Preoperative smoking habits and postoperative pulmonary complications. Mixed treatment comparison analysis provides internally coherent treatment effect estimates based on overviews of reviews and can reveal inconsistency. Enhanced recovery after liver surgery. Examining the theory‐effectiveness hypothesis: A systematic review of systematic reviews Serum Cotinine Concentration and Wound Complications in Head and Neck Reconstruction Preoperative or postoperative therapy for resectable oesophageal cancer: an updated practice guideline. Effects of a Perioperative Smoking Cessation Intervention on Postoperative Complications: A Randomized Trial National Surgical Quality Improvement Program analysis of bariatric operations: modifiable risk factors contribute to bariatric surgical adverse outcomes. Systematic review automation technologies Nutritional status and clinical outcomes in pediatric patients with solid tumors : A systematic review of the literature. A systematic review of anxiety interventions in stroke and acquired brain injury: Efficacy and trial design Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane Systematic Review. Elusive search for effective provider interventions: a systematic review of provider interventions to increase adherence to evidence-based treatment for depression Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach Dietetic guidelines: diet in secondary prevention of cardiovascular disease. Preoperative or postoperative therapy for stage II or III rectal cancer: an updated practice guideline. Nonpharmacological interventions to prevent type 2 diabetes in women diagnosed with gestational diabetes mellitus: a systematic overview Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients. Methods for evidence synthesis in the case of very few studies Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Simulation-Based Skill Training for Trainees in Cardiac Surgery: A Systematic Review. Multimodal prehabilitation in colorectal cancer patients to improve functional capacity and reduce postoperative complications: the first international randomized controlled trial for multimodal prehabilitation Determinants of weight loss maintenance: a systematic review.
OBJECTIVE To examine the effect of preoperative smoking behavior on postoperative pulmonary complications . DESIGN Prospect i ve cohort study . SETTING The Veterans Administration Medical Center , Syracuse , NY . PARTICIPANTS Patients scheduled for noncardiac elective surgery ( n=410 ) . MEASUREMENTS AND RESULTS  Smoking status  was determined by self-report . Postoperative pulmonary complications were determined by systematic extraction of medical record data . Postoperative pulmonary complications occurred in 31 of 141 ( 22.0 % ) current smokers , 24 of 187 ( 12.8 % ) past smokers , and 4 of 82 ( 4.9 % ) never smokers . The odds ratio ( OR ) for developing a postoperative pulmonary complication for current smokers vs never smokers was 5.5 ( 95 % confidence interval [ CI ] , 1.9 to 16.2 ) and 4.2 ( 95 % CI , 1.2 to 14.8 ) after adjustment for type of surgery , type of anesthesia , abnormal chest radiograph , chronic cough , history of pulmonary disease , history of cardiac disease , history of COPD , education level , pulmonary function , body mass index , and age . Current smokers who reported reducing cigarette consumption  prior to surgery were more likely to develop a complication compared with those who did not ( adjusted OR=6.7 , 95 % CI , 2.6 to 17.1 ) . CONCLUSIONS Current smoking was associated with a nearly sixfold increase in risk for a postoperative pulmonary complication . Reduction in smoking within 1 month of surgery was not associated with a decreased risk of postoperative pulmonary complications OBJECTIVES To propose methods for mixed treatment comparisons ( MTC ) based on pooled summaries of the type produced in overviews of review s. STUDY DESIGN AND SETTING Overviews of review s ( umbrella review s ) summarize the results of multiple systematic review s into a single document . They report the summary estimates from the original pairwise meta-analyses and discuss them in narrative form , with the intention of identifying the most effective treatment . We present methods for MTC synthesis , tailored for use with overviews of review s. These generate a single internally consistent summary of all the relative treatment effects and assessment s of whether the summary is consistent with the data . These methods are applied to a published overview of treatments for childhood nocturnal enuresis . We apply the methods to both fixed-effect ( FE ) and r and om-effects ( RE ) meta-analyses of the original trials . RESULTS The summary relative risks based on FE meta-analyses , as originally published , were highly inconsistent . Those based on RE meta-analyses were consistent and could , given st and ard assumptions on comparability of treatment effects in meta- analysis , form a basis for coherent decision making . CONCLUSION Along with the summaries from systematic review s , MTC methods should be used in overviews to provide a single coherent analysis of all treatment comparisons and to check for evidence consistency 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 PURPOSE Health interventions based on theory may be more effective than those that are not . This review of review s synthesizes all published r and omized controlled trial ( RCT ) meta-analytic evidence from the last decade to examine whether theory-based interventions