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Background Preoperative anemia is a frequent complication in pancreatic surgical patients, and it adversely affects morbidity, mortality, and postoperative red blood cell (RBC) transfusion rates. Iron deficiency (ID) is often the underlying cause of anemia and constitutes a modifiable risk factor. Methods Single-center, longitudinal prospective cohort study conducted between May 2019 and August 2022 at the University Medical Center Groningen in the Netherlands. Patients scheduled for pancreatic surgery were referred to the outpatient prehabilitation clinic for preoperative optimization of patient-related risk factors. Patients were screened for anemia (< 12.0 g/dL in women and < 13.0 g/dL in men) and ID (either absolute [ferritin < 30 µg/L] or functional [ferritin ≥ 30 µg/L + transferrin saturation < 20% + C-reactive protein > 5 mg/L]). Intravenous iron supplementation (IVIS) (1,000 mg ferric carboxymaltose) was administered to patients with ID at the discretion of the consulting internist. Pre- and postoperative hemoglobin (Hb) levels were assessed, and perioperative outcomes were compared between patients receiving IVIS (IVIS-group) or standard care (SC-group). Results From 164 screened patients, preoperative anemia was observed in 55 (33.5%) patients, and in 23 (41.8%) of these patients, ID was the underlying cause. In 21 patients, ID was present without concomitant anemia. Preoperative IVIS was administered to 25 patients, out of 44 patients with ID. Initial differences in mean Hb levels (g/dL) between the IVIS-group and SC-group at the outpatient clinic and one day prior to surgery (10.8 versus 13.2, p  < 0.001, and 11.8 versus 13.4, p  < 0.001, respectively) did not exist at discharge (10.6 versus 11.1, p  = 0.13). Preoperative IVIS led to a significant increase in mean Hb levels (from 10.8 to 11.8, p  = 0.03). Fewer SSI were observed in the IVIS-group (4% versus 25.9% in the SC-group, p  = 0.02), which remained significant in multivariable regression analysis (OR 7.01 (1.68 – 49.75), p  = 0.02). Conclusion ID is prevalent in patients scheduled for pancreatic surgery and is amendable to preoperative correction. Preoperative IVIS increased Hb levels effectively and reduced postoperative SSI. Screening and correction of ID is an important element of preoperative care and should be a standard item in daily prehabilitation practice.

IntroductionPatients with end-stage liver disease awaiting orthotopic liver transplantation (OLT) are generally classified as frail due to disease-related malnutrition and a progressive decline in musculoskeletal and aerobic fitness, which is associated with poor pre-OLT, peri-OLT and post-OLT outcomes. However, frailty in these patients may be reversable with adequate exercise and nutritional interventions.Methods and analysisNon-randomised clinical trial evaluating the effect of a home-based bimodal lifestyle programme in unfit patients with a preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold ≤13 mL/kg/min and/or VO2 at peak exercise ≤18 mL/kg/min listed for OLT at the University Medical Center Groningen (UMCG). The programme is patient tailored and comprises high-intensity interval and endurance training, and functional exercises three times per week, combined with nutritional support. Patients will go through two training periods, each lasting 6 weeks.The primary outcome of this study is the impact of the programme on patients’ aerobic fitness after the first study period. Secondary outcomes include aerobic capacity after the second study period, changes in sarcopenia, anthropometry, functional mobility, perceived quality of life and fatigue, incidence of hepatic encephalopathy and microbiome composition. Moreover, number and reasons of intercurrent hospitalisations during the study and postoperative outcomes up to 12 months post OLT will be recorded. Finally, feasibility of the programme will be assessed by monitoring the participation rate and reasons for non-participation, number and severity of adverse events, and dropout rate and reasons for dropout.Ethics and disseminationThis study was approved by the Medical Research Ethics Committee of the UMCG (registration number NL83612.042.23, August 2023) and is registered in the Clinicaltrials.gov register (NCT05853484). Good Clinical Practice guidelines and the principles of the Declaration of Helsinki will be applied. Results of this study will be submitted for presentation at (inter)national congresses and publication in peer-reviewed journals.Trial registration numberNCT05853484.

