Background The primary treatment modality for colorectal cancer is surgery. Prehabilitation is advocated to mitigate risk and reduce complications, with benefits likely to be greatest in the least physically fit patients. There is an intersection between physical inactivity, socioeconomic deprivation and multimorbidity that increases surgical risk; however, these patients are under-represented in trials. This review aimed to scope the available evidence for prehabilitation in the least fit patients undergoing colorectal cancer surgery. Methods A scoping review was conducted using Joanna Briggs Institute methodology and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. MEDLINE, EMBASE and CINAHL were searched for studies investigating exercise prehabilitation in adults undergoing colorectal cancer surgery. Studies were screened for low physical fitness using pre-determined criteria. Data charting included reporting of intervention characteristics (Template for Intervention Description and Replication [TIDieR] framework), adherence, outcomes, socioeconomic status and multimorbidity. Results Twelve studies investigating 408 patients were identified. Despite a relatively uniform high-risk patient profile, prehabilitation interventions were heterogeneous, encompassing six distinct approaches with limited tailoring to low baseline fitness. Trials reporting improved clinical outcomes demonstrated high adherence, but this was inconsistently defined and reported. Behaviour change strategies were not incorporated. No study reported socioeconomic status, and multimorbidity reporting was variable. Conclusions Prehabilitation research in patients with colorectal cancer and low physical fitness has focused on physiological risk. Wider socioeconomic and behavioural determinants of participation require consideration. A conceptual framework is proposed to guide future practice. This emphasises comprehensive risk screening, flexible and patient-centred interventions, and strategies to optimise adherence in those high-risk patients who stand to benefit the most.

Smoking remains the single biggest preventable cause of death and illness in the UK and accounts for half of the difference in life expectancy between our most and least affluent communities. Whilst smoking prevalence is reducing each year, the reduction is slower in more deprived communities than in more affluent communities. In the perioperative period, smoking significantly increases the risk of death, wound infections, cardiorespiratory complications and longer hospital stays. Public Health England have reported that E-cigarettes are 95% safer than smoking in the short to medium term. They have been found to be twice as effective as traditional nicotine replacement therapy at helping smokers quit and with similar rates of adverse effects, and so e-cigarettes are now recommended by NICE and other organisations as stop smoking aids.

BACKGROUND:People with COPD are more likely to be sedentary, a behaviour associated with reduced life expectancy. COPD is also associated with social isolation and socioeconomic deprivation. Therefore, this study aimed to examine the relationship between these determinants and sedentary time. METHODS:This study analysed 23,559 UK Biobank participants with COPD (recruited 2006-2010), with a follow-up accelerometer assessment (2013-2015). Primary analyses were performed on accelerometer participants (n = 1,558) with complete covariate and accelerometer data. Associations between sedentary time, social isolation, and deprivation were explored using multivariable linear regression, stratified by COPD severity (GOLD stages). RESULTS:Sedentary time rose stepwise with disease severity (p < 0.001); with GOLD 4 individuals spending 19% more of their day sedentary than GOLD 1. Social isolation interacted with severity (p = 0.033), predicting an extra 1.5 h of daily sedentary time in GOLD 3-4 (95% CI, 0.49-2.47; p = 0.004). Deprivation had the greatest impact on sedentary time in mild disease. CONCLUSIONS:This large observational study suggests sedentary behaviour is associated with social isolation in severe COPD and socioeconomic deprivation in mild disease severity. This highlights the need to consider individual social and environmental factors alongside a clinical focus to reduce sedentary behaviour.

