The effect of augmented reality on preoperative anxiety in children and adolescents: A randomized controlled trial.

BACKGROUND AND AIMS: Virtual reality has been shown to be an effective non-pharmacological intervention for reducing anxiety of pediatric patients. A newer immersive technology, that of augmented reality, offers some practical advantages over virtual reality, and also seems to show beneficial effects on anxiety. The main objective of this study was to determine whether augmented reality could reduce preoperative anxiety in pediatric patients undergoing elective day surgeries. A secondary outcome was to document the level of satisfaction from pediatric patients toward augmented reality intervention. METHODS: Children and adolescents aged between 5 and 17 years old scheduled for elective day surgery under general anesthesia were randomly divided into two groups. Patients in the control group received standard care, whereas patients in the augmented reality group were accompanied by two virtual characters who taught them relaxation techniques and provided emotional and informational support. Anxiety was measured at the time of admission and at the time of induction using the short version of the modified Yale Preoperative Anxiety Scale. RESULTS: The analysis included 37 pediatric patients in the augmented reality group and 64 in the control group. Anxiety scores were statistically significantly lower in the augmented reality group than those in the control group at the time of admission (median difference [95% CI]: 6.3 [0-10.4], p = .01), while no difference was observed between groups at the time of induction (median difference [95% CI]: -4.2 [-5.2-4.2], p = .58). Most patients in the augmented reality group wished to wear the glasses again and reported to be very satisfied with the intervention. CONCLUSION: To our knowledge, this study is the first large randomized controlled trial to provide empirical evidence of reduction in anxiety for children and adolescents using augmented reality prior to induction of general anesthesia.

Randomized controlled trial (RCT) comparing ultrasound-guided pudendal nerve block with ultrasound-guided penile nerve block for analgesia during pediatric circumcision.

INTRODUCTION: Optimal analgesia for circumcision is still debated. The dorsal penile nerve block has been shown to be superior to topical and caudal analgesia. Recently, the ultrasound-guided pudendal nerve block (group pudendal) has been popularized. This randomized, blinded clinical trial compared group pudendal with ultrasound-guided dorsal penile nerve block (group penile) under general anesthesia for pediatric circumcision. METHODS: Prepubertal males aged 1-12 years undergoing elective circumcision were randomized to either group. The primary outcome was postoperative face, legs, activity, cry, consolability (FLACC) scores. Our secondary outcomes included parent's postoperative pain measure, analgesic consumption during the first 24 hours, surgeon's and parent's satisfaction, time to perform the block, hemodynamic changes intraoperatively and total time in postanesthesia care unit and until discharge. RESULTS: A total of 155 patients were included for analysis (77 in group pudendal and 78 in group penile). Mean age was 7.3 years old. FLACC scores were not statistically different between groups (p=0.19-0.97). Surgeon satisfaction was higher with group pudendal (90.8% vs 56.6% optimal, p<0.01). Intraoperative hemodynamic changes (>20% rise of heart rate or blood pressure) were higher in group pudendal (33.8% vs 9.0%, p<0.01) as was intraoperative fentanyl use (1.3 vs 1.0 µg/kg, p<0.01). Other secondary outcomes were not statistically different. DISCUSSION: Both ultrasound-guided blocks, performed under general anesthesia, provide equivalent postoperative analgesia for pediatric circumcision as evidenced by low pain scores and opioid consumption. Surgeon satisfaction was higher in the pudendal group. TRIAL REGISTRATION NUMBER: NCT03914365.

Cancer risk in children and young adults born preterm: A systematic review and meta-analysis.

INTRODUCTION: Risk of developing a malignancy when born premature is unknown. We hypothesised that risk of certain cancers might be increased in youth born preterm versus term. We therefore performed a systematic review and meta-analysis to evaluate the incidence of malignancy in the context of preterm birth, according to various cancer types. METHODS: The study was designed per MOOSE and PRISMA guidelines. Articles were identified through November 2015. Observational studies exploring the association between childhood malignancy and birth characteristics were included. Of the 1658 records identified, 109 full text articles were evaluated for eligibility. Random effects meta-analyses were conducted on 10/26 studies retained; 95% confidence intervals were computed and adjusted following sensitivity analysis. Publication bias was evaluated using funnel plots, Begg's and Egger's tests. RESULTS: No differences in risk of primary central nervous system tumor [OR 1.05; 95% CI 0.93-1.17, 5 studies, 580 cases] and neuroblastoma [OR 1.09; 95% CI 0.90-1.32, 5 studies, 211 cases] were observed in individuals born <37 versus ≥37 weeks' gestation. Preterm birth was consistently associated with hepatoblastoma [ORs 3.12 (95% CI 2.32-4.20), 1.52 (95% CI 1.1-2.1), 1.82 (95% CI 1.01-3.26), and 2.65 (95% CI 1.98-3.55)], but not leukemia, astrocytoma, ependymoma, medulloblastoma, lymphoma, nephroblastoma, rhabdomyosarcoma, retinoblastoma or thyroid cancer. CONCLUSIONS: Children born premature may be at increased risk for hepatoblastoma but there is no strong evidence of an increased risk of primary central nervous system tumours or neuroblastoma. There is insufficient evidence to conclude whether prematurity modulates the risk of other childhood cancers.

