Objective
The main objective was to assess repeatability and learning effect of the 6-min walk test (6MWT) in a cohort of preoperative cancer patients referred to a prehabilitation program. As a ...secondary objective, we aimed to identify determinants of improvement in the second test.
Materials and methods
Secondary analysis from a large prospective study on the implementation of a multimodal prehabilitation program in a real-life scenario. Eligible patients were assessed at baseline before starting the prehabilitation program. The 6MWT was conducted according to the American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines with two tests being performed under identical conditions separated by 30 min. The distance covered (in meters) and the physiological responses (heart rate, oxygen saturation, fatigue, and dyspnea) to each test were recorded and compared.
Results
A total of 170 patients (60.9%) were analyzed. Repeatability of the distance covered with the 6MWT was excellent (ICC = 0.98; 95% CI: 0.92–0.99), but a mean increase of + 19.5 m (95% CI: 15.6–23.5 m;
p
= < .001) in the second test was found, showing a learning effect with limits of agreement between − 31.3 and 70.4 m. Coefficient of variation was 4%. No clinical factor was found to be associated with an improvement in the second test.
Conclusions
The 6MWT showed excellent repeatability in preoperative cancer patients, but a significant learning effect is present. No associated factors with a clinically meaningful improvement in the second test were identified. In light of these findings, two attempts of the 6MWT should be encouraged in this population.
Introduction: The efficacy-effectiveness gap constitutes a well-known limitation for adoption of digitally enabled integrated care services. The current report describes the co-creation process ...undertaken (2016–2021) to deploy a prehabilitation service at Hospital Clínic de Barcelona with the final aim of achieving sustainable adoption and facilitate site transferability. Methods: An implementation research approach with a population-based orientation, combining experience-based co-design and quality improvement methodologies, was applied. We undertook several design-thinking sessions (Oct-Nov 2017, June 2021 and December 2021) to generate and follow-up a work plan fostering service scalability. The implementation process was assessed using the Comprehensive Framework for Implementation Research, leading to the identification of key performance indicators. Discussion: Personalization and modularity of the intervention according to patients’ surgical risk were identified as core traits to enhance patients’ adherence and value generation. A digitally enabled service workflow, with an adaptive and collaborative case management approach, should combine face-to-face and remotely supervised sessions with intelligent systems for patients’ and professionals’ decision support. The business model envisages operational costs financed by savings generated by the service. Conclusions: Evidence-based co-creation, combining appropriate methodologies and a structured evaluation framework, was key to address challenges associated with sustainable prehabilitation service adoption, scalability and transferability. Resum Introducció: La bretxa eficàcia-efectivitat limita l’adopció de serveis d’atenció integrada amb suport digital. L’estudi descriu el procés de co-creació efectuat (2016–2021) per desplegar, a l’Hospital Clínic de Barcelona, un servei de prehabilitació de pacients de risc per a procediments quirúrgics, amb l’objectiu d’aconseguir una adopció sostenible del servei i facilitar-ne la transferibilitat. Mètodes: Es van aplicar eines de recerca d’implementació amb una orientació poblacional, combinant metodologies de codisseny basades en l’experiència i de millora de la qualitat. Es van realitzar diverses sessions de design-thinking (Octubre-Novembre de 2017, Juny de 2021 i Desembre de 2021) per generar, i fer el seguiment, d’un pla de treball concebut per assolir escalabilitat del servei. El procés d’implementació es va avaluar utilitzant el Consolidated Framework for Implementation Research (CFIR), que va conduir a la identificació d’indicadors clau de rendiment. Discussió: La personalització i la modularitat de la intervenció segons el risc quirúrgic dels pacients es van identificar com a trets bàsics per millorar l’adherència i la generació de valor. La organització de la prehabilitació, amb un enfocament adaptatiu i col·laboratiu de gestió de casos, hauria de combinar sessions presencials i supervisades remotament amb sistemes intel·ligents de suport a la decisió per a pacients i professionals. El model de negoci preveu que els costos operatius de la prehabilitació siguin finançats per l’estalvi generat. Conclusions: El procés de co-creació, combinant metodologies adequades i un marc d’avaluació estructurat, va esser clau per abordar els reptes associats a l’adopció sostenible del servei, així com la seva escalabilitat i transferibilitat. Paraules clau: Activitat física; Atenció continuada; Co-creació; mHealth; Optimització nutricional; Prehabilitació
Prophylactic administration of platelets and fresh frozen plasma (FFP) has been recommended in patients with cirrhosis with low platelets and/or prolonged international normalized ratio (INR) without ...scientific evidence to support this practice. In this analysis, we evaluated the use of prophylactic administration of blood products in outpatients with cirrhosis undergoing endoscopic band ligation (EBL).
This is a multicenter retrospective analysis of consecutive EBL procedures in patients with cirrhosis at 4 hospitals in Spain from 01/2010-01/2017. FFP and/or platelet transfusion were given at the discretion of the physician if INR was >1.5 and/or platelet count <50x109/L. Patient demographics, endoscopic findings, bleeding events after EBL, and the use of prophylactic FFP or platelets were recorded.
