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The New England Journal of Medicine Jul 2023Pelvic radiation plus sensitizing chemotherapy with a fluoropyrimidine (chemoradiotherapy) before surgery is standard care for locally advanced rectal cancer in North... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
Pelvic radiation plus sensitizing chemotherapy with a fluoropyrimidine (chemoradiotherapy) before surgery is standard care for locally advanced rectal cancer in North America. Whether neoadjuvant chemotherapy with fluorouracil, leucovorin, and oxaliplatin (FOLFOX) can be used in lieu of chemoradiotherapy is uncertain.
METHODS
We conducted a multicenter, unblinded, noninferiority, randomized trial of neoadjuvant FOLFOX (with chemoradiotherapy given only if the primary tumor decreased in size by <20% or if FOLFOX was discontinued because of side effects) as compared with chemoradiotherapy. Adults with rectal cancer that had been clinically staged as T2 node-positive, T3 node-negative, or T3 node-positive who were candidates for sphincter-sparing surgery were eligible to participate. The primary end point was disease-free survival. Noninferiority would be claimed if the upper limit of the two-sided 90.2% confidence interval of the hazard ratio for disease recurrence or death did not exceed 1.29. Secondary end points included overall survival, local recurrence (in a time-to-event analysis), complete pathological resection, complete response, and toxic effects.
RESULTS
From June 2012 through December 2018, a total of 1194 patients underwent randomization and 1128 started treatment; among those who started treatment, 585 were in the FOLFOX group and 543 in the chemoradiotherapy group. At a median follow-up of 58 months, FOLFOX was noninferior to chemoradiotherapy for disease-free survival (hazard ratio for disease recurrence or death, 0.92; 90.2% confidence interval [CI], 0.74 to 1.14; P = 0.005 for noninferiority). Five-year disease-free survival was 80.8% (95% CI, 77.9 to 83.7) in the FOLFOX group and 78.6% (95% CI, 75.4 to 81.8) in the chemoradiotherapy group. The groups were similar with respect to overall survival (hazard ratio for death, 1.04; 95% CI, 0.74 to 1.44) and local recurrence (hazard ratio, 1.18; 95% CI, 0.44 to 3.16). In the FOLFOX group, 53 patients (9.1%) received preoperative chemoradiotherapy and 8 (1.4%) received postoperative chemoradiotherapy.
CONCLUSIONS
In patients with locally advanced rectal cancer who were eligible for sphincter-sparing surgery, preoperative FOLFOX was noninferior to preoperative chemoradiotherapy with respect to disease-free survival. (Funded by the National Cancer Institute; PROSPECT ClinicalTrials.gov number, NCT01515787.).
Topics: Adult; Humans; Anal Canal; Antineoplastic Combined Chemotherapy Protocols; Chemoradiotherapy; Chemotherapy, Adjuvant; Disease-Free Survival; Fluorouracil; Leucovorin; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Neoplasm Staging; Organ Sparing Treatments; Oxaliplatin; Rectal Neoplasms; Preoperative Care; Preoperative Period
PubMed: 37272534
DOI: 10.1056/NEJMoa2303269 -
JAMA Network Open Oct 2023Preoperative anxiety is common among adult patients undergoing elective surgery and is associated with negative outcomes. Virtual reality (VR)-based interventions have... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Preoperative anxiety is common among adult patients undergoing elective surgery and is associated with negative outcomes. Virtual reality (VR)-based interventions have been considered simpler, safer, and more effective for reducing anxiety in patients undergoing surgery than conventional care.
OBJECTIVE
To examine the effectiveness of a VR-based intervention with preoperative education in reducing preoperative anxiety among adult patients undergoing elective surgery.
DESIGN, SETTING, AND PARTICIPANTS
An assessor-blinded prospective randomized clinical trial was conducted to recruit adult patients aged 18 years or older who were scheduled for their first elective surgery procedure under general anesthesia within the next 2 to 4 weeks at a preanesthesia assessment clinic in Hong Kong from July to December 2022.
INTERVENTIONS
Participants were randomly assigned to either an intervention group (an 8-minute immersive 360° VR video tour in the operating theater via a head-mounted display console) or a control group (standard care).
MAIN OUTCOMES AND MEASURES
The primary outcome of preoperative anxiety was measured using the Amsterdam Preoperative Anxiety and Information Scale (range, 6-30; higher scores indicate greater anxiety), and the secondary outcomes (ie, stress, preparedness, and pain) were assessed by Visual Analog Scale at 3 time points: baseline at beginning of clinical session (T0), at the end of the clinical session immediately after the intervention (T1), and before the surgery (T2). Pain, satisfaction levels, and postoperative length of stay were evaluated after the surgery (T3). Simulation sickness was assessed after the intervention by use of the Simulation Sickness Questionnaire. A generalized estimating equations model was applied to compare changes in outcomes over time.
