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Background and Objective: This study aims to quantify bedside pleural procedures performed at a quaternary teaching hospital describing technical and epidemiological aspects., Materials and Methods: The authors retrospectively reviewed consecutive patients who underwent invasive thoracic bedside procedures between March 2022 and February 2023., Results: 463 chest tube insertions and 200 thoracenteses were performed during the study period. Most procedures were conducted by 1st-year Thoracic Surgery residents, with Ultrasound Guidance (USG). There was a notable preference for small-bore pigtail catheters, with a low rate of immediate complications., Conclusion: Bedside thoracic procedures are commonly performed in current medical practice and are significant in surgical resident training. The utilization of pigtail catheters and point-of-care ultrasonography by surgical residents in pleural procedures is increasingly prevalent and demonstrates high safety., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2024 HCFMUSP. Published by Elsevier España, S.L.U. All rights reserved.)

Purpose: Nurses routinely assess respiration of hospitalized children; however, respiratory rate measurements are technically difficult due to rapid and small chest wall movements. The aim of this study is to reveal the respiratory status of small children undergoing minor surgery with load cells placed under the bed legs, and to test the hypothesis that respiratory rate (primary variable) is slower immediately after arrival to the ward and recovers in 2 h., Methods: Continuous recordings of the load cell signals were performed and stable respiratory waves within the 10 discriminative perioperative timepoints were used for respiratory rate measurements. Apnea frequencies were calculated at pre and postoperative nights and 2 h immediately after returning to the ward after surgery., Results: Continuous recordings of the load cell signals were successfully performed in 18 children (13 to 119 months). Respiratory waves were appraisable for more than 70% of nighttime period and 40% of immediate postoperative period. There were no statistically significant differences of respiratory rate in any timepoint comparisons (p = 0.448), thereby not supporting the study hypothesis. Respiratory rates changed more than 5 breaths per minute postoperatively in 5 out of 18 children (28%) while doses of fentanyl alone did not explain the changes. Apnea frequencies significantly decreased 2 h immediately after returning to the ward and during the operative night compared to the preoperative night., Conclusion: Respiratory signal extracted from load cell sensors under the bed legs successfully revealed various postoperative respiratory pattern change in small children undergoing minor surgery., Clinical Trail Registration: UMIN (University Hospital Information Network) Clinical Registry: UMIN000045579 ( https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000052039 )., (© 2023. The Author(s) under exclusive licence to Japanese Society of Anesthesiologists.)

Background: Like many surgical subspecialties, there have been frequent advancements and discoveries in the field of hand and upper extremity surgery. With a rapidly growing literature base, it can be difficult to remain updated on the latest recommendations., Methods: A comprehensive literature search was completed on PubMed using MeSH terms. Topics included nutrition management, anticoagulation, immunosuppressive medication management, antibiotic use, skin preparation, splinting, tourniquet use, and suture choice. Data from articles with a level of evidence 1A-3 C were included., Results: A total of 42 articles were identified and reviewed to provide evidence for recommendations regarding various aspects of pre-, intra-, and post-operative care., Conclusions: The objective of this manuscript is to serve as a resource for evidence-based recommendations by the findings of recent evidence related to perioperative care in elective hand surgery. Additional studies are required in certain areas of the literature in order to provide stronger recommendations., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

This study assessed, for the first time, the expression of the genes hOGG1, TP53, and IL-6 in leukocytes by real-time quantitative polymerase chain reaction in surgical patients before (baseline), during (2 h of anesthesia) and 1 day after sevoflurane anesthesia. Additionally, DNA damage was detected by the comet assay, serum interleukin (IL)-6 was detected by flow cytometry, and differential leukocyte counting was also performed. TP53 and hOGG1 expression was downregulated on the day after anesthesia compared to before anesthesia. However, IL-6 expression did not change, and no DNA damage induction was observed during or after anesthesia. At the systemic level, mild neutrophilia and an increase in IL-6 levels occurred after anesthesia. Our findings suggest that sevoflurane anesthesia downregulates gene expression (hOGG1 and TP53) and contributes to an inflammatory status (increased systemic IL-6 and mild neutrophilia) but is not associated with DNA damage in patients without comorbidities who undergo minor elective surgery., (© 2023 Environmental Mutagenesis and Genomics Society.)

Background: Ambu AuraGain has proven to be better compared with other supraglottic airway devices in terms of higher first-attempt insertion success rate, time and ease of insertion, high oropharyngeal leak pressure, and fewer complications in children. The performance of the BlockBuster laryngeal mask has not been evaluated in children., Aims: The primary objective of this study was to compare the oropharyngeal leak pressure of the BlockBuster laryngeal mask with those of the Ambu AuraGain during controlled ventilation in children., Methods: Fifty children aged 6 months to 12 years with normal airways were randomized into group A (Ambu AuraGain) and group B (BlockBuster laryngeal mask). After administration of general anesthesia, an appropriate size supraglottic airway (size 1.5/2.0/2.5) was inserted according to the groups. Oropharyngeal leak pressure, success and ease of supraglottic airway insertion, gastric tube insertion, and ventilatory parameters were noted. The glottic view was graded by fiberoptic bronchoscopy., Results: Demographic parameters were comparable. The mean oropharyngeal leak pressure in the BlockBuster group (24.72 ± 6.81 cm H 2 O) was significantly higher than Ambu AuraGain group (17.20 ± 4.28 cm H 2 O) by 7.52 cm H 2 O (95% CI 4.27 to 10.76; p = 0.001). The mean time for supraglottic airway insertion in the BlockBuster and Ambu AuraGain group was 12.04 ± 2.55 s and 13.64 ± 2.76 s, respectively (mean difference- 1.6 s, 95% CI 0.09-3.12; p = 0.04). Ventilatory parameters, first-attempt supraglottic airway insertion success rate, and ease of gastric tube insertion were comparable between the groups. The BlockBuster group showed easy supraglottic airway insertion compared with the Ambu AuraGain group. The BlockBuster group had better glottic views with only the larynx seen in 23 out of 25 children compared to the Ambu AuraGain with only the larynx seen in 19 out of 25 children. No complication was noted in either group., Conclusions: We found that the BlockBuster laryngeal mask has higher oropharyngeal leak pressure compared with Ambu AuraGain in a pediatric population., (© 2023 John Wiley & Sons Ltd.)