were found to be associated with more effective  adult health behaviour change interventions . METHODS Systematic review s including meta-analyses were identified by search ing Medline , CINAHL , PsycINFO , and CDSR . A narrative synthesis was used to summarize and analyse the evidence . Only review s including RCTs of health behaviour change interventions with adults aged 18 + published from 2007 to 2017 were included . RESULTS Of 8,659 articles , nine systematic review s met inclusion criteria . The majority of review s ( n = 8) suggested no increased effectiveness for theory-based compared to non-theory-based interventions for effectiveness of outcomes relating to health behaviour . Less than half of the RCTs included in the review s reported the use of theory ( 85/183 ) . Two review s suggested interventions based on control theory , motivational interviewing , or self-determination theory were associated with greater effectiveness for physical activity and /or dietary interventions and outcomes . Method ological and reporting issues limit the conclusions . CONCLUSIONS Theory-based interventions as currently operationalized in systematic review s were not found to be more effective than non-theory-based interventions . Method ological and reporting issues at study and review level may not reflect the true utility of theory use within health behaviour interventions . The promotion of theory use may benefit from using a multifaceted argument , rather than a narrow focus of increased effectiveness . Statement of contribution What is already known on this subject ? Theory use is regularly promoted by cl aim ing that it will lead to more effective behaviour change interventions . Theory use has been frequently linked to effectiveness within systematic review s of behaviour change interventions . The theory-effectiveness hypothesis has not been systematic ally examined at the systematic review level . What does this study add ? Theory use as operationalized by systematic review authors was not associated with increased effectiveness within systematic review s examining r and omized controlled trials of behaviour change interventions in adults . Interventions based on control theory , motivational interviewing , or self-determination theory were associated with greater effectiveness for physical activity and /or dietary interventions and outcomes . Theory use should be promoted using a multifaceted argument , and assertions for increased effectiveness of theory-based interventions should only be used in domains where specific evidence exists to support this cl aim Background : The authors examined whether the preoperative serum concentrations of cotinine accurately predict the risk of complications in patients undergoing flap reconstruction of head and neck cancer defects . Methods : Patients with incident stage III or IV squamous cell carcinoma of the head and neck undergoing resection with pedicled or free flap reconstruction were selected from an existing data base of 500 patients with squamous cell carcinoma of the head and neck who participated in a prospect i ve epidemiologic study and were review ed retrospectively .  Preoperative serum cotinine concentrations were determined using a competitive microplate immunoassay .  Complications were defined as any adverse postoperative wound outcome at either the donor or recipient site . Results : Eighty-nine patients underwent 101 flap reconstructions . Thirty-seven wound complications occurred in 33 patients . Forty of the 89 patients had a serum cotinine concentration greater than 10 ng/ml ; twenty ( 50 percent ) developed postoperative complications , whereas only 13 of 49 patients ( 27 percent ) with a serum cotinine concentration of 10 ng/ml or less developed complications ( p = 0.028 ) . The relative risk of wound complications for those with a cotinine concentration greater than 10 ng/ml was approximately double that of patients with a lower cotinine concentration ( relative risk , 1.9 ; 95 percent CI , 1.1 to 3.3 ) . Patients with a cotinine concentration greater than 50 ng/ml had a particularly high risk ( relative risk , 2.3 ; 95 percent CI , 1.1 to 16.7 ; p = 0.024 ) . The relative risk of wound complications was not significantly associated with self-reported smoking status or history . Conclusion : A serum cotinine concentration greater than 10 ng/ml may predict an increased risk of wound complication in head and neck flap reconstruction and may serve as an objective , easily measured variable with which to identify patients who may benefit from an aggressive smoking cessation program before surgery 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 Objective : To determine whether an intervention with smoking cessation starting 4 weeks before general and orthopedic surgery would reduce the frequency of postoperative complications . Summary Background Data : Complications are a major concern after elective surgery and smokers have an increased risk . There is insufficient evidence concerning how the duration of preoperative smoking intervention affects postoperative complications . Methods : A r and omized controlled trial , conducted between February 2004 and December 2006 at 4 university-affiliated hospitals in the Stockholm region , Sweden . The outcome assessment was blinded . The follow-up period for the primary outcome was 30 days . Eligibility criteria were active daily smokers , aged 18 to 79 years . Of the 238 patients assessed , 76 refused participating , and 117 men and women undergoing surgery for primary hernia repair , laparoscopic cholecystectomy , or a hip or knee prosthesis were enrolled . Intervention : Smoking cessation therapy with individual counseling and nicotine substitution started 4 weeks before surgery and continued 4 weeks postoperatively . The control group received st and ard care . The main outcome measure was frequency of any postoperative complication . Results : An intention-to-treat analysis showed that the overall complication rate in the control group was 41 % , and in the intervention group , it was 21 % ( P = 0.03 ) . Relative risk reduction for the primary outcome of any postoperative complication was 49 % and number needed to treat was 5 ( 95 % CI , 3–40 ) . An analysis per protocol showed that abstainers had fewer complications ( 15 % ) than those who continued to smoke or only reduced smoking ( 35 % ) , although this difference was not statistically significant . Conclusion : Perioperative smoking cessation seems to be an effective tool to reduce postoperative complications even if it is introduced as late as 4 weeks before surgery BACKGROUND The increase in obesity coupled with greater acceptance of the field of bariatric surgery has result ed in a substantial rise in the number of weight-loss operations . Because obese individuals are at high risk for surgical complications , concern about the safety of bariatric procedures exists . Earlier investigations of the clinical features associated with surgical complications have produced conflicting results . We sought to identify risk factors for surgical complications in a large , nationally representative population of US veterans . STUDY DESIGN We analyzed data  on bariatric procedures performed at 12 Veterans ' Affairs medical centers approved to perform weight-loss operations between 1998 and 2004 . Detailed pre- , intra- , and postoperative information and longterm mortality data were prospect ively collected using the National Surgical Quality Improvement Program methodology . We used multivariable logistic regression to identify clinical features associated with postoperative complications . RESULTS Among 575 bariatric patients assessed between 1998 and 2004 , 74 % were men with a mean age of 51 years . Thirty-day mortality was 1.4 % . Overall complication rate was 19.7 % . Of those with complications , one-half were of considerable clinical importance , as they were associated with prolonged length of stay . Clinical features that were predictive of adverse events in our multivariable analyses were superobesity , weight>350 pounds , and smoking . A more than 20 pack-year history of smoking was also associated with difficulty in weaning from a ventilator postoperatively . CONCLUSIONS We identified smoking and superobesity as preoperative risk factors associated with postoperative complications . Future studies should examine the effect of preoperative weight loss and smoking cessation on bariatric procedure outcomes Systematic review s , a cornerstone of evidence -based medicine , are not produced quickly enough to support clinical practice . The cost of production , availability of the requisite expertise and timeliness are often quoted as major contributors for the delay . This detailed survey of the state of the art of information systems design ed to support or automate individual tasks in the systematic review , and in particular systematic review s of r and omized controlled clinical trials , reveals trends that see the convergence of several parallel research projects . We surveyed literature describing informatics systems that support or automate the processes of systematic review or each of the tasks of the systematic review . Several projects focus on automating , simplifying and /or streamlining specific tasks of the systematic review . Some tasks are already fully automated while others are still largely manual . In this review , we describe each task and the effect that its automation would have on the entire systematic review process , summarize the existing information system support for each task , and highlight where further research is needed for realizing automation for the task . Integration of the systems that automate systematic review tasks may lead to a revised systematic review workflow . We envisage the optimized workflow will lead to system in which each systematic review is described as a computer program that automatically retrieves relevant trials , appraises them , extracts and synthesizes data , evaluates the risk of bias , performs meta- analysis calculations , and produces a report in real time INTRODUCTION Nutritional status ( NS ) , defined by undernutrition ( body mass index [ BMI ] < 5th percentile ) or overnutrition ( BMI ≥ 85th percentile ) , is a poor prognostic indicator in pediatric oncology patients . The impact of NS has been primarily studied in hematologic malignancies . This review is intended to summarize literature reporting on the association of NS and treatment-related outcomes in pediatric solid tumors . METHODS We search ed four electronic data bases from inception through August 2018 without language restriction , and included studies of children with cancers arising from renal , bone , liver , eye , muscle , vascular , germ cell , and neural crest tissues , reporting on NS as a predictor for toxicity , survival or relapse . Due to data heterogeneity and limited availability of studies , formal statistical analysis was not achievable . Descriptive statistics were summarized in table format . RESULTS Of 8,991 reports identified , 75 full-text articles were evaluated , 10 of which met inclusion criteria . Up to 62 % of patients were over- or undernourished at diagnosis . Abnormal BMI was associated with worse overall survival in Ewing sarcoma ( hazard ratio ( HR ) : 3.46 , P = .022 ) , osteosarcoma ( HR : 1.6 , P < .005 ) , and a trend toward poorer overall survival in rhabdomyosarcoma ( HR : 1.70 , P = .0596 ) . High BMI in osteosarcoma was associated with increased nephrotoxicity ( odds ratio : 2.8 , P = .01 ) and postoperative complications . NS was not a significant predictor of outcomes in other included disease categories . CONCLUSIONS Existing literature supports the prognostic significance of NS in pediatric solid tumor patients and underscores the need for prospect i ve studies to better eluci date underlying physiological changes in this population Objective There is little r and omized controlled trial ( RCT ) evidence to guide treatment for anxiety after stroke . We systematic ally review ed RCTs of anxiety interventions in acquired brain injury ( ABI ) conditions including stroke and traumatic brain injury ( TBI ) in order to summarize efficacy and key aspects of trial design to help guide future RCTs . Methods We search ed the Cochrane trial register , Medline , Embase , PsychInfo and CINAHL systematic ally up to August 2017 . Two independent review ers systematic ally selected studies and extracted data . We summarized the effect size , key study characteristics and sources of potential bias in trial design . Results 14 studies ( 12 stroke ; one stroke & TBI ; one TBI ) with 928 participants were included . Meta- analysis of five psychotherapy comparisons favoured intervention over control ( st and ardized mean difference ( SMD ) : − 0.41 [ − 0.79 , − 0.03 ] , I2 = 28 % ) ; Overall effect size of pharmacotherapy comparisons favoured intervention over control ( SMD : − 2.12 [ − 3.05 , − 1.18 ] , I2 = 89 % ) . One comparison of mixed pharmacotherapy and psychotherapy favoured intervention over usual care ( SMD : − 4.79 [ − 5.87 , − 3.71 ] ) . One comparison favoured  forest therapy versus urban control ( SMD : − 2.00 [ − 2.59 , − 1.41 ] ) . All positive studies carried high or unclear risk of bias . Sample sizes were small in all included studies . Conclusions There is low quality evidence to suggest that psychotherapy and pharmacotherapy may be effective interventions in the treatment of anxiety after stroke based on underpowered studies that carried high risk of bias . Large-scale well- design ed definitive trials are needed to establish whether pharmacological or psychotherapy works . Our review highlighted key considerations for investigators wishing to design high quality trials to evaluate treatments for anxiety after stroke This systematic review and meta- analysis summarizes the clinical effects of increasing perioperative blood flow using fluids with or without inotropes/vasoactive drugs to explicit defined goals in adults . We included r and omized controlled trials of adult patients ( aged 16 years or older ) undergoing surgery . We included 31 studies of 5292 participants . There was no difference in mortality at the longest follow-up : 282/2615 ( 10.8 % ) died in the control group and 238/2677 ( 8.9 % ) in the treatment group , RR of 0.89 ( 95 % CI : 0.76 - 1.05 ; P=0.18 ) . However , the results were sensitive to analytical methods and withdrawal of studies with method ological limitations . The intervention reduced the rate of three morbidities ( renal failure , respiratory failure , and wound infections ) but not the rates of arrhythmia , myocardial infa rct ion , congestive cardiac failure , venous thrombosis , and other types of infections . The number of patients with complications was also reduced by the intervention . Hospital length of stay was reduced in the treatment group by 1.16 days . There was no difference in critical care length of stay . The primary analysis of this review showed no difference between groups but this result was sensitive to the method of analysis , withdrawal of studies with method ological limitations , and was dominated by a single large study . Patients receiving this intervention stayed in hospital 1 day less with fewer complications . It is unlikely that the intervention causes harm . The balance of current evidence does not support widespread implementation of this approach to reduce mortality but does suggest that complications and duration of hospital stay are reduced Background Depression is a common mental health disorder for which clinical practice guidelines have been developed . Prior systematic review s have identified complex organizational interventions , such as collaborative care , as effective for guideline implementation ; yet , many healthcare delivery organizations are interested in less re source -intensive methods to increase provider adherence to guidelines and guideline -concordant practice s. The objective of this systematic review was to assess the effectiveness of  healthcare provider  interventions that aim to increase adherence to evidence -based treatment of depression in routine clinical practice . Methods We search ed five data bases through August 2017 using a comprehensive search strategy to identify English- language r and omized controlled trials ( RCTs ) in the quality improvement , implementation science , and behavior change literature that evaluated