Systematic development and feasibility testing of a multibehavioural digital prehabilitation intervention for patients approaching major surgery (iPREPWELL): A study protocol.

Improving outcomes for people undergoing major surgery, specifically reducing perioperative morbidity and mortality remains a global health challenge. Prehabilitation involves the active preparation of patients prior to surgery, including support to tackle risk behaviours that mediate and undermine physical and mental health and wellbeing. The majority of prehabilitation interventions are delivered in person, however many patients express a preference for remotely-delivered interventions that provide them with tailored support and the flexibility. Digital prehabilitation interventions offer scalability and have the potential to benefit perioperative healthcare systems, however there is a lack of robustly developed and evaluated digital programmes for use in routine clinical care. We aim to systematically develop and test the feasibility of an evidence and theory-informed multibehavioural digital prehabilitation intervention 'iPREPWELL' designed to prepare patients for major surgery. The intervention will be developed with reference to the Behaviour Change Wheel, COM-B model, and the Theoretical Domains Framework. Codesign methodology will be used to develop a patient intervention and accompanying training intervention for healthcare professionals. Training will be designed to enable healthcare professionals to promote, support and facilitate delivery of the intervention as part of routine clinical care. Patients preparing for major surgery and healthcare professionals involved with their clinical care from two UK National Health Service centres will be recruited to stage 1 (systematic development) and stage 2 (feasibility testing of the intervention). Participants recruited at stage 1 will be asked to complete a COM-B questionnaire and to take part in a qualitative interview study and co-design workshops. Participants recruited at stage 2 (up to twenty healthcare professionals and forty participants) will be asked to take part in a single group intervention study where the primary outcomes will include feasibility, acceptability, and fidelity of intervention delivery, receipt, and enactment. Healthcare professionals will be trained to promote and support use of the intervention by patients, and the training intervention will be evaluated qualitatively and quantitatively. The multifaceted and systematically developed intervention will be the first of its kind and will provide a foundation for further refinement prior to formal efficacy testing.

Malnutrition modifies the response to multimodal prehabilitation: a pooled analysis of prehabilitation trials.

Patients with colorectal cancer are at risk of malnutrition before surgery. Multimodal prehabilitation (nutrition, exercise, stress reduction) readies patients physically and mentally for their operation. However, it is unclear whether extent of malnutrition influences prehabilitation outcomes. We conducted a pooled analysis from five 4-week multimodal prehabilitation trials in colorectal cancer surgery (prehabilitation: n = 195; control: n = 71). Each patient's nutritional status was evaluated at baseline using the Patient-Generated Subjective Global Assessment (PG-SGA; higher score, greater need for treatment of malnutrition). Functional walking capacity was measured with the 6-minute walk test distance (6MWD) at baseline and before surgery. A multivariable mixed effects logistic regression model evaluated the potential modifying effect of PG-SGA on a clinically meaningful change of ≥19 m in 6MWD before surgery. Multimodal prehabilitation increased the odds by 3.4 times that colorectal cancer patients improved their 6MWD before surgery as compared with control (95% confidence interval (CI): 1.6 to 7.3; P = 0.001, n = 220). Nutritional status significantly modified this outcome (P = 0.007): Neither those patients with PG-SGA ≥9 (adjusted odds ratio: 1.3; 95% CI: 0.23 to 7.2, P = 0.771, n = 39) nor PG-SGA <4 (adjusted odds ratio: 1.3; 95% CI: 0.5 to 3.8, P = 0.574, n = 87) improved in 6MWD with prehabilitation. In conclusion, baseline nutritional status modifies prehabilitation effectiveness before colorectal cancer surgery. Patients with a PG-SGA score 4-8 appear to benefit most (physically) from 4 weeks of multimodal prehabilitation. Novelty: Nutritional status is an effect modifier of prehabilitation physical function outcomes. Patients with a PG-SGA score 4-8 benefited physically from 4 weeks of multimodal prehabilitation.

Pre-operative nutrition and the elective surgical patient: why, how and what?

Pre-operative nutrition therapy is increasingly recognised as an essential component of surgical care. The present review has been formatted using Simon Sinek's Golden Circle approach to explain 'why' avoiding pre-operative malnutrition and supporting protein anabolism are important goals for the elective surgical patient, 'how' peri-operative malnutrition develops leading in part to a requirement for pre-operative anabolic preparation, and 'what' can be done to avoid pre-operative malnutrition and support anabolism for optimal recovery.