Background: Surgery is a well-known risk factor for venous thromboembolism (VTE). However, for several minor surgical procedures, thromboprophylaxis is not advised., Objectives: These "low-risk" procedures include a wide variation of interventions for which we estimated the VTE risk to verify their "low-risk" status., Patients/methods: We used data from a large population-based case-control study (Multiple Environment and Genetic Assessment study) into causes of VTE, and linked these to the Dutch Hospital Data Registry to identify exposure to surgical procedures. Logistic regression was used to calculate odds ratios for the 90-day and 1-year relative risks of VTE following these procedures, which were adjusted for body mass index (BMI), sex, age, comorbidities, and infection/inflammation., Results: We included 4247 patients with VTE and 5538 control subjects. Median age and BMI were 48.5 years and 25.5 m 2 /kg, respectively. Nine unique procedures or groups of procedures were analyzed. One hundred twenty-three participants-90 cases and 33 controls-had undergone a minor procedure within 90 days of the index date, resulting in a 3.5-fold (OR, 3.5; 95% CI, 2.3-5.3) overall increased VTE risk. Furthermore, venous stripping (OR, 7.2; 95% CI, 2.4-21.2), open abdominal/inguinal hernia repair (OR, 3.7; 95% CI, 1.2-11.6), and laparoscopic cholecystectomy (OR, 3.2; 95% CI, 1.0-10.6) were associated with an increased risk. Other minor procedures were less strongly or not associated with an increased risk. In the 1-year period before the index date, all odds ratios were lower., Conclusion: Of the "low-risk" procedures, we found that venous stripping, open abdominal/inguinal hernia repair, and laparoscopic cholecystectomy were associated with a clearly increased risk of VTE within 90 postoperative days., (Copyright © 2022 International Society on Thrombosis and Haemostasis. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the risk of new persistent opioid use in opioid-naïve men who underwent male fertility procedures., Design: Retrospective cohort study using a claims database., Setting: A database linking electronic medical record data and claims-assessing men who underwent fertility procedures between 2010 and 2021., Patient(s): Opioid-naïve men who underwent fertility procedures (open or laparoscopic varicocelectomy, spermatocele excision, and testicular excisional or incisional biopsy) without further surgical intervention requiring anesthesia in the 2 years after the index procedure. Those with and without perioperative opioid prescriptions were propensity score matched on age, race/ethnicity, smoking status, mental health diagnoses, and preoperative pain diagnoses., Intervention(s): Perioperative opioid prescription., Main Outcome Measure(s): The primary outcome was the incidence of new persistent opioid use (opioid prescription 3-9 months after the index fertility procedure). The secondary outcome was prolonged opioid use (opioid prescription 9-24 months after the index fertility procedure)., Result(s): A total of 387,565 men who underwent fertility procedures were identified, of whom 25.1% received an opioid prescription. After propensity score matching, 97,215 men were included; 4.7% of men who received a perioperative opioid prescription developed new persistent opioid use compared with 2.2% of those without a perioperative opioid prescription (risk ratio, 2.16; 95% confidence interval, 2.05-2.27; number needed to harm, 39). When assessing each unique fertility procedure independently, men who received perioperative opioids had statistically higher odds of developing new persistent opioid use for all procedure types. Men with new persistent opioid use were much more likely to go on and develop prolonged opioid use than men without new persistent opioid use., Conclusion(s): Opioid prescription after male fertility procedures is associated with a significant risk of new persistent opioid use, emphasizing the importance of judicious opioid prescribing for male fertility procedures., (Copyright © 2022 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: To investigate minor procedures performed in general practice, to alleviate the burden on the economy, patients and secondary care physicians., Aims: To determine the range of minor surgical procedures performed in a single group general practice, subsequent referrals made to secondary care, follow-up surgical procedures required and post-operative complications within a patient group., Methods: Retrospective data collection from the electronic records of a single group general practice consisting of 5101 active patients within the previous 12 months. Through use of Socrates software program and statistical analysis, patients were stratified into demographics, including, age, gender, the cost of the procedure, the type of procedure being carried out, the post-operative referral rate to secondary care and any subsequent procedures required. The patients were excluded if their minor procedure was classified as a joint injection., Results: 133 procedures were carried out over the 12-month period. Of these patients, the majority were male, and the mean age was 44 years old. The most common procedures included the removal of ingrown toenails, lesion excisions and punch biopsies. Histological analysis was done on biopsies, with a low rate of misdiagnosis pre-operatively. Additionally, there were minimal referrals and no complications recorded., Conclusions: This study has demonstrated the ability for minor surgery to be safely carried out in primary care. The integration of general practice, general surgery and plastic surgery could provide a higher level of patient care and exchange of skills to help reduce waiting lists and alleviate the burden secondary care., (© 2022. The Author(s).)

Background and Objectives: Office-based minor surgery (OBMS) refers to all surgical procedures performed under local anesthetic in the office setting. It is cost effective for the health economy, safe, and appreciated by patients. It is not yet fully understood why some general practitioners (GPs) perform OBMS and others do not, while there is a growing demand for OBMS. Therefore, we explored factors that influence the performance of OBMS by GPs. The aim of this study is to explore the facilitators and barriers that influence GPs in deciding whether to perform OBMS., Methods: We performed a qualitative study using focus groups consisting of GPs and GP trainers. Two researchers analyzed the data independently., Results: The analysis resulted in a comprehensive list of facilitators and barriers. Besides already known factors such as financial consequences and geographic location, the most important factors influencing the decision to perform OBMS were training and the role of the GP trainer; fear of having to work alone and having to solve unexpected complications; and the influence of collaboration, organization, and facilities in the GP's own practice., Conclusions: The increasing demand for OBMS in primary care centers requires more attention to training aspects, the existing fear, adequate reimbursement for special accreditation, and collaboration and organization. We expect that addressing these factors will result in the strengthening of primary care, improving patient safety, lower referral rates, and a reduction in health care costs.

Background: Although opioids are effective for neonatal postoperative pain management, cumulative opioid exposure may be detrimental. Pain management practices vary among providers, but practice guidelines may promote consistency and decrease opioid use., Purpose: To develop a pain management guideline (PMG) for neonates undergoing minor surgical procedures with the overarching goal of reducing opioid use without compromising the pain experience. The specific aim was for neonatal intensive care unit providers to adhere to the PMG at least 50% of the time., Methods: An interdisciplinary pain and sedation work group in a large level IV neonatal intensive care unit developed an evidence-based PMG for minor surgical procedures. Nurses and providers were educated on the new guideline, and rapid cycle quality improvement methodology provided an opportunity to adjust interventions over 3 months., Results: The PMG was used for 32 neonates following minor surgical procedures: 18 (56%) of the neonates received only acetaminophen and no opioids, 32% required 0.15 mg/kg dose equivalent of morphine or less, and only 9% required more than 0.15 mg/kg dose equivalent of morphine. Overall, opioid use decreased by 88% compared with rates before implementation of the PMG. Providers adhered to the PMG approximately 83.3% of time., Implications for Practice: A PMG is a systematic approach to direct nurses and providers to appropriately assess, prevent, and treat neonatal pain following minor surgery while alleviating opioid overuse., Implications for Research: Future research should focus on determining and mitigating barriers to nurse/provider use of the PMG and developing and implementing a PMG for major surgical procedures., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 by The National Association of Neonatal Nurses.)

