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Clinical Nutrition (Edinburgh, Scotland) Mar 2024Prehabilitation comprises multidisciplinary preoperative interventions including exercise, nutritional optimisation and psychological preparation aimed at improving... (Meta-Analysis)
Meta-Analysis
BACKGROUND & AIMS
Prehabilitation comprises multidisciplinary preoperative interventions including exercise, nutritional optimisation and psychological preparation aimed at improving surgical outcomes. The aim of this systematic review and meta-analysis was to determine the impact of prehabilitation on postoperative outcomes in frail and high-risk patients undergoing major abdominal surgery.
METHODS
Embase, Medline, CINAHAL and Cochrane databases were searched from January 2010 to January 2023 for randomised clinical trials (RCTs) and observational studies evaluating unimodal (exercise) or multimodal prehabilitation programmes. Meta-analysis was limited to length of stay (primary end point), severe postoperative complications (Clavien-Dindo Classification ≥ Grade 3) and the 6-minute walk test (6MWT). The analysis was performed using RevMan v5.4 software.
RESULTS
Sixteen studies (6 RCTs, 10 observational) reporting on 3339 patients (1468 prehabilitation group, 1871 control group) were included. The median (interquartile range) age was 74.0 (71.0-78.4) years. Multimodal prehabilitation was applied in fifteen studies and unimodal in one. Meta-analysis of nine studies showed a reduction in hospital length of stay (weighted mean difference -1.07 days, 95 % CI -1.60 to -0.53 days, P < 0.0001, I = 19 %). Ten studies addressed severe complications and a meta-analysis suggested a decline in occurrence by up to 44 % (odds ratio 0.56, 95 % CI 0.37 to 0.82, P < 0.004, I = 51 %). Four studies provided data on preoperative 6MWT. The pooled weighted mean difference was 40.1 m (95 % CI 32.7 to 47.6 m, P < 0.00001, I = 24 %), favouring prehabilitation.
CONCLUSION
Given the significant impact on shortening length of stay and reducing severe complications, prehabilitation should be encouraged in frail, older and high-risk adult patients undergoing major abdominal surgery.
Topics: Aged; Humans; Abdomen; Exercise; Frail Elderly; Postoperative Complications; Preoperative Exercise
PubMed: 38306891
DOI: 10.1016/j.clnu.2024.01.020 -
European Urology Focus Nov 2023Carbon footprint (CF) has emerged as an important factor when assessing health care interventions. (Review)
Review
CONTEXT
Carbon footprint (CF) has emerged as an important factor when assessing health care interventions.
OBJECTIVE
To investigate the reduction in CF for patients utilizing telemedicine.
EVIDENCE ACQUISITION
The PubMed, Scopus, and Web of Science databases were queried for studies describing telemedicine consultation and reporting on carbon emissions saved and the carbon emissions of telemedicine devices as primary outcomes, and travel distance and time and cost savings and safety as secondary outcomes. Outcomes were tabulated and calculated per consultation. Carbon emissions and travel distances were also calculated for each total study cohort. Risk of bias was assessed using the Newcastle-Ottawa scale, and the Oxford level of evidence was determined.
EVIDENCE SYNTHESIS
A total of 48 studies met the inclusion criteria, covering 68 465 481 telemedicine consultations and savings of 691 825 tons of CO emissions and 3 318 464 047 km of travel distance. Carbon assessment was mostly reported as the estimated distance saved using a conversion factor. Medical specialties used telemedicine to connect specialists with patients at home (n = 25) or at a local center (n = 6). Surgical specialties used telemedicine for virtual preoperative assessment (n = 9), follow-up (n = 4), and general consultation (n = 4). The savings per consultation were 21.9-632.17 min and $1.85-$325. More studies focused on the COVID-19 time frame (n = 33) than before the pandemic (n = 15). The studies are limited by calculations, mostly for the travel distance for carbon savings, and appropriate follow-up to analyze the real impact on travel and appointments.
CONCLUSIONS
Telemedicine reduces the CF of the health care sector. Expanding the use of telemedicine and educating providers and patients could further decrease CO emissions and save both money and time.
PATIENT SUMMARY
We reviewed 48 studies on the use of telemedicine. We found that people used their cars less and saved time and money, as well as CO emissions, if they used teleconsultations. Some studies only looked at how much CO from driving was saved, so there might be more to learn about the benefits of teleconsultations. The use of online doctor appointments is not only good for our planet but also helps patients in saving time and money. This review is registered on the PROSPERO database for systematic reviews (CRD42023456839).
