Prehabilitation in elective abdominal cancer surgery in older patients: systematic review and meta-analysis.

BACKGROUND: Prehabilitation has emerged as a strategy to prepare patients for elective abdominal cancer surgery with documented improvements in postoperative outcomes. The aim of this study was to assess the evidence for prehabilitation interventions of relevance to the older adult. METHODS: Systematic searches were conducted using MEDLINE, Web of Science, Scopus, CINAHL and PsychINFO. Studies of preoperative intervention (prehabilitation) in patients undergoing abdominal cancer surgery reporting postoperative outcomes were included. Age limits were not set as preliminary searches revealed this would be too restrictive. Articles were screened and selected based on PRISMA guidelines, and assessment of bias was performed. Qualitative, quantitative and meta-analyses of data were conducted as appropriate. RESULTS: Thirty-three studies (3962 patients) were included. Interventions included exercise, nutrition, psychological input, comprehensive geriatric assessment and optimization, smoking cessation and multimodal (two or more interventions). Nine studies purposely selected high-risk, frail or older patients. Thirty studies were at moderate or high risk of bias. Ten studies individually reported benefits in complication rates, with meta-analyses for overall complications demonstrating significant benefit: multimodal (risk difference -0·1 (95 per cent c.i. -0·18 to -0·02); P = 0·01, I2  = 18 per cent) and nutrition (risk difference -0·18 (-0·26 to -0·10); P < 0·001, I2  = 0 per cent). Seven studies reported reductions in length of hospital stay, with no differences on meta-analysis. CONCLUSION: The conclusions of this review are limited by the quality of the included studies, and the heterogeneity of interventions and outcome measures reported. Exercise, nutritional and multimodal prehabilitation may reduce morbidity after abdominal surgery, but data specific to older patients are sparse.

ANTECEDENTES: La pre-habilitación ha surgido como una estrategia para preparar a los pacientes para la cirugía electiva del cáncer abdominal con mejoras documentadas en los resultados postoperatorios. El objetivo de este estudio fue evaluar la evidencia sobre las intervenciones de pre-habilitación relevantes en adultos de edad avanzada. MÉTODOS: Se realizaron búsquedas sistemáticas utilizando MEDLINE, Web of Science, Scopus, CINAHL y PsychINFO. Registro PROSPERO: CRD42019120381. Se incluyeron estudios de intervención preoperatoria (pre-habilitación) en pacientes sometidos a cirugía oncológica abdominal que describiesen resultados postoperatorios. No se fijaron límites en la edad dado que las búsquedas preliminares revelaron que ello sería demasiado restrictivo. Los artículos fueron examinados y seleccionados en base a las guías PRISMA y se realizó una evaluación del sesgo. Se llevó a cabo un análisis cualitativo, cuantitativo y metaanálisis de los datos según fuese apropiado. RESULTADOS: Se incluyeron 33 estudios (3.962 patients). Las intervenciones incluyeron ejercicio, nutrición, intervención psicológica, evaluación geriátrica global y optimización, abandono del tabaquismo y multimodal (dos o más intervenciones). Nueve estudios seleccionaron expresamente una población de pacientes de elevado riesgo, frágiles o de edad avanzada. Treinta estudios presentaban un riesgo moderado/alto de sesgo. Diez estudios describieron de forma individual beneficios en las tasas de complicaciones con metaanálisis para las complicaciones globales demostrando un beneficio significativo: multimodal (diferencia de riesgo -0,1 (i.c. del 95% −0,18 a −0,02); P = 0,01, I2 = 18%) e intervención nutricional (diferencia de riesgo −0,18 (i.c. del 95% −0,26 a −0,10); P < 0,001, I2 = 0%). Siete estudios describieron reducciones en la duración de la estancia hospitalaria, sin diferencias en el metaanálisis. CONCLUSIÓN: Las conclusiones de esta revisión están limitadas por la calidad de los estudios incluidos, heterogeneidad de las intervenciones y descripción de las medidas de resultados. Las intervenciones de pre-habilitación de ejercicio, nutricionales y multimodales puede reducir la morbilidad tras cirugía abdominal, pero los datos concretos en pacientes de edad avanzada son escasos.

Randomized clinical trial of long-acting oxytetracycline, foot trimming, and flunixine meglumine on time to recovery in sheep with footrot.

BACKGROUND: Internationally, foot trimming is used by most farmers, and parenteral antibacterials by some, to treat sheep with footrot. Nonsteroidal anti-inflammatory drugs (NSAID) are sometimes used. No clinical trials have compared these treatments. OBJECTIVES: To investigate the above treatments on time to recovery from lameness and foot lesions in sheep with footrot. ANIMALS: Fifty-three sheep with footrot on a commercial farm in England. METHODS: In a randomized factorial design, the sheep were allocated to 6 treatment groups. The treatments were oxytetracycline spray to all sheep (positive control) and one or more of parenteral administration of long-acting oxytetracycline, flunixine meglumine, and foot trimming on day 1 or 6 of diagnosis. Follow-up was for 15 days. Time to recovery from lameness and lesions was investigated with discrete-time survival models. RESULTS: There was significant association (P < .05) between recovery from lameness and lesions. Sheep receiving antibacterials parenterally recovered faster from lameness (odds ratio [OR]: 4.92 [1.20-20.10]) and lesions (OR: 5.11 [1.16-22.4]) than positive controls, whereas sheep foot trimmed on day 1 (lameness-OR: 0.05 [0.005-0.51]; lesions-OR: 0.06 [0.008-0.45]) or day 6 of diagnosis (lameness OR: 0.07 [0.01-0.72]; lesions OR: 0.07 [0.01-04).56]) recovered more slowly than positive controls. NSAID had no significant effect on recovery. CONCLUSIONS AND CLINICAL IMPORTANCE: If foot trimming on day 1 or 6 of diagnosis was stopped and parenteral antibacterials were used, then over 1 million sheep/annum lame with footrot in the United Kingdom would recover more rapidly with benefits to productivity. Globally, this figure would be much higher.

Functional magnetic resonance imaging of human brain activation during cue-induced cocaine craving.

OBJECTIVE: Functional magnetic resonance imaging (MRI) was used to test whether brain activation was detectable in regions previously associated with cocaine cue-induced craving. METHOD: Blood oxygenation level dependent (BOLD) functional activation was measured during presentation of audiovisual stimuli containing alternating intervals of drug-related and neutral scenes to six male subjects with a history of crack cocaine use and six male comparison subjects. RESULTS: Significant activation was detected in the anterior cingulate and left dorsolateral prefrontal cortex in the cocaine-using group. In addition, a correlation between self-reported levels of craving and activation in these regions was found. CONCLUSIONS: These results suggest that functional MRI may be a useful tool to study the neurobiological basis of cue-induced craving.

Stability-indicating assay for hydrochlorothiazide.

A stability-indicating method for determining hydrochlorothiazide in tablet formulations and in the bulk form is described. Hydrochlorothiazide is dissolved or extracted using methanol. An aliquot of the solution, containing sulfadiazine as an internal standard, is chromatographed on a 10 micron C18 column with an aqueous mobile phase containing 5% methanol as the modifier. The pH is adjusted to about 4.5 with acetic acid. The method gave accurate results for nine lots (four different suppliers) of tablets and two bulk drug lots (two different suppliers). The assay has a relative standard deviation of about 1%. The method can also be used as a test for impurities in hydrochlorothiazide. The data in this study indicate that the test should give accurate results for impurities between 0.1 and 5%.