Purpose: The purpose of the study was to conduct validity and reliability testing of the Turkish version of the Parent Self-Efficacy Scale for Child Autonomy toward Minor Surgery (PSESCAMS)., Design: The research is a methodological study., Methods: Data were collected using an Introductory Form and the PSESCAMS. Factor analysis, Cronbach's alpha, and item-total score analysis were used for the data analysis., Findings: The scale consisted of 18 items and four subscales. The Cronbach's alpha coefficient for the overall scale was 0.95, and the Cronbach's alpha values for the subscales were 0.64-0.92. The total factor loading was > 0.45 for both exploratory and confirmatory factor analyses. GFI, AGFI, and CFI were > 0.90, RMSEA was 0.06., Conclusion: PSESCAMS was found to be a valid and reliable measurement tool for Turkish culture., (Copyright © 2021 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to review the rate and type of infectious complications after surgical fixation of hand fractures managed under wide-awake local anesthesia with no tourniquet (WALANT) in minor procedure rooms outside the main operating room., Methods: A two-surgeon retrospective chart review was performed of patients who received surgical fixation of hand fractures under WALANT in minor surgery from March of 2014 to March of 2019., Results a Total of: patients, with distal phalanx ( n = 16), middle phalanx ( n = 7), proximal phalanx ( n = 11), or metacarpal ( n = 26) fractures, were included in the study. The average patient age was 37 years, with a higher proportion of male patients (51:7). Two patients had two fractures each. Thirty of the 58 cases were already open fractures. Fixation was performed using either plates and screws (25 of 58) or nonburied Kirschner wires (31 of 58). Thirty-six percent of patients (21 of 58) were treated with prophylactic antibiotics. One patient developed postoperative cellulitis. The only case of osteomyelitis occurred in a patient with risk factors known to increase rates of infectious complications (open fracture, smoking history, and >24 hours from injury to treatment). No infectious complications occurred in those who sustained closed fractures., Conclusions: Although the minor surgery environment varies significantly from that of the main operating room, infection rates after surgical fixation of hand fractures using WALANT in this setting remain low (3.4 percent), with no documented infections in fractures that were referred closed and opened surgically for operative fixation., Clinical Question/level of Evidence: Therapeutic, IV., Competing Interests: Disclosure : The authors have no financial or conflicts of interest to declare in relation to the content of this article., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Objectives: We aimed to assess general practice (GP) trainees' self-perception of surgical competencies and to explore longitudinal effects of a compact intervention., Design: We performed a mixed-methods study including a before and after comparison in the intervention group (IG), a comparison of attendees and non-attendees (control group (CG)) and a qualitative evaluation of the intervention. Competencies were self-assessed through surveys. Semi-structured interviews were performed after 9 months., Setting: In 2019, a 2-day voluntary seminar focussing on minor surgery/injuries was offered on 13 occasions by educators from KWBW Verbundweiterbildung plus ( Competence Centre for Postgraduate Medical Education Baden-Württemberg )., Participants: All enrolled GP trainees were offered participation. GP trainees who did not attend a seminar (non-attendees) were recruited for CG after the 13th intervention., Intervention: Attendees took part in an interactive, GP-oriented short course incorporating 270 min of focused minor surgery/injuries training (compact intervention) on the second day of the 2-day seminar., Results: 326 GP trainees (IG: n=257; CG: n=69) participated in the study. 17 attendees were interviewed. CG had more often experienced a surgical rotation (p=0.03) and reported higher interest in performing minor surgery in future practice (p=0.03). GP trainees self-rated their all-round competency in minor surgery as average (IG: 3.0±1.0, CG: 3.2±0.9, IG:CG p=0.06). After the intervention, attendees felt that surgical skills should be a core component of GP vocational training (p=0.05). After 9 months, attendees remembered a variety of content and valued the interactive, case-oriented, peer-to-peer approach in a mixed learning group. Some attendees reported they had started to overcome competency gaps in minor surgery., Conclusions: A compact intervention in minor surgery provides an 'intense' stimulus which could foster positive attitudes towards minor surgery and promote longitudinal personal development of related competencies in GP trainees, including those with little interest in surgery. Such measures appear crucial to support individual progress of GP trainees to provide comprehensive primary care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: This trial was conducted to compare effects of continuing versus withholding single-pill combination tablets consisting of angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) on perioperative hemodynamics and clinical outcomes., Methods: Patients undergoing minor abdominal or urological surgery (n = 106) were randomly assigned to Group C, in which ARB/CCB combination tablets were continued until surgery, or Group W, in which they were withheld within 24 h of surgery. Perioperative hemodynamics and clinical outcomes were compared between the Groups., Results: The incidence of hypotension during anesthesia requiring repeated treatment with vasoconstrictors was higher in Group C than Group W (p = 0.0052). Blood pressure during anesthesia was generally lower in Group C than Group W (p < 0.05) despite significantly more doses of ephedrine and phenylephrine administrated in Group C (p = 0.0246 and p = 0.0327, respectively). The incidence of postoperative hypertension did not differ between Groups (p = 0.3793). Estimated glomerular filtration rate (eGFR) on the preoperative day did not differ between Groups (p = 0.7045), while eGFR was slightly lower in Group C than Group W on the first and third postoperative days (p = 0.0400 and p = 0.0088, respectively), although clinically relevant acute kidney injury did not develop., Conclusions: Continuing ARB/CCB combination tablets preoperatively in patients undergoing minor surgery increased the incidence of hypotension during anesthesia, increased requirements of vasoconstrictors to treat hypotension, and might deteriorate postoperative renal function, albeit slightly. These results suggest that withholding ARB/CCB tablets preoperatively is preferable to continuing them., Clinical Trial Registration: This trial is registered with the Japan Registry of Clinical Trials (jRCT) at Japanese Ministry of Health, Labour, and Welfare (Trial ID: jRCT1031190027)., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Background: Although routine coagulation tests, such as prothrombin time (PT) and activated partial thromboplastin time (aPTT) are performed before surgery to identify the risk of perioperative bleeding, bleeding complications are rare in minor surgeries, and false-positive results are often observed. Therefore, this study aimed to analyze the common causes of abnormal results of preoperative coagulation tests in previously healthy children undergoing elective minor surgery and determine the usefulness of performing these tests. Additionally, it aimed to identify the distribution of factor XII activity in children with prolonged aPTT., Methods: The medical records of 363 pediatric patients aged 0 - 18 years, who were referred to the pediatric hematology-oncology department due to abnormal preoperative coagulation tests prior to undergoing minor surgery at the Kyung Hee University Medical Center between March 2008 and October 2020, were retrospectively review-ed., Results: The majority of patients (n = 348, 96%) had prolonged aPTT, few (n = 29, 8%) had a prolonged PT international normalized ratio, and a small number (n = 14, 4%) had both prolonged PT and aPTT. On repeating the coagulation tests, 194 children showed persistent abnormal results. Of these, 184 patients underwent mixing tests, and 176 showed correction for factor deficiency (n = 26) and lupus anticoagulant positive (n = 14). Factor deficiencies included factor XII (n = 16), possibility of von Willebrand disease (vWD; n = 4), factor XI (n = 2), factor VIII (n = 1), factors IX and XII (n = 1), factor VII (n = 1), and factor V (n = 1). The severity of factor deficiency was mild (25 - 38%). One patient with factor VII deficiency received preoperative clotting factors but had postoperative bleeding requiring clotting factor replacement. Another patient with possible vWD received fresh frozen plasma after surgery and had mild symptoms. Linear regression showed no significant correlation between factor XII activity and aPTT in patients with prolonged aPTT (R2 = 0.0002, p = 0.84) or factor XII activity according to aPTT results in those with factor XII deficiency (R2 = 0.04749, p = 0.40)., Conclusions: These results suggest that coagulation tests may be selectively performed in previously healthy children undergoing minor surgery with positive bleeding and/or family history. The distribution of factor XII should be investigated further.

Background: There are limited published data regarding the incidence and risk factors for infection after minor dermatologic procedures, such as skin biopsy, shave, and curettage. Prior studies of infection risk after dermatologic procedures have often not specified the method of preparation of local anesthetic., Objective: To assess the incidence and risk factors for infection after minor procedures performed in a general dermatology clinic using buffered lidocaine prepared in office., Materials and Methods: In this retrospective case-control study, the medical record was searched for cases of infection after skin biopsies, shaves, conventional excisions, and destructions performed in a general dermatology clinic over a 4-year period. Patient and procedure characteristics were compared with uninfected controls., Results: Of 9,031 procedures performed during the study period, there were 34 infections (0.4%). The odds of infection for procedures on the arm and leg were 5.29 and 9.28 times higher, respectively, than those on the head/neck. There was no significant effect of age, sex, smoking, immunosuppression, diabetes, or anticoagulation., Conclusion: The incidence of infection is low after minor dermatologic procedures performed with local anesthesia using buffered lidocaine prepared in office. There is a higher risk of infection on the arm and leg compared with the head and neck., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Recombinant factor IX fusion protein concentrate (rFIXFc) is increasingly used for prophylaxis in people with haemophilia B (PWHB), but experience in the perioperative setting is limited., Aims: To evaluate real-world perioperative factor usage, bleeding and complications in PWHB (≥18 years) who received rFIXFc for surgical haemostasis and to describe the treatment regimens used., Methods: Single centre, retrospective review of all PWHB who underwent a major or minor surgical procedure between June 2017 and July 2020 and received rFIXFc perioperatively for maintenance of surgical haemostasis., Results: A total of 56 PWHB (45 male and 11 female), including people with mild (n = 32), moderate (n = 4) and severe (n = 20) haemophilia B, underwent 11 major and 131 minor procedures with rFIXFc for surgical haemostasis. Haemostasis was rated as excellent (9/11) or good (2/11) in all major procedures. Median total rFIXFc consumption for orthopaedic surgeries was 972 IU/kg (range 812-1031 IU/kg) and for other major (non-orthopaedic) surgeries was 323 IU/kg (range 167-760 IU/kg). The median number of perioperative rFIXFc infusions was 19 (range 17-26) for orthopaedic surgery and 7 (range 5-17) for other major surgeries. The number of infusions in the postoperative period was determined by procedure and patient factors. Complications included bowel ileus and wound infection. Most minor procedures were managed with single infusion of rFIXFc, with no bleeding complications in 95% of minor procedures. There were no thromboembolic events or inhibitor formation., Conclusion: This unique data provides real-world evidence that rFIXFc is safe and effective in achieving haemostasis in PWHB undergoing surgery., (© 2021 The Authors. Haemophilia published by John Wiley & Sons Ltd.)

