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Patients with chronic gastrointestinal, hepatic, and renal disease are frequently encountered in clinical practice. This is due in part to the rising prevalence of risk factors associated with these conditions. These patients are increasingly being considered for surgical intervention and are at higher risk for multiple perioperative complications. Many are able to safely undergo surgery but require unique considerations to ensure optimal perioperative care. In this review, we highlight relevant perioperative physiology and outline our approach to the evaluation and management of patients with select chronic gastrointestinal, hepatic, and renal diseases. A comprehensive preoperative evaluation with a multidisciplinary approach is often beneficial, and specialist involvement should be considered. Intraoperative and postoperative plans should be individualized based on the unique medical and surgical characteristics of each patient.

Pain is the most frequently encountered symptom by patients with fibromyalgia (FM). Dietary supplements (DSs) in particular have a proven impact as a possible adjunctive therapy for symptom management in FM. However, there is currently no conclusive review outlining the evidence for DSs in pain management in FM. This study aims to assess currently available studies evaluating the use of DSs for pain relief in FM. Randomized controlled trials regarding the use of DSs on adult FM patients were included for evidence synthesis. Study results indicated that DSs significantly relieved pain in FM (SMD 1.23; 95% CI 0.02–2.43, P = 0.046) but did not improve quality of life (QoL) (SMD 0.73; 95% CI −0.07–1.53, P = 0.075) in the data. Adverse events of DSs varied from mild to severe, with the most common being gastrointestinal symptoms and androgenic side effects in 5.7% and 3.9% of patients, respectively. More well-designed RCTs are required in the future. The protocol for this review has been published on PROSPERO (CRD42020149941).

Objective To study the direct physiological and emotional impact of an animal-assisted activity (AAA) session (a form of complementary and integrative medicine) in patients with fibromyalgia (FM). Patients and Methods The study population consisted of 221 participants with FM who were attending Mayo Clinic’s Fibromyalgia Treatment Program between August 5, 2017, and September 1, 2018. This was a randomized controlled trial. Participants were randomly assigned to either the treatment group (a 20-minute session with a certified therapy dog and handler) or the control group (a 20-minute session with a handler only). To gain a better understanding of the direct physiological and emotional effects of AAA in patients with FM, we used multiple noninvasive physiologic-emotional biomarkers, including salivary cortisol and oxytocin concentrations, tympanic membrane temperatures, and various cardiac parameters, in addition to standardized pain and mood-based questionnaires. Results Results show a decrease in heart rate, an increase in heart rate variability, an increase in well-being survey scores, an increase in salivary oxytocin, and subsequent tympanic membrane temperature changes, suggesting that participants in the treatment group were in a more positive emotional-physiologic state as a result of the AAA session compared with the control group. Conclusion Our results suggest that a 20-minute therapy dog visit in an outpatient setting can significantly and positively impact the physical and mental health of patients with FM.

Postoperative complications are common. Major guidelines have been published on stratifying and managing adverse cardiovascular events and thromboembolic events, but there is often less literature supporting management of other, more common, postoperative complications, including acute kidney injury, gastrointestinal complications, postoperative anemia, fever, and delirium. These common conditions are frequently seen in hospital and can contribute to longer lengths of stay and rising health care costs. These complications are often due to the interplay between both patient-specific and surgery-specific risk factors. Identifying these risk factors, while addressing and optimizing modifiable risks, can mitigate the likelihood of developing these postoperative complications. Often, a multidisciplinary approach, including care team members through all phases of the surgical encounter, is needed. Cardiovascular and thrombotic complications have been addressed in prior articles in this perioperative series. We aim to cover other common postoperative complications, such as acute renal failure, postoperative gastrointestinal complications, anemia, fever, and delirium that often contribute to longer lengths of stay, rising health care costs, and increased morbidity and mortality for patients.