Emergency laparotomy and laparoscopy for non-traumatic pathologies are common surgical procedures affecting over 28,000 patients every year in England and Wales. The National Emergency Laparotomy Audit (NELA) collects data on patient characteristics and perioperative care. Since its inception there have been demonstrable improvements in aspects of care, but in-hospital mortality and hospital length of stay have plateaued at 9.3% and 11 days respectively. DrEaMing (Drinking, Eating and Mobilising) is a simple care bundle designed to contribute to the early restoration of normal physiological homeostasis in postoperative patients and has been incorporated into many elective surgery enhanced recovery programmes (ERPs). In a study of over 22,000 patients undergoing major elective surgery, delivery of DrEaMing within 24 hours post-surgery was associated with a three-day shorter median hospital length of stay and fewer major complications. It is unknown to what extent elements of ERPs can be incorporated into emergency surgery care pathways and there have been calls to evaluate this with further research. Recent consensus guidelines for emergency laparotomy patients include prioritisation of early mobilisation and early feeding. We report the feasibility of collecting data on DrEaMing rates in emergency laparotomy patients and describe associated barriers to DrEaMing implementation in this cohort of patients.

INTRODUCTION:Emergency tracheal intubation outside the operating theatre carries increased risk for patients. Guidelines caution against high dose propofol for induction in this context, due to associated haemodynamic instability. This study aimed to describe induction strategies and adverse events for these patients in UK practice. METHODS:We conducted a prospective, multicentre cross-sectional service evaluation of adults who required emergency tracheal intubation outside the operating theatre. Data were collected as a convenience sample by anaesthetic and critical care teams using an online form. Primary outcomes were the selection and dose of induction drugs. Secondary outcomes were: vasopressor co-administration; severe hypotension (systolic blood pressure < 80 mmHg); severe hypoxia (peripheral oxygen saturation < 80%); and cardiac arrest. RESULTS:Twenty-three NHS hospitals reported 250 emergency tracheal intubations. Not including 17 (7%) performed during cardiac arrest, there were 233 rapid sequence inductions. Propofol was used in 147 (63%); fentanyl in 172 (74%); ketamine in 53 (23%); and midazolam in 51 (22%). Propofol with fentanyl was the most common combination (97/233, 42%), at median (IQR [range]) doses of 1.4 (0.8-2.0 [0.04-3.3]) mg.kg-1 and 2.0 (1.3-2.9 [0.5-6.0]) μg.kg-1, respectively. Severe hypotension affected 24/219 (11%) patients with recorded post-induction blood pressures. Severe hypoxia affected 14/221 (6%) patients with recorded post-induction oxygen saturations. Post-induction cardiac arrest occurred in 6/233 (3%) patients. For patients who did not receive pre-emptive vasopressors at induction, 40/105 (38%) subsequently required vasopressor administration. DISCUSSION:Patients who required tracheal intubation outside operating theatres experienced high rates of post-induction hypotension. Propofol was the most used induction drug, often at doses typical for elective anaesthesia. Pre-emptive vasopressor use was inconsistent. These practices deviate from existing guidelines and represent a modifiable risk factor for adverse events. We recommend standardised protocols for tracheal intubation outside operating theatres, including guidance on induction drug selection, dose and pre-emptive vasopressor use.

Background Individuals with chronic obstructive pulmonary disease (COPD) often lead sedentary lives, which is linked to negative health outcomes. Understanding the causes of this behaviour is essential for designing effective interventions. In the time following a hospital discharge, people with COPD may be especially sedentary and develop habits that contribute to this behaviour. Therefore, this is an important point at which to evaluate the reasons behind sedentary behaviour.Methods From one acute hospital in England, 12 participants with a recent COPD exacerbation were recruited. Following discharge, semi-structured interviews were conducted to identify perceptions of and barriers and facilitators to reducing sedentary behaviour. Reflexive thematic analysis was employed.Findings Two themes developed: “Focusing on survival” and “Loneliness, social isolation and lack of purpose”. Factors contributing to sedentary behaviour include the need for rest, social isolation, symptom management, fear of dying or being readmitted to hospital from over-exertion, adherence to health professional advice, and lack of motivation and purpose. Concerns about socioeconomic disparities were noted. Participants were ready to embrace positive lifestyle changes.Conclusion Our study found some people with COPD, recently discharged from hospital, may adopt a sedentary lifestyle to manage symptoms and daily activities. Interviews highlight the need to tackle socioeconomic disparities, social support, and feelings of social disconnection. Misconceptions about sedentary behaviour being part of recovery underline the need for education for individuals with COPD and health professionals. The findings suggest strategies to reduce sedentary time, such as enjoyable activities, community involvement, and incorporating sedentary behaviour reduction into pulmonary rehabilitation.