Objective: A resident-run minor surgery clinic was developed to increase resident procedural autonomy. We evaluated whether 1) there was a significant difference between complications and patient satisfaction when procedures were independently performed by surgical residents vs. a surgical attending and 2) if participation was associated with an increase in resident procedural confidence., Design: Third year general surgery residents participated in a weekly procedure clinic from 2014-2018. Post-procedure complications and patient satisfaction were compared between patients operated on by residents vs. the staff surgeon. Residents were surveyed regarding their confidence in independently performing a variety of clinic-based patient care tasks., Setting: Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program., Participants: Post-graduate year three general surgery residents that ran the clinic as part of a general surgery rotation., Results: 1230 patients underwent 1592 procedures (612 in resident clinic, 980 in attending clinic). There was no significant difference in the 30-day complication rate between patients operated on by the resident vs. attending (2.5% vs. 1.9%, p = 0.49). 459 patient satisfaction surveys were administered with a 79.1% response rate. There was no significant difference in the overall quality of care rating between residents and the attending surgeon (87.5% top-box rating vs. 93.1%, p = 0.15). Twenty-one residents completed both a pre- and post-rotation survey (77.8% response rate). The proportion of residents indicating that they could independently perform a variety of patient care tasks significantly increased across the rotation (all p < 0.05)., Conclusion: Mid-level general surgery residents can independently perform office-based procedures without detriment to safety or patient satisfaction. The resident-run procedure clinic serves as an environment for residents to grow in confidence in both technical and non-technical skills. Given the high rate at which patients provide resident feedback, future work may investigate how to best incorporate patient derived evaluations into resident assessment., Competing Interests: DECLARATIONS OF COMPETING INTEREST None., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Children often require anesthesia for simple diagnostic and therapeutic procedures. The aim of this study was to evaluate the feasibility of using virtual reality (VR) to reduce sedation in children undergoing minor surgical procedures., Method: In this prospective, non-randomized clinical trial, pediatric patients at a free-standing children's hospital undergoing hormone implant placement, removal, or exchange were recruited to use VR and local anesthesia instead of procedural sedation or general anesthesia (GA). Patients were enrolled between November 2017 and March 2020, and were compared to historic controls who underwent similar procedures without VR between April 2016 and February 2020. Primary outcome measure was successful procedure completion without sedation or GA. Secondary measures included assessments of pain, fear and anxiety, patient compliance, procedural and recovery times., Results: Twenty-eight patients underwent 29 procedures with VR. Hormone implants (72%), removals (7%), or exchanges (21%) were completed without GA, sedation or IV placement. Procedure lengths and pain scores were similar between VR patients and historic controls, but recovery times were significantly shorter in VR patients (18 vs 65 min, p < 0.001). Participant satisfaction scores were high, with 95% recommending VR to others., Conclusions: VR is a feasible alternative to sedation or GA for select pediatric patients undergoing minor surgical procedures., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: To assess the risk of postoperative SARS-CoV-2 infection during the COVID-19 pandemic., Methods: The CONCEPTION study was a cohort, multidisciplinary study conducted at Conception University Hospital, in France, from March 17th to May 11th, 2020. Our study included all adult patients who underwent minor surgery in one of the seven surgical departments of our hospital: urology, digestive, plastic, gynecological, otolaryngology, gynecology or maxillofacial surgery. Preoperative self-isolation, clinical assessment using a standardized questionnaire, physical examination, nasopharyngeal RT-PCR and chest CT scan performed the day before surgery were part of our active prevention strategy. The main outcome was the occurrence of a SARS-CoV-2 infection within 21 days following surgery. The COVID-19 status of patients after discharge was updated during the postoperative consultation and to ensure the accuracy of data, all patients were contacted again by telephone., Results: A total of 551 patients from six different specialized surgical Departments in our tertiary care center were enrolled in our study. More than 99% (546/551) of included patients underwent a complete preoperative Covid-19 screening including RT-PCR testing and chest CT scan upon admission to the Hospital. All RT-PCR tests were negative and in 12 cases (2.2%), preoperative chest CT scans detected pulmonary lesions consistent with the diagnosis criteria for COVID-19. No scheduled surgery was postponed. One patient (0.2%) developed a SARS-CoV-2 infection 20 days after a renal transplantation. No readmission or COVID-19 -related death within 30 days from surgery was recorded., Conclusions: Minor surgery remained safe in the COVID-19 Era, as long as all appropriate protective measures were implemented. These data could be useful to public Health Authorities in order to improve surgical patient flow during a pandemic., Competing Interests: The authors have declared that no competing interests exist.

Mohs micrographic surgery is a specialized form of skin cancer surgery that has the highest cure rates for several cutaneous malignancies. Certain skin cancers can have small extensions or "roots" that may be missed if an excised tumor is serially cross-sectioned in a "bread-loaf" fashion, commonly performed on excision specimens. The method of Mohs micrographic surgery is unique in that the dermatologist (Mohs surgeon) acts as both surgeon and pathologist, from the preoperative considerations until the reconstruction. Since Dr. Mohs's initial work in the 1930s, the practice of Mohs micrographic surgery has become increasingly widespread among the dermatologic surgery community worldwide and is considered the treatment of choice for many common and uncommon cutaneous neoplasms. Mohs micrographic surgery spares the maximal amount of normal tissue and is a safe procedure with very few complications, most of them managed by Mohs surgeons in their offices. Mohs micrographic surgery is the standard of care for high risks basal cell carcinomas and cutaneous squamous cell carcinoma and is commonly and increasingly used for melanoma and other rare tumors with superior cure rates. This review better familiarizes the dermatologists with the technique, explains the difference between Mohs micrographic surgery and wide local excision, and discusses its main indications., (Copyright © 2021 Sociedade Brasileira de Dermatologia. Published by Elsevier España, S.L.U. All rights reserved.)

Aim: Minor Surgery (MS) is an ever-increasing programmed activity in Primary Health Care Centres (PHC). The aim of this study is to establish the clinical and histopathology diagnostic agreement between PHC and MS and evaluating the efficacy of this activity., Methods and Materials: A retrospective, observational, and reliability study was performed. A total of 234 patient specimens were sent to Histopathology between January 2014 and December 2018 in basic health area of San Benito-La Laguna, Santa Cruz de Tenerife. Of these, 203 specimens met criteria, with 31 being excluded due to death or absence of diagnosis. Sociodemographic and diagnostic variables were analysed, and 10 possible diagnoses were grouped into 3 categories according to their nature. Cohen kappa coefficient was used as the main evaluation measure., Results: The majority of specimens were obtained from women (51.2%), and the mean age was 52.82±17.82 years. The most frequently referred lesion was the epidermoid cyst (20.2-21.67%). A clinical-pathological agreement of 60% was obtained in Minor Surgery, with a specificity of 98.3% and a sensitivity of 61.9%. In Primary Care agreement was 36.1%, with a specificity of 98.4% and a sensitivity of 42.8%. Infectious lesions represented the largest concordance difference obtained, with 27% less in Primary Care compared to Minor Surgery., Conclusions: Minor Surgery is an effective support in the initial diagnosis of lesions referred for evaluation at Primary Care. However, it is necessary to implement improvements in diagnostic efficacy of Primary Care., (Copyright © 2020 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Intervertebral disc changes are a multi-factorial problem whose main clinical feature is pain. Studies show that when clinical treatments fail, the proposed surgical treatments frequently present unsatisfactory results. Traditional lumbar arthrodesis causes important clinical and functional changes that can result in complications and jeopardize the patients' quality of life., Objectives: This study aims to investigate the clinical and functional results of minimally invasive spine surgery in patients with a clinical diagnosis of low-back or sciatic pain and segmental instability, finally correlating these results with the patients' return to work., Methods: Patients signed an informed consent form and were clinical and radiographically re-evaluated by independent professionals in the pre- and postoperative periods. Evaluation methods used the Oswestry disability index, as well as visual analog scale and Medical Outcomes Short Form Health Survey (SF-36) scores. We also retrieved epidemiological data, information on work resumption, and bone consolidation evaluations from the medical records., Results: We evaluated 19 patients who had been operated on 33 levels; visual analog scale and Oswestry disability index scores were initially reduced from 10% to 2% and from 64% to 28%, respectively. SF-36 scores were significantly higher in 5 of the 7 questionnaire scales at the end of the follow-up period. Most patients (68.4%) did not return to work after surgery; the others returned 2 to 67 months after the procedure. All patients received social security benefits after the surgery., Conclusion: Although the procedure presented positive results, it did not result in a satisfactory return-to-work rate. Our results should be analyzed in view of the low educational level and income of the patients, the manual nature of their labor, and the validity of social security benefits.