Perioperative management of gastrostomy tube placement in Duchenne muscular dystrophy adolescent and young adult patients: A role for a perioperative surgical home.

BACKGROUND: In past decades, Duchenne muscular dystrophy patients have been living longer and as the disease advances, patients experience multisystemic deterioration. Older patients often require gastrostomy tube placement for nutritional support. For optimizing the perioperative care, a practice of multidisciplinary team can better anticipate, prevent, and manage possible complications and reduce the overall perioperative morbidity and mortality. AIMS: The aim of this study was to review our experience with perioperative care of adolescent and young adults with Duchenne muscular dystrophy undergoing gastrostomy by various surgical approaches in order to identify challenges and improve future perioperative care coordination to reduce morbidity. METHODS: We retrospectively examined cases of gastrostomy tube placement in patients of ages 15 years and older between 2005 and 2016. We reviewed preoperative evaluation, anesthetic and surgical management, and postoperative complications. RESULTS: Twelve patients were identified; 1 had open gastrostomy, 3 laparoscopic gastrostomies, 5 percutaneous endoscopic guided, and 3 radiologically inserted gastrostomy tubes. All patients had preoperative cardiac evaluation with 6 patients demonstrating cardiomyopathy. Nine patients had preoperative pulmonary consultations and the pulmonary function tests reported forced vital capacity of ≤36% of predicted. Eight patients were noninvasive positive pressure ventilation dependent. General anesthesia with tracheal intubation was administered in 8 patients, and intravenous sedation in 4 patients; 1 received sedation supplemented with regional anesthesia and 3 received deep sedation. One patient had a difficult intubation that resulted in trauma and prolonged tracheal intubation. Three patients developed postoperative respiratory complications. Two patients' procedures were postponed due to inadequate preoperative evaluation and 1 because of disagreement between anesthesia and procedural services as to the optimal approach for airway management. CONCULSION: Optimal management of the perioperative care of Duchenne muscular dystrophy patients requires input from relevant medical specialists, proceduralist and anesthesiologist. This complexity of care coordination presents an opportunity for anesthesiologists to lead a collaborative perioperative team in management of advanced Duchenne patients coming for gastrostomy.

Ultrasound-Guided Single-Injection Infraclavicular Block Versus Ultrasound-Guided Double-Injection Axillary Block: A Noninferiority Randomized Controlled Trial.

BACKGROUND: Single-injection ultrasound-guided infraclavicular block is a simple, reliable, and effective technique. A simplified double-injection ultrasound-guided axillary block technique with a high success rate recently has been described. It has the advantage of being performed in a superficial and compressible location, with a potentially improved safety profile. However, its effectiveness in comparison with single-injection infraclavicular block has not been established. We hypothesized that the double-injection ultrasound-guided axillary block would show rates of complete sensory block at 30 minutes noninferior to the single-injection ultrasound-guided infraclavicular block. METHODS: After approval by our research ethics committee and written informed consent, adults undergoing distal upper arm surgery were randomized to either group I, ultrasound-guided single-injection infraclavicular block, or group A, ultrasound-guided double-injection axillary block. In group I, 30 mL of 1.5% mepivacaine was injected posterior to the axillary artery. In group A, 25 mL of 1.5% mepivacaine was injected posteromedial to the axillary artery, after which 5 mL was injected around the musculocutaneous nerve. Primary outcome was the rate of complete sensory block at 30 minutes. Secondary outcomes were the onset of sensory and motor blocks, surgical success rates, performance times, and incidence of complications. All outcomes were assessed by a blinded investigator. The noninferiority of the double-injection ultrasound-guided axillary block was considered if the limits of the 90% confidence intervals (CIs) were within a 10% margin of the rate of complete sensory block of the infraclavicular block. RESULTS: At 30 minutes, the rate of complete sensory block was 79% in group A (90% CI, 71%-85%) compared with 91% in group I (90% CI, 85%-95%); the upper limit of CI of group A is thus included in the established noninferiority margin of 10%. The rate of complete sensory block was lower in group A (proportion difference of 12% [95% CI, 2-22]; P = 0.0091), as was surgical success rate (82% [95% CI, 74%-89%] vs 93% [95% CI, 86%-97%]; proportion difference of 11% [95% CI 1-20]; P = 0.0153). Sensory block onset also was slower in group A (log rank test P = 0.0020). Performance times were faster in group I (231 seconds [95% CI, 213-250]) than in group A (358 seconds [95% CI, 332-387]; P < 0.0001). No statistically significant difference was observed for vascular puncture, paresthesia during block performance, or procedure-related pain. No neurologic complication was noted at follow-up. CONCLUSIONS: We failed to demonstrate that the rate of complete sensory block of the double-injection axillary block is noninferior to the single-injection infraclavicular block. However, the rate of complete sensory block at 30 minutes is statistically significantly lower with the axillary block. The ultrasound-guided single-injection infraclavicular block thus seems to be the preferred technique over the axillary for upper arm anesthesia.

