Elizabeth Ball

Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis

BACKGROUND Music is a non-invasive, safe, and inexpensive intervention that can be delivered easily and successfully. We did a systematic review and meta-analysis to assess whether music improves recovery after surgical procedures. METHODS We included randomised controlled trials (RCTs) of adult patients undergoing surgical procedures, excluding those involving the central nervous system or head and neck, published in any language. We included RCTs in which any form of music initiated before, during, or after surgery was compared with standard care or other non-drug interventions. We searched MEDLINE, Embase, CINAHL, and Cochrane Central. We did meta-analysis with RevMan (version 5.2), with standardised mean differences (SMD) and random-effects models, and used Stata (version 12) for meta-regression. This study is registered with PROSPERO, number CRD42013005220. FINDINGS We identified 4261 titles and abstracts, and included 73 RCTs in the systematic review, with size varying between 20 and 458 participants. Choice of music, timing, and duration varied. Comparators included routine care, headphones with no music, white noise, and undisturbed bed rest. Music reduced postoperative pain (SMD -0·77 [95% CI -0·99 to -0·56]), anxiety (-0·68 [-0·95 to -0·41]), and analgesia use (-0·37 [-0·54 to -0·20]), and increased patient satisfaction (1·09 [0·51 to 1·68]), but length of stay did not differ (SMD -0·11 [-0·35 to 0·12]). Subgroup analyses showed that choice of music and timing of delivery made little difference to outcomes. Meta-regression identified no causes of heterogeneity in eight variables assessed. Music was effective even when patients were under general anaesthetic. INTERPRETATION Music could be offered as a way to help patients reduce pain and anxiety during the postoperative period. Timing and delivery can be adapted to individual clinical settings and medical teams. FUNDING None.

Equipment Failure: Causes and Consequences in Endoscopic Gynecologic Surgery

STUDY OBJECTIVE To determine the incidence of equipment failure in gynecologic endoscopy and investigate causes and consequences. DESIGN A prospective observational single-center study between January and April 2006. SETTING Gynecologic surgery department of a university hospital. INTERVENTIONS In all, 116 endoscopic interventions were included: 62 laparoscopies, 51 operative hysteroscopies, and 3 fertiloscopies. Emergency and equipment testing procedures were excluded. MEASUREMENTS AND MAIN RESULTS Equipment malfunctions were divided into 4 categories with regard to imaging, transmission of fluids and light, the electric circuit, and surgical instruments. We also found cases with faulty connections between elements. Factors including human error, loss of time, and actual or potential consequences were analyzed. At least 1 equipment failure was noted in 38.8% of operative procedures, 41.9% of laparoscopies, and 37.3% of hysteroscopies. Fluid, gas, and light transmission was faulty in 36.2%, surgical instruments in 29.3%, the electric circuit in 22.4%, and imaging in 12.1%. Of malfunctions, 46.6% were a result of faulty connection between 2 elements. The most common cause for concern was bipolar forceps and cables in laparoscopy (42.3%) and the assembly of small parts in hysteroscopy (47.4%). Personnel were implicated in 43% of cases (nurses in 72%, surgeons in 12%, both in 16%). One equipment failure increased the total duration of laparoscopy by 7% and of hysteroscopy by 20%. The mean delay was 5.6+/-4.0minutes by equipment failure. Of the incidences, 19% could have led to serious complications for the patient; however, no morbidity or mortality actually occurred in this series. CONCLUSION Equipment malfunction is common in endoscopic surgery and concerns both laparoscopy and hysteroscopy. Consequences are potentially serious. It is mandatory to identify and rectify causes of equipment failure so as to optimize the daily use of endoscopic instruments and improve patient safety. The implementation of systematic checklists is currently under evaluation.