Background and objectives: The laryngeal mask is the method of choice for airway management in children during minor surgical procedures. There is a paucity of data regarding optimal management of mechanical ventilation in these patients. The Supreme™ airway laryngeal mask offers the option to insert a gastric tube to empty the stomach contents of air and/or gastric juice. The aim of this investigation was to evaluate the impact of positive end-expiratory positive pressure (PEEP) levels on ventilation parameters and gastric air insufflation during general anesthesia in children using pressure-controlled ventilation with laryngeal mask. Materials and Methods: An observational trial was carried out in 67 children aged between 1 and 11 years. PEEP levels of 0, 3 and 5 mbar were tested for 5 min in each patient during surgery and compared with ventilation parameters (dynamic compliance (mL/cmH 2 O), etCO 2 (mmHg), peak pressure (mbar), tidal volume (mL), respiratory rate (per minute), FiO 2 and gastric air (mL)) were measured at each PEEP. Air was aspirated from the stomach at the start of the sequence of measurements and at the end. Results : Significant differences were observed for the ventilation parameters: dynamic compliance (PEEP 5 vs. PEEP 3: p < 0.0001, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001), peak pressure (PEEP 5 vs. PEEP 3: p < 0.0001, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001) and tidal volume (PEEP 5 vs. PEEP 3: p = 0.0048, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001). All parameters increased significantly with higher PEEP, with the exception of etCO 2 (significant decrease) and respiratory rate (no significant difference). We also showed different values for air quantity in the comparisons between the different PEEP levels (PEEP 5: 2.8 ± 3.9 mL, PEEP 3: 1.8 ± 3.0 mL; PEEP 0: 1.6 ± 2.3 mL) with significant differences between PEEP 5 and PEEP 3 ( p = 0.0269) and PEEP 5 and PEEP 0 ( p = 0.0209). Conclusions : Our data suggest that ventilation with a PEEP of 5 mbar might be more lung protective in children using the Supreme™ airway laryngeal mask, although gastric air insufflation increased with higher PEEP. We recommend the use of a laryngeal mask with the option of inserting a gastric tube to evacuate potential gastric air.

Little is known regarding the factors associated with surgical antibiotic prophylaxis (SAP) compliance in elective minor surgery. The purposes of this cross-sectional study were to identify the frequency of inappropriate SAP administration and to understand the characteristics associated with such inappropriateness in a sample of elective minor surgical procedures. The study was performed between May and July 2019 among a random sample of patients aged 18 years and older in seven public hospitals randomly selected in the Campania and Calabria Regions of Italy. Globally, only 45% of SAP approaches were deemed completely in accordance with the evidence-based guidelines. Patients with an ordinary admission, those who underwent local anesthesia, those receiving plastic and reconstructive and ophthalmology surgery, and those who had not received a prosthetic implant were more likely to receive an appropriate SAP approach; those receiving obstetrics, gynecological, and urological surgical procedures were less likely than those who underwent abdominal, vascular, and breast surgery. The course of antibiotic prophylaxis was not consistent with the guidelines in 48.5% procedures with one or more reasons for inappropriateness. Appropriate time of the SAP administration was more frequently observed in patients who were older, those with a Charlson comorbidity index of 0, those who did not receive a prosthetic implant, and those receiving plastic and reconstructive surgery; it was less likely in patients receiving obstetrics, gynecological, and urological surgeries compared with those who underwent abdominal, vascular, and breast surgery. Aspects of SAP that need to be improved are molecule choice, time of administration, and specific surgical procedures. Hospital managers should involve surgeons and anesthesiologists in initiatives tailored to optimize SAP prescribing.

Background: It is reported that medical students do not receive adequate opportunities to learn surgical skill and are at risk of being unable to perform simple surgical procedures safely. The usefulness of peer-assisted learning (PAL) as a tool to assist in delivering surgical skills training is worth exploring., Methods: This is a randomised single blinded controlled trial. Fourth-year students from the university's Surgical Society were asked to volunteer as peer tutors and those in 3rd-year were asked to undertake surgical skills training. A cohort of 35 students were selected and randomised to receive basic surgical skills training conducted either by faculty members or peers. The students' performance of basic suturing skills was assessed using a checklist, through directly observed procedural skills (DOPS) technique. The assessment was conducted by faculty blinded to the training. Students' perception to surgical skills training was assessed using a questionnaire survey., Results: The suturing and knotting skills of students learned from their peers was comparable to that acquired from faculty. The students' perceived that their peers could conduct surgical skills training similar to their faculty., Conclusion: PAL approach for basic surgical skills training is as effective as faculty-led training. PAL has the potential to optimise the delivery of surgical skills training in undergraduate medical education., Competing Interests: Conflict of Interest None., (© Penerbit Universiti Sains Malaysia, 2020.)

Background: In Japan, even if physicians have not experienced surgical training, they face many instances in which they must provide initial surgical treatment, especially during off-hours. This study aimed to identify the frequency and fields of commonly encountered problems in a Japanese emergency department., Methods: A retrospective review was performed to identify walk-in outpatients with exogenous problems visiting during off-hours in the Japanese educational hospital providing primary to tertiary emergency care between January 1 and December 31, 2014. Diseases were aggregated according to International Classification of Primary Care (Second Edition; ICPC-2)., Results: During the study period, 33 424 patients visited and 7476 were classified into the "exogenous" group. We analyzed the data of 7421 patients after excluding 55 who were deemed undiagnosable based on reviews of the charts. The median age of patients who visited the ED during off-hours was 29 years (range: 0-101 years, IQR: 8-60 years). Altogether, 226 types of problems included in ICPC-2 were identified during the study period. The majority fields of exogenous problems were 'skin,' 'Musculoskeletal,' and 'eye.' The 15 problems with the highest frequencies accounted for 50.2% of the total problems., Conclusions: We identified surgical problems with high treatment frequencies among patients visiting the ED during off-hours. Providing education focusing on these frequent surgical problems can help to improve the initial treatment quality and reduce the anxiety for those doctors who provide initial surgical treatment., Competing Interests: 7The authors have stated explicitly that there are no conflicts of interest in connection with this article., (© 2020 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

Background: The provision of minor surgical services is an established part of the task profile of general practitioners (GPs) in many countries in Europe and elsewhere. This study aimed to collect data on the clinical process and outcomes for specified minor surgical procedures undertaken in Irish general practice by GPs experienced in minor surgery in order to document the scope and safety of minor surgery being undertaken., Methods: Over a six-month period, 24 GPs in 20 practices recorded data on a pre-determined list of procedures undertaken in adults (aged 18 and older); procedures for ingrown toenails were also recorded for those aged 12-18 years. Clinical data were rendered fully anonymous by the participating GPs, entered onto the Excel database template and returned to the project team monthly., Results: On average, each practice undertook 212 procedures in a six-month period. The four most frequent procedures include two relatively non-invasive procedures (cryosurgical ablation of skin lesions and aspiration and/or injection of joints) and two more invasive procedures (full thickness excision of skin lesion and shave, punch or incisional biopsy). Overall, 83.8% of relevant specimens were submitted for histology. Combining benign and malignant cases, there was an overall 87% clinical and histological concordance; 85% of malignancies were suspected clinically. A complication was recorded in 0.9% after 1 month., Conclusions: Irish GPs with experience in minor surgery can provide a range of surgical services in the community safely.

