Multidisciplinary Tracheotomy Teams: An Analysis of Patient Outcomes and Resource Allocation Breast cancer teams: the impact of constitution, new cancer workload, and methods of operation on their effectiveness The impact of a bariatric rehabilitation service on weight loss and psychological adjustment - study protocol Proactive care of older people undergoing surgery ('POPS'): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Enhanced recovery after liver surgery. Community-based care for the management of type 2 diabetes: an evidence-based analysis. Implementation of complete mesocolic excision at a university hospital in Denmark: An audit of consecutive, prospectively collected colon cancer specimens. Bariatric Surgery May Improve Employment Status in Unemployed, Underserved, Severely Obese Patients Prophylaxis of Venous Thromboembolism Using Two Different Doses of Low-Molecular-Weight Heparin (Nadroparin) in Bariatric Surgery: A Prospective Randomized Trial Exercise improves quality of life in bariatric surgery candidates: results from the Bari-Active trial. Does Surgically Induced Weight Loss Improve Daytime Sleepiness? Knowledge retention from preoperative patient information Evaluation of Health Status and Quality of Life after Bariatric Surgery: Comparison of Standard Roux-en-Y Gastric Bypass, Vertical Banded Gastroplasty and Laparoscopic Adjustable Silicone Gastric Banding Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology. Community-based care for chronic wound management: an evidence-based analysis. Improvement in health-related quality of life following Roux-en-Y gastric bypass. A tailored, supportive care intervention using systematic assessment designed for people with inoperable lung cancer: a randomised controlled trial. Antidepressant therapy in patients undergoing coronary artery bypass grafting: the MOTIV-CABG trial. Intervention-related Increases in Preoperative Physical Activity are Maintained 6-months after Bariatric Surgery: Results from the Bari-Active Trial Preoperative or postoperative therapy for resectable oesophageal cancer: an updated practice guideline. Management of Depression in Patients With Cancer: A Clinical Practice Guideline. Teams Talking Trials: results of an RCT to improve the communication of cancer teams about treatment trials. Outcomes of preoperative weight loss in high-risk patients undergoing gastric bypass surgery.
We sought to establish the effect of introducing a multidisciplinary tracheotomy management team ( MDT ) . Tracheotomies are high-cost interventions with potentially devastating complications . Multidisciplinary teams have been introduced in many hospitals with the aim of reducing complications , however , data supporting them are lacking . There is currently insufficient evidence to conclude MDTs reduce length of hospital or intensive care unit ( ICU ) stay , and there is little information on cost analysis . A chart review identified patients who had a tracheotomy inserted at a major metropolitan teaching hospital with an acute spinal medicine service 2 years before and after the MDT was implemented . The primary outcome was time to decannulation . Other outcomes included tracheotomy complications , the proportion of patients decannulated , length of ICU and hospital stay , and admission cost . Our search identified 174 ( 78 prior and 96 post-MDT ) patients . Baseline demographics were similar between groups . There was no difference in time to decannulation , the decannulation rate , or the length of hospital or ICU stay . Complication rates were low in both groups . There was an increase in the proportion of patients who received speaking valves and a reduction in cost of admission in a subgroup of patients who did not undergo head and neck surgery . There is insufficient evidence to support the widespread introduction of tracheotomy MDTs . Institutions considering introducing a tracheotomy team should carefully consider their case-mix , volume , and available re sources as well as the structure and responsibilities of the team , and the timing of its activities within the working week . The potential benefits of MDTs including teaching of staff , and collaboration of teams should be acknowledged . Given the potentially significant implication s for cost to the health system , a r and omized trial is needed to guide policy in this area National guidance and clinical guidelines recommended multidisciplinary teams ( MDTs ) for cancer services in order to bring specialists in relevant disciplines together , ensure clinical decisions are fully informed , and to coordinate care effectively . However , the effectiveness of cancer teams was not previously evaluated systematic ally . A r and om sample of 72 breast cancer teams in Engl and was studied ( 548 members in six core disciplines ) , stratified by region and caseload . Information about team constitution , processes , effectiveness , clinical performance , and members ' mental well-being was gathered using appropriate instruments . Two input variables , team workload ( P=0.009 ) and the proportion of breast care nurses ( P=0.003 ) , positively predicted overall clinical performance in multivariate analysis using a two-stage regression model . There were significant correlations between individual team inputs , team composition variables , and clinical performance . Some disciplines consistently perceived their team 's effectiveness differently from the mean . Teams with shared leadership of their clinical decision-making were most effective . The mental well-being of team members appeared significantly better than in previous studies of cancer clinicians , the NHS , and the general population . This study established that team composition , working methods , and workloads are related to measures of effectiveness , including the quality of clinical care Background Bariatric surgery is currently the most effective form of obesity management for those whose BMI is greater than 40 ( or 35 with co morbidities ) . A minority of patients , however , either do not show the desired loss of excess weight or show weight regain by follow up . Research highlights some of the reasons for this variability , most of which centres on the absence of any psychological support with patients describing how although surgery fixes their body , psychological issues relating to dietary control , self esteem , coping and emotional eating remain neglected . The present study aims to evaluate the impact of a health psychology led bariatric rehabilitation service ( BRS ) on patient health outcomes . The bariatric rehabilitation service will provide information , support and mentoring pre and post surgery and will address psychological issues such as dietary control , self esteem , coping and emotional eating . The package reflects the rehabilitation services now common place for patients post heart attack and stroke which have been shown to improve patient health outcomes . Methods / Design The study is a r and omised control trial and patients will be allocated to receive either usual care or the bariatric