Nerve stimulation for chronic pelvic pain and bladder pain syndrome: a systematic review

Chronic pelvic pain (CPP) and bladder pain syndrome (BPS) can have a negative impact on quality of life. Neuromodulation has been suggested as a possible treatment for refractory pain. To assess the effectiveness of tibial and sacral nerve stimulation in the treatment of BPS and CPP. We searched until July 2012: the Cochrane Library, EMBASE (1980–2012), Medline (1950–2012), Web of knowledge (1900–2012), LILACS (1982–2012) and SIGLE (1990–2012) with no language restrictions. We manually searched through bibliographies and conference proceedings of the International Continence Society. Randomized and prospective quasi‐randomized controlled studies vs. sham nerve stimulation treatment or usual care of patients with CPP and BPS who underwent sacral or tibial nerve stimulation were included. Any studies involving transcutaneous stimulation were excluded. The outcome was a cure or improvement in symptoms. Three studies with 169 patients treated with tibial nerve stimulation were included; two for CPP and one for BPS. There were improvements in pain, urinary and quality of life scores. There were no reported data for sacral nerve stimulation. There is scanty literature reporting variable success of posterior tibial nerve stimulation in improving pain, urinary symptoms and quality of life in CPP and BPS. In view of the dearth of quality literature, a large multi‐centered clinical trial investigating the effectiveness of electrical nerve stimulation to treat BPS and CPP along with the cost‐analysis of this treatment is recommended.

In Vivo Analysis of Trophoblast Cell Invasion in the Human

In vivo analysis of trophoblast cell invasion is highly dependent on histological techniques, which are amply described in standard textbooks. The emphasis of this chapter therefore lies on material collection and interpretation of tissue sections, rather than on histological techniques per se. Proper identification of vascular structures on placental bed histological sections is important, the more because invading trophoblastic cells induce significant structural changes in uterine blood vessels, which may be disturbed in complicated pregnancies. Guidelines for distinguishing several vascular structures are provided, and different approaches for qualitative and quantitative assessment of spiral artery changes are discussed. The purpose of such studies is not only to obtain a better insight into mechanisms of trophoblast invasion and associated maternal tissue changes, but also to understand placental bed defects in various pregnancy complications.

Gynaecological laparoscopy: 'see and treat' should be the gold standard.

Purpose of review Two hundred and fifty thousand gynaecological laparoscopies are performed yearly in the UK, many of them diagnostic. Unless a patient has major endometriosis and needs advanced surgery, the Royal College of Obstetricians and Gynaecologists suggest a ‘see and treat’ policy. Thus, gynaecologists who undertake laparoscopy should be competent at performing intermediate level laparoscopic surgery, including excision of endometriosis, adhesions and benign ovarian tumours, rather than converting to laparotomy or referring patients to another unit. In order to reduce operative risk and make best use of resources, preoperative assessment should triage patients into those with unlikely pelvic pathology who do not require laparoscopy in the first instance, those with severe endometriosis, who need referral to a specialist centre and the intermediate group who is best served with a ‘see and treat’ policy. Recent findings Appraisal of alternatives to diagnostic laparoscopy in infertility assessment and recent reports of modified ultrasound scanning improve the predictive value and will help to avoid unnecessary laparoscopies. Preoperative predictors for severe endometriosis can determine who needs specialist referral. ‘See and treat’ laparoscopies require adequate education, and workable training methods are under investigation. Summary Negative laparoscopies should be avoided and ‘see and treat’ laparoscopy should replace diagnostic procedures. Thorough preoperative assessment helps to identify women suitable for ‘see and treat’ laparoscopy.

Systematic reviews to evaluate causation: an overview of methods and application

Currently systematic reviews focus on diagnosis or effectiveness of treatment. It is the understanding of disease aetiology that underpins medical education, practice and research. Whether an association meets causal criteria is usually assessed qualitatively. However, this can also be examined through evidence synthesis and systematic reviews to evaluate disease causation and mechanisms are much needed. It is important in such a review to specify the questions to be addressed regarding causal criteria such as strength, consistency, temporality, specificity, biological gradient, plausibility and experimental evidence. The next step is to conduct a thorough literature search to identify the relevant studies and to assess them for their quality, particularly in relation to the risk of bias, ascertainment of exposures and ascertainment of outcomes. Data synthesis can then examine if the observed associations in collated studies are consistent, strong and temporal using techniques such as meta-analysis, testing for heterogeneity and meta-regression. Biological plausibility and coherence with existing theories can also be examined systematically through an assessment of the basic scientific literature. Experimental evidence might also be collated and synthesised to determine if removal of a causal agent alters the outcome. Through these steps a systematic review can help to establish whether an association is causal or not.