Purpose Preoperative malnutrition is associated with poor postoperative outcomes in patients with pancreatic cancer. This study evaluated the effectiveness of current practice in nutritional support for patients with pancreatic cancer. Methods Observational multicenter HPB network study conducted at the Isala Clinics Zwolle, Medical Spectrum Twente, Medical Center Leeuwarden, and University Medical Center Groningen between October 2021 and May 2023. Patients with a suspected pancreatic malignancy scheduled for surgery were screened for malnutrition using the Patient-Generated Subjective Global Assessment (PG-SGA) questionnaire and referred to a dedicated dietician for nutritional support comprising pancreatic enzyme replacement therapy, dietary advice, and nutritional supplements to achieve adequate caloric and protein intake. At baseline, 1 day preoperatively, and 3 months postoperatively, the nutritional status and muscle thickness were evaluated. Results The study included 30 patients, of whom 12 (40%) classified as malnourished (PG-SGA ≥ 4) at baseline. Compared to well-nourished patients, malnourished patients were younger, were predominantly female, and had a higher body mass index, despite having lost more body weight in the past 6 months. All malnourished patients and 78% of the well-nourished patients received nutritional support. Consequently, a preoperative increase in caloric and protein intake and body weight were observed. Postoperatively, despite a further increase in caloric intake, a considerable decrease in protein intake, body weight, and muscle thickness was observed. Conclusion Malnutrition is prevalent in patients undergoing pancreatic surgery. Nutritional support by a dedicated dietician is effective in enhancing patients’ preoperative nutritional status. However, postoperative monitoring of adequate nutritional intake in patients could be improved.

The widespread implementation of a preoperative assessment of aerobic capacity requires a practical field test. This study investigated the validity of the modified steep ramp test (SRT) for evaluating preoperative aerobic capacity and to evaluate its usefulness for preoperative risk assessment in patients planned for pancreatic surgery. Patients scheduled for pancreatic surgery who preoperatively performed cardiopulmonary exercise testing (CPET) and the modified SRT within 14 days were included. To assess its criterion validity, the correlation between the achieved work rate at peak exercise (WRpeak) at the modified SRT and oxygen uptake (VO2) at peak exercise (VO2peak) during CPET was determined. To evaluate the ability of the modified SRT to correctly classify patients as fit or unfit, receiver operating characteristic (ROC) analyses were performed based on the CPET VO2peak cutoff 18.0 ml.kg−1.min−1 and VO2 at the ventilatory anaerobic threshold (VAT) cutoff 11.0 ml.kg−1.min−1. Forty-eight patients (21 females) aged 68.7 ± 7.6 years were included. Modified SRT WRpeak (W/kg) demonstrated a very strong correlation with CPET VO2peak (ρ = 0.865, r = 0.926). The modified SRT WRpeak cutoff to most accurately classify patients as fit or unfit was 2.095 W/kg for the CPET VO2peak cutoff (area under the curve (AUC) of 0.948) and the CPET VO2 at the VAT cutoff (AUC of 0.814). The modified SRT is a valid short-term practical exercise test to preoperatively assess aerobic capacity in patients undergoing pancreatic surgery. A modified SRT performance below 2.1 W/kg seems clinically most suitable to select candidates for further preoperative CPET evaluation and/or prehabilitation, given its positive and negative predictive value. [Display omitted] •WRpeak reached at the modified SRT strongly correlates with CPET VO2peak.•The modified SRT WRpeak cutoff to best classify patients as (un)fit was 2.1 W.kg−1.•The short-term, practical modified SRT is suitable for preoperative risk assessment.