Risk for preterm and very preterm delivery in women who were born preterm.

OBJECTIVE: To evaluate whether women who themselves were born preterm are at increased risk of preterm delivery and, if so, whether known maternal complications of preterm birth such as hypertension or diabetes explain this risk. METHODS: We conducted a population-based cohort study of all women born preterm (51,148) and term (823,991) in Québec, Canada, between 1976 and 1995; after frequency matching 1:2 preterm to term, we examined the relationship of preterm birth between women and their offspring. RESULTS: The study included 7,405 women who were born preterm (554 before 32 weeks of gestation and 6,851 at 32-36 weeks of gestation) and 16,714 women born term, who delivered 12,248 and 27,879 newborns, respectively. Overall, 14.2% of women born before 32 weeks of gestation, 13.0% of 32-36 weeks of gestation, and 9.8% of those born term delivered prematurely at least once during the study period, including 2.4%, 1.8%, and 1.2%, respectively, who delivered very preterm (both P<.001 for trend). After adjustment for factors including own birth weight for gestational age and pregnancy complications, the overall odds of preterm first live delivery associated with being born preterm was elevated by 1.63-fold (95% confidence interval [CI] 1.22-2.19) for women born before 32 weeks of gestation and 1.41-fold (95% CI 1.27-1.57) for those born at 32-36 weeks of gestation relative to women born term. CONCLUSION: Women who themselves were born preterm are at increased risk of delivering their neonates prematurely. This is independent of prematurity risks associated with hypertension and diabetes. LEVEL OF EVIDENCE: II.

New reference curves for head circumference at birth, by gestational age.

BACKGROUND: The measurement of head circumference (HC) at birth reflects intrauterine brain development. HC charts currently used in Canada are either dated, mixed-gender, nonrepresentative of lower gestational ages (GAs), or reflective of other populations. METHODS: To create both birth weight and HC curves, we combined weight and HC data from the Canadian Neonatal Network (CNN) database (admissions in NICUs across Canada) with McGill's Obstetrical Neonatal Database (MOND; all births at a tertiary hospital in Montreal, Canada). We included CNN data for GAs of 23 to 34 weeks (2003-2007) and MOND data for GAs of 35 to 41 weeks (1995-2006). Nonsingletons, congenital anomalies, and measurements greater than ±4 SD from the mean were excluded. Distributions of birth weight and HC at each GA were statistically (penalized spline regression) smoothed. Birth weight curves were compared with recent Canadian reference curves and HC curves with historical and/or frequently used curves. RESULTS: We included 39,896 births (3121 births at <30 weeks' GA) to generate the curves. Current weight curves were similar to Canadian reference charts for both genders. Weight and HC measurements in boys were higher than in girls. When classified according to recent international references, the proportion of CNN-MOND infants at ≥32 weeks' GA with HCs <10th percentile was significantly underestimated. When classified according to historical reference curves, a significant number of CNN-MOND infants of all GAs with HCs <10th and >90th percentiles were misclassified. CONCLUSIONS: We developed recent gender-specific reference curves for HC at birth for singletons at 23 to 41 completed weeks' GA, which included a large number of very premature infants, reflecting the current geotemporal Canadian population.

Pregnancy complications among women born preterm.

BACKGROUND: Adults who were born with low birth weights are at increased risk of cardiovascular and metabolic conditions, including pregnancy complications. Low birth weight can result from intrauterine growth restriction, preterm birth or both. We examined the relation between preterm birth and pregnancy complications later in life. METHODS: We conducted a population-based cohort study in the province of Quebec involving 7405 women born preterm (554 < 32 weeks, 6851 at 32-36 weeks) and a matched cohort of 16 714 born at term between 1976 and 1995 who had a live birth or stillbirth between 1987 and 2008. The primary outcome measures were pregnancy complications (gestational diabetes, gestational hypertension, and preeclampsia or eclampsia). RESULTS: Overall, 19.9% of women born at less than 32 weeks, 13.2% born at 32-36 weeks and 11.7% born at term had at least 1 pregnancy complication at least once during the study period (p < 0.001). Women born small for gestational age (both term and preterm) had increased odds of having at least 1 pregnancy complication compared with women born at term and at appropriate weight for gestational age. After adjustment for various factors, including birth weight for gestational age, the odds of pregnancy complications associated with preterm birth was elevated by 1.95-fold (95% confidence interval [CI] 1.54-2.47) among women born before 32 weeks' gestation and 1.14-fold (95% CI 1.03-1.25) among those born at 32-36 weeks' gestation relative to women born at term. INTERPRETATION: Being born preterm, in addition to, and independent of, being small for gestational age, was associated with a significantly increased risk of later having pregnancy complications.

Androgens and body fat distribution.

An important sex difference in body fat distribution is generally observed. Men are usually characterized by the android type of obesity, with accumulation of fat in the abdominal region, whereas women often display the gynoid type of obesity, with a greater proportion of their body fat in the gluteal-femoral region. Accordingly, the amount of fat located inside the abdominal cavity (intra-abdominal or visceral adipose tissue) is twice as high in men compared to women. This sex difference has been shown to explain a major portion of the differing metabolic profiles and cardiovascular disease risk in men and women. Association studies have shown that circulating androgens are negatively associated with intra-abdominal fat accumulation in men, which explains an important portion of the link between low androgens and features of the metabolic syndrome. In women, the low circulating sex hormone-binding globulin (SHBG) levels found in abdominal obesity may indirectly indicate that elevated free androgens are related to increased visceral fat accumulation. However, data on non SHBG-bound and total androgens are not unanimous and difficult to interpret for total androgens. These studies focusing on plasma levels of sex hormones indirectly suggest that androgens may alter adipose tissue mass in a depot-specific manner. This could occur through site-specific modulation of preadipocyte proliferation and/or differentiation as well as lipid synthesis and/or lipolysis in mature adipocytes. Recent results on the effects of androgens in cultured adipocytes and adipose tissue have been inconsistent, but may indicate decreased adipogenesis and increased lipolysis upon androgen treatment. Finally, adipose tissue has been shown to express several steroidogenic and steroid-inactivating enzymes. Their mere presence in fat indirectly supports the notion of a highly complex enzymatic system modulating steroid action on a local basis. Recent data obtained in both men and women suggest that enzymes from the aldoketoreductase 1C family are very active and may be important modulators of androgen action in adipose tissue.

Regional differences in adipose tissue metabolism in obese men.

We examined omental and subcutaneous adipose tissue adipocyte size, and lipolysis and lipoprotein lipase (LPL) activity in a sample of 33 men aged 22.6 to 61.2 years and with a body mass index ranging from 24.6 to 79.1 kg/m2. We tested the hypothesis that lipolysis rates would be higher in the omental fat depot than in subcutaneous adipose tissue and that this difference would persist across the spectrum of abdominal adiposity values. Omental and subcutaneous adipose tissue samples were obtained during surgery. Adipocytes were isolated by collagenase digestion. Adipocyte size and LPL activity as well as basal, isoproterenol-, forskolin-, and dibutyryl cyclic adenosine monophosphate-stimulated lipolysis were measured. Although adipocytes from both fat compartments were larger in obese subjects, no difference was observed in the size of omental vs subcutaneous fat cells. Lipoprotein lipase activity, expressed as a function of cell number, was significantly higher in omental than in subcutaneous fat tissue (P<.005). Basal lipolysis and lipolytic responses to isoproterenol, forskolin, or dibutyryl cyclic adenosine monophosphate, expressed either as a function of cell number or as a fold response over basal levels, were not significantly different in omental vs subcutaneous fat cells. When stratifying the sample in tertiles of waist circumference, adipocyte diameter was similar in the omental and subcutaneous depots for all adiposity values. Omental adipocyte size reached a plateau in the 2 upper tertiles of waist circumference, that is, from a waist circumference of 125 cm and above. Lipoprotein lipase activity was significantly higher in omental cells in the middle tertile of waist circumference (P=.05), and no regional difference was noted in lipolysis values across waist circumference tertiles. In conclusion, in normal-weight to morbidly obese men, although adipocyte size and lipolysis tended to increase with higher waist circumference, no difference was observed between the omental and subcutaneous fat depot.