Topics: Humans; Carbon; Carbon Dioxide; Carbon Footprint; Delivery of Health Care; Referral and Consultation; Systematic Reviews as Topic; Telemedicine
PubMed: 38036339
DOI: 10.1016/j.euf.2023.11.013 -
World Journal of Surgery Mar 2024Worldwide, ERAS Society guidelines have ushered in a new era of perioperative care. The purpose of this systematic review is to compare published core elements and...
Enhanced recovery after surgery (ERAS ) Society abdominal and thoracic surgery recommendations: A systematic review and comparison of guidelines for perioperative and pharmacotherapy core items.
INTRODUCTION
Worldwide, ERAS Society guidelines have ushered in a new era of perioperative care. The purpose of this systematic review is to compare published core elements and pharmacotherapy recommendations embedded within ERAS Society abdominal and thoracic surgery (ATS) guidelines. Determining whether a consensus exists for pharmacological core items would make future guideline preparation for similar surgeries more standardized and could improve patient care by reducing unnecessary protocol variations.
METHODS
From the ERAS Society website as of May 2023, 16 current ERAS published ATS guidelines were included in the analysis to determine consensus and differing statements regarding each ERAS perioperative and pharmacotherapy-related item. The aims were to (a) determine whether a consensus for each item could be derived, (b) identify gaps in ERAS protocol development, and (c) propose potential research directions for addressing the identified gaps in the literature.
RESULTS
Core items with consensus included: preoperative smoking and alcohol cessation; avoiding bowel reparation and fasting; multimodal preanesthetic, perioperative analgesia, and postoperative nausea and vomiting regimens; low molecular weight heparins for in-hospital and at-home venous thromboembolism prophylaxis; antibiotic prophylaxis; skin preparation; goal-directed perioperative fluid management with balanced crystalloids; perioperative nutrition care; ileus prevention with peripherally-acting mu receptor antagonists; and glucose control.
CONCLUSION
While consensus was found for aspects of 21 current ERAS guideline core items related to pharmacotherapy choice, details related to doses, regimen, timing of administration as well as unique aspects pertaining to specific surgeries remain to be researched and harmonized to promote guideline consistency and further optimize patient outcomes.
Topics: Humans; Enhanced Recovery After Surgery; Perioperative Care; Postoperative Nausea and Vomiting; Thoracic Surgery; Thoracic Surgical Procedures; Practice Guidelines as Topic
PubMed: 38348514
DOI: 10.1002/wjs.12101 -
Diseases of the Esophagus : Official... Feb 2024Esophagectomy for esophageal cancer is associated with high morbidity. It remains unclear whether prehabilitation, a strategy aimed at optimizing patients' physical and... (Meta-Analysis)
Meta-Analysis
Esophagectomy for esophageal cancer is associated with high morbidity. It remains unclear whether prehabilitation, a strategy aimed at optimizing patients' physical and mental functioning prior to surgery, improves postoperative outcomes. A systematic review and meta-analysis was conducted to evaluate the effect of prehabilitation on post-operative outcomes after esophagectomy. Data sources included Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and PEDro, with information from 1 January 2000 to 5 August 2023. The analysis included randomized controlled trials and observational studies that compared prehabilitation interventions to standard care prior to esophagectomy. A random effects model was used to generate a pooled estimate for pairwise meta-analysis, meta-analysis of proportions, and meta-analysis of means. A total of 1803 patients were included with 584 in randomized controlled trials (RCTs) and 1219 in observational studies. In the randomized evidence, there were no significant differences between prehabilitation and control in the odds of postoperative pneumonia (15.0 vs. 18.9%, odds ratio (OR) 1.06 [95% confidence interval (CI): 0.66;1.72]) or pulmonary complications (14 vs. 25.6%, OR 0.68 [95% CI: 0.32;1.45]). In the observational data, there was a reduction in both postoperative pneumonia (22.5 vs. 32.9%, OR 0.48 [95% CI: 0.28;0.83]) and pulmonary complications (26.1 vs. 52.3%, OR 0.35 [95% CI: 0.17;0.75]) with prehabilitation. Hospital and intensive care unit length of stay (days), operative mortality, and severe complications (Clavien-Dindo ≥ 3) did not differ between groups in both the randomized data and observational data. Prehabilitation demonstrated reductions in postoperative pneumonia and pulmonary complications in observational studies, but not RCTs. The overall certainty of these findings is limited by the low quality of the available evidence.
