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The Cochrane Database of Systematic... Apr 2020Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. This is an update of a Cochrane Review first published in 2010 and subsequently updated in 2012, twice in 2014, in 2017 and 2018.
OBJECTIVES
To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We also assessed the side effects of vaginal cleansing solutions to determine adverse events associated with the intervention.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (7 July 2019), and reference lists of retrieved studies.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) and quasi-RCTs assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. Cluster-RCTs were eligible for inclusion, but we did not identify any. We excluded trials that utilized vaginal preparation during labor or that did not use antibiotic surgical prophylaxis. We also excluded any trials using a cross-over design. We included trials published in abstract form only if sufficient information was present in the abstract on methods and outcomes to analyze.
DATA COLLECTION AND ANALYSIS
At least three of the review authors independently assessed eligibility of the studies. Two review authors were assigned to extract study characteristics, quality assessments, and data from eligible studies.
MAIN RESULTS
We included 21 trials, reporting results for 7038 women evaluating the effects of vaginal cleansing (17 using povidone-iodine, 3 chlorhexidine, 1 benzalkonium chloride) on post-cesarean infectious morbidity. Trials used vaginal preparations administered by sponge sticks, douches, or soaked gauze wipes. The control groups were typically no vaginal preparation (17 trials) or the use of a saline vaginal preparation (4 trials). One trial did not report on any outcomes of interest. Trials were performed in 10 different countries (Saudi Arabia, Pakistan, Iran, Thailand, Turkey, USA, Egypt, UK, Kenya and India). The overall risk of bias was low for areas of attrition, reporting, and other bias. About half of the trials had low risk of selection bias, with most of the remainder rated as unclear. Due to lack of blinding, we rated performance bias as high risk in nearly one-third of the trials, low risk in one-third, and unclear in one-third. Vaginal preparation with antiseptic solution immediately before cesarean delivery probably reduces the incidence of post-cesarean endometritis from 7.1% in control groups to 3.1% in vaginal cleansing groups (average risk ratio (aRR) 0.41, 95% confidence interval (CI) 0.29 to 0.58; 20 trials, 6918 women; moderate-certainty evidence). This reduction in endometritis was seen for both iodine-based solutions and chlorhexidine-based solutions. Risks of postoperative fever and postoperative wound infection are also probably reduced by vaginal antiseptic preparation (fever: aRR 0.64, 0.50 to 0.82; 16 trials, 6163 women; and wound infection: RR 0.62, 95% CI 0.50 to 0.77; 18 trials, 6385 women; both moderate-certainty evidence). Two trials found that there may be a lower risk of a composite outcome of wound complication or endometritis in women receiving preoperative vaginal preparation (RR 0.46, 95% CI 0.26 to 0.82; 2 trials, 499 women; low-certainty evidence). No adverse effects were reported with either the povidone-iodine or chlorhexidine vaginal cleansing. Subgroup analysis suggested a greater effect with vaginal preparations for those women in labour versus those not in labour for four out of five outcomes examined (post-cesarean endometritis; postoperative fever; postoperative wound infection; composite wound complication or endometritis). This apparent difference needs to be investigated further in future trials. We did not observe any subgroup differences between women with ruptured membranes and women with intact membranes.
AUTHORS' CONCLUSIONS
Vaginal preparation with povidone-iodine or chlorhexidine solution compared to saline or not cleansing immediately before cesarean delivery probably reduces the risk of post-cesarean endometritis, postoperative fever, and postoperative wound infection. Subgroup analysis found that these benefits were typically present whether iodine-based or chlorhexidine-based solutions were used and when women were in labor before the cesarean. The suggested benefit in women in labor needs further investigation in future trials. There was moderate-certainty evidence using GRADE for all reported outcomes, with downgrading decisions based on limitations in study design or imprecision. As a simple intervention, providers may consider implementing preoperative vaginal cleansing with povidone-iodine or chlorhexidine before performing cesarean deliveries. Future research on this intervention being incorporated into bundles of care plans for women receiving cesarean delivery will be needed.