Emergency laparotomy is a high-risk surgery, and postoperative functional decline contributes to the 1-yr mortality of 25%. However, there is no established guidance around postoperative interventions to restore functional capacity, including early mobilisation. This scoping review synthesised current evidence on the definition of early mobilisation, delivery of interventions, barriers, and outcomes reported for postoperative mobilisation interventions.The review followed a structured methodological framework and was registered with Open Science Framework. Studies were identified through MEDLINE, Embase, and CINAHL. Eligible studies described an early mobilisation protocol (in isolation or as a bundled intervention) after emergency laparotomy. Data were extracted and analysed descriptively.Fourteen studies (2783 participants) were included, with all but one published since 2018. Mobilisation out of bed within 24 h of surgery was the most frequently used definition of early mobilisation. Adherence rates ranged from 31% to 96%. Interventions were heterogeneous, ranging from encouragement to achieve mobilisation targets through to comprehensive multidisciplinary programmes. Intervention groups tended to achieve earlier and greater mobilisation. Key modifiable barriers were pain, fatigue, and limited physiotherapy staffing. All studies reported physical performance outcomes; only one reported quality of life outcomes.This scoping review found heterogeneity in the delivery, dose, timing, and adherence to mobility interventions. Barriers to mobilisation after emergency laparotomy mirror those described after elective surgery. We suggest alignment in reporting the impact of individual factors (such as frailty and socioeconomic context) and core outcomes (including patient-centred measures) to standardise early postoperative mobilisation interventions and allow for synthesis of the evidence base. Scoping review protocol:Open Science Framework (https://doi.org/10.17605/OSF.IO/R63CP).

BACKGROUND:Chronic obstructive pulmonary disease (COPD) affects over 300 million people and is the third leading cause of death. People with COPD spend a large amount of their day sedentary, which is associated with reduced life expectancy. METHODS:A systematic search was conducted across electronic databases, including Medline, CINAHL, PsycINFO, and Cochrane Library. Due to the heterogeneity of study design and siting of the activity monitor, a narrative synthesis was conducted. RESULTS:1086 studies were identified; six met inclusion criteria, and two reported a decreased sedentary time. Nordic walking reduced sedentary time by 128 minutes/day compared to baseline, significantly more than the control group (p < 0.01). Another study using a behaviour change intervention reduced sedentary behaviour by 64 minutes/day compared to baseline, significantly more than the control group (p = 0.018). Both studies were conducted for over 12 weeks, with a multi-modal approach incorporating behaviour change techniques, goal setting, education, self-monitoring and feedback. No studies focusing on reducing sedentary behaviour alone reported significant changes. CONCLUSIONS:Few interventional studies have focused on reducing sedentary behaviour in people with COPD. Interventions that have effectively reduced sedentary time primarily focused on physical activity and adopted a multi-modal strategy. This suggests that future interventions could consider a multi-modal approach, which includes behaviour change and the incorporation of enjoyable light physical activities into daily living. We cannot conclude from the available evidence that solely targeting sedentary time will reduce sedentary behaviour. Longer interventions may reduce sedentary behaviour, but there is a lack of studies on both short- and long-term approaches.PROSPERO registration number CRD 42024510434.