Topics: Humans; Esophageal Neoplasms; Esophagectomy; Intensive Care Units; Pneumonia; Preoperative Exercise; Randomized Controlled Trials as Topic; Observational Studies as Topic
PubMed: 38018252
DOI: 10.1093/dote/doad066 -
Journal of Clinical Medicine Sep 2023This systematic review was aimed at gathering the clinical and technical applications of CAD/CAM technology for craniofacial implant placement and processing of... (Review)
Review
This systematic review was aimed at gathering the clinical and technical applications of CAD/CAM technology for craniofacial implant placement and processing of auricular prostheses based on clinical cases. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, an electronic data search was performed. Human clinical studies utilizing digital planning, designing, and printing systems for craniofacial implant placement and processing of auricular prostheses for prosthetic rehabilitation of auricular defects were included. Following a data search, a total of 36 clinical human studies were included, which were digitally planned and executed through various virtual software to rehabilitate auricular defects. Preoperative data were collected mainly through computed tomography scans (CT scans) (55 cases); meanwhile, the most common laser scanners were the 3dMDface System (3dMD LLC, Atlanta, Georgia, USA) (6 cases) and the 3 Shape scanner (3 Shape, Copenhagen, Denmark) (6 cases). The most common digital design software are Mimics Software (Mimics Innovation Suite, Materialize, Leuven, Belgium) (18 cases), Freeform software (Freeform, NC, USA) (13 cases), and 3 Shape software (3 Shape, Copenhagen, Denmark) (12 cases). Surgical templates were designed and utilized in 35 cases to place 88 craniofacial implants in auricular defect areas. The most common craniofacial implants were Vistafix craniofacial implants (Entific Medical Systems, Goteborg, Sweden) in 22 cases. A surgical navigation system was used to place 20 craniofacial implants in the mastoid bone. Digital applications of CAD/CAM technology include, but are not limited to, study models, mirrored replicas of intact ears, molds, retentive attachments, customized implants, substructures, and silicone prostheses. The included studies demonstrated a predictable clinical outcome, reduced the patient's visits, and completed the prosthetic rehabilitation in reasonable time and at reasonable cost. However, equipment costs and trained technical staff were highlighted as possible limitations to the use of CAD/CAM systems.
PubMed: 37762891
DOI: 10.3390/jcm12185950 -
European Archives of... Apr 2024We performed this systematic review and meta-analysis to explore the impact of preoperative sarcopenia on postoperative complication risks after head and neck cancer... (Review)
Review
PURPOSE
We performed this systematic review and meta-analysis to explore the impact of preoperative sarcopenia on postoperative complication risks after head and neck cancer (HNC) surgery.
METHODS
We identified eligible studies by searching Ovid-MEDLINE, Ovid-Embase, EBM Reviews-Cochrane Central Register of Controlled Trials, Web of Science Core Collection, and Scopus. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.
RESULTS
Twenty-one studies with a total of 3480 patients met our inclusion criteria. The presence of sarcopenia significantly increased the incidence of overall postoperative complications (OR = 1.72, 95% CI 1.23, 2.41; P = 0.002; I = 59%). Subgroup analyses showed a higher risk of postoperative complications in the populations in which sarcopenia was diagnosed with low L3-skeletal muscle index (L3-SMI) or low cross-sectional area of the rectus femoris, but not in the group that sarcopenia was diagnosed with low C3-SMI. Preoperative sarcopenia also substantially increased the risk of severe postoperative complications (OR = 2.26), pharyngocutaneous fistulas (OR = 2.15), free flap-related complications (OR = 1.63), and surgical site infections (OR = 1.84). We also found a tendency toward a higher incidence of wound complications and 30-day mortality in patients with sarcopenia.
CONCLUSION
Preoperative sarcopenia is a negative prognostic indicator for postoperative complications in patients with HNC after surgery. To reduce the incidence of postoperative complications and improve poor prognosis, further attention needs to be paid to the evaluation and management of preoperative sarcopenia.