Topics: Administration, Intravaginal; Anti-Infective Agents, Local; Benzalkonium Compounds; Cesarean Section; Chlorhexidine; Disinfection; Endometritis; Female; Fever; Humans; Povidone-Iodine; Pregnancy; Preoperative Care; Randomized Controlled Trials as Topic; Surgical Wound Infection
PubMed: 32335895
DOI: 10.1002/14651858.CD007892.pub7 -
BMC Cancer Sep 2021Artificial intelligence (AI) is increasingly being used in medical imaging analysis. We aimed to evaluate the diagnostic accuracy of AI models used for detection of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Artificial intelligence (AI) is increasingly being used in medical imaging analysis. We aimed to evaluate the diagnostic accuracy of AI models used for detection of lymph node metastasis on pre-operative staging imaging for colorectal cancer.
METHODS
A systematic review was conducted according to PRISMA guidelines using a literature search of PubMed (MEDLINE), EMBASE, IEEE Xplore and the Cochrane Library for studies published from January 2010 to October 2020. Studies reporting on the accuracy of radiomics models and/or deep learning for the detection of lymph node metastasis in colorectal cancer by CT/MRI were included. Conference abstracts and studies reporting accuracy of image segmentation rather than nodal classification were excluded. The quality of the studies was assessed using a modified questionnaire of the QUADAS-2 criteria. Characteristics and diagnostic measures from each study were extracted. Pooling of area under the receiver operating characteristic curve (AUROC) was calculated in a meta-analysis.
RESULTS
Seventeen eligible studies were identified for inclusion in the systematic review, of which 12 used radiomics models and five used deep learning models. High risk of bias was found in two studies and there was significant heterogeneity among radiomics papers (73.0%). In rectal cancer, there was a per-patient AUROC of 0.808 (0.739-0.876) and 0.917 (0.882-0.952) for radiomics and deep learning models, respectively. Both models performed better than the radiologists who had an AUROC of 0.688 (0.603 to 0.772). Similarly in colorectal cancer, radiomics models with a per-patient AUROC of 0.727 (0.633-0.821) outperformed the radiologist who had an AUROC of 0.676 (0.627-0.725).
CONCLUSION
AI models have the potential to predict lymph node metastasis more accurately in rectal and colorectal cancer, however, radiomics studies are heterogeneous and deep learning studies are scarce.
TRIAL REGISTRATION
PROSPERO CRD42020218004 .
Topics: Artificial Intelligence; Bias; Colorectal Neoplasms; Deep Learning; Humans; Lymph Nodes; Lymphatic Metastasis; Magnetic Resonance Imaging; Preoperative Care; Publication Bias; ROC Curve; Radiologists; Rectal Neoplasms; Sensitivity and Specificity; Tomography, X-Ray Computed
PubMed: 34565338
DOI: 10.1186/s12885-021-08773-w -
The Cochrane Database of Systematic... Jul 2021Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require a combination of surgery and chemotherapy for optimal treatment.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require a combination of surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery.
OBJECTIVES
To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)).
SEARCH METHODS
We searched the following databases up to 9 October 2020: the Cochrane Central Register of Controlled Trials (CENTRAL), Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information.
SELECTION CRITERIA
Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data and assessed risk of bias in each included trial. We extracted data of overall (OS) and progression-free survival (PFS), adverse events, surgically-related mortality and morbidity and quality of life outcomes. We used GRADE methods to determine the certainty of evidence.
