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Background and aim Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPC), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity. This review and meta-analysis is to assess the impact of physiotherapy regimens following esophagectomy or gastrectomy. Methods An electronic literature search was performed in MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases, to identify articles evaluating the effect of physiotherapy interventions following esophagectomy or gastrectomy. A meta-analysis was performed to assess the impact of prehabilitation and peri- or postoperative rehabilitation on the functional capacity, incidence of PPC and postoperative morbidity, in-hospital mortality rate, the Length of Hospital Stay (LOS) and the Health-Related Quality of Life (HRQoL). Results Seven RCTs and 7 cohort studies assessing prehabilitation totalling 960 patients, and 5 RCTs and 5 cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien-Dindo score > II). No significant difference was observed in functional exercise capacity, and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, a shorter LOS and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue and pain scores. Conclusion Our meta-analysis shows that implementation of an exercise intervention may be beneficial in both the preoperative and peri- or postoperative period. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which subgroup of patients will gain the most benefit.

Aim The accuracy and safety of symptom checkers in diagnosing and triaging patients is of concern; especially those with life-threatening conditions. The study's aims were to: 1. assess the accuracy of symptom checkers in diagnosing and triaging myocardial infarctions (MI) and, 2. determine whether differences in gender or presentation type exist. Method This prospective diagnostic accuracy study assessed 8 symptom checkers using 100 MI patients of various presentations: typical or atypical. The ability of a symptom checker in providing MI as the first diagnosis (D1) and the first 3 (D3) diagnoses were diagnostic accuracy measures. Triage advice was deemed correct if the symptom checker recommended seeking emergency treatment. Results Symptom checkers correctly diagnosed 48.0±31.4% of cases with MI first. D3 accuracy was 72.6±20.2%. Mean triage accuracy was 82.6±12.6%. 24.0±16.2% of atypical cases had a correct primary diagnosis. D3 accuracy for atypical MI was 43.8±20.6%, significantly lower than that of typical MI (p<0.01). Atypical case triage accuracy was 52.7±20.0%, significantly lower than typical cases (84.2±14.7%, p<0.01). 10.0% of the atypical female cases were diagnosed correctly with MI as the first diagnosis. Female atypical cases had significantly lower accuracy than typical female cases for all accuracy measures (p<0.01). Conclusions Symptom checkers generally provide low accuracy for diagnosing MI. Approximately 20% of cases were under-triaged. Results varied between symptom checkers: patients who presented with atypical symptoms tended to be under-diagnosed and under-triaged, especially those who were female. This demonstrated potential gender bias and therefore raises questions regarding symptom checker regulation and safety.

Introduction Technological innovations are pivotal to surgical training. It is unclear however, if these technologies deployed intra-operatively affect surgeon performance or cognitive burdens. Methods Ethical approval was gained from our institute. Forty-eight medical students, foundation, and core surgical doctors completed accredited eLearning on Laparoscopic cholecystectomy and basic laparoscopic skill modules on a VR-simulator. Operative workflows with step-by-step instructions to perform a level-1 laparoscopic cholecystectomy were prepared by expert surgeons. Participants were randomly allocated to complete the procedure with or without workflows, and then crossover twice, for a total of three cholecystectomies. After each simulation, participants completed a validated surgical task load index (SURG-TLX), measuring cognitive demands. After the study, they completed training evaluations. Screen-recordings of the procedures were blindly assessed by expert surgeons, using validated OSATS scores and procedure-specific performance and error scores (Eubanks et al, 1999). Statistical significance was defined with a p-value <0.05. Results Demographics did not differ significantly between groups. At the final attempt, OSATS were slightly improved, but not significantly, when using workflows (19 v. 17, p=0.9); as were performance scores (72 v. 71.5, p=0.73) and error scores (17 v. 22, p=0.268). Surg-TLX scores were also reduced although only significantly for Temporary-Demands (p=0.037). Procedure time was longer in the workflow group (20.5 v. 14 minutes, p=0.033). Above 90% of participants agreed workflows were enjoyable, user-friendly and aided learning. Conclusion Real-time operative workflows are perceived as useful learning adjuncts and may diminish cognitive burdens. Further research is needed to confirm if workflows improve performance and diminish errors. Take-home message In a VR simulated procedure, intra-operative surgical workflows do not seem to affect surgeon cognitive burden. OSATS, performance and error scores may be improved but further research is needed.