human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery ( ERAS ) programs . Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce . We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease . Methods The ERAS program was initiated in 2009 . Patients who underwent esophagectomy and were treated according to the ERAS program were included . Items of ERAS included preoperative nutrition , early extubation , early removal of nasogastric tube , and early mobilization . Primary outcome parameters were hospital stay and the incidence of postoperative complications . Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol . A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient . Results Between 2008 and August 2010 , 181 patients in our department underwent esophagectomy .  Of these , 103 patients were included in the ERAS program ( ERAS+ group ) and were compared to 78 patients who had undergone an esophagectomy in 2008 ( ERAS– group ) .  Overall hospital stay was 14 days versus 15 days ( ERAS+ and ERAS– , respectively ; p = 0.013 ) . There were no significant differences in the incidence of postoperative complications in either group . The percentage of achieved items varied between 42 and 93 % per item . Conclusions The implementation of an ERAS program in esophageal surgery was feasible and result ed in a small but significant reduction in overall hospital stay , whereas overall morbidity was not affected This study explores the experiences of and the nursing care for nine women with breast cancer undergoing immediate breast reconstruction ( IBR ) with a TRAM-flap . The study was prospect i ve and descriptive and source and method triangulation was used . Source triangulation consisted of the patients ' and nurses ' perspectives , whilst method triangulation combined interviews , question naires and medical records . One result is that the meaning of IBR for the women operated is related to feelings of hope , normality and ' wholeness ' . Another result is that not all the needs of the patients are assessed and met ; the nursing care during admission is mainly focused on the physical care and after dismissal the patients are left in a situation characterized by vulnerability and a sense of emptiness . The study points to some implication s in the means of quality development and rehabilitation BACKGROUND  Surgical complications after breast reconstruction can be associated with significant morbidity , dissatisfaction , and cost . We used the ACS-NSQIP data sets from 2005 to 2011 to derive predictors of morbidity and to stratify risk after immediate breast reconstruction ( IBR ) . STUDY DESIGN Surgical complications after implant and autologous reconstruction were assessed using the ACS-NSQIP 2005 to 2011 data sets . Patient demographics , clinical characteristics , and operative factors were associated with the likelihood of experiencing a surgical complication . A " model cohort " of 12,129 patients was r and omly selected from the study cohort to derive predictors . Weighted odds ratios derived from logistic regression analysis were used to create a composite risk score and to stratify patients . The remaining one-third of the cohort ( n = 6,065 ) were used as the " validation cohort " to assess the accuracy value of the risk model . RESULTS On adjusted analysis , autologous reconstruction ( odds ratio [ OR ] 1.41 , p < 0.001 ) , American Society of Anesthesiologists physical status ≥ 3 ( OR 1.25 , p = 0.004 ) , class I obesity ( OR 1.38 , p < 0.001 ) , class II obesity ( OR 1.91 , p < 0.001 ) , class III obesity ( OR 1.70 , p < 0.001 ) , and active smoking ( OR 1.46 , p < 0.001 ) were associated with complications . Risk factors were weighted and patients were stratified into low ( 0 to 2 , n = 9,133 , risk = 7.14 % ) , intermediate ( 3 to 4 , n = 1,935 , risk = 10.90 % ) , high ( 5 to 7 , n = 1,024 , risk = 16.70 % ) , and very high ( 8 to 9 , n = 37 , risk = 27.02 % ) risk categories based on their total risk score ( p < 0.001 ) . Internal validation of the " model cohort " using the " validation cohort " was performed demonstrating accurate prediction of risk across groups : low ( 7.1 % vs 7.1 % , respectively , p = 0.9 ) , intermediate ( 10.9 % vs 12.0 % , respectively , p = 0.38 ) , high ( 16.7 % vs 16.8 % , respectively , p = 0.95 ) , and very high ( 27.0 % vs 30.0 % , respectively , p = 1.0 ) . CONCLUSIONS Surgical complications after IBR are related to preoperatively identifiable factors that can be used to accurately risk stratify patients , which may assist with counseling , selection , and perioperative decision-making BACKGROUND Mild perioperative hypothermia , which is common during major surgery , may promote surgical-wound infection by triggering thermoregulatory vasoconstriction , which decreases subcutaneous oxygen tension . Reduced levels of oxygen in tissue impair oxidative killing by neutrophils and decrease the strength of the healing wound by reducing the deposition of collagen . Hypothermia also directly impairs immune function . We tested the hypothesis that hypothermia both increases susceptibility to surgical-wound