Publications by authors named "N J Smart"

408 Publications

Resistance training in heart failure patients: a systematic review and meta-analysis.

Heart Fail Rev 2021 Sep 20. Epub 2021 Sep 20.

School of Science and Technology, University of New England, Armidale, NSW, 2351, Australia.

Aerobic training (AT) has been the primary mode of exercise training in cardiac rehabilitation. Historically, the reason for the prescription of AT was that it was speculated that although RT may be beneficial for some clinical outcomes, it may have an adverse effect on ventricular structure and function. However, RT has now made its way into current cardiac rehabilitation guidelines, including those directed towards patients with HF, albeit differences exist across institutions and guidelines. A systematic search of PubMed, EMBASE and Cochrane Trials Register on April 30, 2021, was conducted for exercise-based rehabilitation trials in HF. Randomised and controlled trials that reported on resistance training versus usual care or trials that directly compared RT to an AT intervention were included. Resistance training versus controls improves parameters of lower (SMD 0.76 (95%CI 0.26, 1.25, p = 0.003] and upper extremity muscle strength (SMD 0.85 (95%CI 0.35, 1.35), p = 0.0009], both key parameters of physical function throughout the lifespan. Importantly, RT in isolation, versus control, improves VO2peak [MD: 2.64 ml/kg/min (95%CI 1.67, 3.60), p < 0.00001] and 6MWD [MD: 49.94 m (95%CI 34.59, 65.29), p < 0.00001], without any detrimental effect on left ventricular parameters. Resistance training in HF patients is safe and improves parameters of physical function and quality of life. Where people with HF are unable to, or are not inclined to, partake in aerobic activity, RT alone is appropriate to elicit meaningful benefit.
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http://dx.doi.org/10.1007/s10741-021-10169-8DOI Listing
September 2021

Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages.

Br J Surg 2021 Sep 1. Epub 2021 Sep 1.

Colorectal Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain.

Background: There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work-life balance globally.

Methods: A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career.

Results: Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P = 0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P < 0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work-life balance.

Conclusion: Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects.
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http://dx.doi.org/10.1093/bjs/znab275DOI Listing
September 2021

The effectiveness and safety of isometric resistance training for adults with high blood pressure: a systematic review and meta-analysis.

Hypertens Res 2021 Aug 12. Epub 2021 Aug 12.

Department of Exercise Physiology, School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.

High blood pressure (BP) is a global health challenge. Isometric resistance training (IRT) has demonstrated antihypertensive effects, but safety data are not available, thereby limiting its recommendation for clinical use. We conducted a systematic review of randomized controlled trials comparing IRT to controls in adults with elevated BP (systolic ≥130 mmHg/diastolic ≥85 mmHg). This review provides an update to office BP estimations and is the first to investigate 24-h ambulatory BP, central BP, and safety. Data were analyzed using a random-effects meta-analysis. We assessed the risk of bias with the Cochrane risk of bias tool and the quality of evidence with GRADE. Twenty-four trials were included (n = 1143; age = 56 ± 9 years, 56% female). IRT resulted in clinically meaningful reductions in office systolic (-6.97 mmHg, 95% CI -8.77 to -5.18, p < 0.0001) and office diastolic BP (-3.86 mmHg, 95% CI -5.31 to -2.41, p < 0.0001). Novel findings included reductions in central systolic (-7.48 mmHg, 95% CI -14.89 to -0.07, p = 0.035), central diastolic (-3.75 mmHg, 95% CI -6.38 to -1.12, p = 0.005), and 24-h diastolic (-2.39 mmHg, 95% CI -4.28 to -0.40, p = 0.02) but not 24-h systolic BP (-2.77 mmHg, 95% CI -6.80 to 1.25, p = 0.18). These results are very low/low certainty with high heterogeneity. There was no significant increase in the risk of IRT, risk ratio (1.12, 95% CI 0.47 to 2.68, p = 0.8), or the risk difference (1.02, 95% CI 1.00 to 1.03, p = 0.13). This means that there is one adverse event per 38,444 bouts of IRT. IRT appears safe and may cause clinically relevant reductions in BP (office, central BP, and 24-h diastolic). High-quality trials are required to improve confidence in these findings. PROSPERO (CRD42020201888); OSF ( https://doi.org/10.17605/OSF.IO/H58BZ ).
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http://dx.doi.org/10.1038/s41440-021-00720-3DOI Listing
August 2021

A semi-Markov model comparing the lifetime cost-effectiveness of mesh prophylaxis to prevent parastomal hernia in patients undergoing end colostomy creation for rectal cancer.