PubMed: 38647686
DOI: 10.1007/s00405-024-08577-1 -
Nutrients Jul 2023Initial evidence indicates that preoperatively initiated administration of omega-3 fatty acids (FAs) attenuates the postoperative inflammatory reaction. The effects of... (Meta-Analysis)
Meta-Analysis Review
UNLABELLED
Initial evidence indicates that preoperatively initiated administration of omega-3 fatty acids (FAs) attenuates the postoperative inflammatory reaction. The effects of immunonutrition containing omega-3 FAs, such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), on the inflammatory response to abdominal surgery continues to be unclear, although improved outcomes have been reported. Therefore, we determined the effectiveness of preoperatively initiated omega-3 FAs administration on postoperative inflammation defined as CRP (C-Reactive Protein), IL-6 (Interleukin 6), and WBC (White Blood Count) and potential effects on postoperative length of hospital stay (LOS) due to an improved inflammatory response.
METHODS
a literature search of Cochrane Library was conducted to identify all randomized controlled trials (RCTs) investigating the effects of preoperatively initiated omega-3 to standard care, placebo, or other immunonutrients excluding omega-3 FAs in patients undergoing abdominal surgery until the end of December 2022.
RESULTS
a total of 296 articles were found during the initial search. Thirteen RCTs involving 950 patients were identified that met the search criteria. These were successively analyzed and included in this meta-analysis. There was no significant difference between the groups with respect to inflammatory markers IL-6: -0.55 [-1.22; 0.12] = 0.10, CRP: -0.14 [-0.67; 0.40] = 0.55, WBC: -0.58 [-3.05; 1.89] 0.42, or hospital stay -0.5 [-1.43; 0.41] = 0.2.
CONCLUSION
although reduced inflammatory markers were observed, preoperative administration of omega-3 FAs immunonutrients had no significant effect on the postoperative inflammatory response in patients undergoing abdominal surgeries. Yet, results obtained from this study are inconclusive, likely attributed to the limited number of trials and patients included. Further studies are required to obtain a better educated verdict.
Topics: Humans; Interleukin-6; Fatty Acids, Omega-3; Eicosapentaenoic Acid; Docosahexaenoic Acids; Inflammation; Dietary Supplements
PubMed: 37571352
DOI: 10.3390/nu15153414 -
Paediatric Anaesthesia May 2024Two prior reviews highlight the scarcity and conflicting nature of available data on chronic postsurgical pain in children, reporting a wide prevalence range of 3.2% to... (Review)
Review
Two prior reviews highlight the scarcity and conflicting nature of available data on chronic postsurgical pain in children, reporting a wide prevalence range of 3.2% to 64% (at ≥3 months). This updated systematic review aimed to consolidate information on the prevalence of pediatric chronic postsurgical pain. A thorough literature search of full English-text publications from April 2014 to August 2021 was conducted using Ovid MEDLINE, PubMed, and Cochrane Database of Systematic Reviews, with search terms: postoperative pain, child, preschool, pediatrics, adolescent, chronic pain. Seventeen relevant studies were identified. Most assessed chronicity once greater than 3 months duration postoperatively (82%), were predominantly prospective (71%) and conducted in inpatient settings (88%). The surgeries examined included orthopedic (scoliosis and limb), urological, laparotomy, inguinal, and cardiothoracic procedures, involving numbers ranging from 36 to 750, totaling 3137 participants/2792 completers. The studies had wide variations in median age at surgery (6 days to 16 years), the percentage of female participants (unspecified or 12.5% to 90%), and follow-up duration (2.5 months to 9 years). Various pain, functional, psychosocial, and health-related quality of life outcomes were documented. Chronic postsurgical pain prevalence varied widely from 2% to 100%. Despite increased data, challenges persist due to heterogeneity in definitions, patient demographics, mixed versus single surgical populations, diverse perioperative analgesic interventions, follow-up durations and reported outcomes. Interpretation is further complicated by limited information on impact, long-term analgesia and healthcare utilization, and relatively small sample sizes, hindering the assessment of reported associations. In some cases, preoperative pain and deformity may not have been addressed by surgery and persisting pain postoperatively may then be inappropriately termed chronic postsurgical pain. Larger-scale, procedure-specific data to better assess current prevalence, impact, and whether modifiable factors link to negative long-term outcomes, would be more useful and allow targeted perioperative interventions for at-risk pediatric surgical patients.
