiety without the use of anxiolytics.

TRIAL REGISTRATION

This study was registered on clinicaltrials.gov registry ( NCT03685422 ) on 26 Sep 2018.

Risk Factors for Increased Postoperative Pain and Recommended Orderset for Postoperative Analgesic Usage

An interdisciplinary pain team was established at our institution to explore options for improving pain control in patients undergoing orthopedic surgery by identifying traits that put a patient at increased risk for inadequate pain control postoperatively.

RELATIONSHIP OF ANXIETY AND PREOPERATIVE DEPRESSION WITH POST-OPERATIVE PAIN

ABSTRACT Objectiv:e to analyze the relationship of anxiety and depression in the preoperative period with the presence of pain in the postoperative period. Method: cohort study conducted at a university hospital in the state of Minas Gerais (Brazil), between february and July 2017, with 65 patients. A collection instrument was elaborated for the demographic and clinical characteristics. The Hospital Anxiety and Depression Scale was used to assess anxiety and depression; pain intensity was measured using the Verbal Numerical Scale. Data were submitted to descriptive and inferential statistical analysis. Results: according to demographic and clinical characteristics, most patients were female, with a median age of 44 years and surgical specialty of the digestive tract. In the preoperative period, 31 (47.7%) had anxiety, and nine (13.8%), depression. None of the patients reported pain immediately prior to surgery. The incidence of moderate to severe postoperative pain was 32 (49.2%) patients. There was a statistically significant difference in the distribution of patients with postoperative pain in relation to the presence or absence of preoperative anxiety (p value <0.001). There is no statistically significant difference in the distribution of patients with postoperative pain in relation to the presence or absence of preoperative depression (0.733). In multivariate analysis, preoperative anxiety was a predictive factor for postoperative pain. Depression was not a predictive factor of postoperative pain. Conclusion: It was demonstrated that, regardless of the demographic and clinical characteristics of the studied sample, the presence of anxiety in patients in the preoperative period is a predictive factor of postoperative pain.

The Association Between Resilience and Mental Health in the Somatically Ill

BACKGROUND

Resilience refers to an individual's positive adaptation to the experience of adversity. The maintenance of mental health is commonly considered a sign of successful coping with adverse conditions. The goal of the present meta-analysis was to investigate the association between resilience and mental health in patients with a somatic illness or health problem.

METHODS

Studies were included if they reported measures of association between resilience, as assessed using a version of Wagnild and Young's Resilience Scale, and self-reported mental health. A systematic literature search was conducted in the Medline, Web of Science, PsycInfo, PubPsych, and ProQuest databases and in the dissertation catalogue of the German National Library. In addition, a manual search was carried out. The study was registered with PROSPERO (registration number: CRD42017054822).

RESULTS

55 studies involving a total of 15 003 patients were included in the meta-analysis. Assuming a random-effects model, the weighted mean Pearson correlation between resilience and mental health was r = 0.43 (95% confidence interval [0.39; 0.48], p<0.001). This association was robust, although the heterogeneity among individual effect sizes was substantial (I2 = 89.6%). Correlations tended to be weaker in unpublished studies than in published ones.

CONCLUSION

Despite substantial heterogeneity across studies, the findings suggest a strong association between resilience and mental health in the somatically ill. In clinical practice, a lack of resilience as a resource for successful coping might indicate a need for psychosocial support during treatment for somatic illness.

Resilience factors may buffer cellular aging in individuals with and without chronic knee pain

Telomere length, a measure of cellular aging, is inversely associated with chronic pain severity. While psychological resilience factors (e.g., optimism, acceptance, positive affect, and active coping) are associated with lower levels of clinical pain and greater physical functioning, it is unknown whether resilience may buffer against telomere shortening in individuals with chronic pain. Additionally, a broader conceptualization of resilience that includes social and biobehavioral factors may improve our understanding of the relationship between resilience, chronic pain, and health outcomes. In individuals with and without chronic knee pain, we investigated whether (1) psychological resilience would be positively associated with telomere length and if (2) a broader conceptualization of resilience including social and biobehavioral factors would strengthen the association. Seventy-nine adults, 45 to 85 years of age, with and without knee pain completed demographic, health, clinical pain, psychological, social, and biobehavioral questionnaires. Resilience levels were determined by summing the total number of measures indicating resilience based on published clinical ranges and norms. Blood samples were collected, and telomere length was determined. In regression analyses controlling for sex, race, age, and characteristic pain intensity, greater psychological resilience and psychosocial/biobehavioral resilience were associated with longer telomeres ( p = .0295 and p = .0116, respectively). When compared, psychosocial/biobehavioral resilience was significantly more predictive of telomere length than psychological resilience ( p < .0001). Findings are promising and encourage further investigations to enhance understanding of the biological interface of psychosocial and biobehavioral resilience factors in individuals with musculoskeletal chronic pain conditions.

Cost-effectiveness assessment in outpatient sinonasal surgery

AIMS

To assess the cost-effectiveness of outpatient sinonasal surgery in terms of clinical efficacy and control of expenses.

METHODS

A retrospective study was conducted from January 2014 to January 2016. Patients scheduled for outpatient sinonasal surgery were systematically included. Clinical data were extracted from surgical and anesthesiology computer files. The cost accounting methods applied in our institution were used to evaluate logistic and technical costs. The standardized hospital fees rating system based on hospital stay and severity in diagnosis-related groups (Groupes homogènes de séjours: GHS) was used to estimate institutional revenue.

RESULTS

Over 2years, 927 outpatient surgical procedures were performed. The crossover rate to conventional hospital admission was 2.9%. In a day-1 telephone interview, 85% of patients were very satisfied with the procedure. All outpatient cases showed significantly lower costs than estimated for conventional management with overnight admission, while hospital revenue did not differ between the two.

CONCLUSION

This study confirmed the efficacy of outpatient surgery in this indication. Lower costs could allow savings for the health system by readjusting the rating for the procedure. More precise assessment of cost-effectiveness will require more fine-grained studies based on micro costing at hospital level and assessment of impact on conventional surgical activity and post-discharge community care.