Preoperative anxiety has been studied in different medical disciplines, but it is unknown in minor surgical procedures such as foot nail surgery. This study aimed to determine the prevalence of preoperative anxiety and postoperative pain in foot nail surgery. The validated Amsterdam preoperative anxiety and information scale (APAIS) was used to evaluate preoperative anxiety and the need for information in 155 patients undergoing foot nail surgery. In addition, a questionnaire was used to collect other variables such as age, sex and educational level. The verbal numeric scale was employed to value the postoperative pain after 24 h. Age and sex influenced ( p < 0.05) preoperative anxiety, which had a prevalence of 22.6%. More than 43% of patients needed more information and this was correlated with anxiety (r = 0.629; p < 0.001). There was a significant difference when comparing the total anxiety between the group of participants who had more pain and that who had less pain ( p < 0.001). The prevalence of anxiety was high in the participants of this study, being greater in young patients and in women. There was a deficit of information, increasing the level of preoperative anxiety, which in turn was related with greater postoperative pain., Competing Interests: The authors declare no conflicts of interest.

Background and Objectives: Academic medical centers (AMC) are among some of the most expensive places to provide care. One way to cut costs is by decreasing unnecessary referrals to specialists for procedures that can be provided by well-trained primary care physicians. Our goal is to measure the financial impact of an office-based minor procedure service driven entirely by family physicians., Methods: We examined claims data for procedures performed on patients insured under our AMC's home-grown accountable care organization-style health plan (Stanford Health Care Alliance [SHCA]). Descriptive statistics was used to compare the volume and cost of procedures performed by family medicine (FM) versus specialty care (SC). We preformed a subanalysis of SC procedures to explore the degree to which consultation and facility fees increased costs for SC. We used mathematical modeling to estimate the impact on cost of care if procedures were shifted from SC to FM and to calculate a return on investment (ROI)., Results: Our data set examined 6,974 outpatient procedures performed on SHCA patients from 2016-2018 at a cost of $5,263,720 to SHCA. FM performed 6% of procedures at an average cost of $236 per procedure, while SC performed 94% of procedures at an average cost of $787 per procedure. FM saved money for all 12 types of skin, musculoskeletal, and reproductive procedures assessed; the average saved per procedure was $551. This represents a 70% cost savings. ROI was 2.33; for every $1 spent on FM procedures, SHCA saved $2.33., Conclusion: A family medicine minor procedure service significantly lowered health spending at our AMC.

Aims To assess the quality of information targeting lay people regarding post-operative instructions after minor oral surgery (MOS), and to determine the level of evidence of any scientific articles cited in the instructions.Design and setting A dynamic Internet-based cross-sectional study.Materials and methods An Internet search for professional organisations/specialist dental societies in ten English-speaking countries with a search of their websites was conducted to locate post-operative instructions. Where not readily available, these were requested from each respective organisation/society. Reliability and quality of the instructions were assessed using the DISCERN instrument. Evidence level of cited articles was analysed using the Joanna Briggs Institute Levels of Evidence.Results Of the 59 identified organisations/societies, 26 sets of instructions were assessed. Overall quality of information was low, represented by median scores of 45%, 42.9% and 42.7% for reliability, quality of information and total DISCERN score, respectively. Only two instructions cited articles to support their content; these were of moderate-low level evidence.Conclusion Post-operative instructions following MOS that target the lay public have low quality and cite articles of moderate-low level evidence to support their content. Peak organisations should ensure such content is easily locatable, of high quality and is supported by high-level evidence.

Context: Before surgery, people can become concerned about risks that may arise, experiencing fear and stress. It is possible to implement nonpharmacological interventions to reduce fear and preoperative stress using expressive arts, including music therapy., Objective: The aim of this study was to assess the effectiveness of live harp music and compare it with that of recorded harp music in reducing preoperative stress and fear and changes in blood pressure (BP) and heart rate (HR)., Design: The study was a pilot study, with a quasi-experimental design., Setting: The study took place in a surgery unit's clinic, held weekly, in a teaching hospital in Milan, Italy., Participants: Participants were 46 people undergoing day surgery, divided into 2 groups: 24 in the intervention group and 22 in the control group. No one dropped out of the study., Intervention: The intervention group listened to live harp music and the control group listened to recorded harp music, immediately before a surgical intervention. The research team had defined a musical protocol based on the theoretical principles of harp therapy., Outcome Measures: Before and after the musical intervention, the research team investigated each patient's level of fear and stress, using the same self-evaluation questionnaire (HR) and blood pressure (BP)., Results: Of the 46 participants, 46% were male, and 54% were female. Fear values were reduced significantly and in equal measure in the intervention (P = .001) and control (P = .0001) groups. The live harp music was more effective in reducing HR (P = .001) and diastolic BP (P = .007), than was recorded harp music, with P = .151 and P = .164, respectively. Based on the results, the research team determined that a randomized controlled trial (RCT) would require 90 patients for both the intervention and control groups., Conclusions: Harp therapy brought benefits by significantly reducing fear and stress and HR and BP. It would be useful to perform a multicenter RCT to confirm these results.

Objective  This paper aims to evaluate patients with articular calcaneal fractures treated with a minimally invasive surgical technique between January 2015 and August 2016, with emphasis on radiographic results. Methods  Retrospective study of 49 patients with 64 displaced calcaneal fractures treated with open reduction by minimal lateral access to the subtalar joint and minimal fixation. Pre- and postoperative radiographic studies were performed to measure the angles of Böhler and Gissane. Results  The average angle of Böhler before surgery was 2.5°, increasing to an average value of 25.3° after the minimally invasive surgical treatment. The average angle of Gissane before surgery was 136.3°, decreasing to an average value of 114.3° after the procedure. Conclusion  The minimally invasive surgical technique improves the radiographic parameters of intra-articular calcaneal fractures, with appropriate anatomical restoration of anatomical shape., Competing Interests: Conflitos de Interesse Os autores declaram não haver conflitos de interesse.

Background and Objectives: In this retrospective report the aim was to present the experience about bleeding characteristics and management of minor surgeries in rare bleeding disorders (RBDs)., Methods: Twenty-six patients were included; with Factor (F) V, FV+VIII, VII, FXI deficiency and afibrinogenemia. Six of the patients were asymptomatic., Results: Fifty-three percent of the patients suffered from mucosal bleeding. Life-threatening bleedings were observed only in the patients with afibrinogenemia and good hemostatic control could only be provided with plasma-derived (pd)-fibrinogen concentrate. Twelve of the patients had undergone 17 minor surgeries. In the patients with FVII and FXI deficiencies with plasma F:C activity between 20-47%, there was a history of uneventful tooth extractions, circumcisions and a pilonidal sinus operation performed without any replacement treatment, whereas one patient with plasma F:C activity of FVII 47% had a history of poor hemostatic control during an adeno-tonsillectomy operation. Although some of these patients were asymptomatic to be on the safe side, minor operations were performed with preoperative administration of one dose of (pd)-fibrinogen concentrate to one afibrinogenemia patient, recombinant active FVII (rFVIIa) to 2 FVII deficient patients and fresh frozen plasma (FFP) to 3 FXI deficient and 1 FVII deficient patients plus postoperatively tranexamic acid (TXA) for 5-7 days. Only with one dose of the replacement therapy just before surgeries good hemostatic control was achieved and none of them had bleeding neither during nor after the surgeries., Conclusion: We suggest that minor operations must be performed with preoperative replacement therapies plus 5-7 days of antifibrinolytics under close observation of the hematologist and the surgeon.