outpatient provider interventions , in the absence of practice re design efforts , to increase adherence to treatment guidelines or guideline -concordant practice s for depression . We used meta- analysis to summarize odds ratios , st and ardized mean differences , and incidence rate ratios , and assessed quality of evidence ( QoE ) using the GRADE approach . Results Twenty-two RCTs promoting adherence to clinical practice guidelines or guideline -concordant practice s met inclusion criteria . Studies evaluated diverse provider interventions , including distributing guidelines to providers , education/training such as academic detailing , and combinations of education with other components such as targeting implementation barriers . Results were heterogeneous and analyses comparing provider interventions with usual clinical practice did not indicate a statistically significant difference in guideline adherence across studies . There was some evidence that provider interventions improved individual outcomes such as medication prescribing and indirect comparisons indicated more complex provider interventions may be associated with more favorable outcomes . We did not identify types of provider interventions that were consistently associated with improvements across indicators of adherence and across studies . Effects on patients ’ health in these RCTs were inconsistent across studies and outcomes . Conclusions Existing RCTs describe a range of provider interventions to increase adherence to depression guidelines . Low QoE and lack of replication of specific intervention strategies across studies limited conclusions that can be drawn from the existing research . Continued efforts are needed to identify successful strategies to maximize the impact of provider interventions on increasing adherence to evidence -based treatment for depression . Trial registration PROSPERO record CRD42017060460 on Aims : With the increase in the number of systematic review s available , a logical next step to provide decision makers in healthcare with the evidence they require has been the conduct of review s of existing systematic review s. Syntheses of existing systematic review s are referred to by many different names , one of which is an umbrella review . An umbrella review allows the findings of review s relevant to a review question to be compared and contrasted . An umbrella review 's most characteristic feature is that this type of evidence synthesis only considers for inclusion the highest level of evidence , namely other systematic review s and meta-analyses . A methodology working group was formed by the Joanna Briggs Institute to develop method ological guidance for the conduct of an umbrella review , including diverse types of evidence , both quantitative and qualitative . The aim of this study is to describe the development and guidance for the conduct of an umbrella review . Methods : Discussion and testing of the elements of methods for the conduct of an umbrella review were held over a 6-month period by members of a methodology working group . The working group comprised six participants who corresponded via teleconference , e-mail and face-to-face meeting during this development period . In October 2013 , the methodology was presented in a workshop at the Joanna Briggs Institute Convention . Workshop participants , review authors and method ologists provided further testing , critique and feedback on the proposed methodology . Results : This study describes the methodology and methods developed for the conduct of an umbrella review that includes published systematic review s and meta-analyses as the analytical unit of the review . Details are provided regarding the essential elements of an umbrella review , including presentation of the review question in a Population , Intervention , Comparator , Outcome format , nuances of the inclusion criteria and search strategy . A critical appraisal tool with 10 questions to help assess risk of bias in systematic review s and meta-analyses was also developed and tested . Relevant details to extract from included review s and how to best present the findings of both quantitative and qualitative systematic review s in a reader friendly format are provided . Conclusions : Umbrella review s provide a ready means for decision makers in healthcare to gain a clear underst and ing of a broad topic area . The umbrella review methodology described here is the first to consider review s that report other than quantitative evidence derived from r and omized controlled trials . The methodology includes an easy to use and informative summary of evidence table to readily provide decision makers with the available , highest level of evidence relevant to the question posed AIM To produce dietetic guidelines summarizing the systematic review evidence on dietary advice for secondary prevention of cardiovascular disease . METHODS The Cochrane Library , MEDLINE and EMBASE were comprehensively search ed for systematic review s on aspects of diet and heart health . Review s were included if they search ed systematic ally for r and omised controlled trials relating to diet and secondary prevention of cardiovascular disease . Two members of the UK Heart Health and Thoracic Dietitians Group critically appraised each review . The quality and results of each review were discussed and summarized in a whole group meeting . The guidelines were trialled in seven dietetic departments and modified where necessary . RESULTS Providing evidence -based dietary information ( including increasing omega-3 fat plus fruit and vegetable intake ) to all people after myocardial infa rct ion will save more lives than concentrating dietary advice on those in need of weight loss or lipid lowering . The practice of prioritizing dietetic time to those with raised lipids is out of date since the advent of statin therapy . CONCLUSION There is good systematic review evidence that dietary advice to those with cardiovascular disease can reduce mortality and morbidity as well as modify risk factors .  