Information and anesthesia: what does the patient desire?

OBJECTIVE: The aim of the study was to assess the patient's desire for information regarding their preoperative care and to assess the anaesthetists' perception of that desire. STUDY DESIGN: Questionnaire. METHODS: The question: "Would you like to be fully informed about" 13 topics of the perioperative management was asked to 106 patients at the time of the preoperative visit. Two answers were possible: Yes I want to know; No I don't want to know. 22 senior anaesthesists were also interviewed and were asked to speculate about the patients response to each item. Data were compared with those of a similar questionnaire used in different countries. RESULTS: One hundred patients who underwent general, orthopaedic, urologic surgery were interviewed. Patients sought information most frequently concerning: postoperative pain and postoperative recovery (88%), time for ambulation (83%), duration of anaesthesia (77%) and different methods of anaesthesia (77%). Only 63% patients desired to be informed about all possible complications of anaesthesia. Senior anaesthesists had a correct perception of patients desire for information about the 4 important items but not for the complications of anaesthesia. CONCLUSION: Our study suggests that an exhaustive information about anaesthesia is not wished by every patients.     

Perioperative deep vein thrombosis prevention: what works, what does not work and does it improve outcome?

PURPOSE OF REVIEW: To critically evaluate the benefit/risk ratio of some strategies for venous thromboembolism prophylaxis (VTE) RECENT FINDINGS: A growing body of evidence shows that graduated elastic stockings are not effective in medical patients. Special surgical settings as bariatric surgery deserve attention with a high VTE risk and no evidence-based data with regard to prophylaxis. Extended prophylaxis is being evaluated in these patients, whereas its efficacy has been demonstrated in abdominal and pelvic surgery for cancer. New oral anticoagulants are about to change the clinical landscape but yet some issues are not solved: no antidote, no monitoring, no standardization for the perioperative bridging in patients with therapeutic doses. In addition, they have not been tested in fragile patients in whom an increased bleeding risk could be feared. Finally, a large bunch of guidelines are now available to help the physician in the decision-making process. SUMMARY: Studies evaluating the benefit/risk ratio of graduated elastic stockings should now take place in surgery. Increasing and splitting the anticoagulant dose (mainly low molecular weight heparins) by two injections a day could be recommended in bariatric surgery and morbidly obese patients. New anticoagulant agents should also be tested in special populations, following the European Medicines Agency guidance. The methodology of clinical trials in VTE prophylaxis has to be moved forward, pending the choice of debatable surrogate end-points as asymptomatic venous thrombosis and disputed issues on the assessment of major bleeding.     

The annual scientific conference: what does the future hold?

It is now expected that medical practitioners around the world will engage in ongoing professional development. Many Colleges, medical associations and societies have made completion of appropriate continuing professional development (CPD) mandatory and medical registration in some jurisdictions is predicated on participation in a CPD programme. This commits doctors to a programme of lifelong learning.     

Living anonymous kidney donation: what does the public think?

BACKGROUND: Health professionals are increasingly turning to living organ donation to augment cadaveric donation. Although living donation is currently performed with donors who are either genetically or emotionally related to the recipient, a 1997 British Columbia Transplant Society survey indicated that 32% of BC residents would be willing to donate a kidney, while alive, to a stranger (unpublished data). The goal of this study is to tap the public pulse about the living anonymous donor (LAD) by replicating and expanding the 1997 findings. METHODS: Five hundred BC residents completed a telephone survey including demographic information, questions about their organ donation behaviors and attitudes, and their willingness to donate a kidney, while alive, to particular individuals (child, spouse, parent, relative, friend, and stranger). To improve the methodological rigor of the 1997 study, an informed condition was added in the current study where participants learned about living donation before being asked about their willingness to donate. RESULTS: There were no differences among the 1997 results and the two conditions in the 2000 survey. Twenty-eight percent of participants in the uninformed condition and 29% of participants in the informed condition indicated that they would be willing to be LADs. LADs were more likely than self-reported non-donors to have registered as cadaveric donors and to endorse attitudes that were congruent with wanting to donate to a stranger. CONCLUSIONS: This study replicates the 1997 findings and increases confidence that a significant minority of British Columbians support living anonymous donation and that some would consider becoming LADs themselves.     

Incentives for living kidney donation: what does the public think?

This mini-review describes a number of recent surveys that have been performed to study public opinion on the idea of introducing incentives for living kidney donation. The results of these surveys are comparable: about a quarter of the population is in favor of this idea, whereas the majority is opposed or undecided.     

Prostate cancer and vitamin D: what does the evidence really suggest?

The optimal approach to vitamin D supplementation for the average healthy person is debatable. In patients with cancer, the role of vitamin D supplementation, possibly in treatment, is even less clear. Vitamin D is shown to play a role in prostate cancer biology; however, the clinical data have not consistently demonstrated a link. Additional studies are needed to determine if higher doses of vitamin D supplements could benefit selected populations (ie, the elderly or patients with cancer) even if they may not be beneficial for the general population.     