IntroductionShort-term exercise prehabilitation programmes have demonstrated promising results in improving aerobic capacity of unfit patients prior to major abdominal surgery. However, little is known about the cardiac and skeletal muscle adaptations explaining the improvement in aerobic capacity following short-term exercise prehabilitation.Methods and analysisIn this single-centre study with a pretest–post-test design, 12 unfit patients with a preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold ≤13 mL/kg/min and/or VO2 at peak exercise ≤18 mL/kg/min, who are scheduled to undergo hepatopancreatobiliary surgery at the University Medical Center Groningen (UMCG), the Netherlands, will be recruited. As part of standard care, unfit patients are advised to participate in a home-based exercise prehabilitation programme, comprising high-intensity interval training and functional exercises three times per week, combined with nutritional support, during a 4-week period. Pre-intervention and post-intervention, patients will complete a cardiopulmonary exercise test. Next to this, study participants will perform additional in-vivo exercise cardiac magnetic resonance (MR) imaging and phosphorus 31-MR spectroscopy of the quadriceps femoris muscle before and after the intervention to assess the effect on respectively cardiac and skeletal muscle function.Ethics and disseminationThis study was approved in May 2023 by the Medical Research Ethics Committee of the UMCG (registration number NL83611.042.23, March 2023) and is registered in the ClinicalTrials.gov register. Results of this study will be submitted for presentation at (inter)national congresses and publication in peer-reviewed journals.Trial registration numberNCT05772819.

Background:Morbidity rates in pancreatic surgery are high, and frail patients with low aerobic capacity are especially at risk of complications and require prophylactic interventions. Previous studies of small patient cohorts receiving intra-abdominal surgery have shown that an exercise prehabilitation program increases aerobic capacity, leading to better treatment outcomes.Objective:In this study, we aim to assess the feasibility of a home-based exercise prehabilitation program in unfit patients scheduled for pancreatic surgery on a larger scale.Methods:In this multicenter study, adult patients scheduled for elective pancreatic surgery with a preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold ≤13 mL/kg/min or a VO2 at peak exercise ≤18 mL/kg/min will be recruited. A total of 30 patients will be included in the 4-week, home-based, partly supervised exercise prehabilitation program. The program comprises 25-minute high-intensity interval training on an advanced cycle ergometer 3 times a week. Training intensity will be based on steep ramp test performance (ie, a short-term maximal exercise test on a cycle ergometer), aiming to improve aerobic capacity. Twice a week, patients will perform functional task exercises to improve muscle function and functional mobility. A steep ramp test will be repeated weekly, and training intensity will be adjusted accordingly. Next to assessing the feasibility (participation rate, reasons for nonparticipation, adherence, dropout rate, reasons for dropout, adverse events, and patient and therapist appreciation) of this program, individual patients’ responses to prehabilitation on aerobic capacity, functional mobility, body composition, quality of life, and immune system factors will be evaluated.Results:Recruitment for this study began in January 2022 and is expected to be completed in the summer of 2023.Conclusions:Results of this study will provide important clinical and scientific knowledge on the feasibility of a partly supervised home-based exercise prehabilitation program in a vulnerable patient population. This might ease the path to implementing prehabilitation programs in unfit patients undergoing complex abdominal surgery, such as pancreatic surgery.Trial Registration:ClinicalTrials.gov NCT05496777; https://classic.clinicaltrials.gov/ct2/show/NCT05496777International Registered Report Identifier (IRRID):DERR1-10.2196/46526

