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Potentially Inappropriate Medications in the Elderly: a Comprehensive Protocol
No full textElderlypatients areatincreasedriskofdrug-related morbidity and mortality. Avoiding the use of potentially inappropriate medications (PIMs) is one of the strategies that has been widely adopted to reduce the harmful consequences of drug use. There are several PIM screening tools available. In thisreview,weprovideanoverviewofexistingscreeningtools to detect PIMs in the elderly, emphasizing the advantages and disadvantages of each. Combining previously published and adopted tools (adjusted Beers list, French consensus panel, McLeod’s list, and Lindblad’s list of clinically important drug–disease interactions), we develop a new comprehensive toolthatalsoincludestheadjustedHanlon’sandMalone ’slists of potentially serious drug–drug interactions in the elderly. In addition to listed PIMs and clinically important drug–drug interactions, alternative therapeutic solutions are suggested. The new protocol differentiates: drugs with an unfavorable benefit/risk ratio (to be avoided regardless of the underlying disease/condition), drugs with a questionable efficacy, and drugs to be avoided with certain diseases/conditions, and providesalistofpotentiallyseriousdrug–druginteractions.Atool consistingofPIMsandpotentialdrug–druginteractionswithin the same protocol provides more comprehensive quality assessment of drug-prescribing behavior to the elderly, which in turn may lead to better prescribing practices
Mortality After Surgery in Europe: a 7 day Cohort Study
No full textBACKGROUND:
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 χ(2) 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<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
Efficacy of Interlaminar vs Transforaminal Epidural Steroid Injection for the Treatment of Chronic Unilateral Radicular pain: Prospective, Randomized Study
No full textThe Positioning of the c-arm and the Patient During the Minimally Invasive pain Treatment
No full textMinimally invasive procedures in pain treatment are an important supplement to conservative pain treatments, to pharmacotherapy as well as to non-pharmacological procedures when these are insufficient as pain treatments. The level of success depends on a careful pick of patients, as well as on the skill and proficiency of the doctor performing the minimally invasive procedures. Up to this point the results of many studies on minimally invasive procedures in pain treatment have been opposed, with the epidural placement of the suringe being unsuccessful in 40% of the cases, even with an experienced anaesthesiologist performeng the procedure. Not using the flouroscope is certainly one of the reasons to such a high level of set-back. The fluoroscope, which has become a standard part of many invasive procedures, is held responsible for the greater efficiency and fewer complications during invasive procedures, all resulting in the increase of minimally invasive pain treatment procedures over all
Klinička obilježja pacijenata sa spondiloartritisima i hla-b27 pozitivnim antigenom
No full textThe aim of this study was to present our experiences in diagnosing spondyloarthritides (SpA), and to list the most common clinical features of HLA-B 27 positive patients.The study included 65 HLA-B 27 positive patients with confirmed diagnosis of ankylosing spondylitis(AS) and psoriatic arthritis (PsA) who were analyzed between 2009 and 2010 in Clinic of Internal Medicine in Osijek. The diagnosis of seronegative spondyloarthritides was based on the ASAS (Assessment in AS Working Group) classification criteria for axial and then supplemented with ASAS criteria for peripheral SpA and was confirmed by radiological techniques. For diagnosing the ankylosing spondylitis (AS), there have been applied the modified New York criteria. Radiological criteria for definite sacroiliitis according to the modified New York criteria is bilateral sacroiliitis, grade 2–4 (2) or unilateral sacroiliitis, grade 3–4. For diagnosing the psoriatic arthritis (PsA), there were used CASPAR diagnostic criteria. Other features of SpA are defined within the existing classification criteria. HLA-B27 antigen was determined by direct immune-fluorescence technique using flow cytometer. The average age of patients was 50.34 years, of whom 27 female (41.53%), 38 male (58.46%). Duration of illness was 15.79 years on average.With 75.38% of patients, there had been determined the diagnosis of AS; 24.62% of patients had the diagnosis of PsA. The most common clinical characteristics that patients had were: inflammatory back pain (pain Inflammation along the lumbosacral spine), peripheral arthritis, intermittent