Gastroenterology Numbers in Canada: A Comparison of Human Resource Databases.

Several databases track gastroenterology (GI) human resource (HR) numbers in Canada. They differ in the data which they collect and, hence, in their estimates of GI HR. The two most likely to reflect current HR are the Canadian Institute of Health Research (CIHI) and Canadian Medical Association (CMA) databases. The estimates of GI's generated by each of the databases correlate closely with each other. Approximately 50 trainees enter the adult GI workforce per year, and approximately five enter the pediatric group. We estimate that Canada as a whole has between 782 and 848 GIs or 2.14 GIs per 100,000 population in 2016. Six of the 10 provinces have fewer than two GIs per 100,000 population. National GI numbers are increasing by 6% per year. Validation studies are required.

The effects of different stretching techniques of the quadriceps muscles on agility performance in female collegiate soccer athletes: a pilot study.

BACKGROUND: Stretching has long been an integral component of pre-performance activities for a multitude of athletic endeavors. Previous research has demonstrated that stretching may have detrimental effects on performance. Specific knowledge of the precise effects of stretching may influence the decision to appropriately apply stretching techniques in the sport and therapeutic settings. OBJECTIVE: The purpose of this pilot study was to examine the effects of static stretching, proprioceptive neuromuscular facilitation (contract-relax) stretching, and no stretching of the quadriceps muscle group on agility performance. METHODS: Twelve healthy, female, collegiate soccer players aged 18 - 25 performed one of the three stretching protocols (static, contract-relax, no stretch) and the agility test (T-test) on three non-consecutive days. Agility times were recorded and compared based on stretching technique and day that each test was performed. RESULTS: No significant difference was found among the means of the different stretching techniques. The t-test agility performance times were as follows: control, =9.7 seconds; static stretch, =9.73 seconds; and contract-relax, =9.62 seconds. CONCLUSION: The results of this study suggest that agility performance may be independent of stretching technique of the quadriceps performed in female collegiate soccer athletes. It is recommended that female soccer athletes about to engage in agility activity may perform either no stretch, static stretch, or contract-relax stretching according to individual preference.

The natural history of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the USA, and it remains one of the few diseases that continues to increase its numbers. The development and progression of COPD can vary dramatically between individuals. A low level of lung function remains the cornerstone of COPD diagnosis and is a key predictor of prognosis. Lung function, however, is not the only factor in determining morbidity and mortality related to COPD, with factors such as body mass index, exercise capability and comorbid disease being important predictors of poor outcomes. Exacerbations of COPD are additional important indicators of both quality of life and outcomes in COPD patients. Definitions of exacerbations can vary, ranging from an increase in symptoms to COPD-related hospitalisations and death. COPD exacerbations are more common in patients with lower levels of lung function and may lead to more rapid declines in lung function. Better understanding of the natural history of COPD may lead to better definitions of specific COPD phenotypes, better interventions and improved outcomes.

Axillary recurrence in breast cancer.

AIM: To determine whether axillary recurrence reflects inadequate axillary treatment or adverse pathological features. METHODS: The case-records were reviewed of 2122 women aged under 75 years, treated for invasive breast cancer during the time-period 1/1/86-31/12/91 in a geographically defined area. Data were abstracted on operations performed, pathological features, post-operative treatments and details of axillary recurrence. The risk of axillary recurrence was examined by pathological, treatment and patient factors. RESULTS: Axillary recurrence was more than twice as likely after inadequate compared to adequate treatment of the axilla (adequate staging or axillary radiotherapy or clearance). Delayed treatment of the axilla was not as successful as adequate primary treatment: multiple axillary recurrences were twice as common, one third of which were uncontrolled at time of death. Inadequate surgical treatment was associated with increased rates of recurrence despite endocrine therapy, chemotherapy or radiotherapy. Lymphoedema was twice as common if axillary radiotherapy was combined with any axillary surgical procedure. CONCLUSIONS: Axillary recurrence is more common in tumours with adverse pathology but may also result from inadequate axillary treatment. In order to minimise axillary recurrence, optimal treatment of the axilla entails adequate staging (sampling of four or more nodes) and treatment (axillary clearance or radiotherapy and endocrine therapy) in all women.

