Respiratory dysfunction in ventilated patients: can inspiratory muscle training help?

Respiratory muscle dysfunction is associated with prolonged and difficult weaning from mechanical ventilation. This dysfunction in ventilator-dependent patients is multifactorial: there is evidence that inspiratory muscle weakness is partially explained by disuse atrophy secondary to ventilation, and positive end-expiratory pressure can further reduce muscle strength by negatively shifting the length-tension curve of the diaphragm. Polyneuropathy is also likely to contribute to apparent muscle weakness in critically ill patients, and nutritional and pharmaceutical effects may further compound muscle weakness. Moreover, psychological influences, including anxiety, may contribute to difficulty in weaning. There is recent evidence that inspiratory muscle training is safe and feasible in selected ventilator-dependent patients, and that this training can reduce the weaning period and improve overall weaning success rates. Extrapolating from evidence in sports medicine, as well as the known effects of inspiratory muscle training in chronic lung disease, a theoretical model is proposed to describe how inspiratory muscle training enhances weaning and recovery from mechanical ventilation. Possible mechanisms include increased protein synthesis (both Type 1 and Type 2 muscle fibres), enhanced limb perfusion via dampening of a sympathetically-mediated metaboreflex, reduced lactate levels and modulation of the perception of exertion, resulting in less dyspnoea and enhanced exercise capacity.     

Improving wellbeing in patients undergoing dialysis: Can meditation help?

Coping with the stress and anxiety caused by end stage kidney disease (ESKD ) symptoms, treatment, restrictions, and social, financial and family stressors, consumes many afflicted with kidney disease. Meditation has been shown to decrease anxiety and stress, and improve wellbeing and quality of life of people with chronic disease. However, the clinical uptake of meditation is low in the ESKD dialysis population. This review describes what meditation and mindful meditation are and how they have been used for people with ESKD . Further research, using active control conditions and larger sample size, is required to identify effective meditation interventions that can improve the wellbeing of our patients and their ability to cope with the demands of ESKD .     

Upper urinary tract stone disease in patients with poor performance status: active stone removal or conservative management?

Background

It remains controversial as to whether active stone removal should be performed in patients with poor performance status because of their short life expectancy and perioperative risks. Our objectives were to evaluate treatment outcomes of active stone removal in patients with poor performance status and to compare life prognosis with those managed conservatively.

Methods

We retrospectively reviewed 74 patients with Eastern Cooperative Oncology Group performance status 3 or 4 treated for upper urinary tract calculi at our four hospitals between January 2009 and March 2016. Patients were classified into either surgical treatment group or conservative management group based on the presence of active stone removal. Stone-free rate and perioperative complications in surgical treatment group were reviewed. In addition, we compared overall survival and stone-specific survival between the two groups. Cox proportional hazards analysis was performed to investigate predictors of overall survival and stone-specific survival.

Results

Fifty-two patients (70.3%) underwent active stone removal (surgical treatment group) by extracorporeal shock wave lithotripsy (n = 6), ureteroscopy (n = 39), percutaneous nephrolithotomy (n = 6) or nephrectomy (n = 1). The overall stone-free rate was 78.8% and perioperative complication was observed in nine patients (17.3%). Conservative treatment was undergone by 22 patients (29.7%) (conservative management group). Two-year overall survival rates in surgical treatment and conservative management groups were 88.0% and 38.4%, respectively (p < 0.01) and two-year stone-specific survival rates in the two groups were 100.0% and 61.3%, respectively (p < 0.01). On multivariate analysis, stone removal was not significant, but was considered a possible favorable predictor for overall survival (p = 0.07). Moreover, stone removal was the only independent predictor of stone-specific survival (p < 0.01).

Conclusions

Active stone removal for patients with poor performance status could be performed safely and effectively. Compared to conservative management, surgical stone treatment achieved longer overall survival and stone-specific survival.

     

Postoperative pain management: can transdermal patches help?

While patient-controlled analgesia and intermittent intravenous opioids are primarily used for pain control, transdermal drug delivery is a possible adjuvant treatment.     

Fesoterodine in patients with overactive bladder syndrome: can the severity of baseline urgency urinary incontinence predict dosing requirement?