A total of 536 patients underwent 1,472 EBL procedures: 72% male; main etiology HCV and alcohol (72%); median MELD score 11; Child-Pugh A/B/C (59/33/8%). EBL procedures were performed for primary (51%) or secondary (49%) prophylaxis. A median of 2 procedures per patient were performed.1-4 FFP and/or platelets were administered in 41 patients (7.6%). The prophylactic transfusion protocol was followed in 16% and 28% of procedures with high INR and/or low platelets, respectively. Post-EBL bleeding occurred in 26 out of 536 patients (4.8%) and in 33 out of 1,472 procedures (2.2%). Bleeding was due to post-EBL ulcers in 21 patients and due to band dislodgment in 5. In 6 patients, bleeding occurred within 24 hours and in the remaining patients it occurred within 2 weeks after EBL. In those that bled, 7 met criteria for transfusion (2 for FFP and 5 for platelets), of whom only 1 received FFP and 4 received platelets; the remaining 19 patients did not meet criteria for transfusion. There was no association between INR or platelet count and bleeding events. Univariate and multivariate analysis revealed that Child-Pugh and MELD scores were risk factors for post-EBL bleeding.
The incidence of post-EBL bleeding is low and is associated with advanced liver disease. Post-EBL bleeding was not related to baseline INR/platelet count and most outpatients with post-EBL bleeding did not meet criteria for prophylactic transfusion.
Patients with chronic liver disease or cirrhosis and enlarged veins (varices) of the esophagus that can potentially bleed commonly need an endoscopy to treat these varices with elastic rubber bands (endoscopic band ligation). Some patients have low platelet counts or prolonged coagulation tests. This analysis of 4 centers evaluated the use of prophylactic administration of blood products in outpatients with cirrhosis undergoing endoscopic band ligation. The results showed that bleeding after band ligation is uncommon and that if bleeding occurs it does not seem to be related with coagulation tests or the administration of blood products to prevent bleeding after band ligation of esophageal varices.
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•Multicenter analysis of prophylactic administration of blood products in 536 outpatients with cirrhosis undergoing EBL.•The prophylactic transfusion protocol was only followed in 16% and 28% of procedures with high INR and/or low platelets, respectively.•Post EBL-bleeding occurred in 26 patients – 4.8% of patients and in 2.2% of procedures.•Patients that bled had higher Child-Pugh and MELD scores compared to those that did not bleed.•There was no clear relationship between post-EBL bleeding and the baseline INR/platelet count before the procedure.
OBJECTIVE:The aim of this study was to assess the impact of personalized prehabilitation on postoperative complications in high-risk patients undergoing elective major abdominal surgery.
SUMMARY ...BACKGROUND DATA:Prehabilitation, including endurance exercise training and promotion of physical activity, in patients undergoing major abdominal surgery has been postulated as an effective preventive intervention to reduce postoperative complications. However, the existing studies provide controversial results and show a clear bias toward low-risk patients.
METHODS:This was a randomized blinded controlled trial. Eligible candidates accepting to participate were blindly randomized (1:1 ratio) to control (standard care) or intervention (standard care + prehabilitation) groups. Inclusion criteria werei) age >70 years; and/or, ii) American Society of Anesthesiologists score III/IV. Prehabilitation covered 3 actionsi) motivational interview; ii) high-intensity endurance training; and promotion of physical activity. The main study outcome was the proportion of patients suffering postoperative complications. Secondary outcomes included the endurance time (ET) during cycle-ergometer exercise.
RESULTS:We randomized 71 patients to the control arm and 73 to intervention. After excluding 19 patients because of changes in the surgical plan, 63 controls and 62 intervention patients were included in the intention-to-treat analysis. The intervention group enhanced aerobic capacity ΔET 135 (218) %; P < 0.001), reduced the number of patients with postoperative complications by 51% (relative risk 0.5; 95% confidence interval, 0.3–0.8; P = 0.001) and the rate of complications 1.4 (1.6) and 0.5 (1.0) (P = 0.001) as compared with controls.
CONCLUSION:Prehabilitation enhanced postoperative clinical outcomes in high-risk candidates for elective major abdominal surgery, which can be explained by the increased aerobic capacity.