MAIN RESULTS
We identified 2227 titles and abstracts through our searches, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1774 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the four studies where data were available and found little or no difference with regard to overall survival (OS) (Hazard Ratio (HR) 0.96, 95% CI 0.86 to 1.08; participants = 1692; studies = 4; high-certainty evidence) or progression-free survival in four trials where we were able to pool data (Hazard Ratio 0.98, 95% CI 0.88 to 1.08; participants = 1692; studies = 4; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were variably and incompletely reported across studies. There are probably clinically meaningful differences in favour of NACT compared to PDS with regard to overall postoperative serious adverse effects (SAE grade 3+): 6% in NACT group, versus 29% in PDS group, (risk ratio (RR) 0.22, 95% CI 0.13 to 0.38; participants = 435; studies = 2; heterogeneity index (I) = 0%; moderate-certainty evidence). NACT probably results in a large reduction in the need for stoma formation: 5.9% in NACT group, versus 20.4% in PDS group, (RR 0.29, 95% CI 0.12 to 0.74; participants = 632; studies = 2; I = 70%; moderate-certainty evidence), and probably reduces the risk of needing bowel resection at the time of surgery: 13.0% in NACT group versus 26.6% in PDS group (RR 0.49, 95% CI 0.30 to 0.79; participants = 1565; studies = 4; I = 79%; moderate-certainty evidence). NACT reduces postoperative mortality: 0.6% in NACT group, versus 3.6% in PDS group, (RR 0.16, 95% CI 0.06 to 0.46; participants = 1623; studies = 5; I = 0%; high-certainty evidence). QoL on the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) scale produced inconsistent and imprecise results in three studies (MD -0.29, 95% CI -2.77 to 2.20; participants = 524; studies = 3; I = 81%; very low-certainty evidence) but the evidence is very uncertain and should be interpreted with caution.
AUTHORS' CONCLUSIONS
The available high to moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT probably reduces the risk of serious adverse events, especially those around the time of surgery, and reduces the risk of postoperative mortality and the need for stoma formation. These data will inform women and clinicians (involving specialist gynaecological multidisciplinary teams) and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
Topics: Antineoplastic Agents; Bias; Carcinoma, Ovarian Epithelial; Chemotherapy, Adjuvant; Cytoreduction Surgical Procedures; Female; Humans; Neoadjuvant Therapy; Ovarian Neoplasms; Postoperative Complications; Preoperative Care; Progression-Free Survival; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 34328210
DOI: 10.1002/14651858.CD005343.pub6 -
Preoperative inflammatory mediators and postoperative delirium: systematic review and meta-analysis.British Journal of Anaesthesia Sep 2021Postoperative delirium has eluded attempts to define its complex aetiology and describe specific risk factors. The role of neuroinflammation as a risk factor, determined... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Postoperative delirium has eluded attempts to define its complex aetiology and describe specific risk factors. The role of neuroinflammation as a risk factor, determined by measuring blood levels of preoperative 'innate' inflammatory mediator levels, has been investigated. However, results have been conflicting. We conducted a systematic review and meta-analysis of the evidence on associations between preoperative blood levels of inflammatory mediators and postoperative delirium in the older person. Influence of type of surgery was also assessed.
METHODS
Original, low risk of bias studies, published in peer-reviewed journals, which fulfilled the eligibility criteria were included. Seventeen articles fulfilled study criteria. Data extraction, synthesis, and risk of bias analysis were guided by Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and quality in prognostic studies guidelines. Meta-analyses used a random-effects model. Inflammatory mediators included C-reactive protein, interleukin-6, -8, and -10, tumour necrosis factor-α, insulin-like growth factor-1, cortisol, and neopterin. Surgical groups were cardiac, noncardiac, and hip fracture.
RESULTS
Higher preoperative interleukin-6 was associated with postoperative delirium with a standardised mean difference (95% confidence interval) of 0.33 (0.11-0.56) and P=0.003. Higher neopterin was also associated with postoperative delirium.
CONCLUSIONS
The association of preoperative blood levels of inflammatory mediators with postoperative delirium may be influenced by the type of surgery and the specific mediator. The potential modulating effect of type of surgery, intrinsic brain vulnerability, and the complex interactions between inflammatory mediators and binding proteins will need to be considered in future studies.
CLINICAL TRIAL REGISTRATION
CRD42019159471 (PROSPERO).
Topics: Aged; Aged, 80 and over; Biomarkers; Delirium; Female; Humans; Inflammation Mediators; Interleukin-6; Male; Middle Aged; Neopterin; Preoperative Care; Risk Assessment; Risk Factors; Surgical Procedures, Operative; Treatment Outcome; Up-Regulation
PubMed: 34218905
DOI: 10.1016/j.bja.2021.04.033 -
Global Spine Journal Jan 2022Systematic review.
STUDY DESIGN
Systematic review.
OBJECTIVES
Synthesize previous studies evaluating clinical utility of preoperative Hb/Hct and HbA1c in patients undergoing common spinal procedures: anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), posterior lumbar fusion (PLF), and lumbar decompression (LD).