Dietary advice that does this most effectively should be prioritized AIMS Uncertainty remains regarding the optimal therapy for patients with stage II or III rectal cancer . Systematic review s and practice guidelines on preoperative and postoperative therapy for rectal cancer were published by the Gastrointestinal Cancer Disease Site Group in 2003 and 2000 , respectively . The systematic review s were up date d and revised and new recommendations for preoperative and postoperative therapy were developed based on the up date d body of evidence . The following research questions were addressed : After appropriate preoperative staging tests , should patients with resectable clinical stage II or III rectal cancer be offered preoperative radiotherapy ( with or without chemotherapy ) ? What is the role of postoperative radiotherapy and /or chemotherapy for patients with resected stage II or III rectal cancer who have not received preoperative radiotherapy  , in terms of improving survival and delaying local recurrence ? MATERIAL S AND METHODS The MEDLINE , EMBASE and Cochrane Library data bases , as well as meeting proceedings from the American Society of Clinical 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 for stage II or III rectal cancer . The draft practice guideline and systematic review s were distributed through a mailed survey to 129 health care providers in Ontario for review . RESULTS Systematic review s on preoperative and postoperative therapy for rectal cancer were developed . On the basis of the evidence contained in these review s , the Gastrointestinal Cancer Disease Site Group drafted recommendations . Of the 33 practitioners who responded to the mailed survey , 97 % agreed with the draft recommendations as stated , 88 % agreed that the report should be approved as a practice guideline and 94 % indicated that they were likely to use the guideline in their own practice . CONCLUSIONS Preoperative chemoradiotherapy is preferred , compared with st and ard fractionation preoperative radiotherapy alone , to decrease local recurrence .  Preoperative chemoradiotherapy is also preferred , compared with a postoperative approach , to decrease local recurrence and adverse effects . For patients with relative contraindications to chemotherapy in the preoperative period , an acceptable alternative is preoperative radiotherapy alone followed by surgery .  Patients with resected stage II or III rectal cancer who have not received preoperative radiotherapy  should be offered postoperative therapy with concurrent chemoradiotherapy plus fluoropyrimidine-based chemotherapy This systematic overview summarizes the relevant evidence from multiple systematic review s of the benefits of nonpharmacological interventions for preventing  type 2 diabetes mellitus ( T2MD ) in women diagnosed with gestational diabetes mellitus ( GDM ) . A comprehensive search using the Cochrane Library , CINAHL , EMBASE and MEDLINE via Ovid SP , and PubMed data bases was completed on 18 November 2015 . Any systematic review s that evaluated r and omized controlled trials ( RCTs ) with defined nonpharmacological interventions for preventing T2DM in women diagnosed with GDM were eligible for inclusion . The authors independently performed critical appraisal s and quality assessment s of the included review s using the AMSTAR tool , and extracted data were converted to coherent values for tabular summarization . Six eligible review s of diet and /or exercise , breastfeeding , and reminder interventions were identified ; however , the method ologies of the review s varied greatly , and the majority of the evidence suggested unclear bias . We found inconsistent reporting on the rates at which diet and exercise interventions reduced the risk of T2DM progression , but these interventions were found to be effective at reducing glycemic load . Combined diet , exercise , and breastfeeding interventions proved to be effective at returning women to their postpartum weight . Neither diet alone nor exercise alone proved to be effective at lowering the risk of T2DM . Overall , there was no robust evidence to support the hypothesis that nonpharmacological interventions are effective at lowering the risk of T2DM in women diagnosed with GDM , and there was no consistent evidence showing that these interventions improved the predictor outcomes of T2DM , such as glycemic load or anthropometric changes The association between preoperative smoking cessation and postoperative pulmonary morbidity was studied prospect ively in 200 consecutive patients undergoing an elective coronary artery bypass surgical procedure .  