Inadequate treatment of symptomatic breast cancer.

BACKGROUND: Early trials that compared breast and axillary treatments showed differing recurrence rates without significant differences in survival. Consequently, there was a wide range of opinion and practice in the management of breast cancer. The present study explored this variability in surgical management to determine the impact of breast and axillary treatment on recurrence and survival. METHODS: The records of 2776 women with histologically confirmed invasive breast cancer diagnosed between 1986 and 1991 were reviewed. The relationship between adequacy of breast and axillary treatment, recurrence and survival was examined in 2122 women who had surgery with curative intent. A Cox proportional hazards model that included tumour size, node status, grade, socioeconomic status and use of adjuvant therapy was used. RESULTS: Inadequate treatment was associated with a significantly higher risk of local recurrence after breast-conserving surgery (relative hazard ratio (RHR) 4.19 (95 per cent confidence interval (c.i.) 2.73 to 6.43); P < 0.001). Inadequate axillary treatment was associated with a significantly higher risk of regional recurrence (RHR 2.29 (95 per cent c.i. 1.65 to 3.16); P < 0.001). The risk of death from breast cancer was significantly higher if locoregional treatment was inadequate (RHR 1.29 (95 per cent c.i. 1.07 to 1.55); P = 0.008). CONCLUSION: Adequate surgery is fundamental to the optimal treatment of breast cancer. Inadequate surgery resulted in higher recurrence rates despite adjuvant treatments.

Why does specialist treatment of breast cancer improve survival? The role of surgical management.

Evidence that the survival of women with breast cancer treated by specialist surgeons is better than that by nonspecialists is limited. Previous reports have not identified the cause of this survival advantage. Our aim was to determine if the survival difference was due to case-mix, adjuvant treatment or the treatment provided by specialist surgeons. The case-records and pathology reports of 2776 women were reviewed. This represented 95% of all those diagnosed with breast cancer between 1/1/1986 and 31/12/1991 in a defined geographical area. Case-mix, surgery, pathology and adjuvant therapies of the 2148 women treated with curative intent were analysed. A standard of adequate surgical management was defined and confirmed as a valid predictor by examining rates of local recurrence, independent of all other prognostic factors. Against this standard, we compared the adequacy of surgical management, local recurrence rates and the survival outcomes of specialists and nonspecialists over an 8-year follow-up period. The inter-relationship between adequacy of surgical management, locoregional recurrence and survival was examined. While the case-mix and prescription of adjuvant therapies were comparable between specialist and nonspecialist surgeons, the efficacy and outcome of local treatment differed widely. Breast cancer patients treated in specialist compared to nonspecialist units had half the risk of inadequate treatment of the breast (24 vs 47%, P<0.001), a five-fold lower risk of inadequate axillary staging (8 vs 40%, P<0.001) and nine times lower risk of inadequate definitive axillary treatment (4 vs 38%, P<0.001). Local recurrence rates were 57% lower (13 vs 23% at eight years, P<0.001) and the risk of death from breast cancer was 20% lower for women treated in specialist units, after allowing for case-mix and adjuvant therapies. Adequacy of surgical management correlated with locoregional recurrence, which in turn correlated with the risk of death. The surgical management in specialised breast units is more often adequate, local and regional recurrence rates are lower, and survival is correspondingly better. We conclude that adequate surgical management of breast cancer is fundamental to improving the outcome from breast cancer irrespective of where it is delivered.

Increased mortality from breast cancer and inadequate axillary treatment.

BACKGROUND: The assessment of axillary nodal status remains divisive: inaccurate staging may result in untreated axillary disease, and appropriate adjuvant therapy not being delivered. The impact of inadequate axillary treatment on survival remains controversial. We analyse the impact of failure to adequately assess the axillary nodal status on survival. METHODS: All women with confirmed breast cancer in a 15-year period were identified, and the original pathology reports examined, and details of radiotherapy obtained. The survival of women by axillary sample size was compared to a reference group of women and corrected for nodal status, tumour size, age, deprivation category and speciality of treating surgeon. FINDINGS: Sampling less than four nodes is associated with a significantly increased risk of death. This cannot be due to understaging the extent of axillary disease nor is fully explainable by differential prescription of adjuvant therapies. We conclude that the survival of the women studied may have been adversely effected by inadequate axillary treatment.

