Differences in antimicrobial consumption, prescribing and isolation rate of multidrug resistant Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii on surgical and medical wards.

In order to provide guidance data for clinically rational use of an antibiotics consuption, prescribing and prevalence of multidrug resistant (MDR) Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii were monitored on the surgical (S) and medical (M) wards of the University Hospital Center "Dr. Dragisa Misovic-Dedinje" (Belgrade, Serbia), in the study period from 2012 to 2015. Appropriateness of antimicrobial use was evaluated using the Global-Prevalence Survey method designed by the University of Antwerp. The percentages of MDR pathogens relative to the total number of isolates of K. pneumoniae and P. aeruginosa were higher on the S (86.2% and 49.1%) than on the M (63.2% and 36.9%) wards. The percentage of MDR A. baumannii was not different between S (93.7%) and M (79.5%) wards. An overall antibiotics consumption (defined daily doses/100 bed-days) during study was 369.7 and 261.5 on the S and M wards, respectively. A total of 225 prescriptions of antimicrobials were evaluated in138 adults admitted to wards on the day of the survey. The percentage of antimicrobials prescribed for prophylaxis on the M and S wards were 0% and 25%, respectively. Therapies were more frequently empiric (S, 86.8% and M, 80%). The percentages of medical errors on the S and M wards were 74.6% and 27.3%, respectively. The quality indicators for antibiotic prescribing on the S and M wards were as follows: the incorrect choice of antimicrobials (35.6% vs. 20.0%), inappropriate dose interval (70.6% vs. 16.9%) or duration of therapy (72.5% vs. 23.1%), a non-documented stop/review data (73.6% vs. 16.9%) and divergence from guidelines (71.9% vs. 23.1%). Treatment based on biomarkers was more common on the M wards as compared to the S wards. The increasing prevalence of MDR pathogens, a very high consumption and incorrect prescribing of antimicrobials need special attention, particularly on the S wards.

Does the metabolic syndrome impact left-ventricular mechanics? A two-dimensional speckle tracking study.

OBJECTIVE: To evaluate left-ventricular mechanics estimated by two-dimensional echocardiography (2DE) speckle tracking analyses in patients with the metabolic syndrome. METHODS: This cross-sectional study included 95 untreated patients with metabolic syndrome and 65 controls similar by sex and age. Metabolic syndrome was defined by the presence of at least three ATP-AHA-NHLB criteria. All the patients underwent adequate laboratory analyses and complete 2DE examination. RESULTS: 2DE global longitudinal and circumferential strain was significantly decreased in the metabolic syndrome group, whereas 2DE global radial strain was similar between the observed groups. The left-ventricular torsion was similar between the metabolic syndrome participants and the controls; whereas the left-ventricular untwisting rate was significantly increased in the metabolic syndrome group. The increasing number of the metabolic syndrome criteria induces progressive reduction of the left-ventricular longitudinal strain from the individuals with no metabolic syndrome risk factors to the individuals with five metabolic syndrome criteria. The same pattern was not noticed for left-ventricular circumferential and radial strain. The combination of increased blood pressure, abdominal obesity and increased fasting glucose level was associated with the higher level of left-ventricular mechanical impairment comparing with other clusters of the metabolic syndrome components. The multivariate analysis of the metabolic syndrome criteria showed that 24-h mean blood pressure, waist circumference and fasting glucose level were independently associated with 2DE global longitudinal and circumferential myocardial strain, and left-ventricular untwisting rate. The interaction between sex and metabolic syndrome significantly impacts the left-ventricular longitudinal strain and untwisting rate. CONCLUSION: Left-ventricular mechanics assessed by 2DE strain is significantly impaired in the metabolic syndrome patients. Among all metabolic syndrome components, blood pressure, waist circumference and fasting glucose level are the most responsible for damage of left-ventricular deformation.

High-normal blood pressure, functional capacity and left heart mechanics: is there any connection?