Introduction: Cardiopulmonary exercise testing (CPET) is the gold-standard assessment of functional capacity and predicts postoperative outcomes in major abdominal and thoracic surgery, as well as in older individuals undergoing elective surgery for colorectal cancer. However, CPET is resource-intensive and not universally available. Simpler objective assessments of functional capacity, such as Clinical Frailty Scale (CFS) scoring, predict postoperative complications and may be useful in aiding shared decision and perioperative planning. Objectives: This study aimed to assess local cohort data and investigate the association between Clinical Frailty Scoring, CPET outcomes, and length of hospital stay. Methods: We conducted a retrospective cohort analysis of all patients who had received a cardiopulmonary exercise test as part of their preoperative assessment for major abdominal and thoracic surgery between May 2018 and December 2022 in four district general hospitals. Results: This study featured 174 patients, age 73 (mean), CFS 3 (mean), who underwent CPET with associated CFS scoring. The CFS scores were weakly correlated with the anaerobic threshold, VO2 peak, and ventilatory equivalents, coefficients measuring −0.34, −0.36, and 0.31 (all p < 0.001), respectively. Linear regression demonstrated a negative coefficient for the association of CFS with the VO2 peak and the AT, measuring −1.22 and −1.70, respectively, both p < 0.001. The CFS score was not predictive of 1-year mortality in this group. In a subgroup analysis (n = 59), there was no association between the CFS score and the length of stay. Conclusions: Our data suggest a weak relationship between the CFS score and the CPET results. Further investigations with larger prospective datasets are required to explore the use of CFS as a surrogate for CPET and its use as an independent predictor for perioperative outcomes. This study supports the limited literature available on this subject.

Objectives: To explore the longitudinal recovery of patients admitted to critical care following COVID-19 over the year following hospital discharge. To understand the important aspects of the patients’ recovery process and key elements of their caregivers’ experiences during this time. Design: A longitudinal qualitative study using semi-structured interviews. Setting: Two acute hospitals in South East England and follow-up in the community. Participants: Six COVID-19 critical care survivors from the first wave of the pandemic (March–May 2020) and five relatives were interviewed 3 months after hospital discharge. The same six survivors and one relative were interviewed again at 1 year. Interviews were transcribed verbatim, anonymised and a reflexive thematic analysis was conducted. Results: Three themes were developed: (1) ‘The cycle of guilt, fear and stigma’; (2) ‘Facing the uncertainties of recovery’ and (3) ‘Coping with lingering symptoms – the new norm’. The first theme highlights survivors’ reluctance to share their experiences associated with contracting the disease. The second theme, explores challenges faced by the survivors and their relatives in navigating the recovery process, given the unknown nature of the illness. The final theme illustrates the mechanisms survivors develop to come to terms with the remnants of their illness and critical care stay. Conclusions: The longitudinal nature of the study highlighted the persisting symptoms of long COVID-19, their impact on survivors and coping methods amidst the ongoing pandemic. Further research into the experiences of those affected in the first and subsequent waves of the COVID-19 pandemic, is desirable to help guide the formulation of the optimally supported recovery pathways.

Urine output is an important clinical measurement and oliguria may highlight the development of acute kidney injury (AKI) earlier than serum creatinine (sCr). Despite the importance of urine output monitoring, there are no definitive guidelines or recommendations for best practice. A survey was sent to healthcare professionals with a specialist interest in AKI to gather opinions of what constitutes a good standard of urine output monitoring and by corollary missed care, post- major surgery. Data was gathered from 221 respondents. Results will inform audit and improvement projects in post-operative nursing care.

The purpose was to directly assess in-competition thermoregulatory responses in recreational runners during a city marathon conducted in cool, ambient conditions using a two-pill ingestion strategy.

Background People with chronic obstructive pulmonary disease (COPD) are more likely to adopt a sedentary lifestyle. Increased sedentary behaviour is associated with adverse health consequences and reduced life expectancy.Aim This mixed-methods systematic review aimed to report the factors contributing to sedentary behaviour in people with COPD.Methods A systematic search of electronic databases (Medline, CINAHL, PsycINFO and Cochrane Library) was conducted and supported by a clinician librarian in March 2023. Papers were identified and screened by two independent researchers against the inclusion and exclusion criteria, followed by data extraction and analysis of quality. Quantitative and qualitative data synthesis was performed.Results 1037 records were identified, 29 studies were included (26 quantitative and 3 qualitative studies) and most studies were conducted in high-income countries. The most common influencers of sedentary behaviour were associated with disease severity, dyspnoea, comorbidities, exercise capacity, use of supplemental oxygen and walking aids, and environmental factors. In-depth findings from qualitative studies included a lack of knowledge, self-perception and motivation. However, sedentarism in some was also a conscious approach, enabling enjoyment when participating in hobbies or activities.Conclusions Influencers of sedentary behaviour in people living with COPD are multifactorial. Identifying and understanding these factors should inform the design of future interventions and guidelines. A tailored, multimodal approach could have the potential to address sedentary behaviour.PROSPERO registration number CRD42023387335.