infection and lengthens hospitalization . METHODS Two hundred patients undergoing colorectal surgery were r and omly assigned to routine intraoperative thermal care ( the hypothermia group ) or additional warming ( the normothermia group ) . The patient 's anesthetic care was st and ardized , and they were all given cefam and ole and metronidazole . In a double-blind protocol , their wounds were evaluated daily until discharge from the hospital and in the clinic after two weeks ; wounds containing culture-positive pus were considered infected . The patients ' surgeons remained unaware of the patients ' group assignments . RESULTS The mean ( + /- SD ) final intraoperative core temperature was 34.7 + /- 0.6 degrees C in the hypothermia group and 36.6 + /- 0.5 degrees C in the normothermia group ( P < 0.001 ) Surgical-wound infections were found in 18 of 96 patients assigned to hypothermia ( 19 percent ) but in only 6 of 104 patients assigned to normothermia ( 6 percent , P = 0.009 ) . The sutures were removed one day later in the patients assigned to hypothermia than in those assigned to normothermia ( P = 0.002 ) , and the duration of hospitalization was prolonged by 2.6 days ( approximately 20 percent ) in hypothermia group ( P = 0.01 ) . CONCLUSIONS Hypothermia itself may delay healing and predispose patients to wound infections . Maintaining normothermia intraoperatively is likely to decrease the incidence of infectious complications in patients undergoing colorectal resection and to shorten their hospitalizations Background The effectiveness of antibiotic prophylaxis for prevention of surgical site infection ( SSI ) following specific types of breast cancer surgery remains uncertain . This study assessed the effectiveness of prophylaxis in modified radical mastectomy  ( MRM ) . Methods Women undergoing MRM for breast cancer were recruited . Women were excluded who had diabetes mellitus , severe malnutrition or known allergy to cephalosporins ; were receiving corticosteroid therapy or were treated with antibiotics within one week prior to surgery ; were scheduled for simultaneous breast reconstruction or bilateral oophorectomy ; had existing local infection . Participants were r and omized to receive either intravenous cefazolin 1 g or placebo within 30 min prior to skin incision . St and ard skin preparation and operative technique for MRM were carried out . Wounds were assessed for SSI and other complications weekly for 30 days . Results A total of 254 women were recruited . Age , clinical stage , prior chemotherapy , and operative time were similar for antibiotic and placebo groups . The overall incidence of SSI was 14.2 % . There were no significant differences in the infection rate over the 30-day follow-up period between the placebo and antibiotic groups ( 15 % vs 13.4 % ; p = 0.719 ) or at each week . The majority of SSI were either cellulitis or superficial infection for both groups . There were no significant differences between groups in treatments required for SSI , incidence of hematoma or seroma . Conclusions The findings of this study , alone and when meta-analyzed with data from studies in similar surgical population s , do not support the use of antibiotic prophylaxis in MRM Background : Pulsed electromagnetic fields have been shown to reduce postoperative pain , inflammation , and narcotic requirements after breast reduction and augmentation surgical procedures . This study examined whether pulsed electromagnetic field therapy could produce similar results in patients undergoing unilateral transverse rectus abdominis myocutaneous ( TRAM ) flap breast reconstruction , a significantly more complex and painful surgical procedure . Methods : In this double-blind , placebo-controlled , r and omized study , 32 patients undergoing unilateral TRAM flap breast reconstruction received active or sham pulsed electromagnetic field therapy .  Pain levels were measured by using a visual analogue scale ; narcotic use and wound exu date volume were recorded starting 1 hour postoperatively . Wound exu date s were analyzed for interleukin-1&bgr;. Results : Mean visual analogue scale pain scores were 2-fold higher in the sham cohort at 5 hours and 4-fold higher at 72 hours ( p < 0.01 ) , along with a concomitant 2-fold increase in narcotic use in sham patients ( p < 0.01 ) . Wound exu date volume was 2-fold higher in the sham cohort at 24 hours ( p < 0.01 ) , and mean interleukin-1&bgr ; concentration in wound exu date s of sham patients was 5-fold higher at 24 hours ( p < 0.001 ) . Conclusions : Pulsed electromagnetic field therapy significantly reduced postoperative pain , inflammation , and narcotic use following TRAM flap breast reconstruction , paralleling its effect in breast reduction patients . Both studies also report a significant reduction of interleukin-1&bgr ; in the wound exu date , supporting a mechanism involving a pulsed electromagnetic field effect on nitric oxide/cyclic guanosine monophosphate signaling , which modulates the body ’s antiinflammatory pathways . Adjunctive pulsed electromagnetic field therapy could impact the speed and quality of wound repair in many surgical procedures . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , UNLABELLED Infusions of carbohydrates before surgery reduce  postoperative insulin resistance . We in-vestigated the effects of a carbohydrate drink , given shortly before surgery , on postoperative metabolism . METHOD Insulin sensitivity , glucose turnover ( [ 6,6 , 2H2]-D-glucose ) and substrate utilization were measured using hyperinsulinemic normoglycemic clamps and indirect calorimetry in two matched groups of patients before and after elective colorectal surgery . The drink group ( n = 7 ) received 800 ml of an isoosmolar carbohydrate rich beverage the evening before the operation ( 100 g carbohydrates ) , as well as another 400 ml ( 50 g carbohydrates ) 2 h before the initiation of anesthesia . The fasted group ( n = 7 ) was operated after an overnight fast . RESULTS After surgery , energy expenditure increased in both groups . Endogenous glucose production was higher after surgery and the difference was significant during low insulin infusion rates in both groups ( P < 0.05 ) . The supressibility of endogenous glucose production by the two step insulin infusion was similar pre- and postoperatively in both groups . At the high insulin infusion rate postoperatively , whole body glucose disposal was more reduced in the fasted group ( -49 + /- 6 % vs -26 + /- 8 % , P < 0.05 vs drink ) . Furthermore , during high insulin infusion rates , glucose oxidation decreased postoperatively only in the fasted group ( P < 0 . 05 ) and postoperative levels of fat oxidation were greater in the fasted group ( P < 0.05 vs drink ) . Only minor postoperative changes in cortisol and glucagon were found and no differences were found between the treatment groups . CONCLUSIONS Patients given a carbohydrate drink shortly before elective colorectal surgery displayed less reduced insulin sensitivity after surgery as compared to patients who were operated after an overnight fast OBJECTIVES To study the impact of different adherence levels to the enhanced recovery after surgery ( ERAS ) protocol and the effect of various ERAS elements on outcomes following major surgery . DESIGN Single-center prospect i ve cohort study before and after reinforcement of an ERAS protocol . Comparisons were made both between and across periods using multivariate logistic regression . All 
    Output:
    
agent
Key recommendations support use of  opioid-sparing perioperative medications  , minimal preoperative fasting and early feeding , use of anesthetic techniques that decrease postoperative nausea and vomiting and pain , use of measures to prevent intraoperative hypothermia , and support of early mobilization after surgery .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery ( ERAS ) programs . Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce . We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease . Methods The ERAS program was initiated in 2009 . Patients who underwent esophagectomy and were treated according to the ERAS program were included . Items of ERAS included preoperative nutrition , early extubation , early removal of nasogastric tube , and early mobilization . Primary outcome parameters were hospital stay and the incidence of postoperative complications . Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol . A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient . Results Between 2008 and August 2010 , 181 patients in our department underwent esophagectomy .  Of these , 103 patients were included in the ERAS program ( ERAS+ group ) and were compared to 78 patients who had undergone an esophagectomy in 2008 ( ERAS– group ) .  Overall hospital stay was 14 days versus 15 days ( ERAS+ and ERAS– , respectively ; p = 0.013 ) . There were no significant differences in the incidence of postoperative complications in either group . The percentage of achieved items varied between 42 and 93 % per item . Conclusions The implementation of an ERAS program in esophageal surgery was feasible and result ed in a small but significant reduction in overall hospital stay , whereas overall morbidity was not affected This study explores the experiences of and the nursing care for nine women with breast cancer undergoing immediate breast reconstruction ( IBR ) with a TRAM-flap . The study was prospect i ve and descriptive and source and method triangulation was used . Source triangulation consisted of the patients ' and nurses ' perspectives , whilst method triangulation combined interviews , question naires and medical records . One result is that the meaning of IBR for the women operated is related to feelings of hope , normality and ' wholeness ' . Another result is that not all the needs of the patients are assessed and met ; the nursing care during admission is mainly focused on the physical care and after dismissal the patients are left in a situation characterized by vulnerability and a sense of emptiness . The study points to some implication s in the means of quality development and rehabilitation BACKGROUND  Surgical complications after breast reconstruction can