Does pelvic venous congestion syndrome exist and can it be treated

Chronic pelvic pain (CPP) is a common and costly health problem in gynecology. Operative pathological findings are often absent. In some women with CPP, pelvic venous congestion has been reported; however, this observation has also been made in asymptomatic women. Thus, it is not clear whether pelvic venous congestion causes CPP and, if it does, whether it is a direct or indirect cause. Venography and non‐invasive imaging methods are used for the diagnosis, but scoring systems have not been validated. The current mainstay of treatment is venography‐controlled embolization, which is less invasive than surgical interventions. However, the only evidence on effectiveness comes from uncontrolled case series. A systematic review of causation evidence is needed to prove whether pelvic venous congestion causes CPP and whether embolization treatment is effective. In addition, if causation is established, good‐quality primary randomized controlled trials on embolization may be required.

The management of endometrial polyps in the 21st century

•  Hysteroscopic endometrial polyp removal appears to be superior to the current practice of blind avulsion. •  Outpatient treatment is safe, cost effective and well tolerated, even in older or nulliparous women. •  New technologies facilitate office hysteroscopy. •  Benign endometrial polyps can regress and rarely progress to malignancy.

The role of magnetic resonance imaging in minimal access surgery.

Purpose of review Magnetic resonance imaging is commonly used for gynaecological malignancies, but also is increasingly used for the investigation of benign gynaecological complaints. This review summarizes the current evidence regarding its use as an adjunct to minimal access surgery for endometriosis, adenomyosis, adhesions and fibroids. Recent findings Magnetic resonance imaging appears to be equal in efficacy to ultrasound for the diagnosis of both fibroids and endometriosis, and perhaps superior for the diagnosis of adenomyosis. It is extremely useful for the preoperative investigation of severe endometriosis, especially recto-vaginal disease. Milder endometriosis is, however, still difficult to diagnose by either ultrasound or magnetic resonance imaging. Magnetic resonance imaging can also be helpful for the detection of adhesions, pelvic collections, congenital defects and fibroids. It is also useful following fibroid embolization. Summary Currently, it is not cost-effective to use magnetic resonance imaging as the modality of first choice when investigating pelvic pain and or menstrual disorders. If preoperative patients are carefully selected, however, it can substantially reduce surgical morbidity by using it to diagnose severe endometriosis and adhesions which may lead to cost savings overall.

Does mindfulness meditation improve chronic pain? A systematic review.

Purpose of review Psychological factors are associated with chronic pain. Mindfulness meditation may ameliorate symptoms. The objective was to evaluate the effects of mindfulness meditation in chronic pain. Recent findings A systematic search of four databases identified 534 citations; 13 Randomised controlled trials satisfied the inclusion criteria. Mindfulness meditation significantly reduced depression [Standardised mean difference (SMD) −0.28; 95% confidence interval (CI) −0.53, −0.03; P = 0.03; I2 = 0%]. For affective pain (SMD −0.13; 95% CI −0.42, 0.16; I2 = 0%), sensory pain (SMD −0.02; 95% CI −0.31, 0.27; I2 = 0%) and anxiety (SMD −0.16; 95% CI −0.47, 0.15; I2 = 0%) there was a trend towards benefit with intervention. Quality of life items on mental health (SMD 0.65; 95% CI −0.27, 1.58; I2 = 69%), physical health (SMD 0.08; 95% CI −0.40, 0.56; I2 = 32%) and overall score (SMD 0.86, 95% CI −0.06, 1.78; I2 = 88%) improved with mindfulness meditation. Summary Mindfulness meditation has most prominent effect on psychological aspects on living with chronic pain, improving associated depression and quality of life.