Nonsteroidal anti-inflammatory drug use is prevalent in sport however the risk associated with their use in athletes is not well-understood. This review discusses the pharmacology of nonsteroidal anti-inflammatory drugs and the prevalence of their use in different sports and factors driving this. Use is very high in sports such as professional football and is sometimes by routine without indication and without medical supervision. However there is a paucity of evidence in other sports. There is good evidence for use of nonsteroidal anti-inflammatory drugs following an acute injury but they may prevent normal tissue healing and remodelling if used longer term for musculoskeletal injuries. There are well-known risks of cardiac, gastrointestinal and renal side effects but little specific data for athletes. Renal events are discussed in detail including the cumulative effect that nonsteroidal anti-inflammatory drug use, dehydration and concurrent illness can have to produce significant renal and systemic insult. We then discuss a pragmatic prescribing model enabling clinicians to utilise the beneficial effects of these medications whilst minimising risks.

ObjectivesTo assess: (1) the feasibility of novel data collection methods (wearable technology and an application-based psychomotor vigilance test (PVT)), (2) the impact of night shift working on fatigue, both objective and perceived, for doctors working night shifts in acute hospital specialties and (3) the effects of shift intensity and naps obtained on participant fatigue.MethodsWe adopted an innovative, multimodal approach to data collection allowing assessment of objective and perceived measures of fatigue, in addition to markers of shift intensity. This comprised 5 min PVT for objective quantification of fatigue (via the validated, smartphone-based NASA PVT+ application), wearable electronic devices (Fitbit Versa2) for assessment of shift intensity (step counts and active minutes) and questionnaires to elicit perceptions of fatigue and shift intensity.ResultsData was collected from 25 participants for a total of 145 night shifts. Objective fatigue (assessed by PVT performance) was significantly increased post night shift, with a PVT mean reaction time 257 ms pre shift versus 283 ms post shift (p<0.0001). However, differences in PVT pre and post shift were not affected by night shift intensity, nor breaks or naps taken on shift. Differences in psychomotor performance between doctors working in different specialties were also observed.ConclusionsThe data collection methods used were found to be feasible with good participant engagement. Findings support existing evidence that night shift working in healthcare workers is associated with fatigue, with psychomotor impairment observed post shift. Lower shift intensity and napping did not appear to mitigate this effect.

IntroductionWe report our experience of the first two years setting up a respiratory failure clinic at a district general hospital on the South Coast, UK.MethodsThe potential cohort was identified following hospitalisation with hypercapnia and use of non-invasive ventilation (NIV) or via community teams. The team comprised a respiratory physiotherapist and consultant. Emphasis was multi-model: goal-setting, symptom-management conversations, smoking cessation, weight management, increasing physical activity, reducing sedentary behaviour, and reviewing suitability of home mechanical ventilation (HMV). Community referrals included the COPD team, pulmonary rehabilitation, weight management, wellbeing hubs and palliative care. The lead consultant reviewed those symptomatic with hypercapnia and a history of hospital admissions for consideration of HMV.ResultsOver 22 months (September 2021 – June 2023), a potential cohort (n=155) was identified, and n= 91 were reviewed. Reasons for exclusion included n=16 not appropriate for review (including on a palliative or cancer pathway), n=19 deaths prior to review, n=29 declined, pending or solely under a tertiary centre. Diagnoses included COPD n=72 (79%), n=16 (18%) had COPD/obesity hypoventilation syndrome (OHS) overlap, n= 8 (9%) OHS/obstructive sleep apnoea, and n=6 (7%) neuromuscular chest wall disease. Mean BMI was 32 (standard deviation, SD 10). Following review, n=26 were discharged and n=24 were subsequently reviewed by the consultant, n=13 (14%) died during this period. Of those with a BMI ≥40, 13/19 agreed to a weight loss management service referral and 47 were referred to local well-being services. On quality of indicators (EQ5D-5L), patients rated moderate problems with mobility and slight problems washing/dressing; average global score for health was 54/100 (SD 21). Patient rated their own level of frailty (Rockwood clinical frailty scale) at a mean of 4.5 (SD 1.4). In those with 12 months follow-up, there were 63 admissions over 12 months prior to clinic review and 17 following review (Wilcoxon signed ranks P<0.001). BMI, MRC dyspnoea and quality of life scores did not change.DiscussionIn our experience of a local respiratory failure clinic, a multi-modal approach to a complex cohort has been well received. A promising reduction in hospital re-admissions requires further investigation.

Background The COVID-19 pandemic has been associated with an unprecedented number of critical care survivors. Their experiences through illness and recovery are likely to be complex, but little is known about how best to support them. This study aimed to explore experiences of illness and recovery from the perspective of survivors, their relatives and professionals involved in their care. Study design In-depth qualitative interviews were conducted with three stakeholder groups during the first wave of the pandemic. A total of 23 participants (12 professionals, 6 survivors and 5 relatives) were recruited from 5 acute hospitals in England and interviewed by telephone or video call. Data analysis followed the principles of Reflexive Thematic Analysis. Findings Three themes were generated from their interview data: (1) Deteriorating fast-a downhill journey from symptom onset to critical care; (2) Facing a new virus in a hospital-a remote place; and (3) Returning home as a survivor, maintaining normality and recovering slowly. Conclusions Our findings highlight challenges in accessing care and communication between patients, hospital staff and relatives. Following hospital discharge, patients adopted a reframed 'survivor identity' to cope with their experience of illness and slow recovery process. The concept of survivorship in this patient group may be beneficial to promote and explore further. Relevance to clinical practice All efforts should be made to continue to improve communication between patients, relatives and health professionals during critical care admissions, particularly while hospital visits are restricted. Adapting to life after critical illness may be more challenging while health services are restricted by the impacts of the pandemic. It may be beneficial to promote the concept of survivorship, following admission to critical care due to severe COVID-19.

Introduction: Hip fractures are associated with significant morbidity and mortality in older people. Accurate risk stratification is important for planning of care, informed decision-making and communication with patients and relatives. The Older Persons' Emergency Risk Assessment (OPERA) score is a risk stratification score for older people admitted to hospital. Our aims were to validate OPERA in hip fracture patients, update the score and compare performance with the Nottingham Hip Fracture Score (NHFS). Methods: This dual-centre 3-year observational study (2016-2018) included acutely admitted hip fracture patients managed surgically aged > 65 years. The primary outcome was 30-day mortality. Secondary outcomes included residence at 120 days and 1-year mortality. Model performance was assessed using area under the curve (AUC) analysis and Brier scores (discrimination) and calibration curves. The OPERA score was updated using regression analysis with additional independent predictors and validated using bootstrap analysis. Results: 2142 patients (median age 86 [80-91] years) were included with a 30-day mortality of 5.2% and a 1-year mortality of 31.4%. 30-day mortality AUC for OPERA was 0.75 (95% CI, 0.73-0.77) and for NHFS 0.68 (0.65-0.70). For 1-year mortality AUC for OPERA was 0.74 (0.73-0.75) and for NHFS 0.70 (0.69-0.71). The OPERA Score was updated to Hip-OPERA, including ASA grade. Hip-OPERA demonstrated an AUC for 30-day mortality of 0.77 (0.73-0.81) and an AUC for 1-year mortality of 0.76 (0.75-0.77). AUC for new residential care status at 120 days was 0.79 (0.78-0.80). Conclusions: Hip-OPERA demonstrated superior discrimination to the NHFS and OPERA for 30-day mortality, 1-year mortality and residence at 120 days following hip fracture. External validation is desirable.