RISKS AND BENEFITS OF DIFFERENT ANESTHESIA TECHNIQUES FOR TRANSURETHRAL RESECTIONS

Transuretralne resekcije kirurški su zahvati na mokraćnom mjehuru, mokraćnoj cijevi ili prostati, a izvode se uz pomoć resektoskopa. Osobe liječene ovom metodom najčešće su starije životne dobi s više pridruženih bolesti. Zbog toga je ova skupina bolesnika izazov prigodom odabira vrste anestezije. Hemodinamska stabilnost, brzo otkrivanje komplikacija intra- i poslijeoperacijski i nepromijenjeno stanje svijesti bolesnika od presudne su važnosti. Pregledom literature i baze podataka cilj ovoga rada je prikazati moguće prednosti i nedostatke anestezioloških tehnika kod bolesnika podvrgnutih transuretralnim resekcijama. Zaključujemo da spinalna anestezija s minimalnim dozama lokalnog anestetika u kombinaciji s opioidom ima prednost pred ostalim vrstama anestezije zbog minimalnog utjecaja na hemodinamsku stabilnost i bolje poslijeoperacijske analgezije. Anesteziolog mora biti svjestan mogućih rizika i prednosti svake tehnike, ali se za bolji ishod preporučuje ipak individualan pristup bolesniku.Transurethral resections are procedures on urinary bladder, urethra or prostate performed with a resectoscope. Patients undergoing this type of surgery are usually older with associated comorbidities. For this reason, they represent a challenge for anesthesiologists and anesthesia technique as well. Hemodynamic stability and the possibility to diagnose complications during or after the operation without impairment of consciousness is of great importance. After detailed literature and database search, we reviewed different approaches to anesthesia for the specifi c group of patients. According to our search, we conclude that spinal anesthesia with minimal doses of local anesthetic in combination with an opioid is preferable over general anesthesia because of the minimal effect on hemodynamic stability and postoperative analgesic requirement. The anesthesiologist must be aware of the risks and benefi ts of each anesthesia technique; therefore, individual approach is crucial for optimal outcome

SAMOPROCIJENJENA SURADLJIVOST BOLESNIKA KORELIRA SA SERUMSKIM FOSFOROM, OSTATNOM DIUREZOM I STATUSOM UHRANJENOSTI BOLESNIKA NA HEMODIJALIZI: MEĐUNARODNO, MULTICENTRIČNO ISTRAŽIVANJE

Compliance is a major obstacle to achieving phosphorus control in the majority of patients with end-stage renal disease. We investigated self-reported medication adherence and its correlation with serum phosphate levels and nutritional status in hemodialysis patients. A total of 417 patients from Croatia, Montenegro and Bosnia and Herzegovina, mean age 63.82 (range, 21-92) years, were included in the study. There were 55.1% of male patients with the mean dialysis vintage of 68.67 (range, 3-456) months. A signifi cant positive correlation was found between self-reported adherence and serum phosphorus (0.192), and negative correlation with hemoglobin, prealbumin, albumin, Kt/V and residual diuresis (-0.187, -0.227, -0.100, 0.192, and -0.106, respectively). On the other hand, the number of pills taken daily correlated signifi cantly with residual diuresis, serum prealbumin, serum glucose, triglycerides, ferritin and ultrafi ltration volume (0.241, 0.154, 0.158, 0.112, 0.201 and 0.125, respectively). In conclusion, self-reported medication adherence correlates with serum phosphate levels, residual diuresis and nutritional status in hemodialysis patients.Suradljivost je glavna prepreka kontroli fosfora u većine bolesnika sa završnim stadijem kronične bubrežne bolesti. Istražili smo povezanost suradljivosti s uzimanjem lijekova, procijenjene od strane samih bolesnika, s koncentracijom fosfora u serumu i statusom uhranjenosti bolesnika na hemodijalizi. U istraživanje je uključeno 417 bolesnika iz Hrvatske, Crne Gore i Bosne i Hercegovine. Prosječna dob bila je 63,82 godine (raspon, 21-92), 55,1 % ih je bilo muškog spola, prosječno liječenih dijalizom 68,67 (raspon, 3-456) mjeseci. Nađena je statistički značajna pozitivna korelacija između suradljivosti i serumskog fosfora (0,192), a negativna s prealbuminom, albuminom, Kt/V i ostatnom diurezom (redom, -0,187, -0,227, -0,100, 0,192 i -0,106). S druge strane, broj dnevno unesenih tableta je statistički značajno korelirao s ostatnom diurezom, serumskim prealbuminom, glukozom, trigliceridima, feritinom i volumenom ultrafi ltracije (redom, 0,241, 0,154, 0,158, 0,112, 0,201 i 0,125). Zaključno, samoprocijenjena suradljivost bolesnika korelira sa serumskim fosforom, ostatnom diurezom i statusom uhranjenosti bolesnika na hemodijalizi

SAMOPROCIJENJENA SURADLJIVOST BOLESNIKA KORELIRA SA SERUMSKIM FOSFOROM, OSTATNOM DIUREZOM I STATUSOM UHRANJENOSTI BOLESNIKA NA HEMODIJALIZI: MEĐUNARODNO, MULTICENTRIČNO ISTRAŽIVANJE

Compliance is a major obstacle to achieving phosphorus control in the majority of patients with end-stage renal disease. We investigated self-reported medication adherence and its correlation with serum phosphate levels and nutritional status in hemodialysis patients. A total of 417 patients from Croatia, Montenegro and Bosnia and Herzegovina, mean age 63.82 (range, 21-92) years, were included in the study. There were 55.1% of male patients with the mean dialysis vintage of 68.67 (range, 3-456) months. A signifi cant positive correlation was found between self-reported adherence and serum phosphorus (0.192), and negative correlation with hemoglobin, prealbumin, albumin, Kt/V and residual diuresis (-0.187, -0.227, -0.100, 0.192, and -0.106, respectively). On the other hand, the number of pills taken daily correlated signifi cantly with residual diuresis, serum prealbumin, serum glucose, triglycerides, ferritin and ultrafi ltration volume (0.241, 0.154, 0.158, 0.112, 0.201 and 0.125, respectively). In conclusion, self-reported medication adherence correlates with serum phosphate levels, residual diuresis and nutritional status in hemodialysis patients.Suradljivost je glavna prepreka kontroli fosfora u većine bolesnika sa završnim stadijem kronične bubrežne bolesti. Istražili smo povezanost suradljivosti s uzimanjem lijekova, procijenjene od strane samih bolesnika, s koncentracijom fosfora u serumu i statusom uhranjenosti bolesnika na hemodijalizi. U istraživanje je uključeno 417 bolesnika iz Hrvatske, Crne Gore i Bosne i Hercegovine. Prosječna dob bila je 63,82 godine (raspon, 21-92), 55,1 % ih je bilo muškog spola, prosječno liječenih dijalizom 68,67 (raspon, 3-456) mjeseci. Nađena je statistički značajna pozitivna korelacija između suradljivosti i serumskog fosfora (0,192), a negativna s prealbuminom, albuminom, Kt/V i ostatnom diurezom (redom, -0,187, -0,227, -0,100, 0,192 i -0,106). S druge strane, broj dnevno unesenih tableta je statistički značajno korelirao s ostatnom diurezom, serumskim prealbuminom, glukozom, trigliceridima, feritinom i volumenom ultrafi ltracije (redom, 0,241, 0,154, 0,158, 0,112, 0,201 i 0,125). Zaključno, samoprocijenjena suradljivost bolesnika korelira sa serumskim fosforom, ostatnom diurezom i statusom uhranjenosti bolesnika na hemodijalizi

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research