Background The role of dobutamine stress echocardiography (DSE) in the risk stratification of patients undergoing noncardiac surgery in the current era is unclear. The aim of this study was to evaluate the yield of DSE and the additive role of DSE to clinical criteria for preoperative risk stratification of patients undergoing noncardiac surgery. Methods The study included 4,494 patients undergoing DSE ≤90 days before noncardiac surgery. The primary outcome was a composite of postoperative myocardial infarction, cardiac arrest, and all-cause mortality ≤30 days after noncardiac surgery. Results The overall 30-day postoperative cardiac event rate was 2.3%. The mortality rate was 0.9% overall and 0.7% and 1.3% after normal and abnormal results on DSE, respectively. Among clinical variables, the modified Revised Cardiac Risk Index score demonstrated the strongest association with postoperative risk (P Conclusions Baseline and peak-stress findings on preoperative DSE add to the prognostic utility of clinical variables for stratifying cardiac risk after noncardiac surgery.

Objective: Mental health problems among children and adolescents are increasingly observed during the outbreak of COVID-19, leading to significant healthcare concerns. Survey studies provide unique opportunities for research during this pandemic, while there are no existing systematic reviews in this setting. The objective was to summarize existing survey studies addressing the effects of the current COVID-19 pandemic on the mental health of children and adolescents. Methods: For this systematic review, we performed an electronic search in multiple databases from December 2019 to December 2020. The quality appraisal of the included studies was performed with the Critical Appraisal Skills Programme Qualitative Checklist. Because of the high methodological heterogeneity between studies, a narrative synthesis of the qualitative data was used. Results: In total, 35 survey studies with 65,508 participants, ranging from 4 to 19 years of age, are included in this review. Anxiety (28%), depression (23%), loneliness (5%), stress (5%), fear (5%), tension (3%), anger (3%), fatigue (3%), confusion (3%), and worry (3%) were the most common mental health issues reported. Children and adolescents with psychiatric and/or developmental disorders, such as severe obesity, chronic lung disease, attention deficit hyperactivity disorder, cystic fibrosis, and obsessive-compulsive disorders, were especially vulnerable to the mental health effects of the COVID-19 pandemic. Age, gender, psychological quality, and negative coping strategies were identified as risk factors for the development of mental health problems. Social and family support, along with a positive coping style, was associated with better outcomes. Conclusion: The impact of the COVID-19 pandemic on mental health of children and adolescents is multifaceted and substantial. Survey studies regarding child and adolescent mental health amid COVID-19 indicated that anxiety, depression, loneliness, stress, and tension are the most observed symptoms. Positive coping strategies with family and social support may be important to achieving better outcomes. Due to limited available evidence, more well-designed studies in this area are urgently needed.

Objective To reevaluate the frequency and pattern of complementary and integrative medicine (CIM) use in patients with fibromyalgia (FM). Patients and Methods Consecutive patients with FM who were referred to the Mayo Clinic fibromyalgia treatment program from January 5 through July 27, 2017, were invited to complete a survey about their use of CIM therapies in the preceding 6 months. The survey asked about 3 primary CIM domains: treatments and techniques, vitamins and minerals, and herbs and other dietary supplements. For direct comparative purposes, we reused the survey instrument from our prior analogous study of CIM use, performed in 2003. Results Of the 310 patients who completed the survey, 304 (98.1%) reported using some form of CIM, similar to the percentage reported in our 2003 study (98%). The most frequently used CIM therapies in the current cohort were spiritual healing (54.0% [163 of 302]), massage therapy (50.0% [152 of 304]), chiropractic treatments (39.3% [118 of 300]), aromatherapy (39.0% [117 of 300]), exercise for a specific medical problem (38.6% [117 of 303]), melatonin (37.9% [77 of 203]), magnesium (36.3% [107 of 295]), green tea (36.1% [73 of 202]), and fish oil (34.5% [68 of 197]). We noted numerous substantial differences from the 2003 data in terms of the pattern of CIM use. Conclusion The use of CIM therapies among patients with FM continues to be extremely common for adult patients of all ages. Given the continued high prevalence of CIM use, health care professionals must have awareness and knowledge of these various modalities and their potential incorporation into a multifaceted FM treatment regimen.