IMPORTANCE: Colorectal surgery is associated with substantial morbidity rates and a lowered functional capacity. Optimization of the patient’s condition in the weeks prior to surgery may attenuate ...these unfavorable sequelae. OBJECTIVE: To determine whether multimodal prehabilitation before colorectal cancer surgery can reduce postoperative complications and enhance functional recovery. DESIGN, SETTING, AND PARTICIPANTS: The PREHAB randomized clinical trial was an international, multicenter trial conducted in teaching hospitals with implemented enhanced recovery after surgery programs. Adult patients with nonmetastasized colorectal cancer were assessed for eligibility and randomized to either prehabilitation or standard care. Both arms received standard perioperative care. Patients were enrolled from June 2017 to December 2020, and follow-up was completed in December 2021. However, this trial was prematurely stopped due to the COVID-19 pandemic. INTERVENTIONS: The 4-week in-hospital supervised multimodal prehabilitation program consisted of a high-intensity exercise program 3 times per week, a nutritional intervention, psychological support, and a smoking cessation program when needed. MAIN OUTCOMES AND MEASURES: Comprehensive Complication Index (CCI) score, number of patients with CCI score more than 20, and improved walking capacity expressed as the 6-minute walking distance 4 weeks postoperatively. RESULTS: In the intention-to-treat population of 251 participants (median IQR age, 69 60-76 years; 138 55% male), 206 (82%) had tumors located in the colon and 234 (93%) underwent laparoscopic- or robotic-assisted surgery. The number of severe complications (CCI score >20) was significantly lower favoring prehabilitation compared with standard care (21 of 123 17.1% vs 38 of 128 29.7%; odds ratio, 0.47 95% CI, 0.26-0.87; P = .02). Participants in prehabilitation encountered fewer medical complications (eg, respiratory) compared with participants receiving standard care (19 of 123 15.4% vs 35 of 128 27.3%; odds ratio, 0.48 95% CI, 0.26-0.89; P = .02). Four weeks after surgery, 6-minute walking distance did not differ significantly between groups when compared with baseline (mean difference prehabilitation vs standard care 15.6 m 95% CI, −1.4 to 32.6; P = .07). Secondary parameters of functional capacity in the postoperative period generally favored prehabilitation compared with standard care. CONCLUSIONS AND RELEVANCE: This PREHAB trial demonstrates the benefit of a multimodal prehabilitation program before colorectal cancer surgery as reflected by fewer severe and medical complications postoperatively and an optimized postoperative recovery compared with standard care. TRIAL REGISTRATION: trialregister.nl Identifier: NTR5947
Prehabilitation has potential for improving surgical outcomes as shown in previous randomized controlled trials. However, a marked efficacy-effectiveness gap is limiting its scalability. ...Comprehensive analyses of deployment of the intervention in real-life scenarios are required.
To assess health outcomes and cost of prehabilitation.
Prospective cohort study with a control group built using propensity score-matching techniques.
Prehabilitation Unit in a tertiary-care university hospital.
Candidates for major digestive, cardiac, thoracic, gynecologic, or urologic surgeries.
Prehabilitation program, including supervised exercise training, promotion of physical activity, nutritional optimization, and psychological support.
The comprehensive complication index, hospital and intensive care unit length of stay, and hospital costs per patient until 30 days after surgery. Patients were classified by the degree of program completion and level of surgical aggression for sensitivity analysis.
The analysis of the entire study group did not show differences in study outcomes between prehabilitation and control groups (n=328 each). The per-protocol analysis, including only patients completing the program (n=112, 34%), showed a reduction in mean hospital stay 9.9 (7.2) vs 12.8 (12.4) days; P =0.035. Completers undergoing highly aggressive surgeries (n=60) additionally showed reduction in mean intensive care unit stay 2.3 (2.7) vs 3.8 (4.2) days; P =0.021 and generated mean cost savings per patient of €3092 (32% cost reduction) ( P =0.007). Five priority areas for action to enhance service efficiencies were identified.
The study indicates a low rate of completion of the intervention and identifies priority areas for re-design of service delivery to enhance the effectiveness of prehabilitation.
The use of sedation for diagnostic procedures including gastrointestinal endoscopy is rapidly growing. Recovery of cognitive function after sedation is important because it would be important for ...most patients to resume safe, normal life soon after the procedure. Computerized tests have shown being accurate descriptors of cognitive function. The purpose of the present study was to evaluate the time course of cognitive function recovery after sedation with propofol and remifentanil. A prospective observational double blind clinical study conducted in 34 young healthy adults undergoing elective outpatient colonoscopy under sedation with the combination of propofol and remifentanil using a target controlled infusion system. Cognitive function was measured using a validated battery of computerized cognitive tests (Cogstate™, Melbourne, Australia) at different predefined times: prior to starting sedation (Tbaseline), and then 10 min (T10), 40 min (T40) and 120 min (T120) after the end of colonoscopy. Tests included the assessment of psychomotor function, attention, visual memory and working memory. All colonoscopies were completed (median time: 26 min) without significant adverse events. Patients received a median total dose of propofol and remifentanil of 149 mg and 98 µg, respectively. Psychomotor function and attention declined at T10 but were back to baseline values at T40 for all patients. The magnitude of psychomotor task reduction was large (d = 0.81) however 100% of patients were recovered at T40. Memory related tasks were not affected 10 min after ending sedation. Cognitive impairment in attention and psychomotor function after propofol and remifentanil sedation was significant and large and could be easily detected by computerized cognitive tests. Even though, patients were fully recovered 40 min after ending the procedure. From a cognitive recovery point of view, larger studies should be undertaken to propose adequate criteria for discharge after sedation.
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