Study Type – Therapy (RCT)
Level of Evidence 1b

OBJECTIVES

To determine whether baseline urgency urinary incontinence (UUI) episodes predict the need for increased doses of fesoterodine in patients with overactive bladder (OAB), as clinicians would benefit from data that help to predict which patients require higher doses of antimuscarinics to manage UUI episodes.

PATIENTS AND METHODS

In this pooled analysis of data from two double‐blind, placebo‐controlled trials, patients were randomized to placebo or fesoterodine 4 or 8 mg for 12 weeks and stratified into tertiles (>0–<2, 2–<4, or ≥4) according to the number of UUI episodes/24 h as recorded in 3‐day bladder diaries at baseline. The change in mean UUI episodes/24 h from baseline to end of study was assessed using analysis of covariance.

RESULTS

In a post hoc analysis of data from two clinical trials, there were significant reductions from baseline in UUI episodes for fesoterodine 4 and 8 mg vs placebo in patients (n) with >0–<2 (422), 2–<4 (424) and ≥4 (481) UUI episodes at baseline (all P < 0.01). In patients with 2–<4 and ≥4 UUI episodes at baseline, fesoterodine 8 mg gave significantly greater mean reductions (?1.92 and ?4.17, respectively) vs fesoterodine 4 mg (?1.43 and ?3.31) (P < 0.05). The most common adverse events were dry mouth (placebo, 8%; fesoterodine 4 mg, 19%; and 8 mg, 35%) and constipation (placebo, 2%; fesoterodine 4 mg, 5%; and 8 mg, 6%).

CONCLUSION

Fesoterodine 4 and 8 mg significantly reduced UUI episodes vs placebo; this effect appeared to be greater with fesoterodine 8 mg in patients with ≥2 UUI episodes/24 h at baseline. Fesoterodine was well tolerated, although higher doses increased the incidence of adverse events. These findings might aid the clinical identification of patients with OAB who would most benefit from increasing the dose of fesoterodine from 4 to 8 mg.     

How reliable is conventional urinary cytology in post-transplant patients?

INTRODUCTION AND OBJECTIVES: Factors like cold, flushing solutions, ischemia and reperfusion may alter the microscopic appearance of transitional cells leading to falsely positive results of urinary cytology in patients after kidney transplantation. After seeing 1 patient presenting with two consecutive highly suspicious cytology specimens 3 days after transplantation and no sign of urothelial tumor at retrograde urography, we analyzed the cytological picture of transitional cells in post-transplant patients. MATERIAL AND METHODS: We investigated 31 urine specimens of 11 patients undergoing kidney transplantation preoperatively (if possible) and on days 1, 3 and 9 postoperatively. Microscopic cytology was performed by using Papanicolaou's criteria: 0 - no cytology possible (no cells), I+II - negative cytology, III - doubtful, IV - suspicious for tumor, V - tumor cells. All microscopic examinations were performed by one experienced senior pathologist. RESULTS: Mean patient age was 55.8 (+/- 17.5) years, mean residual diuresis 856 (+/- 636) ml, mean cold ischemia time 13.6 (+/- 6.4) h, mean creatinine level on day 1: 582 microM/l, day 3: 533 microM/l and day 9: 259 microM/l. None of the urinary cytology results were suspicious for malignant transformation (Papanicolaou I+II). No patient presented signs of urothelial malignancy after a mean follow-up of 3 months. CONCLUSION: Although microscopic urinary cytology may be falsely positive in 1-12% of non-transplanted patients due to urothelia atypia, inflammation or radiation/chemotherapy, the present study suggests that conventional microscopic cytology examinations in post-transplant patients are not heavily altered and do not lead to an increased false-positive rate.     

Incisional hernia in patients at risk: can it be prevented?

Introduction  

Incisional hernia is a long-term complication of laparotomy. Its exact frequency varies according to different authors, but is always around 10–15%. There are patients who present with systemic associated diseases [chronic obstructive pulmonary disease (COPD), obesity, severe cardiopathies, immunodeficiencies, etc.] that favour or increase the risk of appearance of an incisional hernia. The aim of the present study was to assess whether the prophylactic placement of a polypropylene mesh in patients at risk can reduce or avoid the appearance of an incisional hernia.     

Optional filters in trauma patients: can retrieval rates be improved?

