Implications of nocebo in anaesthesia care

Innovative change not as yet fully integrated in pediatric anesthesia

Pediatric hypnosis is an extremely valuable adjuvant therapeutic tool to reduce pain and ameliorate anxiety in children undergoing procedures and pediatric anesthesia. This perspective summarises; why Integrating hypnosis into practice has this potential, some techniques that are particularly useful in this setting, the training oppurtunities to learn more, and recommendations for future pediatric anesthesia hypnotic research. There is definite capacity for change by Integrating hypnosis into our practice. Not only will this ensure more capable, confident children who present for peri-operative care but also reduce costs and the environmental impact of the pharmaceutical agents we currently employ for sedation and anxiolysis.

All Palliative Care Should Be Integrative Palliative Care

Integrative medicine and palliative care are philosophically similar, with a focus on whole person care and wellbeing. Integrative medicine provides a large toolbox of evidence-informed treatment modalities but doesn't prioritize the care of seriously ill people. Palliative care takes a holistic approach to reducing the suffering of seriously ill people, their families, and their caregivers, but the available treatment toolbox is often limited to pharmaceuticals, procedures, and radiation. The ideal care of families facing serious illness employs the philosophy and conventional expertise of palliative care clinicians coupled with an evidence-supported expanded treatment toolbox provided by the field of complementary and integrative medicine. This emerging field is called integrative palliative care. Reducing physical, emotional, and spiritual suffering is the fundamental goal of palliative care and all available effective tools should be employed toward this aim. Therefore, all palliative care should be integrative palliative care.

Nocebo expectations rather than placebo expectations affect topical pain relief: A randomized clinical trial

Patients' expectations and beliefs regarding the potential benefits and harms of medical interventions may induce placebo and nocebo effects, and affect the response to pain therapies. In a randomized clinical trial, we examined the effect of placebo and nocebo expectations on pain relief and adverse events (AEs) in association with a topical treatment among 65 cancer survivors experiencing chronic musculoskeletal pain. Participants received either a 1% camphor-based topical pain patch or a placebo treatment for 14 days. We measured pain severity with the worst pain item of the Brief Pain Inventory (BPI) at baseline and 14 days and treatment expectations at baseline with validated expectation questionnaires. We found that high vs. low nocebo expectations decreased pain severity improvements by 2.5 points (95% confidence interval [CI] -3.8 to -1.2; p<0.001) on a 0-10 numeric rating scale of the BPI and pain response rate by 42.7% (95% CI 0.2-0.6; p<0.001) at day 14, irrespective of placebo expectation status or treatment arms. Patients with high vs. low nocebo expectations in the true arm reported 22.4% more unwanted AEs. High nocebo expectations were associated with increased AEs by 39.5% (odds ratio: 12.0, 95% CI 1.2, 145.5; p=0.029) and decreased pain response in the true arm vs. placebo. Our study demonstrated that nocebo expectations, rather than placebo expectations, elevate the risk of AEs and compromise the effect of topical pain interventions. The findings raise the possibility that nocebo expectations may worsen somatic symptoms through heightening central pain amplification and should be further investigated.

An Individualized Postoperative Pain Risk Communication Tool for Use in Pediatric Surgery: Co-Design and Usability Evaluation

BACKGROUND

Risk identification and communication tools have the potential to improve health care by supporting clinician-patient or family discussion of treatment risks and benefits and helping patients make more informed decisions; however, they have yet to be tailored to pediatric surgery. User-centered design principles can help to ensure the successful development and uptake of health care tools.

OBJECTIVE

We aimed to develop and evaluate the usability of an easy-to-use tool to communicate a child's risk of postoperative pain to improve informed and collaborative preoperative decision-making between clinicians and families.

METHODS

With research ethics board approval, we conducted web-based co-design sessions with clinicians and family participants (people with lived surgical experience and parents of children who had recently undergone a surgical or medical procedure) at a tertiary pediatric hospital. Qualitative data from these sessions were analyzed thematically using NVivo (Lumivero) to identify design requirements to inform the iterative redesign of an existing prototype. We then evaluated the usability of our final prototype in one-to-one sessions with a new group of participants, in which we measured mental workload with the National Aeronautics and Space Administration (NASA) Task Load Index (TLX) and user satisfaction with the Post-Study System Usability Questionnaire (PSSUQ).

RESULTS

A total of 12 participants (8 clinicians and 4 family participants) attended 5 co-design sessions. The 5 requirements were identified: (A) present risk severity descriptively and visually; (B) ensure appearance and navigation are user-friendly; (C) frame risk identification and mitigation strategies in positive terms; (D) categorize and describe risks clearly; and (E) emphasize collaboration and effective communication. A total of 12 new participants (7 clinicians and 5 family participants) completed a usability evaluation. Tasks were completed quickly (range 5-17 s) and accurately (range 11/12, 92% to 12/12, 100%), needing only 2 requests for assistance. The median (IQR) NASA TLX performance score of 78 (66-89) indicated that participants felt able to perform the required tasks, and an overall PSSUQ score of 2.1 (IQR 1.5-2.7) suggested acceptable user satisfaction with the tool.

CONCLUSIONS

The key design requirements were identified, and that guided the prototype redesign, which was positively evaluated during usability testing. Implementing a personalized risk communication tool into pediatric surgery can enhance the care process and improve informed and collaborative presurgical preparation and decision-making between clinicians and families of pediatric patients.

