Background Preoperative physical fitness is predictive of postoperative outcome. Patients with lesser aerobic capacity are at greater risk of postoperative complications, longer hospital stays, and ...mortality. Prehabilitation may improve physical fitness, but it is unknown whether enhanced fitness translates to an improvement in postoperative outcome. Methods This systematic review and meta-analysis aimed to assess the ability of prehabilitation to influence postoperative outcome after intra-abdominal operations. Randomized controlled trials with at least 1 group undergoing a preoperative exercise intervention/prehabilitation were included. The following databases were searched: AMED, CINAHL, EMBASE, PubMed/Medline, and The Cochrane Library. Data extracted from 9 full-articles included author(s), population demographics, type of operation, postoperative measures of outcome, and type of treatment of the prehabilitation and control groups. Methodologic quality was assessed using GRADEpro, and the Cochrane risk of bias tool was used to measure study bias. Results Prehabilitation consisting of inspiratory muscle training, aerobic exercise, and/or resistance training can decrease all types of postoperative complications after intra-abdominal operations (odds ratio: 0.59, 95% confidence interval: 0.38–0.91, P = .03). It is unclear from our meta-analysis whether prehabilitation can decrease postoperative length of stay, because the number of studies that examined length of stay was small ( n = 4). No postoperative mortality was reported in any study, and conclusions could not be drawn on the ability of exercise to influence operative mortality. The methodologic quality of studies was, however, “very low.” Conclusion Prehabilitation appears to be beneficial in decreasing the incidence of postoperative complications; however, more high-quality studies are needed to validate its use in the preoperative setting.
Abstract Study objective To assess the ability of field tests of exercise tolerance, such as the 6-minute walk test (6MWT) and incremental shuttle walk test (ISWT), to predict postoperative outcome ...following intra-abdominal surgery. Design A systematic review. Setting A hospital-affiliated university. Measurements The following databases were searched: AMED, CINAHL, EMBASE, PEDro, PubMed/MEDLINE, and The Cochrane Library. Six full-text articles were included. Data extraction included author, population demographics, surgery type, postoperative outcome measure, and field test results. The risk of bias was performed using the Quality in Prognosis Studies tool. Results Surgical procedures reviewed were colorectal (n = 3), upper gastrointestinal (n = 1), and intra-abdominal surgery (n = 2). Field tests of exercise tolerance showed little ability to predict postoperative mortality; however, the overall rate of mortality was low. Patients achieving lower distances on the ISWT tended to have longer hospital stays and an increased risk of overall complications. The 6MWT does not appear able to predict postoperative cardiac or pulmonary complications; however, it may be suitable to predict general complications. Conclusions Field tests may be able to predict postoperative outcome; however, further validation is needed. The ISWT appears to be the superior field test. The 6MWT and stair climb test require further validation to assess their predictive ability.
Virtual models of care are seen as a sustainable solution to the growing demand for health care. This paper analyses the experience of virtual care among patients diagnosed with COVID-19 in home ...isolation or health hotel quarantine using a patient-reported experience questionnaire. Results found that patients respond well to virtual models of care during a pandemic. Lessons learned can inform future developments of virtual care models.
Our objective was to (1) evaluate the linguistic and cultural acceptability of a Spanish translation of the Ohio State University traumatic brain injury identification method (OSU TBI-ID) and (2) to ...assess the usability and acceptability of a tablet-based version of this instrument in a cohort of Spanish-dominant older adults.
University clinical research center and local community center.
Community-dwelling Spanish-dominant adults age 50 years or older without dementia residing in the Bay Area of California (N=22).
Cross-sectional cohort study.
Qualitative assessment of linguistic or cultural acceptability of a Spanish translation of the OSU TBI-ID as well as usability or acceptability of a tablet-based self-administered version of this instrument.
The Spanish translation had high linguistic and cultural acceptability and was further optimized based on participant feedback. Cognitive interviews to review survey wording revealed high levels of homogeneity in the clinical definitions and synonyms given by participants—for example, results for the clinical term “Quedó Inconsciente/Pérdida (temporal) de la conciencia” (To be unconscious/Temporary loss of consciousness) used in the survey included “perder el conocimiento” (loss of consciousness), “knockeado” (knocked out), “No es que esté dormida, porque está inconsciente, pero su corazón está todavía palpitando” (it’s not that they’re sleeping, because they’re unconscious, but their heart is still palpitating). The tablet interface had low observer-based usability, revealing that participants with <13 years of education (n=6) had more difficulty using the tablet which could be improved with minor changes to the coding of the application and minimal in-person technology support. Acceptability of the tool was low among all but 1 participant.
This linguistically optimized Spanish translation of the OSU TBI-ID is recommended for use as a semistructured interview among Spanish-dominant older adults. Although the tablet-based instrument may be used by interviewers as an efficient electronic case report form among older adults, further research is needed, particularly among older adults with varying levels of education, to validate this instrument as a self-administered survey.