Objective To evaluate the association between smoking and cognitive function in patients with fibromyalgia. Patients and Methods We surveyed 668 patients with fibromyalgia from May 1, 2012 through November 30, 2013 at a major tertiary referral center. Patients were categorized by smoking status. Primary outcome of interest was cognitive function (MASQ questionnaire), and secondary outcomes included fibromyalgia symptom severity (FIQ-R questionnaire), quality of life (SF-36 questionnaire), fatigue (MFI-20 questionnaire), sleep (MOS-sleep scale), anxiety (GAD-7 questionnaire), and depression (PHQ-9 questionnaire). Independent Students' t-tests and χ2 tests were performed for continuous and categorical variables, respectively. Univariate regression analysis identified variables predictive of outcomes, adjusting for age, gender, body mass index, marital status, and educational level. Results Ninety-four (14.07%) patients self-identified as smokers. There was an association of lower education level, unmarried status, and younger age in smokers compared with nonsmokers. In the adjusted univariate regression analysis, fibromyalgia smokers reported greater perceived total cognitive dysfunction (P=.009) and greater subscale scores of perceived difficulty in language (P=.03), verbal memory (P=.003), visual-spatial memory (P=.02), and attention (P=.04) compared with nonsmokers with fibromyalgia. For secondary outcomes, smokers with fibromyalgia reported greater severity of fibromyalgia-related symptoms (P=.006), worse quality-of-life index in the mental component scale (P=.02), greater sleep problems (P=.01), and increased anxiety (P=.001) compared with nonsmokers who had fibromyalgia. Conclusion In patients with fibromyalgia, smoking is a risk factor for cognitive dysfunction. Moreover, smokers with fibromyalgia were more likely to report increased severity of fibromyalgia symptoms, worse quality of life, more sleep problems, and increased anxiety compared with nonsmokers with fibromyalgia.

Public interest in autonomous sensory meridian response (ASMR) is growing on digital media platforms. Some people can elicit the response by watching videos containing triggering sounds and images. People susceptible to ASMR's effects report tingling sensations on the head and neck, as well as feelings of euphoria, relaxation, and mood elevation. Underlying mechanisms of the phenomenon are not well understood, but physiologic evidence corroborates some of the self-reported positive effects. Healthcare professionals should be aware of this emerging topic, and the potential for therapeutic applications should be investigated.

Background and Aims Fibromyalgia Syndrome (FMS) is a chronic centralized pain disorder characterized by widespread pain and fatigue. Of those affected by FMS, the majority are women, and minimal research exists involving men. The purpose of this paper is to describe the pain and fatigue experiences of men with FMS from two Western countries, Spain and the United States, in order to support more accurate and earlier recognition and diagnosis in men. Design and Methods We used individual and focus group interviews with qualitative and quantitative assessments. Settings and Participants/Subjects Ten men in Spain and seven men in the United States provided information about their symptoms, psychosocial and health-seeking behaviors, and gender experiences with FMS. Results Men articulated types, trends, and triggers of pain and fatigue that enrich an understanding of their symptoms. For example, men report more localized pain than generalized pain. Employment status and activities, among other contextual factors, impacted men's pain and fatigue experiences. Conclusions Men experience distinct facets of pain and fatigue compared with women, with notable similarities and differences across the Spanish and U.S. samples. Cross-cultural comparisons highlight contextual factors that may inspire future inquiries about determinants of men's experiences with FMS. Clinical Implications The present study could be useful for anyone treating men suffering from FMS, especially care providers in nursing, medical, and psychology fields. These initial findings may prompt a closer examination of recommendations for assessment and diagnostic criteria used internationally for patients with FMS with better recognition of men's experience.