pain in the gluteus, sacroiliitis, enthesitis, uveitis, dactilitis.Cilj ovog rada bio je prikazati naša iskustva u dijagnostici spondiloartritisa (SpA) te navesti najtipičnija klinička obilježja HLA-B27 pozitivnih bolesnika. U istraživanju je uključeno 65 HLA-B 27 pozitivnih bolesnika s potvr|enom dijagnozom ankilozantnog spondilitisa (AS) i psorijatičnog artritisa (PsA) koji su tijekom 2009 i 2010 godine liječeni na Internoj klinici u Osijeku. Dijagnoza seronegativnih spondiloartritisa temeljila se na ASAS (Assessment in AS working group) klasifikacijskim kriterijima za aksijalni i periferni SpA i bila potvr|ena radiološkim metodama. Za dijagnosticiranje ankilozantnog spondilitisa (AS) primijenili su se modificirani New york kriteriji. Radiološki kriterij za definitivni sakroileitis prema modificiranim New York kriterijima je bilateralni sakroiliitis stupnja 2–4 (2) ili unilateralni sakroiliitis stupnja 3–4. Za dijagnozu psorijatičnog artritisa (PsA) korišteni su CASPAR dijagnostički kriteriji. Ostale značajke SpA definirane su u sklopu postojećih klasifikacijskih kriterija. HLA-B27 antigen je određivan je direktnom imunofluorescentnom metodom na protočnom citometru. Prosječna starost pacijenata bila je 50,34 godina, od kojih je 27 žena (41,53%), 38 muških (58,46%). Trajanje bolesti bilo je u prosjeku 15,79 godina. U 75,38 % bolesnika postavljena je dijagnoza AS; 24.62% bolesnika imalo je dijagnozu PSA. Najčešće kliničke karakteristike koje su pacijenti imali bili su: upalna križobolja (inflamatorna bol duž lumbosakralnog dijala kralježnice), periferni artritis, naizmjenična bol u gluteusima, sakroiliitis, entezitis, uveitis, daktilitis. Ovo naše istraživanje je pokazalo da se kliničke značajke HLA B 27 pozitivnih pacijenata sa SpA u Istočnoj Slavoniji ne razlikuju od kliničkih manifestacija pacijenata sa SpA u drugim dijelovima Europe koje su iznesene u različitim studijama
Sugammadex, a new drug for Reversion of Muscle Relaxants
No full textSugamadeks je novi lijek za reverziju neuromuskularnog bloka. Po kemijskoj građi on je alfa-ciklodekstrin s lipofilnom unutrašnjom stranom molekule koja omogućuje stvaranje stabilnih kompleksa, tzv. enkapsulaciju molekula mišićnih relaksatora, napose rokuronija. Fizička enkapsulacija novi je mehanizam eliminacije relaksatora s mjesta njegova učinka. Ona omogućuje brzu i potpunu reverziju dubokog i plitkog neuromuskularnog bloka ovisnu o primijenjenoj dozi. Sugamadeks nema neželjenih kolinergičkih muskarinskih nuspojava koje se opažaju nakon primjene inhibitora kolinesteraze neostigmina i edrofonija kao što su bradikardija, hipersalivacija i abdominalne boli. Nakon primjene prilagođene doze sugamadeksa učinak rokuronija može biti kratak kao i učinak sukcinilkolina. Ovo je osobito važno u situacijama kada se bolesnik ne može intubirati niti ventilirati ili kada je kirurški zahvat nepredviđeno brzo završen. Kliničke studije na većem broju bolesnika pokazat će omjer koristi i rizika njegove primjene u skupinama osjetljivih bolesnika, osobito može li sugamadeks smanjiti učestalost poslijeoperacijskih respiracijskih komplikacija.Sugammadex is a new pharmacological agent for neuromuscular block reversion. It is a cyclic oligosaccharide, a gamma cyclodextrin with lipophylic inner coat that enables forming of stable complexes with steroidal neuromuscular blocking drugs, especially with rocuronium. A physical encapsulation of the relaxants is a novel elimination pathway and it produces fast and complete reversion of both deep and shallow neuromuscular block. Consequently, sugammadex has no unwanted cholinergic muscarinic effects observed with cholinesterase inhibitors such as bradycardia, hypersalivation, and increased gastrointestinal motility. Since the effects of sugammadex are dose dependent it can very rapidly reverse the effects of rocuronium. After the adjusted dose of sugammadex was given, the duration of action of rocuronium can be made as short as that of succinylcholine. This characteristic is especially important in the ’can’t intubate, can’t ventilate’ situation and after surgical procedure was unexpectedly finished. Clinical studies involving more patients are needed to show the real risk-benefit profile and safety in the special patients’ population
Evaluation of Antiaggregatory Activity of Flavonoid Aglycone Series
No full textBACKGROUND:
Among natural compounds, present in every day diet, flavonoids have shown beneficial effect in prevention of cardiovascular diseases that can be attributed, at least partially to the described antiaggregatory activity i.e. antiplatelet effects of flavonoids. Due to the ever increasing pharmacological interest in antiplatelet agents a systematic experimental evaluation of large flavonoid series is needed.
