Healthcare provider–child–parent communication in the preoperative surgical setting

Objectives:  Although preoperative preparation programs were once common, most children currently undergoing outpatient surgery are first exposed to the hospital on the day of the procedure. It is advocated that these outpatient children undergo the preparation just prior to surgery.
Aim:  To assess the amount of time that healthcare providers spend with children and families on the day of surgery in the preoperative area.
Materials and Methods:  The study used video infrastructure in the preoperative holding area of Yale New Haven Children's Hospital to record all interactions between children, families, and healthcare providers. Videotapes were coded to characterize and quantify behaviors of healthcare professionals.
Results:  On the day of surgery, healthcare providers spent medians of 2.75–4.81 min interacting with children and parents in the preoperative area. Families spent a median of 46.5 min in the preoperative area. Healthcare professionals spent the most time in medical talk (averages of 42.5–48.2% of time spent with family) and little time was spent in nonmedical talk (range of 6.2–6.9% of time spent with family). Anesthesiologists and surgeons spent 28% and 18% of the interview in talk to children; admitting nurses spent more of the interview talking to children (43%).
Conclusions:  Families interact with healthcare providers for only a small proportion of the time they spent in the preoperative area. This is likely to be a result of increased production pressure in the perioperative settings and has implications for providing preparation for surgery on the morning of the procedure.     

The place of premedication in pediatric practice

Behind the multiple arguments for and against the use of premedication, sedative drugs in children is a noble principle that of minimizing psychological trauma related to anesthesia and surgery. However, several confounding factors make it very difficult to reach didactic evidence-based conclusions. One of the key confounding issues is that the nature of expectations and responses for both parent and child vary greatly in different environments around the world. Studies applicable to one culture and to one hospital system (albeit multicultural) may not apply elsewhere. Moreover, the study of hospital-related distress begins at the start of the patient's journey and ends long after hospital discharge; it cannot be focused completely on just the moment of anesthetic induction. Taking an example from actual practice experience, the trauma caused by the actual giving of a premedication to a child who absolutely does not want it and may struggle may not be recorded in a study but could form a significant component of overall effect and later psychological pathology. Clearly, attitudes by health professionals and parents to the practice of routine pediatric premedication, vary considerably, often provoking strong opinions. In this pro–con article we highlight two very different approaches to premedication. It is hoped that this helps the reader to critically re-evaluate a practice, which was universal historically and now in many centers is more selective.     

Prevention of Restenosis by External Beam Ionizing Irradiation

Intravascular brachytherapy with gamma sources has been proved to prevent in-stent restenosis in recent clinical trials. Beta sources are also being investigated. The intravascular use of radioactive sources has raised theoretical and logistic problems and renewed the interest in teletherapy for the treatment and prevention of restenosis. We review the literature published on the use of teletherapy in animal models and compare it to brachytherapy from biological and logistic points of view. Developing technologies for stereotactic radiotreatment of moving targets may offer new solutions and are being studied.     

An Improved Sperm Immobilization Test Based on Multiple Exposure Photography

ABSTRACT: An improved method for objective evaluation of results in the complement dependent sperm immobilization test, with the aid of the multiple exposure photography (MEP) method is described. With this method it is possible to determine the percentage of residual motility of spermatozoa quantitatively after incubation with sera suspected of having immobilizing activity in the presence of complement. Long term storage of information, reexamination of data and comparison of results after various treatment are routinely possible with this method.     

Beyond pain: predictors of postoperative maladaptive behavior change in children

Objectives & Aim: Using well‐validated measures and controlling for potential confounding variables such as pain and surgical and anesthetic technique, the goal of this project was to identify the incidence of and risk factors for the development of behavior change in children after surgery. Background: Although researchers have described maladaptive behavior change following surgery, many previous studies are limited by potential confounding variables, including postoperative pain, type of surgery, and surgical and anesthetic procedure. Methods: Participants included 260 children undergoing tonsillectomy and adenoidectomy. Baseline and demographic data were collected prior to surgery and pain and behavioral recovery were recorded for 2 weeks following surgery. A standardized approach to anesthesia and surgical procedure was implemented and well‐validated assessment measures were used. Results: On the first day at home following surgery, 80.4% of children exhibited negative behavior change. Nearly one‐third of children continued to exhibit behavior changes 2 weeks after surgery. Logistic regression analyses that controlled for pain severity identified several predictors of behavior change: preexisting somatic and anxious/depressed problems predicted new onset postoperative general anxiety, χ² (8) = 20.10, P = 0.010; younger age predicted separation anxiety, χ² (4) = 20.41, P < 0.01; and inhibited temperament predicted postoperative sleep disturbance, χ² (2) = 9.19, P = 0.010. Conclusions: Individual child factors above and beyond pain predict maladaptive postoperative behavior change; identification of these predictors may be helpful in both preventing and ameliorating difficulties with behavioral recovery following surgery.     

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 (χ² (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.     

Perioperative anxiety in children

Objectives & Aim: The purpose of this investigation was to examine children’s anxiety across the perioperative setting. Background: Although several studies have examined preoperative anxiety in children, few researchers have illustrated perioperative anxiety; that is, anxiety in children throughout the pre and postoperative continuum. Methods: Participants were 261 children ages 2–12. Anxiety was rated prior to surgery, immediately after surgery, and for 2 weeks at home following surgery. Results: Low child sociability and high parent anxiety predicted perioperative anxiety. Perioperative anxiety was related to postoperative pain and negative postoperative behavioral change. Conclusions: Identification and prevention of anxiety in children can help prevent negative outcomes following surgery.     

PENILE SIZE AND GROWTH IN CHILDREN AND ADOLESCENTS WITH ISOLATED GONADOTROPHIN DEFIENCY (IGnD)

Penile length and circumference were measured in twenty boys with isolated gonadotrophin deficiency, before and during the administration of androgen therapy. Their age ranged between 3 and 20 years. Considering as normal, measurements above the tenth centile, in all the patients but four the penile length was below normal, and in two it was borderline. Penis circumference was normal in two, borderline in four and subnormal in sixteen. Regular administration of androgen therapy increased penile length in eleven out of fourteen patients with achievement of normal length in four. It is concluded that congenital lack of LH and testicular androgen activation causes small sized penises, even in the prepubertal period. Gonadotrophin deficiency should be looked for in patients with measurements below the tenth centile. Early diagnosis and institution of androgen therapy between 11 and 12 years is likely to increase penile size and prevent the psychological side effects of undersized genitals and delayed puberty.     

How many parents should we let into the operating room?

Objective:  This study compared anxiety of children with one and two parents present at anesthesia induction.
Methodology:  Baseline measures of parent and child anxiety were obtained; parents were randomly assigned to the two study groups. Validated and reliable tools were used to assess the outcomes of interest.
Results:  We found that observed anxiety of children as well as compliance of children with the induction process was not different between the two study groups. Parent's anxiety was also evaluated using two-way anova with repeated measures. A group by time interaction was demonstrated and parents in the one-parent group reported significantly higher anxiety than parents in the two-parents group ( M  = 48.6, sd  = 13.1 vs M  = 39.7, sd  = 11.5, P  < 0.02).
Conclusions:  We conclude that while allowing two parents into the operating rooms does not affect observed child anxiety, it does reduce parent self-reported anxiety. As the presence of multiple parents during invasive medical procedures is in congruence with family centered-care we recommend that institutions examine this modality.