rehabilitation service pre and post bariatric surgery . Follow up measures of weight loss and psychological issues will be taken at baseline ( 2 weeks preoperatively ) , 3 , 6 and 12 months postoperatively . The contents of the bariatric service and the follow up measures are based on previous pilot work and have been developed further by the research team working closely with two patient support groups ( BOSPA & WLSinfo ) . This study will take place in St Richard 's Hospital in Chichester in the UK . Discussion It is predicted that a bariatric rehabilitation service will improve weight loss following surgery and will also facilitate changes in other psychological variables such as quality of life , dietary control , self esteem , coping and emotional eating . This also has cost implication s for the NHS and other healthcare providers as improved effectiveness of bariatric surgery reduces the health costs of obese patients in the longer term . Trial registration Clinical Trials.gov NCT01264120 BACKGROUND older people undergoing elective surgery have significant post-operative problems prolonging hospitalisation . OBJECTIVE to design , embed , and evaluate an evidence -based comprehensive geriatric assessment ( CGA ) service for at-risk older patients undergoing elective surgery . SETTING urban teaching hospital . SUBJECTS elective surgical patients aged 65 + . INTERVENTION multidisciplinary preoperative CGA service with post-operative follow-through ( proactive care of older people undergoing surgery [ ' POPS ' ] ) . METHODS observational cohort study and multilevel surveys ( development and modelling phase ) . Prospect i ve ' before and after ' comparison ( exploratory evaluation ) . RESULTS findings from the development phase showed high levels of preoperative co-morbidity , no multidisciplinary preoperative input , and multiple potentially preventable post-operative problems delaying discharge in older elective surgery patients . Comparison of 2 cohorts of elective orthopaedic patients ( pre-POPS vs POPS , N = 54 ) showed the POPS group had fewer post-operative medical complications including pneumonia ( 20 % vs 4 % [ p = 0.008 ] ) and delirium ( 19 % vs 6 % [ p = 0.036 ] ) , and significant improvements in areas reflecting multidisciplinary practice including pressure sores ( 19 % vs 4 % [ p = 0.028 ] ) , poor pain control ( 30 % vs 2 % [ p<0.001 ] ) , delayed mobilisation ( 28 % vs 9 % [ p = 0.012 ] ) and inappropriate catheter use ( 20 % vs 7 % [ p = 0.046 ] ) . Length of stay was reduced by 4.5 days . There were fewer delayed discharges relating to medical complications ( 37 % vs 13 % ) or waits for OT assessment or equipment ( 20 % vs 4 % ) . CONCLUSION a proactive evidence -based CGA service for at-risk older elective surgical patients was developed according to MRC framework for complex interventions . Pre/post comparison in elective orthopaedic patients showed improved ( within method ological limitations ) post-operative outcomes indicative of better clinical effectiveness and efficiency , and contributed to the service obtaining mainstream funding . Informed by the present study , a r and omised controlled trial is ongoing INTRODUCTION In a majority of cases , enhanced recovery after surgery program ( ERP ) leads to a reduced rate of postoperative complications and shortened hospital stays following digestive surgery . The program 's preoperative , perioperative and postoperative measures are implemented by the members of a motivated multidisciplinary team . Having shown its merits in digestive surgery , ERP would be particularly useful in liver surgery due to the elevated rates of morbidity and mortality this type of operation continues to entail . The objective of this review was to evaluate the efficacy of ERP  in liver surgery . METHOD This is a systematic narrative review of the literature on the efficacy of ERP  in liver surgery by laparotomy or laparoscopy . RESULTS Notwithst and ing a number of studies ( n=30 : 5 r and omized trials , 14 cohort studies and 11 meta-analyses ) less sizable than with regard to digestive surgery in general and colorectal surgery in particular , analysis of the literature confirms that in liver surgery , ERP is associated with an overall decrease in complications by 30 to 60 % , but without improvement in the rates of hospital readmission and postoperative mortality . All of the studies report a reduction in average length of stay ( ALOS ) by 2.3 days and in functional recovery , a more objective indicator than ALOS , by 2.5 days . As of now , the economic impact of the ERP programs in liver surgery is neither positive nor negative , the above-mentioned savings being counterbalanced by heightened costs for material and equipment . Laparoscopic surgery is independently associated with better outcomes in terms of complications , functional recovery and ALOS ; that is why it is important to incorporate this surgical approach in ERP as often as possible . Given a lack of robust evidence , Prehabilitation , which is a preoperative optimization process leading to improved functional reserve , has yet to be assigned a place in ERP programs pertaining to liver surgery . Possible roadblocks to application of an ERP program can be overcome through coordination by a team leader , a motivated multidisciplinary team , training courses and dedicated teaching sessions . CONCLUSION ERP is a care improvement process that has a major play to play in organization of liver surgery , and its large-scale application is to be recommended UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes  : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine the efficacy of specialized multidisciplinary community care for the management of type 2 diabetes compared to usual care . CLINICAL NEED TARGET POPULATION AND CONDITION Diabetes ( i.e. diabetes mellitus ) is a highly prevalent chronic metabolic disorder that interferes with the body 's ability to produce or effectively use insulin . The majority ( 90 % ) of diabetes patients have type 2 diabetes . ( 1 ) Based on the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) , intensive blood glucose and blood pressure control significantly reduce the risk of microvascular and macrovascular complications in type 2 diabetics . While many studies have documented that patients often do not meet the glycemic control targets specified by national and international guidelines , factors associated with glycemic control are less well studied , one of which is the provider(s ) of care . Multidisciplinary approaches to care may be particularly important for diabetes management . According guidelines from the Canadian Diabetes Association ( CDA ) , the diabetes health care team should be multi- and interdisciplinary . Presently in Ontario , the core diabetes health care team consists of at least a family physician and /or diabetes specialist , and diabetes educators ( registered nurse and registered dietician ) . Increasing the role played by allied health care professionals in diabetes care and their collaboration with physicians may