Colorectal Dis 2021 Jul 31. Epub 2021 Jul 31.

Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.

Aim: Parastomal hernia (PSH) is a common problem following colostomy. Using prophylactic mesh during end colostomy creation may reduce PSH incidence, but concerns exist regarding the optimal type of mesh, potential long-term complications, and cost-effectiveness of its use. We evaluated the cost-effectiveness of mesh prophylaxis to prevent PSH in patients undergoing end colostomy creation for rectal cancer.

Methods: We developed a decision-analytical model, stratified by rectal cancer stages I-IV, to estimate the lifetime costs, quality-adjusted life-years (QALYs) and net monetary benefits (NMBs) of synthetic, biologic and no mesh from a UK NHS perspective. We pooled the mesh-related relative risks of PSH from 13 randomised controlled trials (RCTs) and superimposed these on the baseline (no mesh) risk from a population-based cohort. Uncertainty was assessed in sensitivity analyses.

Results: Synthetic mesh was less costly and more effective than biologic and no mesh to prevent PSH for all rectal cancer stages. At the willingness-to-pay threshold of £20,000/QALY, the incremental NMBs (95% CI) ranged between £3,412 (£3,384 to £3,439) (stage I) and £1,305 (£1,293 to £1,316) (stage IV) for synthetic versus no mesh, and £2,449 (£2,371 to £2,526) (stage I) and £1,784 (£1,753 to £1,815) (stage IV) for synthetic versus biologic mesh. Synthetic mesh was more cost-effective than no mesh unless the relative risk of PSH was ≥0.97 for stages I-III and ≥0.94 for stage IV.

Conclusions: Synthetic mesh was the most cost-effective strategy to prevent the formation of PSH in patients after end colostomy for any rectal cancer stage; however, conclusions are dependent on which subset of RCTs are considered to provide the most robust evidence.
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http://dx.doi.org/10.1111/codi.15848DOI Listing
July 2021

Use of prophylactic mesh during initial stoma creation to prevent parastomal herniation: a systematic review and meta-analysis of randomised controlled trials.

Colorectal Dis 2021 Jul 31. Epub 2021 Jul 31.

Royal Devon and Exeter Hospital, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.

Aim: Parastomal hernia (PSH) is a common complication following stoma creation. Previous reviews found mesh reinforcement during initial stoma creation beneficial in reducing PSH incidence. Since then, several multicentre randomised controlled trials (RCTs) produced widely ranging results rendering previous findings debatable. This current review assessed whether combining the latest larger multicentre RCTs would alter the previous findings.

Methods: The Cochrane Library, MEDLINE and Embase were searched from the respective dates of inception until 15 January 2021. RCTs were included if they compared mesh with no mesh during initial stoma creation in adult patients to prevent PSH. Included RCTs were summarised narratively and meta-analysed to estimate the relative risk (RR) of PSH incidence (primary analysis), peristomal complications and PSH repair (secondary analyses). Several subgroup analyses were performed, including mesh type (synthetic/biologic), surgical technique (open/laparoscopic) and mesh position (sublay/intraperitoneal).

Results: Thirteen RCTs were included in the primary meta-analysis (1070 patients); PSH incidence was reduced in patients with mesh compared with patients without mesh at maximal follow-up (RR = 0.54; 95% CI 0.39-0.77; I  = 67%; P < 0.01). The number of PSH repairs was fewer in patients who had mesh (RR = 0.63; 0.35-1.14; I  = 6%; P = 0.39), with no difference in peristomal complications (RR = 0.96; 0.55-1.70; I  = 0%; P = 0.71), comparing with no mesh. Subgroup analyses suggested that placing synthetic mesh using an open sublay technique might be more beneficial.

Conclusions: Prophylactic mesh reinforcement during initial stoma creation reduces PSH incidence and potentially its repair, without an increase in peristomal complications. However, substantial heterogeneity among included RCTs limits confidence in the results.
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http://dx.doi.org/10.1111/codi.15849DOI Listing
July 2021
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