be associated with significant morbidity , dissatisfaction , and cost . We used the ACS-NSQIP data sets from 2005 to 2011 to derive predictors of morbidity and to stratify risk after immediate breast reconstruction ( IBR ) . STUDY DESIGN Surgical complications after implant and autologous reconstruction were assessed using the ACS-NSQIP 2005 to 2011 data sets . Patient demographics , clinical characteristics , and operative factors were associated with the likelihood of experiencing a surgical complication . A " model cohort " of 12,129 patients was r and omly selected from the study cohort to derive predictors . Weighted odds ratios derived from logistic regression analysis were used to create a composite risk score and to stratify patients . The remaining one-third of the cohort ( n = 6,065 ) were used as the " validation cohort " to assess the accuracy value of the risk model . RESULTS On adjusted analysis , autologous reconstruction ( odds ratio [ OR ] 1.41 , p < 0.001 ) , American Society of Anesthesiologists physical status ≥ 3 ( OR 1.25 , p = 0.004 ) , class I obesity ( OR 1.38 , p < 0.001 ) , class II obesity ( OR 1.91 , p < 0.001 ) , class III obesity ( OR 1.70 , p < 0.001 ) , and active smoking ( OR 1.46 , p < 0.001 ) were associated with complications . Risk factors were weighted and patients were stratified into low ( 0 to 2 , n = 9,133 , risk = 7.14 % ) , intermediate ( 3 to 4 , n = 1,935 , risk = 10.90 % ) , high ( 5 to 7 , n = 1,024 , risk = 16.70 % ) , and very high ( 8 to 9 , n = 37 , risk = 27.02 % ) risk categories based on their total risk score ( p < 0.001 ) . Internal validation of the " model cohort " using the " validation cohort " was performed demonstrating accurate prediction of risk across groups : low ( 7.1 % vs 7.1 % , respectively , p = 0.9 ) , intermediate ( 10.9 % vs 12.0 % , respectively , p = 0.38 ) , high ( 16.7 % vs 16.8 % , respectively , p = 0.95 ) , and very high ( 27.0 % vs 30.0 % , respectively , p = 1.0 ) . CONCLUSIONS Surgical complications after IBR are related to preoperatively identifiable factors that can be used to accurately risk stratify patients , which may assist with counseling , selection , and perioperative decision-making BACKGROUND Mild perioperative hypothermia , which is common during major surgery , may promote surgical-wound infection by triggering thermoregulatory vasoconstriction , which decreases subcutaneous oxygen tension . Reduced levels of oxygen in tissue impair oxidative killing by neutrophils and decrease the strength of the healing wound by reducing the deposition of collagen . Hypothermia also directly impairs immune function . We tested the hypothesis that hypothermia both increases susceptibility to surgical-wound infection and lengthens hospitalization . METHODS Two hundred patients undergoing colorectal surgery were r and omly assigned to routine intraoperative thermal care ( the hypothermia group ) or additional warming ( the normothermia group ) . The patient 's anesthetic care was st and ardized , and they were all given cefam and ole and metronidazole . In a double-blind protocol , their wounds were evaluated daily until discharge from the hospital and in the clinic after two weeks ; wounds containing culture-positive pus were considered infected . The patients ' surgeons remained unaware of the patients ' group assignments . RESULTS The mean ( + /- SD ) final intraoperative core temperature was 34.7 + /- 0.6 degrees C in the hypothermia group and 36.6 + /- 0.5 degrees C in the normothermia group ( P < 0.001 ) Surgical-wound infections were found in 18 of 96 patients assigned to hypothermia ( 19 percent ) but in only 6 of 104 patients assigned to normothermia ( 6 percent , P = 0.009 ) . The sutures were removed one day later in the patients assigned to hypothermia than in those assigned to normothermia ( P = 0.002 ) , and the duration of hospitalization was prolonged by 2.6 days ( approximately 20 percent ) in hypothermia group ( P = 0.01 ) . CONCLUSIONS Hypothermia itself may delay healing and predispose patients to wound infections . Maintaining normothermia intraoperatively is likely to decrease the incidence of infectious complications in patients undergoing colorectal resection and to shorten their hospitalizations Background The effectiveness of antibiotic prophylaxis for prevention of surgical site infection ( SSI ) following specific types of breast cancer surgery remains uncertain . This study assessed the effectiveness of prophylaxis in modified radical mastectomy  ( MRM ) . Methods Women undergoing MRM for breast cancer were recruited . Women were excluded who had diabetes mellitus , severe malnutrition or known allergy to cephalosporins ; were receiving corticosteroid therapy or were treated with antibiotics within one week prior to surgery ; were scheduled for simultaneous breast reconstruction or bilateral oophorectomy ; had existing local infection . Participants were r and omized to receive either intravenous cefazolin 1 g or placebo within 30 min prior to skin incision . St and ard skin preparation and operative technique for MRM were carried out . Wounds