represent a more cost-effective option for diabetes management . Several systematic review s and meta-analyses have examined multidisciplinary care programs , but these have either been limited to a specific component of multidisciplinary care ( e.g. intensified education programs ) , or were conducted as part of a broader disease management program , of which not all were multidisciplinary in nature . Most review s also do not clearly define the intervention(s ) of interest , making the evaluation of such multidisciplinary community programs challenging . EVIDENCE -BASED ANALYSIS METHODS RESEARCH QUESTIONS What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a registered nurse , registered dietician and physician ( primary care and /or specialist ) for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 1]What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a pharmacist and a primary care physician for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 2 ] INCLUSION CRITERIA English language full-reportsPublished between January 1 , 2000 and September 28 , 2008R and omized controlled trials ( RCTs ) , systematic review s and meta-analysesType 2 diabetic adult population ( ≥18 years of age)Total sample size ≥30Describe specialized multidisciplinary community care defined as ambulatory-based care provided by at least two health care disciplines ( of which at least one must be a specialist in diabetes ) with integrated communication between the care providers . Compared to usual care ( defined as health care provision by non-specialist(s ) in diabetes , such as primary care providers ; may include referral to other health care professionals/services as necessary)≥6 months follow-up EXCLUSION CRITERIA Studies where discrete results on diabetes can not be abstract edPredominantly home-based interventions Inpatient-based interventions OUTCOMES OF INTEREST The primary outcomes for this review were glycosylated hemoglobin ( rHbA1c ) levels and systolic blood pressure ( SBP ) . SEARCH STRATEGY A literature search was performed on September 28 , 2008 using OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , the Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1 , 2000 and September 28 , 2008 . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also examined for any additional relevant studies not identified through the search . Articles with unknown eligibility were review ed with a second clinical epidemiologist , then a group of epidemiologists until consensus was established . The quality of evidence was assessed as high , moderate , low or very low according to GRADE methodology . Given the high clinical heterogeneity of the articles that met the inclusion criteria , specific models of specialized multidisciplinary community care were examined based on models of care that are currently being supported in Ontario , models of care that were commonly reported in the literature , as well as suggestions from an Expert Advisory Panel Meeting held on January 21 , 2009 . SUMMARY OF FINDINGS The initial search yielded 2,116 unique citations , from which 22 RCTs trials and nine systematic review s published were identified as meeting the eligibility criteria . Of these , five studies focused on care provided by at least a nurse , dietician , and physician ( primary care and /or specialist ) model of care ( Model 1 ; see Table ES 1 ) , while three studies focused on care provided by at least a pharmacist and primary care physician ( Model 2 ; see Table ES 2 ) . Based on moderate quality evidence , specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in HbA1c of 1.0 % compared with usual care . The effects of this model on SBP , however , are uncertain compared with usual care , based on very-low quality evidence . Specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in both HbA1c of 1.05 % ( based on high quality evidence ) and SBP of 7.13 mm Hg ( based on moderate quality evidence ) compared to usual care . For both models , the evidence does not suggest a preferred setting of care delivery ( i.e. , primary care vs. hospital outpatient clinic vs. community clinic ) . Table ES1 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 1 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.00 [ -1.27 , -0.73]4 % (p=0.37)Moderate- quality Subgroup : Moderate-to-High Quality -0.91 [ -1.19 , -0.62]0 % (p=0.74)Systolic Blood Pressure ( mm Hg)-2.04 [ -13.80 , 9.72]89 % (p=0.002)Very-low quality * Mean change from baseline to follow-up between intervention and control groupsTable ES2 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 2 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.05 [ -1.57 , -0.52]0 % (p=0.75)High- quality Systolic Blood Pressure ( mm Hg)-7.13 [ -11.78 , -2.48]46 % (p=0.17)Moderate quality * Mean change from baseline to follow-up between intervention and control groups AIM Over recent years there has been a new focus on the quality of colon cancer surgery following the description and introduction of complete mesocolic excision ( CME ) . In the same period , laparoscopic surgery has been widely applied to the treatment of colon cancer . We aim ed to evaluate the introduction of both CME and laparoscopic-assisted surgery  at Aarhus University Hospital , Denmark between 2008 and 2011 . Secondly we aim ed to evaluate the impact on the quality of surgery of post-operative team meetings where pathologists demonstrated the plane of surgery on the specimens . METHOD A series of 209 consecutive and prospect ively collected colon cancer specimens were evaluated by assessing the plane of surgery and measuring the amount of tissue resected . Multivariate analyses were used to control for influencing factors . RESULTS The proportion of specimens resected in the mesocolic plane was high and increased significantly following the introduction of post-operative team meetings ( 52%-76 % , p = 0.02 ) . Laparoscopic surgery enhanced the distance between the tumour and the arterial tie by a mean of 27 mm ( p < 0.0001 ) and the distance between the nearest bowel wall and the arterial tie by 26 mm ( p < 0.0001 ) when compared to an open approach . Factors such as body mass index and age influenced the outcome for surgical quality . CONCLUSION Implementation of CME and laparoscopic-assisted surgery for colon cancer is a challenge and requires continuous training and feedback . Post-operative multidisciplinary team meetings may be a key element in this process Background The purpose of this study was to determine the impact of bariatric surgery on employment status in underserved , unemployed patients with severe obesity . Methods A retrospective review of all unemployed severely obese patients seen in our urban safety-net bariatric surgery program was performed . Preoperative patient question naires and medical records were review ed to evaluate patient employment status at the time of initial evaluation by the multidisciplinary bariatric surgery team . Follow-up data was obtained on all available patients ( including those who did not undergo surgery ) , including weight and employment status . A st and ardized telephone question naire was administered to supplement details regarding employment . Changes in employment status and body weight were determined in both groups . Results Here , 193 unemployed severely obese patients were evaluated by the multidisciplinary obesity team . The vast majority of patients ( > 80 % ) were minorities ( primarily Hispanic ) and publicly insured . Seventy-two underwent bariatric surgery and 121 did not . Twenty-four percent of the surgical patients and 9 % of the non-surgical patients had acquired full-time employment at least one year postoperatively ( p = 0.043 ) . There was a 10-point body mass index reduction in the surgical group , compared to 1-point reduction in the non-surgical group after one year . Conclusions Bariatric surgery may improve employment status in an unemployed severely obese patient cohort . Future research in this area should collect detailed prospect i ve data on employment prior to surgery and assess changes longitudinally to provide a more complete picture of the impact of bariatric surgery on employment Background : Obese patients undergoing bariatric surgery  are at a high risk of developing fatal pulmonary embolism or post-thrombotic syndrome . The prophylactic use of low molecular weight heparins ( LMWHs ) is correlated with a significant reduction in post-operative venous thrombosis in patients undergoing orthopedic or general surgery . In morbidity obese patients , the limited number of comparative trials are too sparse to allow a consensus on the effective dose and dosing schedule . Methods : In a prospect i ve study to evaluate the effect of two doses of nadroparin as prophylaxis for venous thromboembolism following bariatric surgery , 60 consecutive patients undergoing Rouxen-Y gastric bypass  were r and omized to receive either 0.6 ml ( 5700 IU ) or 1.0 ml ( 9500 IU ) of nadroparin started pre-operatively and then given once daily post-operatively until discharge . Results : No statistically significant differences between the two groups were detected in any of the measured coagulation parameters either preoperatively or at days 1 , 3 and 5 postoperatively . No thrombotic events were observed pre- or post- operatively , and no patient developed meta-thrombotic syndrome at the 3 and 6 months follow-up . No bleeding events occurred in the patients given the lower dose compared with two major hemorrhages in those given the higher dose . Conclusion : Our results indicate that 0.6 ml ( 5700 IU ) of nadroparin once daily is safe and well-tolerated , and it is as effective in prophylaxis of venous thromboembolism as the higher dose of 1 ml ( 9500 IU ) , in such high risk patients OBJECTIVE To examine the impact of a pre-bariatric surgery physical activity intervention ( PAI ) , design ed to increase bout-related ( ≥10 min ) moderate to vigorous PA ( MVPA ) , on health-related quality of life ( HRQoL ) . METHODS Analyses included 75 adult participants ( 86.7 % female ; BMI = 45.0 ± 6.5 kg m(-2 ) ) who were r and omly assigned to 6 weeks of PAI ( n = 40 ) or st and ard pre-surgical care ( SC ; n = 35 ) .  PAI received 6 individual weekly counseling sessions to increase walking exercise . Participants wore an objective PA monitor for 7 days and completed the SF-36 Health Survey  at baseline and post-intervention to evaluate bout-related MVPA and HRQoL changes , respectively . RESULTS PAI increased bout-related MVPA from baseline to post-intervention ( 4.4 ± 5.5 to 21.0 ± 21.4 min day(-1 ) ) versus no change ( 7.9 ± 16.6 to 7.6 ± 11.5 min day(-1 ) ) for SC ( P = 0.001 ) . PAI reported greater improvements than SC on all SF-36 physical and mental scales ( P < 0.05 ) , except role-emotional . In PAI , better baseline scores on the physical function and general health scales predicted greater bout-related MVPA increases ( P < 0.05 ) , and greater bout-related MVPA increases were associated with greater post-intervention improvements on the physical function , bodily pain , and general health scales ( P < 0.05 ) . CONCLUSIONS Increasing PA preoperatively improves physical and mental HRQoL in bariatric surgery c and i date s. Future studies should examine whether this effect improves surgical safety , weight loss outcomes , and postoperative Morbid obesity is associated with excessive daytime sleepiness and reduced health-related quality of life . We prospect ively evaluated the pre- and postoperative responses of bariatric surgery recipients with the Epworth Sleepiness Scale ( ESS ) and the Short Form-12 . Participants ( n = 223 ; 79 % women ) with a mean body mass index ( BMI ) and ESS of 44.8 ± 7.9 kg/m2 and 7.9 ± 4.5 , respectively , received a vertical gastrectomy ( 76 % ) or Roux-en-Y gastric bypass ( 12 % ) . Preoperatively , 30 % of patients complained of excessive daytime sleepiness ( ESS > 10 ) . Patients with preoperative excessive daytime sleepiness were more obese ( p = 0.002 ) , had higher fasting glucose levels ( p = 0.02 ) , more likely to have a diagnosis of sleep-disordered breathing ( p < 0.001 ) , report snoring ( p < 0.001 ) , and had lower health-related quality of life measures particularly physical function ( p < 0.001 ) , depression ( p = 0.006 ) , and sexual satisfaction ( p = 0.04 ) than non-sleepy patients . At 12-months postoperatively , most patients experienced a significant reduction in BMI ( 28.6 ± 5.5 kg/m2 , p < 0.001 ) and excessive daytime sleepiness ( mean ESS 5.3 ± 3.3 , p < 0.001 ) . Patients with a clinical ly relevant improvement in the ESS at 12-months post-operatively had greater improvements in physical function ( p = 0.009 ) and snoring ( p = 0.010 ) and were more likely still using positive airway pressure therapy ( p = 0.032 ) than patients without a clinical ly relevant improvement . Statistically and clinical ly significant improvements in all health-related quality of life measures were noted at 24 months . Bariatric surgery is associated with dramatic weight loss and improvements in physical functioning and daytime sleepiness Background Preoperative education is a common feature of the preoperative preparation for many surgical procedures . It is anticipated that this education will result in beneficial outcomes for the patient . Many studies have evaluated the effectiveness of different formats used to deliver the information , and the effect of this information on a variety of outcomes . While there has been substantial research and several meta‐analyses undertaken on different aspects of preoperative education , there has been no previous attempt to summarise this body of research to evaluate its impact on knowledge and underst and ing of patients . Objective The objective of this review was to present the best available evidence related to knowledge retention and /or correct performance of postoperative activities after preoperative patient education . Review method This review considered all studies that included adults in a hospital setting , either as in patients or same day surgical patients , and who received some form of information and /or instruction before an operative