RESULTS
A total of 74 participants (mean [SD] age, 46.34 [14.52] years; 38 men [51.4%] and 36 women [48.6%]) were recruited and randomized to the control group (37 participants) and intervention group (37 participants). Compared with the control group, the VR-based intervention group showed significantly decreased preoperative anxiety at T1 (β, -5.46; 95% CI, -7.60 to -3.32; P < .001) and T2 (β, -5.57; 95% CI, -7.73 to -3.41; P < .001), lower stress at T1 (β, -10.68; 95% CI, -16.00 to -5.36; P < .001) and T2 (β, -5.16; 95% CI, -9.87 to -0.45; P = .03), and higher preparedness at T1 (β, 6.60; 95% CI, 0.97 to 12.19; P = .02). Satisfaction levels were significantly increased in the intervention group vs the control group (mean [SD] score, 81.35 [9.24] vs 65.28 [8.16]; difference, 16.07; 95% CI, 12.00 to 20.15; P < .001). No significant differences in pain and postoperative length of stay were found.
CONCLUSIONS AND RELEVANCE
The findings of this study suggest that a VR-based intervention is a feasible and effective way to reduce preoperative anxiety in adult patients undergoing elective surgery. Given the promising results of this study, further study in the form of large-scale, multicenter, randomized clinical trials with broader implementation is warranted.
TRIAL REGISTRATION
Chinese Clinical Trial Registry Identifier: ChiCTR2100051690.
Topics: Adult; Female; Humans; Male; Middle Aged; Anxiety; Anxiety Disorders; Pain; Prospective Studies; Virtual Reality
PubMed: 37906193
DOI: 10.1001/jamanetworkopen.2023.40588 -
JPMA. the Journal of the Pakistan... Aug 2023We conceptualize and define endocrine and metabolic prehabilitation as enhancement of physical, psychosocial and social health, prior to a planned medical, surgical or...
We conceptualize and define endocrine and metabolic prehabilitation as enhancement of physical, psychosocial and social health, prior to a planned medical, surgical or radiotherapeutic endocrine/metabolic intervention, in order to ensure optimal therapeutic outcomes during and after the procedure. This is similar to, but different from the process of endocrine rehabilitation, which follows endocrine therapy. All health care professionals, working as a team, should take responsibility of endocrine prehabilitation.
Topics: Humans; Preoperative Exercise; Health Personnel; Medicine; Physical Examination
PubMed: 37697776
DOI: 10.47391/JPMA.23-56 -
Journal of Cardiovascular Development... Nov 2023Minimally invasive cardiac surgery (MICS) has been used since the 1990s and encompasses a wide range of techniques that lack full sternotomy, including valve and... (Review)
Review
Minimally invasive cardiac surgery (MICS) has been used since the 1990s and encompasses a wide range of techniques that lack full sternotomy, including valve and coronary artery graft surgery as well as transcatheter procedures. Due to the potential benefits offered to patients by MICS, these procedures are becoming more common. Unique anaesthetic knowledge and skills are required to overcome the specific challenges presented by MICS, including mastery of transoesophageal echocardiography (TOE) and the provision of thoracic regional analgesia. This review evaluates the relevance of MICS to the anaesthetist and discusses pre-operative assessment, the relevant adjustments to intra-operative conduct that are necessary for these techniques, as well as post-operative care and what is known about outcomes.
PubMed: 37998520
DOI: 10.3390/jcdd10110462 -
The Journal of International Medical... May 2024The aging world population obliges physicians to establish measures to optimize and estimate the outcomes of increasingly frail patients. Thus, in the last few years... (Review)
Review
The aging world population obliges physicians to establish measures to optimize and estimate the outcomes of increasingly frail patients. Thus, in the last few years there has been an increase in the application of frailty indices. Multiple scales have emerged that can be applied in the perioperative setting. Each one has demonstrated some utility, either by way of establishing postoperative prognosis or as a method for the clinical optimization of patient care. Anaesthesiologists are offered a wide choice of scales, the characteristics and appropriate management of which they are often unaware. This narrative review aims to clarify the concept of frailty, describe its importance in the perioperative setting and evaluate the different scales that are most applicable to the perioperative setting. It will also establish paths for the future optimization of patient care.