OBJECTIVE: To evaluate the relationship between functional capacity and left ventricular (LV) and left atrial (LA) myocardial deformation, assessed by two- and three-dimensional (2DE and 3DE) strain analysis, in subjects with high-normal blood pressure (BP). METHODS: This cross-sectional study included 64 subjects with optimal BP and 75 subjects with high-normal BP of similar gender and age. All the subjects underwent a complete 2DE and 3DE examination and cardiopulmonary exercise testing. RESULTS: 3DE global longitudinal strain was significantly lower in the group with high-normal BP than in the optimal BP group (- 20.1 ± 2.4 vs - 18.5 ± 2.3%, p < 0.001). Similar results were obtained for 3DE global circumferential strain (- 21.8 ± 2.6 vs - 19.3 ± 2.4%, p < 0.001), as well as for 3DE global radial strain (45.1 ± 8.8 vs 42.3 ± 7.2%, p = 0.042), and 3DE global area strain (- 30.1 ± 4.2 vs - 28.1 ± 3.8%, p < 0.001). LV twist was similar between the observed groups, whereas untwisting rate was significantly decreased in the subjects with high-normal BP (- 123 ± 30 vs - 112 ± 26°/s, p = 0.023). Peak VO2 was significantly lower in the high-normal BP group (30.8 ± 4 vs 28.3 ± 3.7 ml/kg/min, p < 0.001). 2DE LV ejection fraction (ß = 0.38, p = 0.014), 2DE global longitudinal strain (ß = 0.35, p = 0.019) and 3DE global longitudinal strain (ß = 0.27, p = 0.042) were independently associated with peak VO2. CONCLUSION: LV and LA mechanics, as well as functional capacity are significantly impaired in the subjects with high-normal BP. LV and LA myocardial deformations are associated with peak oxygen uptake.

High-normal blood pressure impacts the right heart mechanics: a three-dimensional echocardiography and two-dimensional speckle tracking imaging study.

OBJECTIVE: The aim of this study was to examine the relationship between increasing blood pressure (BP) and right ventricular (RV) and right atrial (RA) mechanics using two-dimensional echocardiography (2DE) strain analysis and three-dimensional echocardiography (3DE). METHODOLOGY: This cross-sectional study included 58 individuals with optimal BP, 57 individuals with high-normal BP, and 59 recently diagnosed untreated hypertensive patients of similar age and sex distribution. Data were analyzed according to 24-h systolic blood pressure values (cutoff values were 120 and 130 mmHg). All individuals underwent complete 2DE and 3DE examination. RESULTS: The global longitudinal RV strain decreased gradually from controls, to high-normal BP individuals, to hypertensive patients, whereas systolic and early diastolic strain rates were similar between high-normal BP and hypertensive patients, but decreased in comparison with optimal BP individuals. The same trend was observed for the global longitudinal RA strain and systolic and early diastolic strain rates. 3DE examination revealed that RV volumes were increased in hypertensive patients in comparison with optimal BP individuals, which resulted in a lower 3DE RV ejection fraction in hypertensive patients. Multivariate analysis showed that the RV wall thickness was the only echocardiographic parameter that was, in the same time, independently associated with global RV and RA strain, and RV diastolic function. CONCLUSION: The right heart deformation is significantly impaired in individuals with high-normal BP. This subclinical impairment of RV and RA mechanics and function in high-normal BP individuals seems to be similar to the impairment found in recently diagnosed hypertensive patients.

The different effects of resveratrol and naringenin on isolated human umbilical vein: the role of ATP-sensitive K⁺ channels.

The blood flow from the placenta to the fetus depends on human umbilical vein (HUV) vascular tone. ATP-sensitive K(+) (K(ATP)) channels link the metabolic state of the cell to membrane potential, and their activation in the HUV represents protection against hypoxia. The aims of our study were to assess the effects of resveratrol and naringenin on the HUV and to define the roles of K(ATP) channels in their effects. Serotonin or 100 mM K(+) were used for precontraction of the HUV without endothelium. The cumulative concentration-response curves were obtained by adding increasing concentrations of resveratrol or naringenin. Glibenclamide was used, in order to test the role of K(ATP) channels in its effect. Resveratrol induced more potent vasodilatation of serotonin- and 100 mM K(+)-precontracted HUV than naringenin. Glibenclamide induced significant shift to the right of the concentration-response curves of resveratrol and P1075 (a specific opener of K(ATP) channels). Western blotting showed that HUV expressed protein Kir6.1. Thus, resveratrol and naringenin produce dilatation of HUV. It seems that K(ATP) channels are involved in the relaxation of HUV induced by resveratrol, while naringenin seems to interact with other ion channels. The K(+) channel-independent mechanism(s) of these polyphenols could not be excluded.