procedure . Interventions were the methods of preoperative patient education , instruction or teaching , and included evaluations of the effectiveness of different presentations such as : written information ; audio‐visual aids ; computer‐assisted instruction ; learning packages in either group or individual formats , at either pre‐admission or post‐admission . The primary outcomes were those associated with the underst and ing of the information related to the operative or postoperative period that were provided in the intervention and included : increased knowledge ; ability to perform postoperative activities ; time to teach skills . This review considered r and omised controlled trials that evaluated forms of preoperative patient education and their effect on patient underst and ing , knowledge and ability to perform postoperative activities . Results The findings of this review support the use of pamphlets to inform patients and to improve their skills . The role of videos as a preoperative instruction tool has not been rigorously evaluated . However , existing studies support the use of preoperative videos to improve patient knowledge and skill . The data suggest that the instructional method , the act of educating a patient by delivering directions for actions or behaviour is useful for improving patients ' knowledge of their treatment and their ability to perform and comply with required exercises . However , instruction is likely to be more effective if provided before admission . If teaching is to be done after admission , using a group format has been shown to be equally as effective as individual instruction . Conclusions Although numerous studies have been performed on many aspects of preoperative education , little high‐ quality research has assessed the effectiveness of this information on patient knowledge and ability to perform specific skills such as exercises . Further research is required to examine : ( i ) the effectiveness of pamphlets and other written material for people with English as a second language or limited literary skills ; ( ii ) the accuracy of information provided in preoperative pamphlets ;  ( iii ) the effectiveness of pamphlets  on  general population s ; ( iv ) the role of videos and learning packages ;  ( v ) the effectiveness of preoperative instruction ; and ( vi ) the changes in patient misconceptions with the provision of preoperative information Background : This study is a trial to compare the effects and outcomes of three different  bariatric procedures performed in two centers .  St and ard Roux-en-Y gastric bypass was performed by Dr. Norman Samuels in Fort Lauderdale ( Florida ) ; vertical b and ed gastroplasty and laparoscopic adjustable silicone gastric b and ing were done in Hallein ( Salzburg ) by Dr. Emanuel Hell and Dr. Karl Miller . Methods : In a prospect i ve comparative study 30 matched patients from each group were followed to assess post-operative improvement in health status and quality of life , to compare the three different techniques . The  Bariatric Analysis and Reporting Outcome System ( BAROS  ) as described by Oria and Moorehead has been used for evaluation . Results : The observation time was at least 3 years ( 3 to 8 years ) in each individual case . A significant increase in quality of life and health status in 75 % of the surgically-treated patients was observed when compared with a non-operated control group of morbidly obese patients . Conclusions : By utilizing BAROS it has been found possible to compare the results of different procedures done by different surgeons with different techniques , utilizing patients from different cultures and with different language s. The results of this comparative study favor the st and ard gastric bypass for the treatment of morbid obesity . This operation is superior to purely gastric restrictive procedures in weight loss and improvement of quality of life : The purpose of this up date of the European Society of Anaesthesiology ( ESA ) guidelines on the pre-operative evaluation of the adult undergoing noncardiac surgery is to present recommendations based on the available relevant clinical evidence . Well performed r and omised studies on the topic are limited and therefore many recommendations rely to a large extent on expert opinion and may need to be adapted specifically to the healthcare systems of individual countries . This article aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthesiologists all over Europe to integrate - wherever possible - this knowledge into daily patient care . The Guidelines Committee of the ESA formed a task force comprising members of the previous task force , members of ESA scientific subcommittees and an open call for volunteers was made to all individual active members of the ESA and national societies . Electronic data bases were search ed from July 2010 ( end of the literature search of the previous ESA guidelines on pre-operative evaluation ) to May 2016 without language restrictions . A total of 34 066 abtracts were screened from which 2536 were included for further analysis . Relevant systematic review s with meta-analyses , r and omised controlled trials , cohort studies , case-control studies and cross-sectional surveys were selected . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) system was used to assess the level of evidence and to grade recommendations . The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members , individual or national ( thus including most European national anaesthesia societies ) . Comments were collated and the guidelines amended as appropriate . When the final draft was complete , the Guidelines Committee and ESA Board ratified the guidelines UNLABELLED In August 2008 , the Medical Advisory Secretariat ( MAS ) presented a vignette to the Ontario Health Technology Advisory Committee ( OHTAC ) on a proposed targeted health care delivery model for chronic care . The proposed model was defined as multidisciplinary , ambulatory , community-based care that bridged the gap between primary and tertiary care , and was intended for individuals with a chronic disease who were at risk of a hospital admission or emergency department visit . The goals of this care model were thought to include : the prevention of emergency department visits , a reduction in hospital admissions and re-admissions , facilitation of earlier hospital discharge , a reduction or delay in long-term care admissions , and an improvement in mortality and other disease-specific patient outcomes .OHTAC approved the development of an evidence -based assessment to determine the effectiveness of specialized community based care for the management of  heart failure , Type 2 diabetes and chronic wounds .  