Simple Summary Therapy dogs and their benefits to human health have been studied extensively, but investigating the animal’s welfare during therapy sessions is limited. Moreover, existing literature has mixed results as to the emotional state and wellbeing of the therapy animals. This study focuses on 19 therapy dogs’ wellbeing during animal-assisted activities, by evaluating their heart rate and heart rate variability, salivary cortisol and oxytocin, and ear temperatures. The results demonstrated that the dogs’ wellbeing was not negatively affected during these visits. Moreover, pre- and post-visit physiological indicators remained stable and some of the dogs’ parameters suggested the therapy dogs may have been in a more relaxed state at the end of the session. Abstract Therapy dogs are increasingly being incorporated into numerous clinical settings. However, there are only a handful of studies that have focused on the impact of animal-assisted activity or therapy sessions on the wellbeing of the therapy dogs. Furthermore, these studies show mixed results. The goal of this study was to provide an in-depth picture of the effects of these interactions on the dogs involved by considering multiple physiological measures known to be associated with emotional state (continuous heart rate, heart rate variability, pre- and post-session tympanic membrane temperatures, and salivary cortisol and oxytocin concentrations). Nineteen Mayo Clinic Caring Canine therapy dogs completed five 20-minute animal-assisted activity (AAA) visits each in an outpatient clinical setting (Mayo Clinic Fibromyalgia and Chronic Fatigue Clinic). From a physiological perspective, the dogs showed a neutral to positive response to the AAA sessions. Heart rate (HR) was significantly lower at the end of the session compared with the beginning of the session (F = 17.26, df1 = 1, df2 = 29.7, p = 0.0003). The right tympanic membrane temperature was lower post-session (F = 8.87, df1 = 1, df2 = 107, p = 0.003). All other emotional indicators remained stable between pre- and post-session. These results suggest that the dogs involved were not negatively affected by their participation in the AAA. Moreover, there was some evidence suggesting the dogs may have been in a more relaxed state at the end of the session (lower HR and lower right tympanic membrane temperature) compared to the beginning of the session.

Systemic lupus erythematosus (SLE) is a chronic inflammatory disease of unknown cause that affects multiple organ systems. Disease susceptibility is conferred by an interaction between genetics, aberrant immunologic mechanisms, hormonal influences, and environmental factors. SLE has a wide range of heterogeneous clinical manifestations and is characterized by disease flares and remissions. There is a broad spectrum of disease severity, leading to significant morbidity and increased mortality.

Evidence in perioperative medicine is published in a wide variety of journals, given the multidisciplinary nature of its practice which spans medicine and its subspecialties, as well as surgery and anesthesiology. It can be difficult to identify new and important evidence, as perioperative practice continues to evolve in multiple areas such as medication management, anticoagulation and cardiac risk stratification, among others. New, high-quality evidence is published each year, and must be placed into the context of not only existing literature, but also practical real-world patient care. We sought to systematically identify, critically evaluate and concisely summarize the practice implications of 10 articles published in 2015 for the practicing perioperative clinician.

Objective To assess whether the Berlin Sleep Questionnaire and the Snoring, Tired, Observed, Pressure, Body mass, Age, Neck, and Gender questionnaire (STOP-BANG) might be suitable replacements for an overnight sleep pulse oximetry as screening tools for sleep disordered breathing in patients with fibromyalgia. Participants: From June 8, 2018 through July 25, 2018, adult patients with a confirmed diagnosis of fibromyalgia (via the 1990 and/or 2010 American College of Rheumatology Fibromyalgia Classification Criteria) who attended Mayo Clinic’s Fibromyalgia Treatment Program were invited to participate in the study. Methods: The design was a prospective comparative study with a retrospective chart review component. Participants completed 2 validated surveys: the Berlin Sleep Questionnaire and the STOP-BANG. Medical records were reviewed for demographic information and overnight pulse oximetry test results. Results: Results from both questionnaires indicate that there is an association between sleep apnea risk category (defined by questionnaire) and oximetry results. Fisher’s exact test for STOP-BANG and Berlin Sleep Questionnaire are statistically significant ( P