Summary Background New approaches are urgently required to address increasing rates of gonorrhoea and the emergence and global spread of antibiotic-resistant Neisseria gonorrhoeae . We used ...whole-genome sequencing to study transmission and track resistance in N gonorrhoeae isolates. Methods We did whole-genome sequencing of isolates obtained from samples collected from patients attending sexual health services in Brighton, UK, between Jan 1, 2011, and March 9, 2015. We also included isolates from other UK locations, historical isolates from Brighton, and previous data from a US study. Samples from symptomatic patients and asymptomatic sexual health screening underwent nucleic acid amplification testing; positive samples and all samples from symptomatic patients were cultured for N gonorrhoeae , and resulting isolates were whole-genome sequenced. Cefixime susceptibility testing was done in selected isolates by agar incorporation, and we used sequence data to determine multi-antigen sequence types and penA genotypes. We derived a transmission nomogram to determine the plausibility of direct or indirect transmission between any two cases depending on the time between samples: estimated mutation rates, plus diversity noted within patients across anatomical sites and probable transmission pairs, were used to fit a coalescent model to determine the number of single nucleotide polymorphisms expected. Findings 1407 (98%) of 1437 Brighton isolates between Jan 1, 2011, and March 9, 2015 were successfully sequenced. We identified 1061 infections from 907 patients. 281 (26%) of these infections were indistinguishable (ie, differed by zero single nucleotide polymorphisms) from one or more previous cases, and 786 (74%) had evidence of a sampled direct or indirect Brighton source. We observed multiple related samples across geographical locations. Of 1273 infections in Brighton (including historical data), 225 (18%) were linked to another case elsewhere in the UK, and 115 (9%) to a case in the USA. Four lineages initially identified in Brighton could be linked to 70 USA sequences, including 61 from a lineage carrying the mosaic penA XXXIV allele, which is associated with reduced cefixime susceptibility. Interpretation We present a whole-genome-sequencing-based tool for genomic contact tracing of N gonorrhoeae and demonstrate local, national, and international transmission. Whole-genome sequencing can be applied across geographical boundaries to investigate gonorrhoea transmission and to track antimicrobial resistance. Funding Oxford National Institute for Health Research Health Protection Research Unit and Biomedical Research Centre.
Summary Background The use of prophylactic radiotherapy to prevent procedure-tract metastases (PTMs) in malignant pleural mesothelioma remains controversial, and clinical practice varies worldwide. ...We aimed to compare prophylactic radiotherapy with deferred radiotherapy (given only when a PTM developed) in a suitably powered trial. Methods We did a multicentre, open-label, phase 3, randomised controlled trial in 22 UK hospitals of patients with histocytologically proven mesothelioma who had undergone large-bore pleural interventions in the 35 days prior to recruitment. Eligible patients were randomised (1:1), using a computer-generated sequence, to receive immediate radiotherapy (21 Gy in three fractions within 42 days of the pleural intervention) or deferred radiotherapy (same dose given within 35 days of PTM diagnosis). Randomisation was minimised by histological subtype, surgical versus non-surgical procedure, and pleural procedure (indwelling pleural catheter vs other). The primary outcome was the incidence of PTM within 7 cm of the site of pleural intervention within 12 months from randomisation, assessed in the intention-to-treat population. This trial is registered with ISRCTN, number ISRCTN72767336. Findings Between Dec 23, 2011, and Aug 4, 2014, we randomised 203 patients to receive immediate radiotherapy (n=102) or deferred radiotherapy (n=101). The patients were well matched at baseline. No significant difference was seen in PTM incidence in the immediate and deferred radiotherapy groups (nine 9% vs 16 16%; odds ratio 0·51 95% CI 0·19–1·32; p=0·14). The only serious adverse event related to a PTM or radiotherapy was development of a painful PTM within the radiotherapy field that required hospital admission for symptom control in one patient who received immediate radiotherapy. Common adverse events of immediate radiotherapy were skin toxicity (grade 1 in 50 54% and grade 2 in four 4% of 92 patients vs grade 1 in three 60% and grade 2 in two 40% of five patients in the deferred radiotherapy group who received radiotherapy for a PTM) and tiredness or lethargy (36 39% in the immediate radiotherapy group vs two 40% in the deferred radiotherapy group) within 3 months of receiving radiotherapy. Interpretation Routine use of prophylactic radiotherapy in all patients with mesothelioma after large-bore thoracic interventions is not justified. Funding Research for Patient Benefit Programme from the UK National Institute for Health Research.