Specialisation and breast cancer survival in the screening era.

It is recommended that specialist surgeons treat all breast cancer, although the limited evidence to support this is based on treatment patterns prior to the introduction of screening. Whether a specialist survival advantage exists in the post-screening era is uncertain, as referral and treatment patterns may have changed, in addition to the effect of screening on the natural history of breast cancer. Our aim was to determine the impact of screening on the caseload and case-mix of specialist surgeons, to determine if the survival advantage associated with specialist care is maintained with longer follow-up and persists after the introduction of screening. Using the West of Scotland Cancer Registry, all 7197 women treated for breast cancer in a 15-year time period (1980-1994) in a geographically defined cohort were followed up for an average of 9 years, and pathological stage and socioeconomic status were linked with mortality data. We show that the caseload of specialists has increased substantially (from 11 to 59% of the total workload) and that smaller cancers have been selectively referred. However, even after allowing for pathological stage, socioeconomic status and method of detection, specialist treatment was associated with a significantly lower risk of dying (prescreening: relative risk of dying=0.83, 95% CI=0.75-0.92; post-screening: relative risk of dying=0.89, 95% CI=0.78-1.00). We conclude that this survival benefit is most consistent with effective surgical management rather than selective referral, the influx of screen-detected cancers or adjuvant therapies.

Ultrasonographic anatomy and biometric analysis of the thoracic and abdominal organs in healthy foals from birth to age 6 months.

Knowledge of normal renal parameters, as documented in mature horses, is essential for the accurate evaluation of abnormal kidneys. Although the ultrasonographic appearance and location of the abdominal organs in foals and the renal dimensions in neonates have been reported, there is currently no information available for the assessment of normal organ growth in foals. The objectives of the study were to describe the ultrasonographic characteristics, location and variations of the thoracic and abdominal organs with relation to age, height and weight; and provide a growth table for comparison with diseased foals. The thoracic and abdominal cavities of 10 healthy foals were evaluated at ages 1, 7, 14 and 21 days and 1, 2, 3, 4, 5 and 6 months. The equipment used was an Ausonics Opus Plus ultrasound. For every evaluation, weight and height were obtained, the foals were sedated and the area of study was clipped and cleaned. The ultrasonographic location, appearance and measurements of the different organs were recorded for each examination. The study revealed that foals age >1 month resemble the mature ultrasonographic pattern. Continual growth of the organs was observed from Day 1 to age 6 months, being faster in the first month. Organ growth was closely correlated with age, but not with sex, height or weight in healthy foals up to age 6 months. Our study has provided measurements of longitudinal organ growth in healthy foals, presented in a simple form for easy comparison with diseased individuals.

Staging quality is related to the survival of women with endometrial cancer: a Scottish population based study. Deficient surgical staging and omission of adjuvant radiotherapy is associated with poorer survival of women diagnosed with endometrial cancer in Scotland during 1996 and 1997.

The association between treatment variation and survival of women with endometrial cancer was investigated. A retrospective cohort based upon the complete Scottish population registered on in-patient and day-case hospital discharge data (Scottish Morbidity Record-1) and cancer registration (Scottish Morbidity Record-6) coded C54 and C55 in ICD10, between 1st January 1996 to 31st December 1997 were analysed. Seven hundred and three patients who underwent surgical treatment out of 781 patients that were diagnosed with endometrial cancer in Scotland during 1996 and 1997. The overall quality of surgical staging was poor. The quality of staging was related to both the year that the surgeon passed the Member of the Royal College of Obstetricians and Gynaecologists examination and also to 'specialist' status but was not related to surgeon caseload. Two clinically important prognostic factors were found to be associated with survival; whether the International Federation of Obstetrics and Gynaecology stage was documented, RHR=2.0 (95% CI=1.3 to 3.1) and also to the use of adjuvant radiotherapy, RHR=2.2 (95% CI=1.5 to 3.5). The associations with survival were strongest in patients with advanced disease, International Federation of Obstetrics and Gynaecology stages 1C through to stage 3. Deficiencies in staging and variations in the use of adjuvant radiotherapy represent a possible source of avoidable mortality in patients with endometrial cancer. Consequently, there should be a greater emphasis on improving the overall quality of surgical staging in endometrial cancer.