Objective To evaluate the association between smoking and cognitive function in patients with fibromyalgia. Patients and Methods We surveyed 668 patients with fibromyalgia from May 1, 2012 through November 30, 2013 at a major tertiary referral center. Patients were categorized by smoking status. Primary outcome of interest was cognitive function (MASQ questionnaire), and secondary outcomes included fibromyalgia symptom severity (FIQ-R questionnaire), quality of life (SF-36 questionnaire), fatigue (MFI-20 questionnaire), sleep (MOS-sleep scale), anxiety (GAD-7 questionnaire), and depression (PHQ-9 questionnaire). Independent Students' t-tests and χ2 tests were performed for continuous and categorical variables, respectively. Univariate regression analysis identified variables predictive of outcomes, adjusting for age, gender, body mass index, marital status, and educational level. Results Ninety-four (14.07%) patients self-identified as smokers. There was an association of lower education level, unmarried status, and younger age in smokers compared with nonsmokers. In the adjusted univariate regression analysis, fibromyalgia smokers reported greater perceived total cognitive dysfunction (P=.009) and greater subscale scores of perceived difficulty in language (P=.03), verbal memory (P=.003), visual-spatial memory (P=.02), and attention (P=.04) compared with nonsmokers with fibromyalgia. For secondary outcomes, smokers with fibromyalgia reported greater severity of fibromyalgia-related symptoms (P=.006), worse quality-of-life index in the mental component scale (P=.02), greater sleep problems (P=.01), and increased anxiety (P=.001) compared with nonsmokers who had fibromyalgia. Conclusion In patients with fibromyalgia, smoking is a risk factor for cognitive dysfunction. Moreover, smokers with fibromyalgia were more likely to report increased severity of fibromyalgia symptoms, worse quality of life, more sleep problems, and increased anxiety compared with nonsmokers with fibromyalgia.

Experiential learning has been suggested as a framework for planning continuing medical education (CME). We aimed to (1) determine participants' learning styles at traditional CME courses and (2) explore associations between learning styles and participant characteristics.Cross-sectional study of all participants (n = 393) at two Mayo Clinic CME courses who completed the Kolb Learning Style Inventory and provided demographic data.A total of 393 participants returned 241 surveys (response rate, 61.3%). Among the 143 participants (36.4%) who supplied complete demographic and Kolb data, Kolb learning styles included diverging (45; 31.5%), assimilating (56; 39.2%), converging (8; 5.6%), and accommodating (34; 23.8%). Associations existed between learning style and gender (p = 0.02). For most men, learning styles were diverging (23 of 63; 36.5%) and assimilating (30 of 63; 47.6%); for most women, diverging (22 of 80; 27.5%), assimilating (26 of 80; 32.5%), and accommodating (26 of 80; 32.5%).Internal medicine and psychiatry CME participants had diverse learning styles. Female participants had more variation in their learning styles than men. Teaching techniques must vary to appeal to all learners. The experiential learning theory sequentially moves a learner from Why? to What? to How? to If? to accommodate learning styles.

Several medications have been used perioperatively in patients undergoing noncardiac surgery in an attempt to improve outcomes. Antiplatelet therapy for primary prevention of cardiovascular events should generally be discontinued seven to 10 days before surgery to avoid increasing the risk of bleeding, unless the risk of a major adverse cardiac event exceeds the risk of bleeding. Antiplatelet therapy for secondary prevention should be continued perioperatively, except before procedures with very high bleeding risk, such as intracranial procedures. Antiplatelet drugs should be continued and surgery delayed, if possible, for at least 14 days after percutaneous coronary intervention without stent placement, 30 days after percutaneous coronary intervention with bare-metal stent placement, and six to 12 months after percutaneous coronary intervention with drug-eluting stent placement. Perioperative beta blockers are recommended for patients already receiving these agents, and it is reasonable to consider starting therapy in patients with known or strongly suspected coronary artery disease or who are at high risk of perioperative cardiac events and are undergoing procedures with a high risk of cardiovascular complications. Long-term statin therapy should be continued perioperatively or started in patients with clinical indications who are not already receiving statins. Clonidine should not be started perioperatively, but long-term clonidine regimens may be continued. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers generally can be continued perioperatively if patients are hemodynamically stable and have good renal function and normal electrolyte levels.