METHODS
We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on preoperative Hb/Hct and HbA1c and post-operative outcomes in adult patients undergoing ACDF, PCF, PLF, or LD surgeries.
RESULTS
Total of 4,307 publications were assessed. Twenty-one articles met inclusion criteria.
PCF AND ACDF
Decreased preoperative Hb/Hct were significant predictors of increased postoperative morbidity, including return to operating room, pulmonary complications, transfusions, and increased length of stay (LOS). For increased HbA1c, there was significant increase in risk of postoperative infection and cost of hospital stay.
PLF
Decreased Hb/Hct was reported to be associated with increased risk of postoperative cardiac events, blood transfusion, and increased LOS. Elevated HbA1c was associated with increased risk of infection as well as higher visual analogue scores (VAS) and Oswestry disability index (ODI) scores.
LD
LOS and total episode of care cost were increased in patients with preoperative HbA1c elevation.
CONCLUSION
In adult patients undergoing spine surgery, preoperative Hb/Hct are clinically useful predictors for postoperative complications, transfusion rates, and LOS, and HbA1c is predictive for postoperative infection and functional outcomes. Using Hct values <35-38% and HbA1c >6.5%-6.9% for identifying patients at higher risk of postoperative complications is most supported by the literature. We recommend obtaining these labs as part of routine pre-operative risk stratification.
LEVEL OF EVIDENCE
III.
PubMed: 33472418
DOI: 10.1177/2192568220979821 -
BMC Geriatrics Dec 2017Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of... (Review)
Review
BACKGROUND
Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of risk of postoperative delirium associated with preoperative medication use.
METHODS
A systematic search in Medline and EMBASE was conducted using MeSH terms and keywords for postoperative delirium and medication. Studies which included patients 18 years and older who underwent major surgery were included. The methodological quality of included studies was assessed independently by two authors using the Newcastle-Ottawa quality assessment scale for cohort studies.
RESULTS
Twenty-nine studies; 25 prospective cohort, three retrospective cohort and one post hoc analysis of RCT data were included. Only four specifically aimed to assess medicines as an independent predictor of delirium, all other studies included medicines among a number of potential predictors of delirium. Of the studies specifically testing the association with a medication class, preoperative use of beta-blockers (OR = 2.06[1.18-3.60]) in vascular surgery and benzodiazepines RR 2.10 (1.23-3.59) prior to orthopedic surgery were significant. However, evidence is from single studies only. Where medicines were included as one possible factor among many, hypnotics had a similar risk estimate to the benzodiazepine study, with one significant and one non-significant result. Nifedipine use prior to cardiac surgery was found to be significantly associated with delirium. The non-specific grouping of psychoactive medication use preoperatively was generally higher with an associated two-to-seven-fold higher risk of postoperative delirium, while only two studies included narcotics without other agents, with one significant and one non-significant result.
CONCLUSIONS
There was a limited number of high quality studies in the literature quantifying the direct association between preoperative medication use and postsurgical delirium. More studies are required to evaluate the association of specific preoperative medications on the risk of postoperative delirium so that comprehensive guidelines for medicine use prior to surgery can be developed to aid delirium prevention.
TRIAL REGISTRATION
This systematic review has been registered on PROSPERO International prospective register of systematic reviews (Registration number: CRD42016051245 ).
Topics: Aged; Benzodiazepines; Delirium; Humans; Postoperative Complications; Premedication; Preoperative Care; Risk Adjustment; Surgical Procedures, Operative
PubMed: 29284416
DOI: 10.1186/s12877-017-0695-x -
Journal of Clinical Anesthesia Dec 2021Preoperative assessment is a standard evaluation, traditionally done in-person in a preanesthesia clinic, for patients who will be undergoing a procedure involving... (Meta-Analysis)
Meta-Analysis Review
STUDY OBJECTIVE
Preoperative assessment is a standard evaluation, traditionally done in-person in a preanesthesia clinic, for patients who will be undergoing a procedure involving anesthesia. Given the increased adoption of virtual care during the coronavirus disease 2019 (COVID-19) pandemic, the purpose of this systematic review and meta-analysis is to review the effectiveness of virtual preoperative assessment for the evaluation of surgical patients.