Prophylactic inferior vena cava interruption may be appropriate in trauma patients at risk for pulmonary embolism for whom anticoagulation is contraindicated. The Recovery filter is approved for removal up to 180 days from insertion. High retrieval rates need to be achieved before we can lower the threshold for inserting these filters prophylactically. The objective of this study was to evaluate the retrieval rate of the Recovery filter in this patient population and how it has influenced our practice. This is a retrospective study in which the records of 122 consecutive trauma patients in whom the Recovery filters were inserted between October 2003 and October 2005 were reviewed. Patients who had the new generation of this filter were excluded. All these filters were inserted with the intention of retrieval. We attempted to contact all these patients at 3 months. The technical factors associated with failure to retrieve these filters were reviewed. There were no complications related to filter insertion. Excluding six patients (4.9%) who expired from causes unrelated to the insertion procedure, 20 patients could not be reached (17.3%) and 21 patients declined retrieval (18.1%). The filters were considered permanent in 18 patients (15.5%) if they were not ambulatory or if they developed inferior vena cava occlusion. Inferior vena cava occlusion was diagnosed in four patients (5.5%). Seventy-three (62.9%) patients presented for follow-up and were evaluated by color venous duplex ultrasound. We attempted to retrieve the filters in 52 patients and were successful in 45 (86.5%). However, the total retrieval rate was 40.5%. All failures of retrieval were related to tilting of the filters or bending of the limbs. There were no complications related to the retrieval procedure. Insertion and retrieval of the Recovery inferior vena cava filter are safe. In spite of the thorough follow-up and the good success rate in retrieving the filters, the overall retrieval rate in this patient population is still low. This should be strongly considered at the time of insertion. Multiple factors were found to contribute. Attention to details in patient selection and follow-up as well as modifications in technique may improve the retrieval rate.     

Renal physiology: acid–base balance

Acid–base balance is a fundamental part of human homeostasis. The human body has evolved a system which allows exquisite control, involving multi-organ systems, over the pH of the intracellular and extracellular fluid. The Henderson–Hasselbalch equation relates pH to the dissociation constant, pK_a, and relative concentrations of dissociated and undissociated acid. One of the clinical applications of this equation is in the use of local anaesthetic agents, applying knowledge of pH and pK_a to select the most appropriate drug. In order to exert such fine control over pH, buffer systems exist that rapidly permit correction of any deviance outside the normal range. The principal buffer system is the bicarbonate buffer system, mediated through carbonic anhydrase. The renal system exerts control over the ultimate fate of bicarbonate and hydrogen ions through a series of chemical reactions, culminating in the excretion of excess acid or base. Abnormalities in acid–base balance can have profound consequences and it is therefore vital to understand the basis of the abnormality in order to effectively treat the condition.     

Anesthetic technique for cesarean delivery and neonatal acid–base status: a retrospective database analysis

IntroductionA previous meta-analysis reported lower umbilical artery pH with spinal anesthesia for cesarean delivery compared to general or epidural anesthesia. Ephedrine was used in the majority of studies. The objective of this study was to evaluate the effect of anesthetic technique on neonatal acid–base status now that phenylephrine has replaced ephedrine in our institution.MethodsWe retrospectively reviewed our database to identify patients who underwent cesarean delivery and had umbilical artery pH available. We decided a priori to test separately cases where cesarean delivery was performed emergently (category I and II) or non-emergently (category III and IV). Multivariable models were constructed to detect significant predictors of lower umbilical artery pH.ResultsOne thousand sixty-four cases were included (647 emergent, 417 non emergent). In emergent cesarean delivery, anesthesia type was a significant predictor of lower umbilical artery pH (P <0.0001) with the pairwise comparisons showing lower neonatal umbilical artery pH [mean (95% CI)] with general anesthesia [7.16 (7.13, 7.19)] compared with spinal anesthesia [7.24 (7.22, 7.25)] and epidural anesthesia [7.23 (7.21, 7.24)], with no difference between spinal and epidural anesthesia. When excluding cases where general anesthesia was chosen due to insufficient time to place a neuraxial block or dose an existing epidural catheter, anesthesia type was not a predictor of lower umbilical artery pH. Anesthetic technique was not a predictor of lower umbilical artery pH in non-emergent cases.ConclusionsSpinal anesthesia was not associated with lower umbilical artery pH compared to other types of anesthesia. This might be due to the use of phenylephrine in our practice.     