Topics: Humans; Frailty; Geriatric Assessment; Aged; Frail Elderly; Prognosis; Preoperative Care; Preoperative Period
PubMed: 38818532
DOI: 10.1177/03000605241251705 -
Cureus Aug 2023Value-based care, prioritizing patient outcomes over service volume, is steering a transformative course in anesthesiology in the United States. With the rise of this... (Review)
Review
Value-based care, prioritizing patient outcomes over service volume, is steering a transformative course in anesthesiology in the United States. With the rise of this patient-centric approach, anesthesiologists are adopting dynamic roles to meet the demands of medical institutions, insurers, and patients for high-quality, cost-effective care. The urgency for this transition is accentuated by persistent challenges in reducing postoperative mortality rates and surgical complications, further spotlighted by the coronvirus disease 2019 (COVID-19) pandemic. Anesthesiologists engage in preoperative optimization, personalized care delivery, and evidence-based practices, bolstering their influence in the perioperative environment. Their collaboration with perioperative stakeholders propels the shift toward a value-driven healthcare landscape. This review analyzes the implementation of value-based care in American anesthesiology, assesses the significance of technology in enhancing its delivery, and outlines potential strategies for improving its application.
PubMed: 37791193
DOI: 10.7759/cureus.44410 -
Soins; La Revue de Reference Infirmiere Apr 2024The maintenance and optimization of functional capacities before, during, and after treatment are major challenges for frailty persons as cancer's patients. It is now...
The maintenance and optimization of functional capacities before, during, and after treatment are major challenges for frailty persons as cancer's patients. It is now known that physical activity in prehabilitation plays a crucial role in limiting, among other things, post-operative complications. The benefits have already been demonstrated in various studies, including a decrease in hospitalization duration, an increase in cardiorespiratory endurance, improvement in quality of life, and better fatigue management. It is observed that patients who undergo prehabilitation are those who recover their preoperative capacities the fastest. However, it is estimated that only one-third of patients with access to prehabilitation improve their physical capacities.
Topics: Humans; Preoperative Exercise; Quality of Life; Exercise; Hospitalization; Patients
PubMed: 38614513
DOI: 10.1016/j.soin.2024.02.004 -
Saudi Journal of Anaesthesia 2023Nowadays, the pre-operative evaluation of older patients is a critical step in the decision-making process. Clinical assessment and care planning should be considered a... (Review)
Review
Nowadays, the pre-operative evaluation of older patients is a critical step in the decision-making process. Clinical assessment and care planning should be considered a whole process rather than separate issues. Clinicians should use validated tools for pre-operative risk assessment of older patients to minimize surgery-related morbidity and mortality and enhance care quality. Traditional pre-operative consultation often fails to capture the pathophysiological and functional profiles of older patients. The elderly's pre-operative evaluation should be focused on determining the patient's functional reserve and reducing any possible peri-operative risk. Therefore, older adults may benefit from the Comprehensive Geriatric Assessment (CGA) that allows clinicians to evaluate several aspects of elderly life, such as depression and cognitive disorders, social status, multi-morbidity, frailty, geriatric syndromes, nutritional status, and polypharmacy. Despite the recognized challenges in applying the CGA, it may provide a realistic risk assessment for post-operative complications and suggest a tailored peri-operative treatment plan for older adults, including pre-operative optimization strategies. The older adults' pre-operative examination should not be considered a mere stand-alone, that is, an independent stage of the surgical pathway, but rather a vital step toward a personalized therapeutic approach that may involve professionals from different clinical fields. The aim of this review is to revise the evidence from the literature and highlight the most important items to be implemented in the pre-operative evaluation process in order to identify better all elderly patients' needs.
PubMed: 37779566
DOI: 10.4103/sja.sja_613_23 -
Ugeskrift For Laeger Jan 2024With an increasing aging population, there will be a greater need for cancer evaluation and treatment in older patients. Age alone is not a good predictor of... (Review)
Review
With an increasing aging population, there will be a greater need for cancer evaluation and treatment in older patients. Age alone is not a good predictor of postoperative morbidity, and a multidisciplinary approach is crucial for managing comorbidities. Preoperative optimisation, such as prehabilitation, may in some cases reduce postoperative complications, and minimal invasive techniques should be preferred whenever possible. In general, as summarised in this review, cancer treatment in older patients should be individualised based on comorbidities and life expectancy.
Topics: Humans; Aged; Preoperative Care; Postoperative Complications; Neoplasms; Aging; Morbidity
PubMed: 38305320
DOI: 10.61409/V08230489