Locul medicaţiei alfablocante selective în tratamentul prostatitei cronice

Abstract Although the term “chronis prostatitis" has been used for different entities that cannot be easily separated, it has been estimated that up to half of all men suffer from symptoms of prostatitis at some point in their lives. Having these aspects in mind, the authors have tried, in this prospective study, to evaluate the impact of introducing selective alfa blockers in the treatment of chronic prostatitis(Tamsulosin and Alfuzosine).The including criterias were: age between 30 and 55; at least one episode of prostatitis in the past; a normal prostate size and a postvoid residual urine volume< 20 ml.Each patient has recived a file containing general recom andations and has filled out two questionforms (NIH-CPSID Chronic Prostatitis Symptom Index Domain), to evaluate the situation before and three months from the treatment after 3 month. Based on this we have evaluated the benefits of the treatment from the point of view of: pain, urinary symptoms and a better quality of life. The preliminary results show that urinary simptoms have been ameliorated and that almost all the patients have noticed the benefits of selective alfa blockers. The ondulant evolution of the illness raises numerous obstacles for urologists trying to find the ideal treatment for prostatitis Rezumat Pornind de la dificultăţile de diagnostic şi de tratament ale prostatitei cronice (unanim recunoscută in lumea urologică) şi de la estimarea că aproape jumătate din numărul bărbaţilor vor prezenta simptome de prostatită la un moment dat, am încercat să evaluăm într-un studiu prospectiv, aflat în desfăşurare, impactul medicaţiei alfablocante selective (Tamsulosin, Alfuzosin SR) asupra simptomatologiei acestei patologii. Au fost incluşi în studiu pacienţi cu vârsta între 30 şi 55 de ani, cu cel puţin un episod de prostatită în antecedente, dimensiunile prostatei (evaluate echografic) în limite normale, reziduu vezical d" 20ml. Fiecare pacient a primit un dosar care cuprinde o fişă cu recomandări generale şi două chestionare de evaluare (NIHCPSI) la început şi după 3 luni de la tratament. Schema de tratament a inclus: antibioterapie, tratament cu antiinflamatorii, alfablocantul selectiv (Tamsulosin sau Alfuzosin). Am introdus pentru pacienţii care admiteau un consum important de proteine animale şi tratament cu Allopurinol, dar lotul este încă prea mic pentru a trage concluzii. Pe baza chestionarelor am evaluat atât beneficiile tratamentului sub raportul durerii (totalul punctelor 1, 2, 3, 4), al simptomelor urinare (totalul punctelor 5 şi 6), cât şi impactul asupra calităţii vieţii (7, 8, 9). Rezultatele preliminare ale studiului nostru la lotul respectiv indică benefică asocierea alfablocantelor, în special pentru ameliorarea simptomelor urinare. Considerăm, totodată, că evoluţia ondulantă a bolii ridică numeroase obstacole în calea stabilirii unui tratament ideal în prostatita cronică

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial: study protocol for a multicentre international trial of cardiac output-guided fluid therapy with low-dose inotrope infusion compared with usual care in patients undergoing major elective gastrointestinal surgery.

INTRODUCTION: Postoperative morbidity and mortality in older patients with comorbidities undergoing gastrointestinal surgery are a major burden on healthcare systems. Infections after surgery are common in such patients, prolonging hospitalisation and reducing postoperative short-term and long-term survival. Optimal management of perioperative intravenous fluids and inotropic drugs may reduce infection rates and improve outcomes from surgery. Previous small trials of cardiac-output-guided haemodynamic therapy algorithms suggested a modest reduction in postoperative morbidity. A large definitive trial is needed to confirm or refute this and inform widespread clinical practice. METHODS: The Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial is a multicentre, international, parallel group, open, randomised controlled trial. 2502 high-risk patients undergoing major elective gastrointestinal surgery will be randomly allocated in a 1:1 ratio using minimisation to minimally invasive cardiac output monitoring to guide protocolised administration of intravenous fluid combined with low-dose inotrope infusion, or usual care. The trial intervention will be carried out during and for 4 hours after surgery. The primary outcome is postoperative infection of Clavien-Dindo grade II or higher within 30 days of randomisation. Participants and those delivering the intervention will not be blinded to treatment allocation; however, outcome assessors will be blinded when feasible. Participant recruitment started in January 2017 and is scheduled to last 3 years, within 50 hospitals worldwide. ETHICS/DISSEMINATION: The OPTIMISE II trial has been approved by the UK National Research Ethics Service and has been approved by responsible ethics committees in all participating countries. The findings will be disseminated through publication in a widely accessible peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER: ISRCTN39653756.The OPTIMISE II trial is supported by Edwards Lifesciences (Irvine, CA) and the UK National Institute for Health Research through RMP’s NIHR Professorship