Background: The opioid abuse epidemic has highlighted the risks associated with these medications., Objective: To determine whether filling a postoperative opioid prescription after low acuity urologic surgery is associated with new persistent opioid use., Design, Setting, and Participants: A retrospective cohort study was conducted using linked administrative data from Ontario, Canada. Participants were adults who underwent their first vasectomy, transurethral prostatectomy, urethrotomy, circumcision, spermatocelectomy, or hydrocelectomy between 2013 and 2016. We excluded men with prior opioid use, confounding concurrent procedures, prolonged hospitalization, or cancer., Intervention: Whether the patient filled a prescription for an opioid within 5 d of their surgery., Outcome Measurements and Statistical Analysis: The primary outcome was evidence of at least two opioid prescriptions filled 9-15 mo after urologic surgery. The secondary outcome was admission for opioid overdose. Primary analysis was adjusted logistic regression analysis., Results and Limitations: We identified 91 083 men, most of whom underwent vasectomy (78%). A total of 32 174 (35%) men filled a prescription for an opioid after their procedure. The most common opioid prescribed was codeine (70%), and urologists were the primary prescribers (81%). Men who filled a postprocedure opioid prescription did not differ, for most of the 57 medical comorbidities or markers of healthcare utilization that we measured, from those who did not fill an opioid prescription. There was long-term opioid use in 1447 (1.6%); men who had filled a postoperative opioid prescription had a significantly higher risk of long-term opioid use (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.3-1.6) and opioid overdose (OR 3.0, 95% CI 1.5-5.9). A limitation is that we could not determine the indication for long-term opioid prescriptions., Conclusions: Prescription of opioids after low acuity urology procedures is significantly associated with increased opioid use at 1yr after surgery; efforts should be made to reduce postoperative opioids, especially for urologic procedures that do not typically require opioids., Patient Summary: Filling an opioid prescription after minor urologic surgeries is associated with an increased risk of persistent long-term use of opioid medications and a higher risk of serious long-term complications such as hospital visits for an opioid overdose.', (Copyright © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objectives To assess the appropriateness of oral surgery referrals, after triage, to intermediate minor oral surgery (IMOS) practices in East Kent and whether or not referrals vary according to the referring general dental practitioner's (GDP's) place of qualification and experience.Design A retrospective study of the records of 441 triaged referrals sent to three IMOS practices in East Kent, over a ten-week period. An assessment tool was developed in line with local and national referral guidelines. Information on all referrals was obtained from the IMOS provider and referral records. Descriptive analysis of the data was performed.Results The most common reason for referral was for extraction of teeth requiring bone removal (n = 155; 35%). However, the majority of teeth removed were recorded as a non-surgical extraction (n = 363; 82%). Medical histories were included appropriately in the referral communications, with only 0.2% of all referrals being inappropriate. The proportion of appropriate and inappropriate referrals was very similar and it was found that referral rate was lower from dentists who had been qualified for more than ten years. GDPs working in the same location as the IMOS provider made a greater total number of referrals as well as more inappropriate referrals.Conclusions In the group of GDPs and IMOS providers studied, a wide variation was observed between the GDP's reason for referral and the treatment provided. It may be concluded that the vast majority of extractions were safely completed in an IMOS dental practice in a primary care setting.

Several studies have shown the efficacy of psychological interventions in reducing preoperative anxiety in children undergoing surgery. This study aims to investigate the effectiveness of a specific non-pharmacological technique, the relaxation-guided imagery, in reducing both preoperative anxiety and postoperative pain in a sample of 60 children (6-12 years old) undergoing minor surgery who were randomly assigned to the experimental group (N = 30) or the control group (N = 30). The first group received the relaxation-guided imagery, before the induction of general anesthesia; the second group received standard care. The levels of preoperative anxiety and postoperative pain were assessed using, respectively, the modified Yale Preoperative Anxiety Scale and the Face, Legs, Activity, Cry, and Consolability Scale. The results showed a statistically significant difference between groups, with less anxiety and less pain for children included in the experimental group (p < .001; p < .001).Conclusion: Results suggest that relaxation-guided imagery reduces preoperative anxiety and postoperative pain in children. Future studies should focus on developing protocols and studying the eventual reduction of administered drugs for anesthesia and pain. What is Known: • Literature suggests the usefulness of relaxation-guided imagery in reducing anxiety and pain in the perioperative period. • Stronger evidences are needed to support the application of relaxation-guided imagery as routine care in pediatric surgery. What is New: • To our knowledge, this is the first randomized study to investigate the efficacy of relaxation-guided imagery in reducing preoperative anxiety and postoperative pain within a single pediatric sample. • The present study provides stronger evidence in an area that is lacking in research.

Introduction There is set to be a change in the way that oral surgery will be delivered with the introduction of managed clinical networks. The changes may require general dental practitioners (GDPs) to carry out more minor oral surgery in primary care.Aim To determine the effectiveness of courses on GDPs carrying minor oral surgery in primary care.Method Forty general dental practitioners attending a hands-on oral surgery course were surveyed regarding their understanding, knowledge and confidence in oral surgery skills. The same survey was circulated at the start and end of the course.Results All delegates reported an improvement post-course in their skills and knowledge. Overall, 40% of delegates felt relatively confident or very confident in tooth sectioning and bone removal, compared to 91% having little confidence before the course. Furthermore, 87% and 68% of the delegates felt relatively confident or very confident in suturing and raising a mucoperiosteal flap, respectively, by the end of the course.Conclusion Minor oral surgery courses can lead to an increase in skills, knowledge and confidence among GDPs. These courses are likely to be better supplemented in conjunction with refresher courses and mentoring. Barriers, however, remain to increasing minor oral surgery provision in primary care, including equipment availability and patient choice.

Objective: Minor surgical procedures under general anaesthesia require a patent airway without the use of muscle relaxant. Supraglottic airway devices have been widely used for airway management. A study was undertaken to compare first-time insertion success rate, insertion time, sealing pressure and complications between the Baska ® mask and I-gel., Methods: After approval from the institutional ethical committee, a randomised single-blinded study was conducted on 50 American Society of Anesthesiologists' physical status I and II female patients aged 18-40 years who underwent minor surgical procedures under general anaesthesia. Patients were randomly categorized into two groups of 25 each; group Baska ® mask and group I-gel, and the first-time success rate, mean insertion time and sealing pressure were measured. The results were analysed using unpaired t-test, Mann-Whitney U test, Chi-square test and ANOVA. A p value <0.05 was considered to be statistically significant., Results: The first-time insertion success rate of the Baska ® mask was 21/24 (88%) when compared with the I-gel, which was 23/25 (92%) (p=0.585). The insertion time of the Baska ® mask was 14.9±6.2 s, whereas that of the I-gel was 14.7±4.4 s (p=0.877). The mean sealing pressure of the Baska ® mask was significantly higher when compared with the I-gel (28.9±3.5 vs. 25.9±2.5 cmH 2 O) (p=0.001)., Conclusion: The Baska ® mask had a similar first-time insertion success rate and insertion time as the I-gel. The sealing pressure of the Baska ® mask was significantly greater than that of the I-gel. Both devices had complications that were comparable., Competing Interests: Conflict of Interest: The authors have no conflicts of interest to declare.

Objectives: To explore the knowledge, practice, barriers and reported self-confidence of family medicine (FM) residents in Riyadh, Kingdom of Saudi Arabia, in performing minor surgical procedures (MSP)., Methods: A cross-sectional study was conducted by distributing questionnaires to 267 family medicine residents in Riyadh, Kingdom of Saudi Arabia between May and July 2016. The questionnaire includes 7 categories with 71 questions about: knowledge, interest, experience and confidence in performing different MSPs, prior training in MSPs, perceived barriers to performing MSPs and ways to improve basic surgical skills., Results: The response rate was 71.9%. Residents had a mean knowledge score of 15.75% and a mean interest score of 10.4 out of 12. Out of 23 MSPs surveyed, residents had performed a mean average of 9.18. The mean of residents' confidence scores was 26.6 out of 63. The most common barrier to performing MSPs was a lack of training (n=115; 59.9%), while the least common barrier was a lack of interest (n=113; 58.9%). Participants consider intensive education to be the the most effective way to improve their performance, while increasing the duration of some rotations found to be the least effective way for improvement., Conclusion: A majority of FM residents were interested in MSP, but had low perceived knowledge, low reported confidence and infrequent practice. Family medicine programs should provide continuous standardized training by a qualified and interested trainer within the FM setting.

