A rapid review of the effectiveness of innovations to support patients on elective surgical waiting lists (preprint)

Surgical waiting times have reached a record high, in particular with elective and non-emergency treatments being suspended or delayed during the COVID-19 pandemic. Prolonged waits for surgery can impact negatively on patients who may experience worse health outcomes, poor mental health, disease progression, or even death. Time spent waiting for surgery may be better utilised in preparing patients for surgery. This rapid review sought to identify innovations to support patients on surgical waiting lists to inform policy and strategy to address the elective surgical backlog in Wales. The review is based on the findings of existing reviews with priority given to robust evidence synthesis using minimum standards (systematic search, study selection, quality assessment, and appropriate synthesis). The search dates for prioritised reviews ranged from 2014-2021. Forty-eight systematic reviews were included. Most available evidence is derived from orthopaedic surgery reviews which may limit generalisability. The findings show benefits of exercise, education, smoking cessation, and psychological interventions for patients awaiting elective surgery. Policymakers, educators, and clinicians should consider recommending such interventions to be covered in curricula for health professionals. Further research is required to understand how various patient subgroups respond to preoperative interventions, including those from underserved and minority ethnic groups, more deprived groups and those with lower educational attainments. Further research is also needed on social prescribing or other community-centred approaches. It is unclear what impact the pandemic (and any associated restrictions) could have on the conduct or effectiveness of these interventions. Rapid Review Details Review conducted by Public Health Wales Review Team ▪ Dr Chukwudi Okolie ▪ Rocio Rodriguez ▪ Dr Alesha Wale ▪ Amy Hookway ▪ Hannah Shaw Review submitted to the WCEC on 1 st April 2022 Stakeholder consultation meeting 6 th April 2022 Rapid Review report issued by the WCEC in June 2022 WCEC Team ▪ Adrian Edwards, Alison Cooper, Ruth Lewis, Becki Law, Jane Greenwell involved in drafting Topline Summary and editing This review should be cited as RR00030. Wales COVID-19 Evidence Centre. Rapid review of the effectiveness of innovations to support patients on elective surgical waiting lists. April 2022. This report can be downloaded here https://healthandcareresearchwales.org/wales-covid-19-evidence-centre-report-library Disclaimer The views expressed in this publication are those of the authors, not necessarily Health and Care Research Wales. The WCEC and authors of this work declare that they have no conflict of interest. TOPLINE SUMMARY Our rapid reviews use a variation of the systematic review approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. They follow the methodological recommendations and minimum standards for conducting and reporting rapid reviews, including a structured protocol, systematic search, screening, data extraction, critical appraisal, and evidence synthesis to answer a specific question and identify key research gaps. They take 1-2 months, depending on the breadth and complexity of the research topic/ question(s), extent of the evidence base, and type of analysis required for synthesis. Who is this summary for? Health Boards and others involved in planning, monitoring, managing waiting lists for surgery. Background / Aim of Rapid Review Surgical waiting times have reached a record high , in particular with elective and non-emergency treatments being suspended or delayed during the COVID-19 pandemic. Prolonged waits for surgery can impact negatively on patients who may experience worse health outcomes, poor mental health, disease progression, or even death. Time spent waiting for surgery may be better utilised in preparing patients for surgery. This rapid review sought to identify innovations to support patients on surgical waiting lists to inform policy and strategy to address the elective surgical backlog in Wales. The review is based on the findings of existing reviews with priority given to robust evidence synthesis using minimum standards (systematic search, study selection, quality assessment, and appropriate synthesis). Key Findings Extent of the evidence base ▪ 48 systematic reviews were included; 17 reviews were prioritised for inclusion in the narrative synthesis . A further 10 protocols of ongoing systematic reviews were included. ▪ Most reviews (n=23) focused on orthopaedic surgical procedures . ▪ Most reviews (n=31) focussed on exercise-based interventions . Other interventions were educational (n=6), psychological (n=2), smoking cessation (n=1), weight loss (n=1), and multicomponent interventions (n=7). ▪ There were limited data provided on socio-demographic characteristics of patients. ▪ No review evaluated the impact of the intervention on surgical treatment. ▪ No evidence relating to the use of social prescribing or other community-centred approaches to support surgical wait-listed patients was identified. ▪ No evidence was identified in the context of the current COVID-19 pandemic . Recency of the evidence base ▪ The search dates for the prioritised reviews ranged from 2014-2021; these were conducted in 2020 (n=3) or 2021 (n=3) for six reviews. Evidence of effectiveness ▪ Preoperative exercise interventions (n=9; 6 were orthopaedic) could help improve preoperative and postoperative outcomes such as pain, muscle strength and function, and reduced incidence of postoperative complications , in people awaiting elective surgery. ▪ Educational interventions (n=3; 1 was orthopaedic) were effective at improving knowledge in patients awaiting elective surgery. However, the evidence about these interventions improving pre- and postoperative pain and physical functioning in orthopaedic patients is limited . There were mixed findings for the effectiveness of preoperative educational interventions on psychological outcomes. ▪ Psychological interventions (n=2; 1 was orthopaedic) evidence is limited but indicates it may have a positive effect on anxiety and mental health components of quality of life postoperatively. The evidence in support of such interventions in reducing postoperative pain is inconclusive. ▪ Smoking cessation interventions (n=1) providing behavioural support and offering nicotine replacement therapy i ncreased short-term smoking cessation and may reduce postoperative morbidity . Intensive preoperative smoking cessation interventions appear to reduce the incidence of postoperative complications, but not brief interventions. ▪ Multicomponent interventions (n=2; 1 was orthopaedic) consisting of both exercise and education components could shorten the length of hospital stay and improve postoperative pain, function, and muscle strength . Best quality evidence Three reviews were treated as high quality. Two evaluating exercise-based interventions (Fenton et al. 2021; Katsura et al. 2015) and one psychological preparation (Powell et al. 2016). Policy Implications ▪ Most available evidence is derived from orthopaedic surgery reviews which may limit generalisability . ▪ These findings show benefits of exercise, education, smoking cessation, and psychological interventions for patients awaiting elective surgery . Policymakers, educators and clinicians should consider recommending such interventions to be covered in health professionals’ curricula . ▪ Further research is required to understand how various patient subgroups respond to preoperative interventions, including those from underserved and minority ethnic groups, more deprived groups and those with lower educational attainments . ▪ Further research is needed on social prescribing or other community-centred approaches . ▪ It is unclear what impact the pandemic (and any associated restrictions) could have on the conduct or effectiveness of these interventions. Strength of Evidence The primary studies included in the reviews were mainly randomised controlled trials, but most had small sample size, varied by surgical type, and often had issues regarding blinding.

Greening of the syllabus in faculties of education sciences through sustainable development goals: the case of public Andalusian universities (Spain)

Purpose>The purpose of this paper is to analyse the presence of the sustainable development goals (SDGs) proposed by the UN (2015) in university degrees within the fields of education, humanities and environmental sciences (ES) at Andalusian public institutions (Spain).Design/methodology/approach>This paper shows an empirical analysis from a mixed methodological model on a total of 99 syllabi and training programs from nine different universities. The collection of information has been carried out through a rubric specifically designed within the framework of this body of research.Findings>The results show that the syllabus of the subjects in the faculties of education includes the SDGs related to the social aspect of sustainability, with special focus on SDG4, SDG5, SDG10, SDG16 and SDG17, whereas others like SDG6 and SDG7 are less represented. SDGs are present in the majority of syllabus of the subjects analysed. It is certainly a positive finding which shows predisposition and a high interest on by the teachers involved. However, this is not enough as there is still a long way to go until achieving a thorough and complete incorporation of the principles of sustainability.Originality/value>This research sheds light on the changes and transformations that the discourse linked to sustainability is generating in the university syllabi. Taking the SDG as a framework this paper highlights the most original aspects: a replicable methodology that allows diagnosing the level of curricular greening of the university syllabi is provided to other contexts the innovative value of connecting teaching with local and global environmental problems in their physical-chemical social and economic dimensions is shown and it has been possible to compare the difficulties of some universities in addressing compliance with the SDGs and curricular sustainability from a systemic and integrative perspective that will lead to methodological transformation and pedagogical renewal.

Prevention of severe COVID-19 in the elderly by early high-titer plasma (preprint)

BackgroundTherapies to interrupt progression of early COVID-19 remain elusive. Among them, convalescent plasma in hospitalized patients was unsuccessful, perhaps because antibody should be administered earlier. We advanced plasma infusions to the first 72 hours of symptoms to arrest COVID-19 progression. MethodsA randomized, double-blind, placebo-controlled trial of convalescent plasma with high IgG titers against SARS-CoV2 in elderly subjects within 72 hours of mild COVID-19 symptoms. The primary endpoint was severe respiratory disease defined as a respiratory rate [≥]30 and/or an O2 sat<93% in room air. The study was interrupted at 76% of its projected sample size, because cases in the region decreased considerably and steady enrollment of study subjects became virtually impossible. Results160 patients underwent randomization. In the intention-to-treat analysis (ITT), 13/80(16.2%) patients receiving plasma vs. 25/80(31.2%) receiving placebo experienced severe respiratory disease [RR(95%CI)= 0.52(0.29,0.94); p=0.026)] with an RRR=48%. A modified ITT analysis, excluding six subjects who experienced the primary endpoint before infusion, showed a larger effect size [RR(95%CI) = 0.40(0.20, 0.81), p=0.007]. High- and low-titer donor analyses, based on a median IgG titer=1:3,200, evidenced a dose-dependent response with an RRR=73.3% for recipients of high-titer plasma (p=0.016) and a number needed to treat (NNT)=4.4. All secondary endpoints exhibited trends towards protection. No solicited adverse events were observed. ConclusionsEarly administration of high-titer convalescent plasma against SARS-CoV2 to mildly ill infected seniors reduced COVID-19 progression. This safe, inexpensive, outpatient intervention facilitates access to treatment from industrialized to LMIC, can decompress demands on hospitals, and may contribute to save lives. Funded by The Bill & Melinda Gates Foundation and The Fundacion INFANT Pandemic Fund. Registered in the Direccion de Sangre y Medicina Transfusional del Ministerio de Salud (PAEPCC19), Plataforma PRIISA (1421), and clinicaltrials.gov (NCT04479163). All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work; RL, GPM, DW and FPP are investigators in a phase 3 SARS CoV2 trial from Pfizer; no other relationships or activities that could appear to have influenced the submitted work.

Modeling the frequency and number of persons to test to detect and control COVID-19 outbreaks in congregate settings (preprint)

BackgroundCongregate settings are at risk for coronavirus disease 2019 (COVID-19) outbreaks. Diagnostic testing can be used as a tool in these settings to identify outbreaks and to control transmission. MethodsWe used transmission modeling to estimate the minimum number of persons to test and the optimal frequency to detect small outbreaks of COVID-19 in a congregate facility. We also estimated the frequency of testing needed to interrupt transmission within a facility. ResultsThe number of people to test and frequency of testing needed depended on turnaround time, facility size, and test characteristics. Parameters are calculated for a variety of scenarios. In a facility of 100 people, 26 randomly selected individuals would need to be tested at least every 6 days to identify a true underlying prevalence of at least 5%, with test sensitivity of 85%, and greater than 95% outbreak detection sensitivity. Disease transmission could be interrupted with universal, facility-wide testing with rapid turnaround every three days. ConclusionsTesting a subset of individuals in congregate settings can improve early detection of small outbreaks of COVID-19. Frequent universal diagnostic testing can be used to interrupt transmission within a facility, but its efficacy is reliant on rapid turnaround of results for isolation of infected individuals.

Fighting the storm: novel anti- TNFα and anti-IL-6 C. sativa lines to tame cytokine storm in COVID-19 (preprint)

The main aspects of severe COVID-19 disease pathogenesis include the increasing hyper-induction of proinflammatory cytokines, also known as ‘cytokine storm’, that precedes acute respiratory distress syndrome (ARDS) and often leads to death. COVID-19 patients often suffer from lung fibrosis, a serious and untreatable condition. There remains no effective treatment for these complications. Out of the cytokines, TNFα and IL-6 play crucial roles in cytokine storm pathogenesis and are likely responsible for the escalation in disease severity. These cytokines also partake in the molecular pathogenesis of fibrosis. Therefore, new approaches are urgently needed that can efficiently and swiftly block TNFα, IL-6, and the inflammatory cytokine cascade in order to curb inflammation and prevent fibrosis, and lead to disease remission.Cannabis sativa has been proposed to modulate gene expression and inflammation and is under investigation for several potential therapeutic applications against autoinflammatory diseases and cancer. Here, we hypothesized that the extracts of our novel C. sativa lines may be used to modulate the expression of pro-inflammatory cytokines and pathways involved in inflammation and fibrosis. To analyze the anti-inflammatory effects of novel C. sativa lines, we used a well-established full thickness human 3D skin artificial EpiDermFTTM tissue model, whereby tissues were exposed to UV to induce inflammation and then treated with extracts of seven new cannabis lines.We noted that out of seven studied extracts of novel C. sativa lines, three (#4, #8 and #14) were the most effective, causing profound and concerted down-regulation of TNFα, IL-6, CCL2, and other cytokines and pathways related to inflammation and fibrosis. Most importantly, one of the tested extracts had no effects at all, and one exerted effects that may be deleterious, signifying that cannabis is not generic and cultivar selection must be based on thorough pre-clinical studies.The observed pronounced inhibition of TNFα and IL-6 is the most important finding, as these molecules are currently considered to be the main actionable targets in COVID-19 cytokine storm and ARDS pathogenesis.  Many currently trialed agents, such as anti-TNFα and anti-IL-6 biologics are expensive and cause an arrays of side effects. On the other hand, anti-TNFα and anti-IL-6 cannabis extracts that are generally regarded as safe (GRAS) modalities can be a useful addition to the current anti-inflammatory regimens to treat COVID-19, as well as various rheumatological diseases and conditions, and ‘inflammaging’ - the inflammatory underpinning of aging and frailty.