Detailed respiratory , cardiovascular , and smoking histories were elicited . Preoperative arterial blood gas analyses and bedside spirometry were performed . Urinary cotinine levels were measured to verify smoking histories . During spirometry , severe angina developed in seven patients , who were hence excluded from the study ; one patient died of hemorrhage intraoperatively . An observer unaware of patients ' preoperative histories assessed the remaining 192 patients throughout the intraoperative and postoperative periods for pulmonary complications . Postoperative pulmonary complications occurred in a third of the current smokers . Patients who had stopped smoking for 2 months or less had a pulmonary complication rate almost 4 times that of patients who had stopped for more than 2 months ( 57.1 % versus 14.5 % ) . Patients who had stopped smoking for more than 6 months had rates similar to those who had never smoked ( 11.1 % and 11.9 % , respectively ) . Preoperative pulmonary dysfunction , increased pack-years of smoking , prolonged surgical time , and the use of enflurane  were independently associated with postoperative pulmonary morbidity ( P less than 0.05 ) . We concluded that smoking cessation should occur at least 2 months preoperatively to maximize the reduction of postoperative respiratory complications In systematic review s , meta‐analyses are routinely applied to summarize the results of the relevant studies for a specific research question . If one can assume that in all studies the same true effect is estimated , the application of a meta‐ analysis with common effect ( commonly referred to as fixed‐effect meta‐ analysis ) is adequate . If between‐ study heterogeneity is expected to be present , the method of choice is a meta‐ analysis with r and om effects . The widely used DerSimonian and Laird method for meta‐analyses with r and om effects has been criticized due to its unfavorable statistical properties , especially in the case of very few studies . A working group of the Cochrane Collaboration recommended the use of the Knapp‐Hartung method for meta‐analyses with r and om effects . However , as heterogeneity can not be reliably estimated if only very few studies are available , the Knapp‐Hartung method , while correctly accounting for the corresponding uncertainty , has very low power . Our aim is to summarize possible methods to perform meaningful evidence syntheses in the situation with only very few ( ie , 2‐4 ) studies . Some general recommendations are provided on which method should be used when . Our recommendations are based on the existing literature on methods for meta‐ analysis with very few studies and consensus of the authors . The recommendations are illustrated by 2 examples coming from dossier assessment s of the Institute for Quality and Efficiency in Health Care Background Postoperative pulmonary complications ( PPC ) are the most frequently observed complications following lung resection , of which pneumonia and atelectasis are the most common . PPCs have a significant clinical and economic impact associated with increased observed number of deaths , morbidity , length of stay and associated cost . The aim of this study was to assess the incidence and impact of PPCs and to identify potentially modifiable independent risk factors . Methods A prospect i ve observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 13 months .  PPC was assessed using a scoring system based on chest x-ray , raised white cell count , fever , microbiology , purulent sputum and oxygen saturations . Results Thirty-four of 234 subjects ( 14.5 % ) had clinical evidence of PPC . The PPC patient group had a significantly longer length of stay ( LOS ) in hospital , high dependency unit ( HDU ) LOS , higher frequency of intensive care unit ( ITU ) admission and a higher number of hospital deaths . Older patients , body mass index ( BMI ) ≥30 kg/m2 , preoperative activity < 400 m , American Society of Anesthesiologists ( ASA ) score ≥3 , smoking history , chronic obstructive pulmonary disease ( COPD ) , lower preoperative forced expiratory volume in 1 s ( FEV1 ) and predicted postoperative ( PPO ) FEV1 were all significantly ( p<0.05 ) associated with PPC on univariate analysis . Multivariate analysis confirmed that age > 75 years , BMI ≥30 kg/m2 , ASA ≥3 , smoking history and COPD were significant independent risk factors in the development of PPC ( p<0.05 ) . Conclusion The clinical impact of PPCs is marked . Significant independent preoperative risk factors have been identified in current clinical practice . Potentially modifiable risk factors include BMI , smoking status and COPD . The impact of targeted therapy requires further evaluation BACKGROUND Simulation-based training has been an important part of the solution to address the shortfalls in cardiac surgery training . This review was conducted to identify and systematic ally summarize existing evidence on outcomes and method ological quality of  simulation-based skills training  for cardiac surgery trainees . METHODS MEDLINE , Embase , and ERIC ( Education Re sources Information Center ) data bases were search ed . Studies included peer- review ed publications with simulation-based skill training in cardiac surgery programs with outcome measures of performance . Data extraction covered the type of skills training , simulator type and fidelity , the level of trainees , assessment tools , assessors , study design and its components , strengths and limitations , and elements required for the Medical Education Research Study Quality Instrument score . The review followed the Preferred Reporting Items for Systematic Review s and Meta-Analyses guidelines . RESULTS Of 16 studies that met the criteria , only four ( 25 % ) r and omized controlled trials were identified , and the remaining were observational studies . Seven observational studies ( 43.7 % ) were single-group pre-post tests . The  mean number of trainees was 20.4 ( SD , 14.1 ) .  