METHODS:
A set of thirty flavonoid aglycones has been selected for the evaluation. All measurements of aggregation were done under standardized and firmly controlled in vitro conditions. The whole blood samples, multiple platelet functional analyzer and adenosine diphosphate (ADP) as a weak agonist of aggregation were selected for this purpose.
RESULTS:
The results were expressed as minimal concentration of flavonoid that can significantly lower the platelet aggregation compared to the corresponding untreated sample (minimal antiaggregatory concentration--MINaAC). All analyzed flavonoids exhibited antiaggregatory activity MINaAC ranging from 0.119 μM to 122 μM, while the most potent representatives were 3,6-dihydroxyflavone (0.119 μM) and syringetin (0.119 μM).
CONCLUSIONS:
Measurable antiplatelet activity established at submicromolar flavonoid concentrations suggests that even a dietary consumption of some flavonoids can make an impact on in vivo aggregation of platelets. These findings also point out a therapeutical potential of some flavonoid
Physicians Overestimate Patient's Knowledge of the Process of Informed Consent: a Cross-sectional Study
No full textAIM
To evaluate the differences in the knowledge and attitudes of physicians and patients regarding the informed consent process.
METHODS
After institutional approval was obtained cohorts of 269 physicians and 265 patients completed a voluntary multiple-choice questionnaire on the informed consent process.
RESULTS
Most of the responses between physicians and patients were significantly different. A total of 77 physicians (30.7%) reported that they personally informed patients about their medical condition and forthcoming clinical procedures in detail and 138 (55%) informed patients as much as necessary. Only 29 patients (11%) reported being informed in detail, and 186 (70.2%) reported that they received only basic information (P < 0.001). Although 132 physicians (52.6%) reported that their patients received sufficient information to be able to decide on their treatment, only 31 patient (11.7%) reported the same (P < 0.001). Half of the doctors (126, 50.2%) reported that they informed their patients in detail on the possible consequences of treatment refusal whereas 23 patients (8.7%) were given such information.
CONCLUSION
There is a great discrepancy between physicians and patients concerning both understanding and knowledge of the informed consent process. The physicians have evaluated their practice of giving information and obtaining informed consent to be more detailed than their patients. The results of this study reflect the need for better communication between doctors and patients as well as physician and patient education programs on the process of informed consen
Učestalost i značaj kolonizacije rodnice streptokokom grupe B trudnica s područja grada Osijeka, Hrvatska
No full textThe aim of the study was to determine the prevalence of vaginal group B streptococcus (GBS) colonization in pregnant
women from Osijek area, the possible effect of GBS colonization on pregnancy outcome and neonatal complications and
the role of intrapartum prophylaxis in this context. This retrospective case-control study took place at the Department of
Gynecology and Obstetrics, Osijek University Hospital Center from December 2003 to June 2006. A total of 118 pregnant
women was enrolled in study and divided into two groups: 59 women in 35th–37th week of gestation, free from risk factors
for infection (control group); and 59 women in 25th–41st week of gestation with risk factors for infection. Low vaginal
swab for GBS isolation and identification on selective and enriched medium was obtained from each woman. GBS colonization was recorded in 29 (24.6%) women: 12 (20.3%) control and 17 (28.8%) women at risk of infection, yielding a statistically non-significant difference (c 2=1.480489; p<0.48). Early neonatal infection was observed in six (20.7%) neonates born to 29 mothers with GBS colonization, pointing to a correlation between vaginal GBS colonization and early
neonatal infection (rs=0.99). Early perinatal infection was found in 22 (18.6%) neonates, including 17 (28.8%) pregnancies