Carbohydrates in forage crops can be divided into neutral detergent-insoluble fiber and neutral detergent-soluble carbohydrates (NDSC); the latter includes organic acids (OA), total ethanol:water-soluble carbohydrates (TESC), starch, and neutral detergent-soluble fiber (NDSF). The accurate and efficient estimation of NDSC in forage crops is essential for improving the performance of dairy cattle. In the present study, visible and near-infrared reflectance spectroscopy (NIRS) were applied to evaluate the feasibility of predicting OA, TESC, starch, NDSF, NDSC, and all related constituents used to calculate these 5 carbohydrate fractions in timothy and alfalfa. Forage samples (n=1,008) of timothy and alfalfa were taken at the first and second harvests at 2 sites in 2007; samples were dried, ground, and then scanned (400 to 2,500nm) using an NIRSystems 6500 monochromator. A calibration (n=60) and a validation (n=15) set of samples were selected for each species and then chemically analyzed. Concentrations of TESC and NDSC in timothy, as well as starch in alfalfa, were successfully predicted, but many other carbohydrate fractions were not predicted accurately when calibrations were performed using single-species sample sets. Both sets of samples were combined to form new calibration (n=120) and validation (n=30) sets of alfalfa and timothy samples. Calibration and validation statistics for the combined sets of alfalfa and timothy samples indicated that TESC, starch, and NDSC were predicted successfully, with coefficients of determination of prediction (RP2) of 0.92, 0.89, and 0.93, and a ratio of prediction to deviation (RPD) of 3.3, 3.1, and 3.6, respectively. The NDSF prediction was classified as moderately successful RP2=0.88,   RPD=2.8. The NIRS prediction of OA was unsuccessful RP2=0.38,   RPD=1.3. All related constituents were predicted successfully RP2>0.90,   RPD>3.0 by NIRS except ethanol-insoluble residual OM, with RP2=0.75   and   RPD=1.9. Our results confirm the feasibility of using NIRS to predict NDSC, its fractions, and other related constituents, except for OA and ethanol-insoluble residual OM, in timothy and alfalfa forage samples.

The response of splanchnic tissue metabolism to different levels of metabolizable protein (MP) was measured in 6 catheterized multiparous lactating Holstein cows. Three diets, balanced to provide similar energy intakes and increasing amounts of MP (g/d)—1922 (low), 2264 (medium), and 2517 (high)—were fed during 21-d experimental periods according to a replicated Latin square. On d 18, 19, or 20, six hourly blood samples were collected simultaneously from the portal and hepatic veins plus an artery to determine net fluxes of nutrients across the portal-drained viscera and the liver. Yields of milk and protein increased, as did urinary N excretion with increasing MP. Portal absorption of essential amino acids (EAA) increased linearly with increasing MP supply, as did liver removal of His, Met, and Phe. In contrast, liver removal of the branched-chain AA (BCAA) and lysine was unaffected by diets. With increasing MP, the ratio of milk output to postliver supply of BCAA, Thr, and Lys decreased linearly, indicating oxidation of these AA in the peripheral tissues. Concomitant to a decreased catabolism of EAA in the liver (His, Met, Phe, and Thr) and/or in peripheral tissues (BCAA, Lys, and Thr), the efficiency of transfer of absorbed EAA into milk protein decreases markedly as protein supply increases. The efficiency of transfer of absorbed AA into milk also varies greatly between AA. These 2 important factors should be taken into account when building predictive schemes for milk protein output.

The mineral concentration of forage grasses plays a significant role in 2 metabolic disorders in dairy cattle production, namely, hypocalcemia (milk fever) and hypomagnesemia (grass tetany). Risks of occurrence of these 2 metabolic disorders can be evaluated by determining the dietary cation-anion difference (DCAD) and the grass tetany (GT) index of forages and specific rations. The objective of this study was to evaluate the feasibility of predicting timothy (Phleum pratense L.) mineral concentrations of Na, K, Ca, Mg, Cl, S, and P, the DCAD, and the GT index by near-infrared reflectance spectroscopy (NIRS). Timothy samples (n = 1,108) were scanned using NIRS and analyzed for the concentration of 7 mineral elements. Calculations of the DCAD were made using 3 different formulas, and the GT index was also calculated. Samples were divided into calibration (n = 240) and validation (n = 868) sets. The calibration, cross-validation, and prediction for mineral concentrations, the DCAD, and the GT index were performed using modified partial least squares regression. Concentrations of K, Ca, Mg, Cl, and P were successfully predicted with coefficients of determination of prediction RP2 of 0.69 to 0.92 and coefficients of variation of prediction (CVP) ranging from 6.6 to 11.4%. The prediction of Na and S concentrations failed, with respective Rp2 of 0.58 and 0.53 and CVP of 82.2 and 12.9%. The 3 calculated DCAD and the GT index were predicted successfully, with RP2 >0.90 and CVP <20%. Our results confirm the feasibility of using NIRS to predict K, Ca, Mg, and Cl concentrations, as well as the DCAD and the GT index, in timothy.