PLEASE VISIT THE MEDICAL ADVISORY SECRETARIAT WEB SITE AT : www.health.gov.on.ca/ohtas to review the following reports associated with the Specialized Multidisciplinary Community-Based care series . Specialized multidisciplinary community-based care series : a summary of evidence -based analysesCommunity-based care for the specialized management of heart failure : an evidence -based analysis Community-based care for chronic wound management : an evidence -based analysis Please note that the evidence -based analysis of specialized community-based care for the management of diabetes titled : " Community-based care for the management of type 2 diabetes : an evidence -based analysis " has been published as part of the Diabetes Strategy Evidence Platform at this URL : http://www.health.gov.on.ca/english/providers/program/mas/tech/ohtas/tech_diabetes_20091020.htmlPLEASE VISIT THE TORONTO HEALTH ECONOMICS AND TECHNOLOGY ASSESSMENT COLLABORATIVE WEB SITE AT : http://theta.utoronto.ca/papers/MAS_CHF_Clinics_Report.pdf to review the following economic project associated with this series : Community-based Care for the specialized management of heart failure : a cost-effectiveness and budget impact analysis . OBJECTIVE The objective of this evidence -based review is to determine the effectiveness of a multidisciplinary wound care team for the management of chronic wounds . CLINICAL NEED CONDITION AND TARGET POPULATION Chronic wounds develop from various aetiologies including pressure , diabetes , venous pathology , and surgery . A pressure ulcer is defined as a localized injury to the skin/ and or underlying tissue occurring most often over a bony prominence and caused , alone or in combination , by pressure , shear , or friction . Up to three fifths of venous leg ulcers are due to venous aetiology . Approximately 1.5 million Ontarians will sustain a pressure ulcer , 111,000 will develop a diabetic foot ulcer , and between 80,000 and 130,000 will develop a venous leg ulcer . Up to 65 % of those afflicted by chronic leg ulcers report experiencing decreased quality of life , restricted mobility , anxiety , depression , and /or severe or continuous pain . MULTIDISCIPLINARY WOUND CARE TEAMS : The term ' multidisciplinary ' refers to multiple disciplines on a team and ' interdisciplinary ' to such a team functioning in a coordinated and collaborative manner . There is general consensus that a group of multidisciplinary professionals is necessary for optimum specialist management of chronic wounds stemming from all aetiologies . However , there is little evidence to guide the decision of which professionals might be needed form an optimal wound care team . EVIDENCE -BASED ANALYSIS METHODS LITERATURE SEARCH A literature search was performed on July 7 , 2009 using OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , OVID EMBASE , Wiley Cochrane , Centre for Review s and Dissemination/International Agency for Health Technology Assessment , and on July 13 , 2009 using the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , and the International Agency for Health Technology Assessment ( INAHTA ) for studies pertaining to leg and foot ulcers . A similar literature search was conducted on July 29 ' 2009 for studies pertaining to pressure ulcers . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also examined for any additional relevant studies not identified through the search . Articles with an unknown eligibility were review ed with a second clinical epidemiologist and then a group of epidemiologists until consensus was established . INCLUSION CRITERIA R and omized controlled trials and Controlled clinical Trials ( CCT ) Systematic review with meta analysis Population includes persons with pressure ulcers ( anywhere ) and /or leg and foot ulcersThe intervention includes a multidisciplinary ( two or more disciplines ) wound care team . The control group does not receive care by a wound care team Studies published in the English language between 2004 and 2009 EXCLUSION CRITERIA : Single centre retrospective observational studies OUTCOMES OF INTEREST Proportion of persons and /or wounds completely healedTime to complete healing Quality of LifePain assessment SUMMARY OF FINDINGS Two studies met the inclusion and exclusion criteria , one a r and omized controlled trial ( RCT ) , the other a CCT using a before and after study design . There was variation in the setting , composition of the wound care team , outcome measures , and follow up periods between the studies . In both studies , however , the wound care team members received training in wound care management and followed a wound care management protocol . In the RCT , Vu et al. reported a non-significant difference between the proportion of wounds healed in 6 months using a univariate analysis ( 61.7 % for treatment vs. 52.5 % for control ; p=0.074 , RR=1.19 ) There was also a non-significant difference in the mean time to healing in days ( 82 for treatment vs. 101 for control ; p=0.095 ) . More persons in the intervention group had a Brief Pain Inventory ( BPI ) score equal to zero ( better pain control ) at 6 months when compared with the control group ( 38.6 % for intervention vs. 24.4 % for control ; p=0.017 , RR=1.58 ) . By multivariate analysis a statistically significant hazard ratio was reported in the intervention group ( 1.73 , 95 % CI 1.20 - 1.50 ; p=0.003 ) . In the CCT , Harrison et al. reported a statistically significant difference in healing rates between the pre ( control ) and post ( intervention ) phases of the study . Of patients in the pre phase , 23 % had healed ulcers 3 months after study enrolment , whereas 56 % were healed in the post phase ( P<0.001 , OR=4.17 ) ( Figure 3 ) . Furthermore , 27 % of patients were treated daily or more often in the pre phase whereas only 6 % were treated at this frequency in the post phase ( P<0.001 ) , equal to a 34 % relative risk reduction in frequency of daily treatments . The authors did not report the results of pain relief assessment . The body of evidence was assessed using the GRADE methodology for 4 outcomes : proportion of wounds healed , proportion of persons with healed wounds , wound associated pain relief , and proportion of persons needing daily wound treatments . In general , the evidence was found to be low to very low quality . CONCLUSION The evidence supports that managing chronic wounds with a multidisciplinary wound care team significantly increases wound healing and reduces the severity of wound-associated pain and the required daily wound treatments compared to persons not managed by a wound care team . The quality of evidence supporting these outcomes is low to very low meaning that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate INTRODUCTION This study explored whether health-related quality of life ( HRQOL ) changes following  Roux-en-Y gastric bypass surgery  were associated with identifiable socio-demographic or clinical characteristics , and it examined the impact on health outcomes of changes in the Danish criteria for bariatric surgery . MATERIAL AND METHODS Participants ( n = 55 ) completed the Short Form Health Survey v2 ( SF-36 ) before and 22 ± 4.2 months after surgery . Information on socio-demographics , body mass index ( BMI ) , co-morbidity and satisfaction with surgery were collected through patient question naires and hospital records . RESULTS There was overall improvement on all SF-36 subscales