Low-fidelity simulators were used in 13 studies ( 81.2 % ) . Most of the studies ( 81.3 % ) were high quality based on a Medical Education Research Study Quality Instrument score of 12 or more . Evidence of assessment tool validation was absent among all studies . No study outcome measures were directed to skills transfer to the operating room or patient outcomes . Overall learning outcomes ' effect sizes were consistently high ( 2.2 ; SD , 1.6 ) , with junior residents benefitting most ( effect size , 2.8 ; SD , 2.2 ) CONCLUSIONS : Simulation-based skill training is associated with improved learning outcomes for cardiac surgery trainees with large effect sizes , but more behavior-level outcomes are required to fully assess its value Background Colorectal cancer ( CRC ) is the second most prevalent type of cancer in the world . Surgery is the only curative option . However , postoperative complications occur in up to 50 % of patients and are associated with higher morbidity and mortality rates , lower health related quality of life ( HRQoL ) and increased expenditure in health care . The number and severity of complications are closely related to preoperative functional capacity , nutritional state , psychological state , and smoking behavior . Traditional approaches have targeted the postoperative period for rehabilitation and lifestyle changes . However , recent evidence shows that the preoperative period might be the optimal moment for intervention . This study will determine the impact of multimodal prehabilitation on patients ’ functional capacity and postoperative complications . Methods / design This international multicenter , prospect i ve , r and omized controlled trial will include 714 patients undergoing colorectal surgery for cancer . Patients will be allocated to the intervention group , which will receive 4 weeks of prehabilitation ( group 1 , prehab ) , or the control group , which will receive no prehabilitation ( group 2 , no prehab ) . Both groups will receive perioperative care in accordance with the enhanced recovery after surgery ( ERAS ) guidelines . The primary outcomes for measurement will be functional capacity ( as assessed using the six-minute walk test ( 6MWT ) ) and postoperative status determined with the Comprehensive Complication Index ( CCI ) . Secondary outcomes will include HRQoL , length of hospital stay ( LOS ) and a cost-effectiveness analysis . Discussion Multimodal prehabilitation is expected to enhance patients ’ functional capacity and to reduce postoperative complications . It may therefore result in increased survival and improved HRQoL. This is the first international multicenter study investigating multimodal prehabilitation for patients undergoing colorectal surgery for cancer . Trial registration Trial Registry : NTR5947 – date of registration : 1 August 2016 BACKGROUND Discerning the determinants of weight loss maintenance is important in the planning of future interventions and policies regarding overweight and obesity . We have therefore systematic ally synthesized recent literature on determinants of weight loss maintenance for individuals with overweight and obesity . METHODS With the use of the Preferred Reporting Items for Systematic Review s and Meta-Analyses statement , prospect i ve studies were identified from search es in PubMed and PsycINFO from 2006 to 2016 . We included articles investigating adults with overweight and obesity undergoing weight loss without surgery or medication .  Included articles were scored on their method ological quality , and a best- evidence synthesis was applied to summarize the results . RESULTS Our search result ed in 8,222 articles of which 67 articles were selected . In total , 124 determinants were identified of which 5 were demographic , 59 were behavioural , 51 were psychological/cognitive and 9 were social and physical environmental determinants . We found consistent evidence that demographic determinants were not predictive of weight loss maintenance . Behavioural and cognitive determinants that promote a reduction in energy intake , an increase in energy expenditure and monitoring of this balance are predictive determinants . CONCLUSION This review identifies key determinants in weight loss maintenance . However , more research regarding cognitive and environmental determinants of weight loss maintenance is needed to advance our knowledge on determinants of weight loss maintenance
Preoperative smoking status was not observed to be associated with postoperative mortality , cardiovascular complications , bleedings , anastomotic leakage , or allograft rejection .
CONCLUSIONS Preoperative smoking was found to be associated with an increased risk of the following postoperative complications : general morbidity , wound complications , general infections , pulmonary complications , neurological complications , and admission to the intensive care unit
OBJECTIVE To systematic ally review and summarize the evidence of an association between preoperative smoking status and postoperative complications elaborated on complication type .
BACKGROUND The conclusions of studies examining the association between preoperative smoking and postoperative complications are inconsistent , thus there is a need for a review and meta- analysis to summarize the existing evidence .