Reporting quality of randomized controlled trials in prehabilitation: a scoping review.

BACKGROUND Inadequate study reporting precludes interpretation of findings, pooling of results in meta-analyses, and delays knowledge translation. While prehabilitation interventions aim to enhance candidacy for surgery, to our knowledge, a review of the quality of reporting in prehabilitation has yet to be conducted. Our objective was to determine the extent to which randomized controlled trials (RCTs) of prehabilitation are reported according to methodological and intervention reporting checklists. METHODS Eligibility criteria: RCTs of unimodal or multimodal prehabilitation interventions. SOURCES OF EVIDENCE search was conducted in March 2022 using MEDLINE, Embase, PsychINFO, Web of Science, CINAHL, and Cochrane. CHARTING METHODS identified studies were compared to CONSORT, CERT & Modified CERT, TIDieR, PRESENT, and CONSORT-SPI. An agreement ratio (AR) was defined to evaluate if applicable guideline items were correctly reported. Data were analyzed as frequency (n, %) and mean with standard deviation (SD). RESULTS We identified 935 unique articles and included 70 trials published from 1994 to 2022. Most prehabilitation programs comprised exercise-only interventions (n = 40, 57%) and were applied before oncologic surgery (n = 32, 46%). The overall mean AR was 57% (SD: 20.9%). The specific mean ARs were as follows: CONSORT: 71% (SD: 16.3%); TIDieR: 62% (SD:17.7%); CERT: 54% (SD: 16.6%); Modified-CERT: 40% (SD:17.8%); PRESENT: 78% (SD: 8.9); and CONSORT-SPI: 47% (SD: 22.1). CONCLUSION Altogether, existing prehabilitation trials report approximately half of the checklist items recommended by methodological and intervention reporting guidelines. Reporting practices may improve with the development of a reporting checklist specific to prehabilitation interventions

Outcomes reported in randomised trials of surgical prehabilitation: a scoping review

BACKGROUND: Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation. METHODS: MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework. RESULTS: We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein. CONCLUSIONS: There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses

International consensus is needed on a core outcome set to advance the evidence of best practice in cancer prehabilitation services and research.

Prehabilitation aims to optimise patients’ physical and psychological status before treatment. The types of outcomes measured to assess the impact of prehabilitation interventions vary across clinical research and service evaluation, limiting the ability to compare between studies and services and to pool data. An international workshop involving academic and clinical experts in cancer prehabilitation was convened in May 2022 at Sheffield Hallam University’s Advanced Wellbeing Research Centre, England. The workshop substantiated calls for a core outcome set to advance knowledge and understanding of best practice in cancer prehabilitation and to develop national and international databases to assess outcomes at a population level

Prehabilitation for Enhanced Recovery After Colorectal Surgery

Background: Postoperative morbidity is largely the product of the preoperative condition of the patient, the quality of surgical care provided, and the degree of surgical stress elicited. Enhanced Recovery After Surgery (ERAS) minimizes surgical stress with standardized evidence-based perioperative care; yet the ERAS care elements focus mainly on the intra- and postoperative periods, which may not sufficiently enhance recovery if preoperative patient-related factors have not been modified before surgery. Prehabilitation programs aim to enhance recovery by targeting the preoperative condition of the patient.Methods: This dissertation includes four manuscripts that broadly contribute to the evidence that supports the hypothesis that the patient’s preoperative status modifies outcomes in colorectal surgery. Results: First, intermediately frail and frail patients with poor functional walking capacity before surgery suffer more postoperative complications than patients with better functional walking capacity. Second, nutrition prehabilitation, with and without exercise, reduces mean length of hospital stay by two days. Third, patient interviews suggest that patients support the idea of using prehabilitation to enhance their preoperative condition. Finally, the last manuscript offers methodological suggestions to measure and analyze external variables as a means of advancing the prehabilitation literature and further enhancing patient outcomes. Conclusion: The findings of this doctoral dissertation add to the growing body of evidence that the process of surgical recovery begins before surgery. Prehabilitation interventions can be applied to support better postoperative recoveries

Oral and parenteral nutrition regimens are similarly effective in attenuating the catabolic stress response to colorectal surgery on the first postoperative day