Introduction/Background To assess sex-related characteristics in patients with fibromyalgia, specifically in terms of patient demographics (age, body mass index, marital status, and educational level), tender point count, symptoms (cognition, sleep disorder, fatigue, anxiety, and depression), and quality-of-life measurements. Material and method We studied 668 consecutive patients (606 women) who participated in the Fibromyalgia Treatment Program at Mayo Clinic (Rochester, Minnesota) from May 2012 through November 2013. All patients completed a series of questionnaires at the initial consult, including the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7), the Medical Outcomes Study Sleep Scale (MOS-Sleep Scale), the Revised Fibromyalgia Impact Questionnaire (FIQ-R), the Multidimensional Fatigue Inventory (MFI-20), the Multiple Ability Self-Report Questionnaire (MASQ), and the 36-item Short-Form Health Survey (SF-36). Non-parametric Wilcoxon rank test and the Chi2 test for continuous variables and categorical variables were used to detect differences between sexes. Results We observed no significant sex-based differences in demographics, including age, marital status, and educational level. Likewise, no significant sex differences were seen in body mass index, mood, sleep, cognition, symptom impact, or fatigue. However, women had a significantly higher tender point count than men (P = 0.001). Conclusion The only sex-related difference observed in our cohort was the tender point count; the assumption of other sex-based differences in the clinical presentation of fibromyalgia was not supported in our study.

Background Current guidelines support the use of dobutamine stress echocardiography (DSE) prior to noncardiac surgery in higher-risk patients who are unable to perform at least 4 metabolic equivalents of physical activity. We evaluated postoperative outcomes of patients in different operative risk categories after preoperative DSE. Methods We collected data from the medical record on 4494 patients from January 1, 2006 to December 31, 2011 who had DSE up to 90 days prior to a noncardiac surgery. Patients were divided into low, intermediate, and high preoperative surgery-specific risk. Baseline demographic data and risk factors were abstracted from the medical record, as were postoperative cardiac events including myocardial infarction, cardiac arrest, and mortality within 30 days after surgery. Results There were 103 cardiac outcomes (2.3%), which included myocardial infarction (n = 57, 1.3%), resuscitated cardiac arrest (n = 26, 0.6%), and all-cause mortality (n = 40, 0.9%). Cardiac event rates were 0.0% (95% confidence interval [CI], 0.0%-3.9%) in the low-surgical-risk group, 2.1% (95% CI, 1.6%-2.5%) in the intermediate-surgical-risk group, and 3.4% (95% CI, 2.0%-4.4%) in the high-risk group. Thirty-day postoperative mortality rates were 0%, 0.9%, and 0.8% for the low-risk, intermediate-risk, and high-risk surgical groups, respectively, and were not statistically different. Conclusions These findings demonstrate low cardiac event rates in patients who underwent a DSE prior to noncardiac surgery. The previously accepted construct of low-, intermediate-, and high-risk surgeries based on postoperative events of 5% overestimates the actual risk in contemporary settings.

Objective The purpose of this study was to evaluate the frequency of migraine headache in a large cohort of patients with fibromyalgia using a brief migraine headache-screening tool. Background Several studies report a high prevalence of fibromyalgia among patients with migraine headaches, but there is a dearth of research evaluating the frequency of migraine headaches in patients with fibromyalgia, despite clinical observations suggesting that migraine headaches are common in patients with fibromyalgia. Design and Methods This was a cross-sectional survey study. Patients (N = 3717) with a previous diagnosis of fibromyalgia who were members of the Mayo Clinic Fibromyalgia Registry were contacted by electronic survey and asked to complete a brief demographic and medical history questionnaire and the validated ID-Migraine screener. Results A total of 1730 patients (46.5%) completed the electronic survey. The majority of participants were white (97.2%), female (92.5%), with a mean age of 56.2 (±13.1) years. Of the respondents, 966 (55.8%) met criteria for migraine headaches. Hypertension (309 [32.3%] vs 294 [40.1%], P = .004), asthma (312 [32.5%] vs 189 [25.9%], P = .011), irritable bowel syndrome (520 [54.6%] vs 348 [47.6], P = .017), chronic fatigue syndrome (486 [50.7%] vs 271 [37.1], P