Can lemon juice be an alternative to potassium citrate in the treatment of urinary calcium stones in patients with hypocitraturia? A prospective randomized study

To investigate that lemon juice could be an alternative to potassium citrate in the treatment of urinary calcium stones in patients with hypocitraturia, 30 patients with hypocitraturic urinary calcium stones were enrolled into study. The patients were divided into three groups equally. Exactly 60 mEq/day fresh lemon juice (≈85 cc/day) and potassium citrate (60 mEq/day) were given to the patients of first and second group, respectively. Dietary recommendations were made for the third group. Blood and 24-h urine tests were performed before treatment and repeated 3 months later. The differences between demographic datas of groups were not significant. There was no significant difference between values of blood tests performed before and after treatment in all groups. Statistically significant differences were found between pre- and post-treatment urine values in each group. Although there was no significant difference between pre-treatment citrate levels of the groups. A significant difference was found between post-treatment citrate levels of the groups. There was 2.5-, 3.5- and 0.8-fold increase in urinary citrate level of lemon juice, potassium citrate and dietary recommendation groups, respectively. Urinary calcium level was decreased only in lemon juice and potassium citrate groups after treatment. While there was no significant difference between pre- and post-treatment urinary oxalate levels in all groups, a significant decrease in urinary uric acid levels was determined in all groups. We suggest that lemon juice can be an alternative in the treatment of urinary calcium stones in patients with hypocitraturia. Additionally, dietary recommendations can increase effectiveness of the treatment.     

Retrograde flexible ureteroscopic approach of upper urinary tract pathology: What is the status in 2014?

Flexible uretero‐renoscopy witnessed dramatic technological improvements, ultimately translating in more diverse indications, better instrument durability, procedural efficacy and safety. Diagnostic exploration of the upper urinary tract, treatment of selected cases of ureteral and especially pyelocaliceal stones, caliceal diverticulum and infundibular stenosis, treatment, and follow‐up of upper urinary tract tumors are the main indications for this approach. We review the technique, results and complications of retrograde flexible ureteroscopy, with an emphasis on the latest developments of the method.     

Water,electrolyte, acid–base,and trace elements alterations in cirrhotic patients

Chronic hepatic patients, and particularly those suffering from cirrhosis, are predisposed to different sort of water, electrolyte, acid–base, and trace elements disorders due to their altered liver function, and also to their exposition to infectious, inflammatory, oncologic, and pharmacologic variables whose combination undermines their homeostatic capability. Hyponatremia, hypokalemia, hyperkalemia, hypocalcemia, metabolic acidosis, respiratory, and metabolic alkalosis are the main internal milieu alterations in this group.     

Is tranexamic acid safe in patients undergoing coronary endarterectomy?

BACKGROUND: Patients undergoing coronary endarterectomy during coronary artery bypass grafting (CABG) are at increased risk of perioperative myocardial infarction due to coronary intimal disruption. Data assessing the safety of the antifibrinolytic drug tranexamic acid (TA) in patients undergoing this procedure are lacking. METHODS: From September 1997 to December 1999, 221 patients underwent nonemergency primary CABG with endarterectomy of the right coronary artery alone in 149, the left anterior descending in 35, or both right and left anterior descending in 27. TA was administered intraoperatively to 87 patients (TA group: average total dose 62 +/- 4.4 mg/kg; range 20 to 109 mg/kg), and was not administered to 134 patients (No TA group). RESULTS: The patient characteristics of the 2 groups were similar. In-hospital mortality consisted of 2 patients in the TA group and 4 patients in the No TA group. Perioperative myocardial infarction rates were 2% and 5% in the TA and No TA groups, respectively (p = 0.49). The relative risk for any type of perioperative cardiac ischemic event in the TA group versus the No TA group was 0.77 (95% CI; 0.4, 1.2). Patients in the TA group had a significant reduction in postoperative chest tube drainage (685 versus 894 mL in the TA versus No TA groups, respectively) and in the use of fresh-frozen plasma (p = 0.03). CONCLUSIONS: These results suggest that the clinical effectiveness of tranexamic acid in reducing postoperative blood loss in patients undergoing coronary endarterectomy is not associated with a higher incidence of myocardial ischemia-related complications.