Background: The stress response elicited by surgery, and exacerbated by fasting, evokes metabolic, hormonal, and immunological changes that can result in loss of body protein. Protein balance can be maintained, and the acute phase response supported, when hypocaloric parenteral nutrition is administered to avoid perioperative fasting. As oral feeding reduces costs and complications associated with parenteral feeding, our objective was to compare parenteral and oral protein kinetic outcomes. Methods: Patients undergoing colorectal surgery were randomly assigned to receive dextrose and amino acids either parenterally (PN) (n=8) or orally (n=8) on the first postoperative day. Both nutrition regimens supplied dextrose at 50% of each patient's measured resting energy expenditure and amino acids at 20%, as either Travasol® or pressurized whey protein. The effects of each regimen on whole body protein turnover and hepatic secretory protein synthesis rates were assessed through primed constant infusions of L-[1-13C] leucine and L-[ring2H5] phenylalanine tracers before and after surgery. Circulating concentrations of glucose, insulin, cortisol, lactate and plasma amino acids were also measured. Results: Both nutrition support regimens were similarly effective in maintaining whole body leucine balance (PN: 0.1+6 µmol/(kg•h); Oral: 4.1+8 µmol/(kg•h)). The oral regimen supported postoperative normoglycemia (PN: 7.1+0.3 mmol/L; Oral: 5.6+0.5 mmol/L). A postoperative increase (p<0.03) in plasma fibrinogen concentration (PN: 3.5+1, 4.5+1 g/L; Oral: 3.9+1, 4.3+1 g/L) was mediated by an increase (p<0.002) in fractional synthesis rate (FSR) (PN: 27+4, 58+11 %/d; Oral: 30+4, 65+5 %/d). In contrast, plasma albumin concentration was lower (p<0.002) after surgery (PN: 36+3, 30+4 g/L; Oral: 37+4, 30+2 g/L), while FSR did not differ from preoperative rate (PN: 15+3, 13+4 %/d; Oral: 14+4, 17+4 %/d). The oral regimen tended to support an enhanced FSR of albumin after surgery (p=0.065). Conclusion: An oral nutrition regimen, based on pressurized whey protein, was utilized just as effectively as a parenteral regimen on the first postoperative day to attenuate the catabolic response to surgery by maintaining protein balance, normoglycemia, and supporting the acute phase response through synthesis of hepatic secretory proteins.Fond : La réponse provoqué par une stresse chirurgicale et exacerbé par le jeûne, évoque des changements métaboliques, hormonales et immunologiques, ce qui cause à notre corps de perdre sa réserve protéiques. L'équilibre protéique peut être maintenue, et la réponse de phase aiguë soutenue, lorsque la nutrition parentérale hypocalorique est administrée afin d'éviter le jeûne périopératoire. Comme l'alimentation orale réduit les coûts et les complications associées par l'alimentation parentérale, notre objectif était de comparer les résultats de protéines parentérales et cinétiques orales. Méthodes : Les patients subissant une chirurgie colorectale ont été assignés de façon aléatoire à recevoir du dextrose et acides aminés soit par voie parentérale (PN) (n=8) ou par voie orale (n=8) durant la première journée postopératoire. Les deux régimes de nutrition ont fourni du dextrose à 50% de la mesure de dépense énergétique au repos de chaque patient et des acides aminés à 20%, soit du Travasol® ou des protéines de lactosérum pressuriser. Les effets de chaque régime sur la composition protéique du corps entier et synthèse protéique du taux de sécrétion hépatiques ont été évalués avec des perfusions continues préparées de traceurs L-[1-13C] leucine et L-[ring2H5] phénylalanine avant et après la chirurgie. Concentrations circulantes d'acides glucose, d'insuline, cortisol, lactate et le plasma d'acide aminés ont été également mesurées. Résultats: Les deux régimes de support nutritionnel ont similairement été efficaces à maintenir une balance de Leucine dans tout le corps entier (PN: 0,1+ 6 µmol/(kg• h); Oral: 4.1+8 µmol/(kg• h)). Le régime oral a soutenu une normo-glycémie postopératoire (PN: 7,1+0,3 mmol/L; Oral: 5.6+0.5 mmol/L). Une augmentation postopératoire (p <0,03) de concentration fibrinogène plasmatique (PN: 3,5+ 1, 4,5+1 g/L; orale: 3,9+ 1, 4,3+1 g/L) a provoquée une augmentation (p <0,002) dans le taux de synthèse fractionnée (FSR) (PN: 27+4, 58+11 %/j; Oral: 30+4, 65+5 % /j). En revanche, la concentration plasmatique d'albumine était plus faible (p <0,002) après la chirurgie (PN: 36+3, 30+4 g/L; Oral: 37+4, 30+2 g/L), tandis que le RSF n'a pas différé du taux pré-opératoire (PN: 15+3, 13+4% / j; Oral: 14+4, 17+4% / j). Le traitement oral a eu tendance d'appuyer un renforcement de FSR d'albumine après la chirurgie (p = 0,065). Conclusion : Un régime de nutrition orale, à base de protéines de lactosérum pressuriser, a été utilisé aussi efficacement qu'un régime parentéral le premier jour post-opératoire afin d'atténuer la réponse catabolique de la chirurgie tout en maintenant l'équilibre protéiques, la normo-glycémie et en soutenant la réponse de phase grâce à la synthèse protéique de la sécrétion hépatique

ERAS From the Patient Perspective

Other Supporting Agencies: Alberta Health Services, DON SCN, Surgical Strategic Clinical SCNPRIHS-AIH

Stillbirth, still life: A qualitative patient-led study on parents’ unsilenced stories of stillbirth

Objective: Explore parents’ experiences of stillbirth using a patient-led qualitative approach. Methods: Parents who had experienced stillbirth in the previous 5 years were recruited through posters and snowball sampling, each participating in one or more data collection event. We conducted a co-design focus group to set the direction of our research, narrative interviews, and a reflect focus group to engage parents in finalizing the analysis and findings. Data were analysed iteratively using a participatory grounded theory approach. Results: Parents’ (n=11) experiences tended to be expressed in the form of two narratives: clinical and personal; the historical silent discourse permeated both narratives. The clinical experience, Abandoned in silence, was sub-divided into three categories: 1) Lead me through the decision with one sub-category: Recognize that I am having a birth and death experience; 2) I need specialized care now; and 3) I need specialized care later. The personal experience, Shrouded in silence, was sub-divided into three categories: 1) I survived the space between; 2) I am learning to forge a new path; and 3) My daughter’s name is Charlotte. Stillbirth is a story of death, but it is also a story of life. In stillbirth, parents require the space to experience both the birth and death elements of the story; yet, one or both elements are often silenced. Stillbirth, still Life was the core concept that emerged from parents’ stories of their stillborn babies. Conclusion: Parents’ narratives are driven by the need to honour their babies’ lives. They are learning to be unsilenced.Maternal, Newborn, Child and Youth Strategic Clinical Networ

Nutrition care process model approach to surgical prehabilitation in oncology

The nutrition care process is a standardized and systematic method used by nutrition professionals to assess, diagnose, treat, and monitor patients. Using the nutrition care process model, we demonstrate how nutrition prehabilitation can be applied to the pre-surgical oncology patient.</p