and in the mean physical score ( PCS ) and mean mental score ( MCS ) ( p = 0.001 ) . A total of five patients had lower PCS and 13 patients had lower MCS after surgery , but we identified no particular characteristics associated with this poorer outcome . Co-morbidity and preoperative PCS/MCS showed a strong correlation with change in PCS/MCS score . CONCLUSION Gastric bypass had a positive overall effect on HRQOL , but further investigation of individual variations is needed . We found no significant differences in HRQOL outcome between those patients who would be accepted for bariatric surgery under the current Danish criteria for bariatric surgery and those patients who only fulfilled the criteria for bariatric surgery before 2011 . FUNDING not relevant . TRIAL REGISTRATION Clinical Trials.gov : NCT02032199 OBJECTIVE People with inoperable lung cancer experience higher levels of distress , more unmet needs and symptoms than other cancer patients . There is an urgent need to test innovative approaches to improve psychosocial and symptom outcomes in this group . This study tested the hypothesis that a tailored , multidisciplinary supportive care programme based on systematic needs assessment would reduce perceived unmet needs and distress and improve quality of life . METHODS A r and omised controlled trial design was used . The tailored intervention comprised two sessions at treatment commencement and completion . Sessions included a self-completed needs assessment , active listening , self-care education and communication of unmet psychosocial and symptom needs to the multidisciplinary team for management and referral . Outcomes were assessed with the Needs Assessment for Advanced Lung Cancer Patients , Hospital Anxiety and Depression Scale , Distress Thermometer and European Organization of Research and Treatment of Cancer Quality of Life Q-C30 V2.0 . RESULTS One hundred and eight patients with a diagnosis of inoperable lung or pleural cancer ( including mesothelioma ) were recruited from a specialist facility before the trial closed prematurely ( original target 200 ) . None of the primary contrasts of interest were significant ( all p > 0.10 ) , although change score analysis indicated a relative benefit from the intervention for unmet symptom needs at 8 and 12 weeks post- assessment ( effect size = 0.55 and 0.40 , respectively ) . CONCLUSION Although a novel approach , the hypothesis that the intervention would benefit perceived unmet needs , psychological morbidity , distress and health-related quality of life was not supported overall BACKGROUND The efficacy of antidepressant therapy in patients undergoing coronary artery bypass grafting ( CABG ) is not clearly established . METHODS This double-blind trial was conducted at University Hospital , Besançon , France . Adult CABG patients were r and omized ( 1:1 ) to receive escitalopram ( 10 mg daily ) or placebo from 2 to 3 weeks before to 6 months after surgery , including 12 months post-surgery follow-up . The primary composite endpoint was the occurrence of mortality or predefined morbidity events . Secondary endpoints included measures of depression , mental and physical health using Beck Depression Inventory Short Form ( BDI ) , and quality of life 36-Item Short Form ( SF-36 ) self assessment s. RESULTS The treated cohort contained 361 patients with mean age 67 years . At 12 months , the proportions of patients with the composite morbidity and mortality endpoint were not different between escitalopram and placebo ( 110 of 182 [ 60.4 % ] vs 108 of 179 [ 60.3 % ] , p = 0.984 ) . However , over the 6 months postoperative period , the BDI and SF-36 Mental Component Summary scores were better overall in the escitalopram group than in the placebo group for all patients ( p = 0.015 and p = 0.014 , respectively ) and preoperatively depressed ( BDI > 3 ) patients ( p = 0.002 and p = 0.005 , respectively ) . Moreover , the SF-36 Pain score was better overall in the escitalopram group than in the placebo group in the preoperatively-depressed subset ( p = 0.026 ) . CONCLUSIONS Antidepressant therapy had no effect on morbidity and mortality events up to 1 year after CABG . However , antidepressant therapy may provide faster improvements to mental health aspects of quality of life and reduce postoperative pain in patients with preoperative depression . Subject to contra-indications , we recommend antidepressant therapy in coronary revascularization patients who are preoperatively depressed Higher preoperative physical activity ( PA ) strongly predicts higher post-operative PA in bariatric surgery ( BS ) patients , providing rationale for preoperative PA interventions ( PAIs ) . However , whether PAI-related increases can be maintained post-operatively has not been examined . This study compared PA changes across pre- ( baseline , post-intervention ) and post-operative ( 6-month follow up ) periods in participants r and omized to 6 weeks of preoperative PAI or st and ard care control ( SC ) . Of 75 participants initially r and omized , 36 ( PAI n=22 ; SC n=14 ) underwent BS .  Changes in daily bout-related ( ⩾10-min bouts ) moderate-to-vigorous PA ( MVPA ) and steps were assessed via the SenseWear Armb and monitor . PAI received weekly counseling to increase walking exercise . Retention ( 86 % ) at post-operative follow up was similar between groups . Intent-to-treat analyses showed that PAI vs SC had greater increases across time ( baseline , post-intervention , follow up ) in bout-related MVPA minutes/day ( 4.3±5.1 , 26.3±21.3 , 28.7±26.3 vs 10.4±22.9 , 11.4±16.0 , 18.5±28.2 ; P=0.013 ) and steps/day ( 5163±2901 , 7950±3286 , 7870±3936 vs 5163±2901 , 5601±3368 , 5087±2603 ; P<0.001 ) . PAI differed from SC on bout-related MVPA at post-intervention ( P=0.016 ; d=0.91 ) , but not follow up ( P=0.15 ; d=0.41 ) , and steps at post-intervention ( P=0.031 ; d=0.78 ) and follow up ( P=0.024 ; d=0.84 ) . PAI participants maintained preoperative PA increases post-operatively . Findings support preoperative PAIs and research to test whether PA changes can be sustained and influence surgical outcomes beyond the initial post-operative period AIMS Oesophageal cancer is an aggressive disease and the optimal therapy for patients with resectable tumours remains unclear . A systematic review and companion practice guideline were published in 2004 ; however , new evidence has become available since the publication of the original report . An up date of the literature search and a revision of the recommendations were undertaken to incorporate the new data . The following research question was addressed : should patients with resectable oesophageal cancer receive preoperative or postoperative therapy together with surgery ? The outcomes of interest were survival , adverse effects and quality of life . MATERIAL S AND METHODS The literature search of the original systematic review was up date d to April 2007 . MEDLINE , EMBASE , Cochrane Library and abstract s from the American Society of Clinical Oncology and the American Society for Therapeutic Radiology and Oncology