Awake craniotomy for brain tumor resection - what does the anaesthesist do?

The numbers of awake craniotomies performed worldwide are rising. The technique allows a maximum of brain tumor resection with a minimal risk of functional damage in patients, where the tumor is growing close to functional relevant brain areas. The maximal resection improves the long-term outcome of these patients. For the anaesthetist awake craniotomy can be challenging, because he misses the advantages of general anaesthesia (safe airway, suppressed reflexes), but has to deal with the added risks of brain mapping and cortical stimulation (induction of epileptic insults). After adequate patient selection and intense (psychological) preparation a careful anaesthesiologist will be able to accompany the patient throughout this procedure safe and comfortable. This article describes the anaesthesiological management at Erasmus MC, University Medical Centre Rotterdam, The Netherlands, in detail.     

Restitution of the aortic valve: what is new, what is proven, and what is obsolete?

Restitution strategies of the insufficient aortic valve belong to the clinical armamentarium. To date, the accumulated body of evidence comprises 126 articles dealing with restitution strategies on the insufficient aortic valve with concomitant aortic surgery. In a cumulative analysis an almost identical number of reimplantation (506) and remodeling (489) procedures were found in the literature, whereas 357 patients underwent aortic valve resuspension. The cumulative results tend to favor the reimplantation technique in terms of longevity of the reconstruction, particularly in congenital degenerative disorders of the aortic wall, whereas remodeling appears to exhibit a more physiologic behavior of the reconstructed valve and re-suspension serves as a simplified approach particularly in acute type A dissection. Although restitution of the native aortic valve has its place in current treatment options, the accumulated worldwide numbers indicate that it is not yet routinely implemented in the vast majority of cardiac institutions.     

Nocturnal non-dipping: what does it augur?

The non-dipping pattern of blood pressure (defined as a nocturnal fall of less than 10%) occurs in about 25% of hypertensives, with increased prevalence in certain sub-groups such as diabetics, African-Americans, and patients with renal disease. It almost certainly has multiple causes, including factors such as the levels of activity and arousal during both the day and the night, the depth and quality of sleep, and the activity of the sympathetic nervous system, among others. In patients with uncomplicated hypertension, the reproducibility is relatively low. There is evidence suggesting that the non-dipping pattern may have an adverse prognosis: thus, it appears to predict the progression of renal disease, to be associated with increased target-organ damage (in some studies), and also to predict increased cardiovascular morbidity. Antihypertensive drug treatment can normalize the non-dipping pattern, but the therapeutic consequences of this are unknown.     

At the beginning of the third millennium: what kind of surgery, what kind of surgeon?

Technological progress and the evolution of biological knowledge lead us to expect major developments in the fields of organ replacement, minimally invasive surgery and tumour therapy in the coming decades. It is widely believed that xenotransplantation may offer a possible solution to the problem of the current chronic shortage of donors, though their use at present encounters formidable immunological obstacles, particularly as regards discordant transplants. Genetic engineering and the realisation of transgenic donors as well as new strategies aimed at modifying the immune status of the donor may well be the key to new developments in this sector. Selective culturing of tissues and the production of totally implantable artificial organs are additional lines of research which may provide useful means of meeting the increasing demand for organs. The enormous advances made in the field of high-tech solutions applied to the biomedical disciplines are destined to open up new frontiers in diagnostics, operating technique and the permanent training of surgeons. In particular, we are about to witness an extension of the use of computer technology and robotics, embracing the simulation and reproduction of virtual reality, telemedicine (teleconsulting and telesurgery) and the creation of experimental models. Minimally invasive surgery will unquestionably benefit from this progress with the possibility of extending its range of indications to procedures in which human limitations are more evident owing to difficulties of access and the size of the target, at the same time guaranteeing high-precision manoeuvres. In the oncological field, high expectations accompany the advances in our knowledge of molecular biology with the genetic mapping of tumours which may pave the way for screening programs and gene therapy. Alongside the scientific and technological development of the surgery of the future, we can expect to see the increasing emergence of: a) economic problems related to the progressive increase in healthcare costs, amongst other things as a result of the powerful impact of high-tech solutions; b) social problems in terms of the inevitable conflict between cost-containment policies and the right to healthcare; c) moral and bioethical problems relating to the possible establishment of genetic registries and to the different patient-care provider relationship which is likely to come about as the result of the interference of machines or robots. The surgeon's persona may undergo profound changes, not merely from the technical and professional training standpoint, but also with regard to his or her effective role, which may no longer be that of a central, dominant figure, but may be scaled down in a context of multidisciplinary co-operation.