DESIGN
Systematic review and meta-analysis.
SETTING
MEDLINE (Ovid), MEDLINE InProcess/ePubs, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov were searched from the initial coverage of the respective database to May 2021. A manual citation search of Google Scholar and PubMed was conducted to identify missed articles. Continued literature surveillance was done through July 2021.
PATIENTS
Patients aged 18 years and older undergoing virtual preoperative anesthesia assessment.
INTERVENTIONS
Virtual preoperative assessment.
MEASUREMENTS
Surgery cancellation rates, patient experience, resources saved, staff experience, success in using the data collected to diagnose and manage patients.
MAIN RESULTS
Fifteen studies (n = 31,496 patients) were included in this review. The average age of patients was 58 ± 15 years, and 47% were male. Virtual preoperative assessment resulted in similar surgery cancellation rates compared to in-person evaluation, with a pooled cancellation rate of 2% (95% confidence interval [CI]: 1-3%). Most studies reported a positive patient experience, with a pooled estimate of 90% (95% CI, 81-95%). There was a high success rate in using the information collected with virtual care, in the range of 92-100%, to diagnose and manage patients resulting in time and cost savings in the range of 24-137 min and $60-67 per patient.
CONCLUSIONS
This systematic review and meta-analysis demonstrates the utility of virtual care for preoperative assessment of surgical patients. Virtual preanesthesia evaluation had similar surgery cancellation rates, high patient satisfaction, and reduced costs compared to in-person evaluation.
Topics: Adult; Aged; COVID-19; Humans; Male; Middle Aged; Pandemics; Patient Satisfaction; Preoperative Care; SARS-CoV-2
PubMed: 34649158
DOI: 10.1016/j.jclinane.2021.110540 -
BMC Geriatrics Mar 2023Postoperative delirium (POD) is a common postoperative complication associated with multiple adverse consequences on patient outcomes and higher medical expenses.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Postoperative delirium (POD) is a common postoperative complication associated with multiple adverse consequences on patient outcomes and higher medical expenses. Preoperative anxiety has been suggested as a possible precipitating factor for the development of POD. As such, we aimed to explore the association between preoperative anxiety and POD in older surgical patients.
METHODS
Electronic databases including MEDLINE (via PubMed), EMBASE (via Embase.com), Web of Science Core Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL Complete; via EBSCOhost) and clinical trial registries were systematically searched to identify prospective studies examining preoperative anxiety as a risk factor for POD in older surgical patients. We used Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies to assess the quality of included studies. The association between preoperative anxiety and POD was summarized with odds ratios (ORs) and 95% confidence intervals (CIs) using DerSimonian-Laird random-effects meta-analysis.
RESULTS
Eleven studies were included (1691 participants; mean age ranging between 63.1-82.3 years). Five studies used a theoretical definition for preoperative anxiety, with the Anxiety subscale of Hospital Anxiety and Depression Scale (HADS-A) as the instrument being most often used. When using dichotomized measures and within the HADS-A subgroup analysis, preoperative anxiety was significantly associated with POD (OR = 2.17, 95%CI: 1.01-4.68, I = 54%, Tau = 0.4, n = 5; OR = 3.23, 95%CI: 1.70-6.13, I = 0, Tau = 0, n = 4; respectively). No association was observed when using continuous measurements (OR = 0.99, 95%CI: 0.93-1.05, I = 0, Tau = 0, n = 4), nor in the subgroup analysis of STAI-6 (six-item version of state scale of Spielberger State-Trait Anxiety Inventory, OR = 1.07, 95%CI: 0.93-1.24, I = 0, Tau = 0, n = 2). We found the overall quality of included studies to be moderate to good.
CONCLUSIONS
An unclear association between preoperative anxiety and POD in older surgical patients was found in our study. Given the ambiguity in conceptualization and measurement instruments used for preoperative anxiety, more research is warranted in which a greater emphasis should be placed on how preoperative anxiety is operationalized and measured.