Summary Background Most patients with multiple sclerosis without previous optic neuritis have thinner retinal layers than healthy controls. We assessed the role of peripapillary retinal nerve fibre ...layer (pRNFL) thickness and macular volume in eyes with no history of optic neuritis as a biomarker of disability worsening in a cohort of patients with multiple sclerosis who had at least one eye without optic neuritis available. Methods In this multicentre, cohort study, we collected data about patients (age ≥16 years old) with clinically isolated syndrome, relapsing-remitting multiple sclerosis, and progressive multiple sclerosis. Patients were recruited from centres in Spain, Italy, France, Germany, Czech Republic, Netherlands, Canada, and the USA, with the first cohort starting in 2008 and the latest cohort starting in 2013. We assessed disability worsening using the Expanded Disability Status Scale (EDSS). The pRNFL thickness and macular volume were assessed once at study entry (baseline) by optical coherence tomography (OCT) and was calculated as the mean value of both eyes without optic neuritis for patients without a history of optic neuritis or the value of the non-optic neuritis eye for patients with previous unilateral optic neuritis. Researchers who did the OCT at baseline were masked to EDSS results and the researchers assessing disability with EDSS were masked to OCT results. We estimated the association of pRNFL thickness or macular volume at baseline in eyes without optic neuritis with the risk of subsequent disability worsening by use of proportional hazards models that included OCT metrics and age, disease duration, disability, presence of previous unilateral optic neuritis, and use of disease-modifying therapies as covariates. Findings 879 patients with clinically isolated syndrome (n=74), relapsing-remitting multiple sclerosis (n=664), or progressive multiple sclerosis (n=141) were included in the primary analyses. Disability worsening occurred in 252 (29%) of 879 patients with multiple sclerosis after a median follow-up of 2·0 years (range 0·5–5 years). Patients with a pRNFL of less than or equal to 87 μm or less than or equal to 88 μm (measured with Spectralis or Cirrus OCT devices) had double the risk of disability worsening at any time after the first and up to the third years of follow-up (hazard ratio 2·06, 95% CI 1·36–3·11; p=0·001), and the risk was increased by nearly four times after the third and up to the fifth years of follow-up (3·81, 1·63–8·91; p=0·002). We did not identify meaningful associations for macular volume. Interpretation Our results provide evidence of the usefulness of monitoring pRNFL thickness by OCT for prediction of the risk of disability worsening with time in patients with multiple sclerosis. Funding Instituto de Salud Carlos III.
Abstract Objective To determine the initial effectiveness of a novel, pediatric office-based intervention in motivating mothers to seek further assessment of positive depression screens. Methods In ...this pilot randomized controlled trial, English-speaking mothers (n = 104) with positive 2-question depression screens and presenting with children 0 to 12 years old for well-child care to a general pediatric training clinic received interventions from a trained research assistant. The Motivating Our Mothers (MOM) intervention included office-based written and verbal targeted depression education and motivational messages encouraging further depression assessment and a semistructured telephone booster delivered 2 days later. The control intervention included nontargeted written and verbal messages and 2 days later, an attention control telephone survey. Both groups received a list of depression care resources. The primary outcome was the proportion of mothers in each group who reported trying to contact any of 6 types of resources to discuss the positive screen at 2 weeks after intervention ( ClinicalTrials.gov NCT01453790 ). Results Despite 6 contact attempts, 10 MOM and 9 control mothers were lost to follow-up. More mothers in the MOM intervention tried to contact a resource compared to control (73.8% vs 53.5%, difference 20.3%, 95% confidence interval for difference −0.1 to 38.5, P = .052). Conclusions Mothers receiving the MOM intervention made more attempts to contact a resource for follow-up of positive depression screens. If found effective in larger studies, MOM may prove a promising approach for motivating depression screen–positive mothers identified in general pediatric settings within and beyond the postpartum period to seek further depression assessment and support.
Dexamethasone was the first intervention proven to reduce mortality in patients with COVID-19 being treated in hospital. We aimed to evaluate the adoption of corticosteroids in the treatment of ...COVID-19 in the UK after the RECOVERY trial publication on June 16, 2020, and to identify discrepancies in care.
We did an audit of clinical implementation of corticosteroids in a prospective, observational, cohort study in 237 UK acute care hospitals between March 16, 2020, and April 14, 2021, restricted to patients aged 18 years or older with proven or high likelihood of COVID-19, who received supplementary oxygen. The primary outcome was administration of dexamethasone, prednisolone, hydrocortisone, or methylprednisolone. This study is registered with ISRCTN, ISRCTN66726260.
Between June 17, 2020, and April 14, 2021, 47 795 (75·2%) of 63 525 of patients on supplementary oxygen received corticosteroids, higher among patients requiring critical care than in those who received ward care (11 185 86·6% of 12 909 vs 36 415 72·4% of 50 278). Patients 50 years or older were significantly less likely to receive corticosteroids than those younger than 50 years (adjusted odds ratio 0·79 95% CI 0·70–0·89, p=0·0001, for 70–79 years; 0·52 0·46–0·58, p<0·0001, for >80 years), independent of patient demographics and illness severity. 84 (54·2%) of 155 pregnant women received corticosteroids. Rates of corticosteroid administration increased from 27·5% in the week before June 16, 2020, to 75–80% in January, 2021.
Implementation of corticosteroids into clinical practice in the UK for patients with COVID-19 has been successful, but not universal. Patients older than 70 years, independent of illness severity, chronic neurological disease, and dementia, were less likely to receive corticosteroids than those who were younger, as were pregnant women. This could reflect appropriate clinical decision making, but the possibility of inequitable access to life-saving care should be considered.
UK National Institute for Health Research and UK Medical Research Council.
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