Clinical hypnosis: implications in anaesthesia and perioperative care

A randomised trial published in the British Journal of Anaesthesia describes hypnosis compared with general anaesthesia in 60 children undergoing superficial surgery. We describe a definition of clinical hypnosis; the goals and conduct of hypnotic communication; and its potential as both an adjunct and, in suitable cases, alternative to traditional pharmacological anaesthesia.

Nocebo language in anaesthetic patient written information

Recent evidence suggests that how anaesthesia information is presented may influence patient treatment outcomes. We conducted an observational study of anaesthetic-based patient information leaflets across NHS Trusts in England for their nocebo terms vs. therapeutic terms, and how adverse effects were presented. In this study, 'nocebo' is wording that may predispose the patient to expect adverse events such as pain or nausea. Data were extracted and analysed for word frequency, weighted proportion and thematic analysis. In total, 42 patient information leaflets from 61 NHS Trusts were analysed. 'Pain' was the second most common word across the leaflets, median (IQR [range]) 0.82 (0.50-1.0 [0.12-1.47]) per 100 words, second only to 'anaesthesia'. In comparison, 'safe' was the most common positively valanced word which featured eight times less frequently than 'pain' 0.10 (0.07-0.18 [0.0-0.84]) and 'comfort' featured 16.5 times less than 'pain' 0.02 (0.0-0.05 [0.0-0.13]). Multiple examples of phrasing that could have potential nocebo effects included, 'you will need strong painkillers' suggesting 'strong pain' and the need for 'painkillers' rather than using therapeutic terms focusing on 'comfort', 'healing' and 'recovery'. Our results suggest a dominance of phrases with negative content in the presentation of anaesthesia information provided to patients. Clinicians need to be aware of inadvertent generation of nocebo-weighted vs. comfort-weighted communication with patients. Our study findings suggest an opportunity for more emphasis to be placed on therapeutic outcomes and effective mitigation strategies of anaesthesia risks to avoid potential unintended nocebo effects of anaesthesia information leaflets or websites.

Identification of Requirements for a Postoperative Pediatric Pain Risk Communication Tool: Focus Group Study With Clinicians and Family Members

BACKGROUND

Pediatric surgery is associated with a risk of postoperative pain that can impact the family's quality of life. Although some risk factors for postoperative pain are known, these are often not consistently communicated to families. In addition, although tools for risk communication exist in other domains, none are tailored to pediatric surgery.

OBJECTIVE

As part of a larger project to develop pain risk prediction tools, we aimed to design an easy-to-use tool to effectively communicate a child's risk of postoperative pain to both clinicians and family members.

METHODS

With research ethics board approval, we conducted virtual focus groups (~1 hour each) comprising clinicians and family members (people with lived surgical experience and parents of children who had recently undergone surgery/medical procedures) at a tertiary pediatric hospital to understand and evaluate potential design approaches and strategies for effectively communicating and visualizing postoperative pain risk. Data were analyzed thematically to generate design requirements and to inform iterative prototype development.

RESULTS

In total, 19 participants (clinicians: n=10, 53%; family members: n=9, 47%) attended 6 focus group sessions. Participants indicated that risk was typically communicated verbally by clinicians to patients and their families, with severity indicated using a descriptive or a numerical representation or both, which would only occasionally be contextualized. Participants indicated that risk communication tools were seldom used but that families would benefit from risk information, time to reflect on the information, and follow-up with questions. In addition, 9 key design requirements and feature considerations for effective risk communication were identified: (1) present risk information clearly and with contextualization, (2) quantify the risk and contextualize it, (3) include checklists for preoperative family preparation, (4) provide risk information digitally to facilitate recall and sharing, (5) query the family's understanding to ensure comprehension of risk, (6) present the risk score using multimodal formats, (7) use color coding that is nonthreatening and avoids limitations with color blindness, (8) present the most significant factors contributing to the risk prediction, and (9) provide risk mitigation strategies to potentially decrease the patient's level of risk.

CONCLUSIONS

Key design requirements for a pediatric postoperative pain risk visualization tool were established and guided the development of an initial prototype. Implementing a risk communication tool into clinical practice has the potential to bridge existing gaps in the accessibility, utilization, and comprehension of personalized risk information between health care professionals and family members. Future iterative codesign and clinical evaluation of this risk communication tool are needed to confirm its utility in practice.

The Importance of Vaccination in the Context of the COVID-19 Pandemic: A Brief Update Regarding the Use of Vaccines

The COVID-19 pandemic has led the world to undertake the largest vaccination campaign in human history. In record time, unprecedented scientific and governmental efforts have resulted in the acquisition of immunizers utilizing different technologies (nucleotide acids, viral vectors, inactivated and protein-based vaccines). Currently, 33 vaccines have already been approved by regulatory agencies in different countries, and more than 10 billion doses have been administered worldwide. Despite the undeniable impact of vaccination on the control of the pandemic, the recurrent emergence of new variants of interest has raised new challenges. The recent viral mutations precede new outbreaks that rapidly spread at global proportions. In addition, reducing protective efficacy rates have been observed among the main authorized vaccines. Besides these issues, several other crucial issues for the appropriate combatting of the pandemic remain uncertain or under investigation. Particularly noteworthy issues include the use of vaccine-boosting strategies to increase protection; concerns related to the long-term safety of vaccines, child immunization reliability and uncommon adverse events; the persistence of the virus in society; and the transition from a pandemic to an endemic state. In this review, we describe the updated scenario regarding SARS-CoV-2 variants and COVID-19 vaccines. In addition, we outline current discussions covering COVID-19 vaccine safety and efficacy, and the future pandemic perspectives.