Social class differences in lung cancer mortality: risk factor explanations using two Scottish cohort studies.

BACKGROUND: The study investigated differences in lung cancer mortality risk between social classes. METHODS: Twenty years of mortality follow-up were analysed in 7052 men and 8354 women from the Renfrew/Paisley general population study and 4021 working men from the Collaborative study. RESULTS: More manual than non-manual men and women smoked, reported morning phlegm, had worse lung function and lived in more deprived areas. Lung cancer mortality rates were higher in manual than non-manual men and women. Significantly higher lung cancer mortality risks were seen for manual compared to non-manual workers when adjusting for age only and adjustment for smoking reduced these risks to 1.41 (95% CI : 1.12-1.77) for men in the Renfrew/Paisley study, 1.28 (95% CI : 0.94-1.75) for women in the Renfrew/Paisley study and 1.43 (95% CI : 1.02-2.01) for men in the Collaborative study. Adjustment for lung function, phlegm and deprivation category attenuated the risks which were of borderline significance for men in the Renfrew/Paisley study and non significant for women in the Renfrew/Paisley study and men in the Collaborative study. Adding extra socioeconomic variables, available in the Collaborative study only, reduced the difference between the manual and non-manual social classes completely. CONCLUSIONS: There is a difference in lung cancer risk between social classes, in addition to the effect of smoking. This can be explained by poor lung health, deprivation and poor socioeconomic conditions throughout life. As well as anti-smoking measures, reducing socioeconomic inequalities and targeting individuals with poor lung function for help with smoking cessation could help reduce future lung cancer incidence and mortality.

Quality of life in lung cancer patients: as an important prognostic factor.

Given that lung cancer is one of the common cancers world-wide, the implications of focusing on quality of life as well as survival require to be understood. We have carried out a study of the relationship between survival and quality of life in patients with lung cancer comparing patients those who lived with those who died within 3 months. The design of the study allowed every patient in a defined geographical area with a potential diagnosis of lung cancer to be studied from first outpatient consultation till after a definitive treatment has been given. Quality of life was measured using three standard questionnaires: the Nottingham Health Profile (NHP), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its lung cancer supplementary questionnaire (QLQ-LC13) in addition to a study specific questionnaire collecting data on demographic, social, clinical and performance status. The contribution of quality of life in relation to survival adjusted for known prognostic factors was determined using Cox's proportional hazard model. In all 129 lung cancer patients were interviewed, and 96 patients were alive at 3-months follow-up. Only 90 of 96 patients alive at 3-months follow-up were assessable. Descriptive analyses showed that those who were dead had more perceived health problems, greater level of symptoms and significant lower physical and role functioning and global quality of life at presentation. On the other hand, univariate analyses showed that patients' aggregate scores on the NHP, the functioning scores, and global quality of life scores alone were significant predictors of survival (P<0.03, P<0.04, P<0.04, respectively ). The multivariate analyses showed that pre-diagnosis global quality of life was the most significant predictor of the length of survival even after adjusting for known prognostic factors (age, P<0.04; extent of disease, P<0.03; global quality of life, P<0.02), while performance status, sex and weight loss were not. This study confirmed that pre-diagnosis quality of life was a significant predictor of survival. Indeed, pre-diagnosis quality of life should be considered as a clinical status which has to be established by physicians before treatment starts as it is such an important predictor of survival.

Sociodemographic Factors, Smoking and Common Mental Disorder in the Renfrew and Paisley (MIDSPAN) Study.