Protezarea ureterului după ureteroscopia retrogradă - experienţa Clinicii Urologice Iaşi

Introducere. În perioada martie 1996 - iulie 2002 în Clinica Urologică laşi s-au efectuat un număr de 200 ureteroscopii retrograde (URSR) din care 32 au fost în scop diagnostic iar 168 în scop terapeutic (163 - extrageri de calculi ureterali pelvini, iliaci sau lombari inferiori şi 5 - extrageri de sonde ureterale JJ malpozijionate). Obiective. Autorii analizează retrospectiv atât cazurile la care au fost inserate sonde ureterale (sondă JJ sau sondă ureterală simplă), cât şi cazurile în care s-a considerat că nu este necesară protezarea ureterului, din perspectiva diecultă|ilor şi complicaţiilor intraoperatorii şi a celor postoperatorii, Metodă. Initial a fost folosit un ureteroscop OLYMPUS 13,5 CH şi litotritia ultrasonică a calculilor, utilizânduse sonotrodul, iar din aprilie 1999 s-a utilizat un ureteroscop semirigid WOLF 8,0 CH şi litotritie pneumatică. Dacă în 1996 s-au practicat doar 6 ureteroscopii, în primele 6 luni ale anului 2002 au fost efectuate 60 asemenea proceduri. Pentru ureteroscopiile diagnostice cu biopsie doar la 2 cazuri s-a considerat necesară inserţia unei sonde JJ în contextul sângerării, la marea majoritate a ureteroscopiilor terapeutice am considerat utilă protezarea ureterului, mai ales cu sonde JJ. Sondele au fost bine tolerate iar suprimarea lor s-a făcut la 2-4 săptămâni după ureteroscopie. Toate cele 12 cazuri la care nu s-a introdus o sondă ureterală la sfârşitul ureteroscopiei retrograde au avut o evoluţie simplă. Concluzii. Pe baza experienţei acumulate considerăm că inserţia unei sonde JJ este utilă, pentru o perioadă de 2-4 săptămâni, ori de cît ori se realizează: o fragmentare dificilă, sângerarea intraoperatorie este importantă, există o stenoză ureterală asociată, se produce o perforaţie ureterală în timpul procedurii sau există fragmente migrate în ureterul lombar superior sau bazinet ori în condiţiile în care se reuşeşte doar fragmentarea calculului. Atunci când se realizează o bună fragmentare iar leziunile provocate de calcul sau de instrumente sunt minore, o sondă ureterală simplă pentru 2-3 zile este o soluţie bună. Ori de câte ori calculul este extras facil, monobloc iar ureterul este de aspect normal, neprotezarea ureterului cu o sondă este o variantă ce credem că trebuie avută în vedere

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background: Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods: The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results: A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion: Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study

Background: Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications. Methods: We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients' preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARRadj). This study is registered with ClinicalTrials.gov, number NCT01865513. Findings: Between June 16, 2014, and April 29, 2015, data from 22 803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21 694); ORadj 1·86, 95% CI 1·53–2·26; ARRadj −4·4%, 95% CI −5·5 to −3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1·31, 95% CI 1·15–1·49; ARRadj −2·6%, 95% CI −3·9 to −1·4) and the administration of reversal agents (1·23, 1·07–1·41; −1·9%, −3·2 to −0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1·03, 95% CI 0·85–1·25; ARRadj −0·3%, 95% CI −2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82–1·31; −0·4%, −3·5 to 2·2) was associated with better pulmonary outcomes. Interpretation: We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications. Funding: European Society of Anaesthesiology

Mortality after surgery in Europe: a 7 day cohort study

Background: Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfirmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe.Methods: We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ² and Fisher’s exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Significance was set at p&lt;0·05. We constructed multilevel logistic regression models to adjust for the differences in mortality rates between countries.Findings: We included 46 539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients were admitted to critical care after surgery with a median length of stay of 1·2 days (IQR 0·9–3·6). 1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude mortality rates varied widely between countries (from 1·2% [95% CI 0·0–3·0] for Iceland to 21·5% [16·9–26·2] for Latvia). After adjustment for confounding variables, important differences remained between countries when compared with the UK, the country with the largest dataset (OR range from 0·44 [95% CI 0·19 1·05; p=0·06] for Finland to 6·92 [2·37–20·27; p=0·0004] for Poland).Interpretation: The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients.Funding: European Society of Intensive Care Medicine, European Society of Anaesthesiology

Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: A 7-day cohort study of elective surgery

The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems. Methods. We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest). Results. A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a threefold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a two-fold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failureto- rescue, indicating differences between hospitals in the risk of death among patients after they develop complications. Conclusions. Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries