BackgroundEvidence suggests that over half of patients undergoing surgical procedures suffer from poorly controlled postoperative pain. In the context of an opioid epidemic, novel strategies for ameliorating postoperative pain and reducing opioid consumption are essential. Psychological interventions defined as strategies targeted towards reducing stress, anxiety, negative emotions and depression via education, therapy, behavioral modification and relaxation techniques are an emerging approach towards these endpoints.ObjectiveThis review explores the efficacy of psychological interventions for reducing postoperative pain and opioid use in the acute postoperative period.Evidence reviewAn extensive literature search was conducted in MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Medline In-Process/ePubs, Embase, Ovid Emcare Nursing, and PsycINFO, Web of Science (Clarivate), PubMed-NOT-Medline (NLM), CINAHL and ERIC, and two trials registries, ClinicalTrials.Gov (NIH) and WHO ICTRP. Included studies were limited to those investigating adult human subjects, and those published in English.FindingsThree distinct forms of psychological interventions were identified: relaxation, psychoeducation and behavioral modification therapy. Study results showed a reduction in both postoperative opioid use and pain scores (n=5), reduction in postoperative opioid use (n=3), reduction in postoperative pain (n=5), no significant reduction in pain or opioid use (n=7), increase in postoperative opioid use (n=1) and an increase in postoperative pain (n=1).ConclusionSome preoperative psychological interventions can reduce pain scores and opioid consumption in the acute postoperative period; however, there is a clear need to strengthen the evidence for these interventions. The optimal technique, strategies, timing and interface requires further investigation.
IntroductionInhaled volatile anaesthetics have a long tradition of use as hypnotic agents in operating rooms and are gaining traction as sedatives in intensive care units (ICUs). However, uptake is impeded by low familiarity with volatiles, unique equipment and education needs. Inhaled anaesthetics are often reserved in ICUs as therapies for refractory and life threatening status asthmaticus, status epilepticus, high and difficult sedation need scenarios given they possess unique pharmacological properties to manage these medical conditions while providing sedation to acutely ill patients. The objective of this systematic review is to collate evidence regarding the efficacy, safety and feasibility of volatile anaesthetics in adult and paediatric ICU patients for these three emergency conditions.Methods and analysisWe will conduct a systematic review of the primary studies in adult and paediatric ICU patients with status asthmaticus, status epilepticus and high/difficult sedation needs. We will include observational and interventional studies published from 1970 to 2021 in English or French investigating patients who have received a volatile inhalational agent for the above indications. We will evaluate the efficacy, safety, feasibility and implementation barriers for the volatile anaesthetics for each of three specified indications. Included studies will not be limited by necessity of a comparator arm. We will also evaluate clinical characteristics, patient demographics and provider attitudes towards volatile anaesthetic administration in defined critical care scenarios. Data will be extracted and analysed across these domains. The databases MEDLINE, EMBASE, the Science Citation Index as well as the Cochrane Central Controlled Trials Register will be queried with our search strategy.Descriptive and statistical analysis will be employed where appropriate. Data extraction and quality assessment will be performed in duplicate using a standardised tool. A narrative approach and statistical analyses will be used to describe patient characteristics, volatile efficacy, safety concerns, technical administration, attitudes towards administration and other implementation barriers.Ethics and disseminationNo ethics board approval will be necessary for this systematic review. This research is independently funded. Results will be disseminated in a peer-reviewed journal and conference presentation.PROSPERO numberCRD42021233083.
Background: Decision analysis allows clinicians to apply evidence-based medicine to guide objective decisions in uncertain scenarios. There is no comprehensive review summarizing the various decision analysis tools used. The authors aimed to appraise and review the decision analytic models used in hand surgery. Methods: A search of English articles on the PubMed, Ovid, and Embase databases was performed. All articles, regardless of date of publishing, were considered. Two reviewers, based on strict inclusion criteria, independently assessed each article. Results: The search resulted in 5525 abstracts, which yielded 30 studies that met inclusion criteria. Included studies were grouped according to medical indications, with scaphoid fractures (n = 6) and carpal tunnel syndrome (n = 5) being the most commonly reported. Included articles used decision analysis (n = 15) and/or economic analyses (n = 23) to discuss diagnostic strategies or compare treatments. The three most common outcomes reported were utility (n = 12), cost per quality-adjusted life-year (n = 16), and quality-adjusted life-years (n = 16). The decision analysis models compared diagnostic strategies, management options, and novel treatments. Conclusions: Decision analysis is increasingly popular in hand surgery. It is useful for comparing surgical strategies through evaluation of quality-of-life outcomes and costing data. The most common model was a simple decision tree. The quality of decision analysis models can be improved with the addition of sensitivity analysis. Surgeons should be familiar with the principles of decision analysis, so that complex decisions can be evaluated using rigorous probabilistic models that combine risks and benefits of multiple strategies.
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