The relationships between common mental disorder measured by the General Health Questionnaire and sociodemographic variables and cigarette smoking were examined from baseline data in a community study of 15,406 men and women, aged between 45 and 64 years from two towns close to Glasgow. Between 1972 and 1976 all those respondents from Renfrew and Paisley between the ages of 45 and 64 years who met the residency criteria were invited to attend community clinics, where a clinical examination was carried out and the General Health Questionnaire was completed by 3783 (53.6 percent) men, and 4683 (56.1 percent) women. Women had a higher risk of disorder than men did. More women (20.3 percent) than men (15.4 percent) were possible cases of common mental disorder. Women showed a decrease in disorder with age but no apparent trend in men was observed. Marital status was significantly associated with disorder, with the widowed and separated showing especially high rates of psychiatric disorder. Married men, in contrast to married women, had relatively low levels of psychiatric disorder. Both social class and level of deprivation of the area were associated with psychiatric disorder. For both men and women there was a trend in disorder associated with social class; men in social class V had twice the level of psychiatric disorder compared to those in social class II. For women there was a shallow gradient showing higher levels of disorder with lower social class. Smoking habits were also related to psychiatric disorder; never- and exsmokers had relatively low rates of psychiatric disorder whereas, among current smokers, risk of psychiatric disorder, increased with the number of cigarettes smoked, though only for women.

[Aspects of FLAIR sequences, 3D-CISS and diffusion-weight MR imaging of intracranial epidermoid cysts]. / Aspects en séquences FLAIR, CISS-3D et en imagerie de diffusion des kystes épidermoïdes intracrâniens.

We propose to assess the usefulness of diffusion-weighted MR Imaging (DWI), fluid-attenuated inversion recovery (FLAIR) and constructive interference in steady state (CISS) sequences in depicting epidermoid cysts (EC). FLAIR, CISS and DWI were obtained in 7 patients among 22. All patients were studied with T1 and T2 sequences. On Spin Echo images, EC demonstrate signal similar to LCS, which may lead to difficult differentiation between EC and arachnoid cyst (AC), specially for inexperienced radiologists. EC appear with a heterogeneous signal on T1 images (32%), irregular limits (91%) and with extension through foramen of Pacchioni in 18% of cases. On FLAIR sequence, the tumors were heterogeneous, different from void signal of CSF in 86% of cases. On CISS sequence, the tumors appear heterogeneous, hyperintense but less than LCS and with irregular limits in all cases. Some more, CISS images allowed to appreciate exact tumor extension and their relations with nerves and vessels. On DWI images, signal is hyperintense in all cases. Our study exhibited the great usefulness of DWI, CISS and FLAIR sequences in diagnosis of EC and in differentiating EC from AC.

Intergenerational 20 year trends in the prevalence of asthma and hay fever in adults: the Midspan family study surveys of parents and offspring.

OBJECTIVE: To estimate trends between 1972-6 and 1996 in the prevalences of asthma and hay fever in adults. DESIGN: Two epidemiological surveys 20 years apart. Identical questions were asked about asthma, hay fever, and respiratory symptoms at each survey. SETTING: Renfrew and Paisley, two towns in the west of Scotland. SUBJECTS: 1,477 married couples aged 45-64 participated in a general population survey in 1972-6; and 2,338 offspring aged 30-59 participated in a 1996 survey. Prevalences were compared in 1,708 parents and 1,124 offspring aged 45-54. MAIN OUTCOME MEASURES: Prevalences of asthma, hay fever, and respiratory symptoms. RESULTS: In never smokers, age and sex standardised prevalences of asthma and hay fever were 3.0% and 5.8% respectively in 1972-6, and 8.2% and 19. 9% in 1996. In ever smokers, the corresponding values were 1.6% and 5.4% in 1972-6 and 5.3% and 15.5% in 1996. In both generations, the prevalence of asthma was higher in those who reported hay fever (atopic asthma). In never smokers, reports of wheeze not labelled as asthma were about 10 times more common in 1972-6 than in 1996. With a broader definition of asthma (asthma and/or wheeze), to minimise diagnostic bias, the overall prevalence of asthma changed little. However, diagnostic bias mainly affected non-atopic asthma. Atopic asthma increased more than twofold (prevalence ratio 2.52 (95% confidence interval 1.01 to 6.28)) whereas the prevalence of non-atopic asthma did not change (1.00 (0.53 to 1.90)). CONCLUSION: The prevalence of asthma in adults has increased more than twofold in 20 years, largely in association with trends in atopy, as measured indirectly by the prevalence of hay fever. No evidence was found for an increase in diagnostic awareness being responsible for the trend in atopic asthma, but increased awareness may account for trends in non-atopic asthma.