were assessed for SSI and other complications weekly for 30 days . Results A total of 254 women were recruited . Age , clinical stage , prior chemotherapy , and operative time were similar for antibiotic and placebo groups . The overall incidence of SSI was 14.2 % . There were no significant differences in the infection rate over the 30-day follow-up period between the placebo and antibiotic groups ( 15 % vs 13.4 % ; p = 0.719 ) or at each week . The majority of SSI were either cellulitis or superficial infection for both groups . There were no significant differences between groups in treatments required for SSI , incidence of hematoma or seroma . Conclusions The findings of this study , alone and when meta-analyzed with data from studies in similar surgical population s , do not support the use of antibiotic prophylaxis in MRM Background : Pulsed electromagnetic fields have been shown to reduce postoperative pain , inflammation , and narcotic requirements after breast reduction and augmentation surgical procedures . This study examined whether pulsed electromagnetic field therapy could produce similar results in patients undergoing unilateral transverse rectus abdominis myocutaneous ( TRAM ) flap breast reconstruction , a significantly more complex and painful surgical procedure . Methods : In this double-blind , placebo-controlled , r and omized study , 32 patients undergoing unilateral TRAM flap breast reconstruction received active or sham pulsed electromagnetic field therapy .  Pain levels were measured by using a visual analogue scale ; narcotic use and wound exu date volume were recorded starting 1 hour postoperatively . Wound exu date s were analyzed for interleukin-1&bgr;. Results : Mean visual analogue scale pain scores were 2-fold higher in the sham cohort at 5 hours and 4-fold higher at 72 hours ( p < 0.01 ) , along with a concomitant 2-fold increase in narcotic use in sham patients ( p < 0.01 ) . Wound exu date volume was 2-fold higher in the sham cohort at 24 hours ( p < 0.01 ) , and mean interleukin-1&bgr ; concentration in wound exu date s of sham patients was 5-fold higher at 24 hours ( p < 0.001 ) . Conclusions : Pulsed electromagnetic field therapy significantly reduced postoperative pain , inflammation , and narcotic use following TRAM flap breast reconstruction , paralleling its effect in breast reduction patients . Both studies also report a significant reduction of interleukin-1&bgr ; in the wound exu date , supporting a mechanism involving a pulsed electromagnetic field effect on nitric oxide/cyclic guanosine monophosphate signaling , which modulates the body ’s antiinflammatory pathways . Adjunctive pulsed electromagnetic field therapy could impact the speed and quality of wound repair in many surgical procedures . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , UNLABELLED Infusions of carbohydrates before surgery reduce  postoperative insulin resistance . We in-vestigated the effects of a carbohydrate drink , given shortly before surgery , on postoperative metabolism . METHOD Insulin sensitivity , glucose turnover ( [ 6,6 , 2H2]-D-glucose ) and substrate utilization were measured using hyperinsulinemic normoglycemic clamps and indirect calorimetry in two matched groups of patients before and after elective colorectal surgery . The drink group ( n = 7 ) received 800 ml of an isoosmolar carbohydrate rich beverage the evening before the operation ( 100 g carbohydrates ) , as well as another 400 ml ( 50 g carbohydrates ) 2 h before the initiation of anesthesia . The fasted group ( n = 7 ) was operated after an overnight fast . RESULTS After surgery , energy expenditure increased in both groups . Endogenous glucose production was higher after surgery and the difference was significant during low insulin infusion rates in both groups ( P < 0.05 ) . The supressibility of endogenous glucose production by the two step insulin infusion was similar pre- and postoperatively in both groups . At the high insulin infusion rate postoperatively , whole body glucose disposal was more reduced in the fasted group ( -49 + /- 6 % vs -26 + /- 8 % , P < 0.05 vs drink ) . Furthermore , during high insulin infusion rates , glucose oxidation decreased postoperatively only in the fasted group ( P < 0 . 05 ) and postoperative levels of fat oxidation were greater in the fasted group ( P < 0.05 vs drink ) . Only minor postoperative changes in cortisol and glucagon were found and no differences were found between the treatment groups . CONCLUSIONS Patients given a carbohydrate drink shortly before elective colorectal surgery displayed less reduced insulin sensitivity after surgery as compared to patients who were operated after an overnight fast OBJECTIVES To study the impact of different adherence levels to the enhanced recovery after surgery ( ERAS ) protocol and the effect of various ERAS elements on outcomes following major surgery . DESIGN Single-center prospect i ve cohort study before and after reinforcement of an ERAS protocol . Comparisons were made both between and across periods using multivariate logistic regression . All 
    Output:
    