with risk factors, pointing to a significant correlation between vaginal GBS colonization, risk factors and early perinatal infection (c 2=88.68; p<0.001); however, gestational age and pregnancy outcome were not influenced by GBS colonization. In eight (36.4%) newborns, early neonatal infection developed in spite of intrapartum administration of antibiotics; three of these children were born to GBS positive mothers, and perinatal GBS infection was demonstrated in one (0.84%) child. Study results revealed a relatively high rate of GBS colonization in the population of pregnant women in Croatia, occasionally leading to early neonatal infection. Large studies are needed to develop national strategy for the prevention of GBS infection in Croatia.Cilj istraživanja bio je utvrditi učestalost kolonizacije rodnice streptokokom grupe B (GBS) trudnica grada Osijeka. Istražiti ima li utvrđena kolonizacija i kakav utjecaj na ishod trudnoće te na nastanak komplikacija kod rođene djece, te kakva je kod toga uloga i značaj intrapartalne profilakse. Među trudnicama s područja grada Osijeka praćenim na Odjelu za ginekologiju i opstetriciju Kliničkog bolničkog centra Osijek, u razdoblju od prosinca 2003. godine do lipnja 2006. godine, provedeno je poprečno-presječno istraživanje. Obrađeno je 118 trudnica podijeljenih u dvije skupine. U probirnoj (kontrolnoj) skupini bilo je 59 trudnica u dobi od 35 do 37 tjedana trudnoće, bez rizičnih čimbenika za infekciju, a u drugoj 59 trudnica s rizičnim čimbenicima za infekciju, trajanja trudnoće od 25 do 41 tjedna. Svakoj trudnici uzet je donji vaginalni obrisak radi izolacije i identifikacije GBS na selektivnoj i obogaćenoj podlozi. Kolonizacija GBS-om utvrđena je kod 29 (24.6%) žena. U probirnoj skupini kod 12 (20.3%), a u rizičnoj skupini 17 (28.8%), bez statistički uočene razlike (c2=1.480489, p<0.48). Kod 6 (20.7%) novorođenčadi od 29 koloniziranih žena GBS-om utvrđena je rana neonatalna infekcija, što govori o korelaciji kolonizacije rodnice GBS-om i rane neonatalne infekcije (rs=0.99). Rana perinatalna infekcija javila se je kod 22 (18.6%) novorođenčadi, pri čemu 17 (28.8%) iz trudnoća žena s rizičnim faktorima, što ukazuje da postoji značajna povezanost kolonizacije rodnice GBS-om, rizičnih faktora i rane infekcije djeteta (c2=88.68, p<0.001), no kolonizacija ne utječe na trajanje i ishod trudnoće. Kod 8 (36.4%) djece se je rana neonatalna infekcija javila usprkos intrapartalnoj primjeni antibiotika, 3 od njih bila su djeca GBS pozitivnih majki, a kod jednog (0.84%) od njih dokazana je perinatalna infekcija GBS-om. Istraživanje je pokazalo kako je i u Hrvatskoj kolonizacija GBS-om značajna pojava u populaciji trudnica, koja u određenog broja trudnica može rezultirati razvojem rane neonatalne infekcije u njihove novorođenčadi. Nužno je provesti šira i sveobuhvatnija istraživanja temeljem kojih će se donijeti nacionalna strategija za prevenciju neonatalnih GBS infekcija u Hrvatskoj
Vitamin B12 Deficiency in Children – Underestimated Danger in the Light of new Knowledge
No full textVitamin B12 (kobalamin) ima dva aktivna oblika, adenozilkobalamin i metilkobalamin, koji imaju ključnu ulogu u dvama važnim metaboličkim putovima u ljudi i njihov je manjak odgovoran za kliničke teškoće u bolesnika. Kobalamin je nuždan tijekom cijelog života, no njegova dovoljna količina posebno je bitna u fetalno i dojenačko doba, kada je iznimno važan za normalan rast i razvoj djeteta, kao i za normalan razvoj središnjega živčanog sustava. Zbog vrlo sločenog prometa i metabolizma njegov se manjak može ožitovati pri raznim priro|enim i stečenim poremećajima. Klinička slika kojom se očituje manjak vitamina B12 obično je nespecifična, nosi velik rizik od trajnih posljedica za bolesnika, a najčešće se vrlo jednostavno liječi ako se na vrijeme prepozna. U Republici Hrvatskoj poremećaji metabolizma kobalamina u djece prerijetko se otkrivaju. Zato je cilj ovog rada skrenuti pozornost na nove spoznaje o metabolizmu kobalamina, prikazati bolesnike s tipičnim kliničkim tijekom i laboratorijskim nalazima te dati smjernice za brzo dijagnosticiranje i liječenje poremećaja vitamina B12 u djece.Vitamin B12 (cobalamin) has two active forms, adenosylcobalamin and methylcobalamin which have a key role in two important metabolic pathways in humans and their deficiency is responsible for clinical problems. Cobalamin is essential during whole life, but its sufficient amount is extra important in fetal and neonatal period, when it is essential for normal child growth and development as well as for normal development of the central nervous system. Because of very complex transport and metabolism, its deficiency can be manifested in numerous congenital and acquired disorders. Vitamin B12 deficiency mostly has non-specific clinical features, it carries a great risk of permanent consequences, but most frequently it is easily curable if diagnosed on time. In Croatia cobalamin deficiency in children has been diagnosed too rarely. Accordingly, the aim of this paper is to point to the recently gained knowledge on cobalamin metabolism, present typical case reports and to provide guidelines for rapid and proper diagnostic and therapeutic approach