Purpose: Procedural sedation is commonly performed in the emergency department (ED). Having safe and fast means of providing sedation and anxiolysis to children is important for the child's tolerance of the procedure, parent satisfaction and efficient patient flow in the ED., Objective: To evaluate fasting times associated with the administration of intranasal midazolam (INM) and associated complications. Secondary objectives included assessing provider and caregiver satisfaction scores., Methods: A prospective observational study was conducted in children presenting to an urban pediatric emergency department who received INM for anxiolysis for a procedure or imaging. Data collected included last solid and liquid intake, procedure performed, sedation depth, adverse events and parent and provider satisfaction., Results: 112 patients were enrolled. The mean age was 3.8 years. There were no adverse events experienced by any patients. Laceration repair was the most common reason for INM use. The median depth of sedation was 2.0 (cooperative/tranquil). The median liquid NPO time was 172.5 min and the median NPO time for solids was 194.0 min. 29.8% were NPO for liquids ≤2 h and 62.5% were NPO for solids ≤2 h. Parent and provider satisfaction was high: 90.4% of parents' and 88.4% of providers' satisfaction scores were a 4 or 5 on a 5 point Likert scale., Conclusion: Our data suggest that short NPO of both solids and liquids are safe for the use of INM. Additionally, parent and provider satisfaction scores were high with the use of INM., (Published by Elsevier Inc.)

Background: Haemodynamic instability during the induction of anaesthesia and surgery is common and may be related to hypovolaemia caused by pre-operative fasting or chronic diuretic therapy. The aim of our prospective, controlled, randomized study was to test the hypothesis that a predefined fluid bolus given prior to general anaesthesia for minor surgery would increase haemodynamic stability during anaesthetic induction., Methods: Two hundred and nineteen fairly healthy adult patients requiring minor surgery were enrolled. All received standard treatment, including a pulse contour analysing device for non-invasive measurement of cardiac index. Infusion therapy was started in all patients at induction. The intervention group (106 patients) was randomized to receive an additional fluid bolus of 8 mL/kg Ringer's acetate solution before the induction of anaesthesia. The primary endpoint was the incidence of haemodynamic instability, defined as a significant reduction of blood pressure or cardiac index during induction of anaesthesia., Results: The interventional group had a lesser incidence of haemodynamic instability during induction (41.5% vs 56.6%, P = .025). This group also had higher cardiac index, stroke volume index, systolic and mean blood pressure and a greater left ventricular end-diastolic area., Conclusions: A fluid bolus prior to anaesthesia reduced the incidence of haemodynamic instability during induction of general anaesthesia. The total fluid volume was slightly greater in the intervention group compared to the control group (1370 ± 439 mL vs 1219 ± 483 mL, P = .007). We conclude that a defined fluid bolus can help stabilizing haemodynamics in patients undergoing general anaesthesia., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Importance: Hypnosis is now widespread in medical practice and is emerging as an alternative technique for pain management and anxiety. However, its effects on postoperative outcomes remain unclear., Objective: To evaluate the efficacy of a preoperative hypnosis session for reducing postoperative breast pain in patients who underwent minor breast cancer surgery., Design, Setting, and Participants: The HYPNOSEIN prospective randomized clinical trial was conducted from October 7, 2014, to April 5, 2016. In this multicenter study in France, 150 women scheduled for minor breast cancer surgery were randomized between control and hypnosis arms, and 148 (71 control and 77 hypnosis) were included in the intent-to-treat analysis., Intervention: On the day of surgery, eligible patients were randomly assigned (1:1) to the control arm or the hypnosis arm. Patients (but not the care teams) were blinded to the arm to which they were assigned. A 15-minute hypnosis session before general anesthesia in the operating room was performed in the hypnosis arm., Main Outcomes and Measures: The primary end point was breast pain reduction (by 2 on a visual analog scale), assessed immediately before discharge from the postanesthesia care unit (PACU). Secondary end points were nausea/vomiting, fatigue, comfort/well-being, anxiety, and PACU length of stay, assessed at different times until postoperative day 30., Results: The median patient age was 57 years (range, 33-79 years) in the control arm and 53 years (range, 20-84 years) in the hypnosis arm. Baseline characteristics were similar in the 2 arms. The median duration of the hypnosis session was 6 minutes (range, 2-15 minutes). The use of intraoperative opioids and hypnotics was lower in the hypnosis arm. The mean (SD) breast pain score (range, 0-10) was 1.75 (1.59) in the control arm vs 2.63 (1.62) in the hypnosis arm (P = .004). At PACU discharge and with longer follow-up, no statistically significant difference in breast pain was reported. Fatigue was significantly lower in the hypnosis arm on the evening of surgery (mean [SD] score, 3.81 [2.15] in the control arm vs 2.99 [2.56] in the hypnosis arm; P = .03). The median PACU length of stay was 60 minutes (range, 20-290 minutes) in the control arm vs 46 minutes (range, 5-100 minutes) in the hypnosis arm (P = .002). Exploratory analyses according to patient perception of whether she received hypnosis showed significantly lower fatigue scores in the perceived hypnosis subgroup on the evening of surgery (mean [SD], 4.13 [2.26] for no perceived hypnosis vs 2.97 [2.42] for perceived hypnosis; P = .01). Anxiety was also significantly lower on the evening of surgery in the perceived hypnosis subgroup (mean [SD], 0.75 [1.64] for perceived hypnosis vs 1.67 [2.29] for no perceived hypnosis; P = .03)., Conclusions and Relevance: The results of this study do not support a benefit of hypnosis on postoperative breast pain in women undergoing minor breast cancer surgery. However, other outcomes seem to be improved, which needs to be confirmed by further studies., Trial Registration: EudraCT Identifier: 2014-A00681-46 and ClinicalTrials.gov Identifier: NCT03253159.

Introduction: To work in the National Health Service (NHS) as a dentist, the practitioner needs to be on the UK dental "performer's list". To apply for access to this list and work as a General Dental Practitioner (GDP), dentists must be qualified from the European Economic Area (EEA) or, those trained in the UK, must undertake Dental Foundation Training (DFT). Dentists interested in further taught learning or pursuing specialist training must continue working as "Dental Core Trainees" (DCTs). Most of these jobs are available in Oral and Maxillofacial Surgery (OMFS) Units and require dentists to undertake unsupervised surgical procedures. It is currently estimated that over 400 "junior dentists" undertake DCT a year. It is the aim of this study to ascertain whether confidence in simple surgical procedures improves when compared to GDPs of similar experience., Methods: One hundred and two junior dentists, 34 DFTs, 20 DCT1s, 21 DCT2s and 27 second and third year post-DFT GDPs all working across the Midlands, UK, had Likert scale responses about confidence in 14 minor surgical skills assessed. Results were analysed to ascertain whether gender, year group and number of extractions had any effect on confidence., Conclusions: We conclude that confidence in minor surgical procedures improves significantly when undertaking DCT OMFS posts, with the most significant improvement in confidence occurring within the first 6 months. Dental Core Trainees become significantly more confident in their surgical ability within the first 6 months when compared to GDPs with longer postgraduate experience., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Methoxyflurane delivered via a hand-held inhaler is a proven analgesic which has been used in Australasia for emergency relief of trauma associated pain since the 1970s. The agent is self-administered by the patient under the supervision of trained personnel. More than 5 million patients have received inhaled methoxyflurane without significant side effects. Methoxyflurane is also licensed in Australasia for the relief of pain in monitored conscious patients requiring analgesia for minor surgical procedures. Recent clinical studies undertaken in a variety of outpatient settings, including colonoscopy, prostate biopsy, dental procedures, bone marrow biopsy, and the management of burns dressings, indicate that inhaled methoxyflurane has significant analgesic activity, without producing deep sedation or respiratory depression. Return to full psychomotor activity is rapid. Thus, methoxyflurane may be a suitable and well-tolerated alternative to traditional i.v. sedative agents for outpatient medical and surgical procedures. There are direct advantages to the patient in terms of rapid recovery and an early return to normal activities, and significant benefits for outpatient departments in terms of cost saving and rate of throughput. Further randomised controlled trials comparing the efficacy, safety, and cost-effectiveness of inhaled methoxyflurane against traditional i.v. sedative techniques are currently in progress., (Copyright © 2018 British Journal of Anaesthesia. All rights reserved.)