were search ed for reports of r and omised controlled trials and meta-analyses comparing preoperative or postoperative therapy with surgery alone or other preoperative or postoperative therapy . After the completion of the draft systematic review and practice guideline , the report was distributed through a mailed survey to 133 health care providers in Ontario for review and feedback . RESULTS The up date d literature search yielded eight new r and omised controlled trial reports and seven new meta- analysis reports for consideration , together with the evidence review ed in the original review publication . Of the 31 practitioners who responded to the mailed survey , 80 % agreed with the draft recommendations as stated , 83 % agreed that the report should be approved as a practice guideline and 86 % indicated that they would probably use the guideline in their own practice . CONCLUSIONS Preoperative cisplatin-based chemotherapy plus radiotherapy is recommended as the preferred modality for the management of surgically resectable patients with oesophageal cancer .  Preoperative cisplatin-based chemotherapy alone is an alternative choice for the management of these patients PURPOSE This report up date s the Cancer Care Ontario Program in Evidence -Based Care guideline for the management of  depression in adult patients with cancer . This guideline covers pharmacologic , psychological , and collaborative care interventions , with a focus on integrating practical management tools to assist clinicians in delivering appropriate treatments for depression in patients with cancer . METHODS Recommendations were developed by synthesizing information from extant guidelines and review s and search ing for r and omized controlled trials from the date of data base inception ( 1964 for MEDLINE and 1974 for EMBASE ) to January 2015 . Quality assessment of guidelines and systematic review s were conducted by using the Appraisal of Guidelines for Research and Evaluation II ( AGREE II ) , Assessment of Multiple Systematic Review s ( AMSTAR ) , and Cochrane Risk of Bias tools . Final recommendations were developed through a st and ardized Program in Evidence -Based Care multidisciplinary expert and knowledge user review process . RESULTS Two high- quality relevant clinical practice guidelines , eight pharmacologic trials , nine psychological trials , and eight collaborative care intervention trials composed the evidence base upon which the recommendations were developed . Eight specific recommendations were made to establish a st and ard of care for the management of depression in patients with cancer . The recommendations and practical management tools were review ed as being well organized and helpful , although systemic barriers to implementation were identified . CONCLUSION This up date d guideline supports the previous general recommendation that patients with cancer who have depression may benefit from psychological and /or pharmacologic interventions , without evidence for the superiority of any specific treatment over another . New recommendations for a collaborative care model that incorporates a stepped care approach suggest that multidisciplinary mental health care restructuring may be required for optimal management of depression BACKGROUND Previous research has shown that communication between members of multidisciplinary teams ( MDTs ) is often suboptimal and communication about trials between MDTs and their patients is difficult . Educational interventions can help dyadic exchanges with different aspects of trial recruitment but less work has focussed on team interventions . METHODS 22 multidisciplinary cancer teams in the UK participated in an RCT of a novel Teams Talking Trials ( TTT ) Workshop aim ed at improving the following : awareness , involvement , communication and recruitment to cancer trials . MDTs were r and omised following either 6 or 12 months of audits , which were repeated after the intervention . Audits included numbers approached about trials , team members ' attitudes , involvement and awareness of their teams ' trial portfolios . RESULTS There was no significant difference in the rate of approaching patients about trials post workshop ( estimated improvement 22 % higher regression coefficient of 0.2 , exp . (0.2)=1.22 ) . There was improvement in team members ' involvement in trials in 4 areas ( p≤0.04 ) : the pressure to enter patients into RCTs , the likelihood of a start-up meeting to discuss a newly accepted trial , the informational role played by individuals and recognition of this HCP 's role by other team members . Also , confidence in communication about RCTS increased and awareness of different aspects of trial management improved on all 14 aspects ( p=0.001 ) . CONCLUSION Attendance by teams at focussed workshops design ed to enhance communication and trial recruitment improved several aspects of team functioning , but a significant impact on the number of patients approached could not be demonstrated HYPOTHESIS Modest , preoperative weight loss will improve perioperative outcomes among high-risk , morbidly obese patients undergoing Roux-en-Y gastric bypass .  DESIGN A prospect i ve , longitudinal assessment of characteristics and outcomes of gastric bypass patients . SETTING All patients undergoing open or laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity or its comorbid medical problems at Geisinger Medical Center in Danville , Pennsylvania , during a 3-year period from May 31 , 2002 , to February 24 , 2006 , were included in this analysis . Patients were required to participate in a st and ardized multidisciplinary preoperative program that encompasses medical , psychological , nutritional , and surgical interventions and education . In addition , patients were encouraged to achieve a 10 % loss of excess body weight prior to surgical intervention . RESULTS Of the 884 subjects , 425 ( 48 % ) lost more than 10 % of their excess body weight prior to the operation . After surgery ( mean follow-up , 12 months ) , this group was more likely to achieve 70 % loss of excess body weight ( P < .001 ) . Those who lost more than 5 % of excess body weight prior to surgery were statistically less likely to have a length of stay of greater than 4 days ( P = .03 ) . CONCLUSIONS This study shows that high-risk morbidly obese c and i date s for bariatric surgery who are able to achieve a loss of 5 % to 10 % excess body weight prior to surgery have a higher probability of a shorter length of hospital stay and more rapid postoperative weight loss
Preoperative and post-operative intensive interventions improved symptoms of depression and anxiety , quality of life , diastolic blood pressure , and resting heart rate but not lipids or glycaemic measures .
This systematic review and meta- analysis of intervention studies aims to evaluate the effect of preoperative and /or post-operative support for adults who elect bariatric surgery delivered by a multidisciplinary team ( MDT )  on post-operative body composition , mental health , co-morbidities , quality of life , and side effects .