Topics: Humans; Aged; Aged, 80 and over; Emergence Delirium; Delirium; Prospective Studies; Anxiety; Postoperative Complications; Risk Factors
PubMed: 36997928
DOI: 10.1186/s12877-023-03923-0 -
British Journal of Anaesthesia Jul 2021In the general adult population, lymphopaenia is associated with an increased risk for hospitalisation with infection and infection-related death. The quality of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In the general adult population, lymphopaenia is associated with an increased risk for hospitalisation with infection and infection-related death. The quality of evidence and strength of association between perioperative lymphopaenia across different surgical procedures and mortality/morbidity has not been examined by systematic review or meta-analysis.
METHODS
We searched MEDLINE, Embase, Web of Science, Google Scholar, and Cochrane databases from their inception to June 29, 2020 for observational studies reporting lymphocyte count and in-hospital mortality rate in adults. We defined preoperative lymphopaenia as a lymphocyte count 1.0-1.5×10 L. Meta-analysis was performed using either fixed or random effects models. Quality was assessed using the Newcastle-Ottawa Scale. The I index was used to quantify heterogeneity. The primary outcome was in-hospital mortality rate and mortality rate at 30 days.
RESULTS
Eight studies met the inclusion criteria for meta-analysis, comprising 4811 patients (age range, 46-91 yr; female, 20-79%). These studies examined preoperative lymphocyte count exclusively. Studies were of moderate to high quality overall, ranking >7 using the Newcastle-Ottawa Scale. Preoperative lymphopaenia was associated with a threefold increase in mortality rate (risk ratio [RR]=3.22; 95% confidence interval [CI], 2.19-4.72; P<0.01, I=0%) and more frequent major postoperative complications (RR=1.33; 95% CI, 1.21-1.45; P<0.01, I=6%), including cardiovascular morbidity (RR=1.77; 95% CI, 1.45-2.15; P<0.01, I=0%), infections (RR=1.45; 95% CI, 1.19-1.76; P<0.01, I=0%), and acute renal dysfunction (RR=2.66; 95% CI, 1.49-4.77; P<0.01, I=1%).
CONCLUSION
Preoperative lymphopaenia is associated with death and complications more frequently, independent of the type of surgery.
PROSPERO REGISTRY NUMBER
CRD42020190702.
Topics: Elective Surgical Procedures; Hospital Mortality; Humans; Lymphopenia; Morbidity; Postoperative Complications; Preoperative Care; Prospective Studies
PubMed: 33795133
DOI: 10.1016/j.bja.2021.02.023 -
Journal of Oncology Practice May 2015The management of cancer varies across its type, stage, and natural history. This necessitates involvement of a variety of individuals and groups across a number of... (Review)
Review
PURPOSE
The management of cancer varies across its type, stage, and natural history. This necessitates involvement of a variety of individuals and groups across a number of provider types. Evidence from other fields suggests that a team-based approach helps organize and optimize tasks that involve individuals and groups, but team effectiveness has not been fully evaluated in oncology-related care.
METHODS
We undertook a systematic review of literature published between 2009 and 2014 to identify studies of all teams with clear membership, a comparator group, and patient-level metrics of cancer care. When those teams included two or more people with specialty training relevant to the care of patients with cancer, we called them multidisciplinary care teams (MDTs). After reviews and exclusions, 16 studies were thoroughly evaluated: two addressing screening and diagnosis, 11 addressing treatment, two addressing palliative care, and one addressing end-of-life care. The studies included a variety of end points (eg, adherence to quality indicators, patient satisfaction with care, mortality).
RESULTS
Teams for screening and its follow-up improved screening use and reduced time to follow-up colonoscopy after an abnormal screen. Discussion of cases within MDTs improved the planning of therapy, adherence to recommended preoperative assessment, pain control, and adherence to medications. We did not see convincing evidence that MDTs affect patient survival or cost of care, or studies of how or which MDT processes and structures were associated with success.
CONCLUSION
Further research should focus on the association between team processes and structures, efficiency in delivery of care, and mortality.
Topics: Clinical Competence; Cooperative Behavior; Delivery of Health Care, Integrated; Humans; Interdisciplinary Communication; Medical Oncology; Neoplasms; Patient Care Team; Patient Compliance; Physician's Role; Quality Indicators, Health Care; Time Factors; Treatment Outcome; Workflow
PubMed: 25873056
DOI: 10.1200/JOP.2014.003350