PubMed: 38738779
DOI: 10.1111/pan.14918 -
Cureus May 2024Despite being a generally successful procedure, pain following reverse total shoulder arthroplasty (rTSA) is a known complication. The aim of this systematic review is... (Review)
Review
Despite being a generally successful procedure, pain following reverse total shoulder arthroplasty (rTSA) is a known complication. The aim of this systematic review is to identify preoperative risk factors for pain following rTSA to encourage evidence-based interventions, inform clinicians, and aid in surgical planning. Studies that reported preoperative risk factors and pain after rTSA were included. Studies which reported outcome measures that incorporated pain scores yet did not display them independently, studies which only reported intraoperative risk factors, and studies involving participants under 18 were excluded. The search was conducted on May 31, 2023, across the following databases: PubMed, Web of Science, Embase, Scopus, and Cochrane Central Register of Controlled Trials. Four independent researchers conducted this systematic review, and a descriptive analysis was subsequently performed. Twenty-five studies were included following the evaluation of full-text articles, involving a total of 9,470 shoulders. Preoperative risk factors identified were categorised into the following groups: BMI, smoking, radiographic findings, age and sex, prior surgery, functional ability and pain, and psychosocial. The strongest associations identified were preoperative opioid use and smoking, which were both associated with worse pain outcomes following rTSA; other preoperative risk factors highlighted in this review showed either weak or no correlation. Preoperative opioid use and smoking are likely risk factors for the development of pain after rTSA. Although the studies included varying levels of quality, the identification of modifiable risk factors is useful in optimising management prior to surgery and guiding patient expectations. The lack of evidence regarding associations with non-modifiable risk factors further reinforces the potential benefits of the procedure on diverse population groups and is useful in itself for assessing the candidacy of patients for the procedure, particularly when postoperative pain is a factor being considered.
PubMed: 38736766
DOI: 10.7759/cureus.60041 -
Annals of Emergency Medicine Jun 2024We conducted a systematic review and network meta-analysis to evaluate the comparative efficacy of peripheral nerve block types for preoperative pain management of hip... (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVE
We conducted a systematic review and network meta-analysis to evaluate the comparative efficacy of peripheral nerve block types for preoperative pain management of hip fractures.
METHODS
We searched Cochrane, Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar for randomized clinical trials. We included participants aged more than 16 years with hip fractures who received peripheral nerve blocks or analgesics for preoperative pain management. The primary outcomes were defined as absolute pain score 2 hours after block placement, preoperative consumption of morphine equivalents, and length of hospital stay. We used a random-effects network meta-analysis conceptualized in the Bayesian framework. Confidence of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA).
RESULTS
We included 63 randomized controlled studies (4,778 participants), of which only a few had a low risk of bias. The femoral nerve block, 3-in-1 block, fascia iliaca compartment block, and pericapsular nerve group block yielded significantly lowered pain scores at 2 hours after block placement compared with those with no block (standardized mean differences [SMD]: -1.1; 95% credible interval [CrI]: -1.7 to -0.48, [confidence of evidence: low]; SMD: -1.8; 95% CrI: -3.0 to -0.55, [low]; SMD: -1.4; 95% CrI: -2.0 to -0.72, [low]; SMD: -2.3; 95% CrI: -3.2 to -1.4, [moderate], respectively). The pericapsular nerve group block, 3-in-1 block, fascia iliaca compartment block, and femoral nerve block resulted in lower pain scores than the no-block group. Additionally, the pericapsular nerve group block yielded a lower pain score than femoral nerve block or fascia iliaca compartment block (SMD: -1.21; 95% CrI: -2.18 to -0.23, [very low]: SMD: -0.92; 95% CrI: -1.70 to -0.16, [low]). However, both the fascia iliaca compartment block and femoral nerve block did not show a reduction in morphine consumption compared with no block. To our knowledge, no studies have compared the pericapsular nerve group block with other methods regarding morphine consumption. Furthermore, no significant difference was observed between peripheral nerve blocks and no block in terms of the length of hospital stay.
CONCLUSIONS
Compared with no block, preoperative peripheral nerve blocks for hip fractures appear to reduce pain 2 hours after block placement. Comparing different blocks, pericapsular nerve group block might be superior to fascia iliaca compartment block and femoral nerve block for pain relief, though the confidence evidence was low in most comparisons because of the moderate to high risk of bias in many of the included studies and the high heterogeneity of treatment strategies across studies. Therefore, further high-quality research is needed.
Topics: Humans; Hip Fractures; Nerve Block; Pain Management; Preoperative Care; Network Meta-Analysis; Pain Measurement; Randomized Controlled Trials as Topic; Femoral Nerve; Length of Stay
PubMed: 38385910
DOI: 10.1016/j.annemergmed.2024.01.024