Two- and three-dimensional speckle tracking analysis of the relation between myocardial deformation and functional capacity in patients with systemic hypertension.

The purpose of this study was to investigate left ventricular (LV) mechanics in hypertensive patients by 2- and 3-dimensional (3D) speckle tracking imaging, and determine the relation between the LV mechanics and functional capacity in this population. This cross-sectional study included 51 recently diagnosed, untreated, hypertensive patients, 49 treated subjects with well-controlled arterial hypertension, 52 treated participants with uncontrolled hypertension, and 50 controls adjusted by gender and age. All the subjects underwent 24-hour blood pressure monitoring, complete 2-dimensional and 3D examination, and cardiopulmonary exercise testing. 3D global longitudinal, circumferential, radial, and area strains were similar between the control group and well-controlled hypertensive patients but significantly decreased in comparison with patients with untreated or inadequately controlled hypertension. Similar findings were obtained for LV torsion and twist rate, whereas LV untwisting rate significantly deteriorated from the controls, across the well-controlled group, to the patients with untreated or uncontrolled hypertension. Peak oxygen uptake was significantly lower in the patients with untreated and uncontrolled hypertension than in the controls and the well-treated hypertensive patients. Peak oxygen uptake was independently associated with LV untwisting rate (ß = 0.28, p = 0.03), 3D LV ejection fraction (ß = 0.31, p = 0.024), and 3D global longitudinal strain (ß = 0.26, p = 0.037) in the whole hypertensive population in our study. In conclusion, LV mechanics and functional capacity are significantly impaired in the patients with uncontrolled and untreated hypertension in comparison with the controls and the well-controlled hypertensive patients. Functional capacity is independently associated with 3D global longitudinal strain, LV untwisting rate, and 3D LV ejection fraction.

The impact of high-normal blood pressure on left ventricular mechanics: a three-dimensional and speckle tracking echocardiography study.

To assess the presence of subclinical left ventricular myocardial dysfunction in subjects with high-normal blood pressure (BP) and untreated arterial hypertension, using three-dimensional (3D) echocardiography strain analysis. This cross-sectional study included 49 subjects with optimal BP, 50 subjects with high-normal BP, and 50 newly diagnosed untreated hypertensive patients matched by gender and age. All the subjects underwent 24 h blood pressure monitoring and complete two-dimensional and 3D echocardiography examination. The enrolled subjects were grouped according to 24 h systolic BP values, dividing the subjects with optimal BP from those with high-normal BP and the hypertensive patients (cut-off values were 120 and 130 mmHg, respectively). 3D global longitudinal strain was significantly lower in the high-normal BP group and the hypertensive patients, in comparison with the optimal BP group (-20.5 ± 3.3 vs. -18.7 ± 2.8 vs. -17.6 ± 2.7%, p < 0.001). Similar results were obtained for 3D global circumferential strain (-18.6 ± 3 vs. -17.1 ± 2.9 vs. -16 ± 2.5 %, p < 0.001), as well for 3D global radial strain (49.4 ± 9.5 vs. 44.7 ± 8.1 vs. 43.5 ± 7.8%, p = 0.002), and global area strain (-31.2 ± 4.8 vs. -28.7 ± 4.2 vs. -27.1 ± 4.5%, p < 0.001). LV twist was increased in the hypertensive patients in comparison with the high-normal and the optimal BP groups (10.1° ± 2.4° vs. 10.8° ± 2.6° vs. 13.8° ± 3.1°, p < 0.01), whereas untwisting rate significantly and gradually decreased from the optimal BP group, across the high-normal BP group, to the hypertensive patients (-135 ± 35 vs. -118 ± 31 vs. -102 ± 27°/s, p < 0.001). 3D echocardiography revealed that the subjects with high-normal BP suffered subclinical impairment of LV mechanics similar as the hypertensive patients.

Effects of the metabolic syndrome on right heart mechanics and function.

BACKGROUND: We sought to investigate right ventricular (RV) and right atrial (RA) deformation obtained using 3-dimensional echocardiography (3DE) and 2-dimensional (2DE) strain in subjects with the metabolic syndrome (MS). METHODS: This cross-sectional study included 108 untreated subjects with the MS and 75 control subjects similar according to sex and age. The MS was defined by the presence ≥ 3 American Heart Association/National Heart, Lung, and Blood Institute criteria. All the subjects underwent adequate laboratory analyses and complete 2DE and 3DE examination. RESULTS: 2DE global longitudinal strain of the RV was significantly decreased in the MS group compared with the control subjects (-24 ± 5 vs -27 ± 5%; P < 0.001). Similar results were obtained for the RA longitudinal strain (40 ± 5 vs 44 ± 7%; P < 0.001). Systolic and early diastolic RV and RA strain rates were decreased, whereas late diastolic strain rates were increased among the MS participants compared with the control subjects. 3DE RV ejection fraction was significantly decreased in the MS subjects (55 ± 4 vs 58 ± 4%; P < 0.001). The multivariate analysis of MS criteria showed that systolic blood pressure, waist circumference, and fasting glucose were independently associated with RV and/or RA myocardial function and deformation. CONCLUSIONS: RV mechanics and RA mechanics, assessed using 3DE and 2DE strain, were significantly deteriorated in the MS subjects. Among all MS risk factors, systolic blood pressure, abdominal circumference, and fasting glucose were the most responsible for the right heart remodelling.

Is there a relationship between right-ventricular and right atrial mechanics and functional capacity in hypertensive patients?

BACKGROUND: We sought to assess right-ventricular and right atrial deformation in patients with arterial hypertension by two-dimensional speckle tracking imaging and three-dimensional echocardiography (3DE), and define the relationship between right-ventricular mechanics and exercise capacity in the study population. METHODS: This cross-sectional study included recently diagnosed untreated hypertensive patients, well controlled hypertensive patients, treated patients with unsatisfactory controlled blood pressure and control individuals adjusted by sex and age. All the patients underwent complete two-dimensional echocardiography and 3DE examination, as well as cardiopulmonary exercise testing. RESULTS: Right-ventricular strain, and systolic and early diastolic strain rates were significantly decreased in the untreated and the uncontrolled hypertensive patients in comparison with the controls and the well controlled participants. Similar results were obtained for right atrial strain and strain rates. 3DE right-ventricular volumes were increased, whereas 3DE right-ventricular ejection fraction was decreased in the uncontrolled hypertensive patients in comparison with the controls and the well treated patients. Differences in 3DE right-ventricular volumes disappeared after adjustment for body surface area. Considering the whole study population, global right-ventricular strain (ß = 0.29, P = 0.018) and 3D right-ventricular stroke volume (ß = 0.22, P = 0.041) were independently associated with peak oxygen uptake (VO(2max)) which was significantly decreased in the untreated and the uncontrolled hypertensive patients in comparison with the remaining two groups. CONCLUSION: Our study showed that right-ventricular and right atrial mechanics, as well as exercise capacity, are significantly deteriorated in the hypertensive patients who are untreated or ineffectively treated. Global right-ventricular strain and 3DE right-ventricular stroke volume are independently associated with functional capacity in the whole study population.

Circadian blood pressure pattern and right ventricular and right atrial mechanics: A two- and three-dimensional echocardiographic study.

The purpose of this investigation was to evaluate right ventricular (RV) and right atrial (RA) function and mechanics in untreated hypertensive patients with different blood pressure (BP) patterns by using two-dimensional (2DE) speckle tracking analyses and three-dimensional echocardiography (3DE). This cross-sectional study included 174 recently diagnosed hypertensive patients. All patients underwent a 24-hour ambulatory BP monitoring and complete 2DE and 3DE examination, including 2DE speckle tracking analysis. Our results showed that 2DE RV global longitudinal strain was significantly lower in the non-dippers. Similar results were obtained for 2DE RV systolic and early diastolic strain rate. The RA longitudinal strain, as well as RA systolic and early diastolic strain rate, was decreased in non-dippers. Our results revealed that 3DE RV end-diastolic and end-systolic volumes were increased, whereas 3DE RV ejection fraction was reduced in non-dipper hypertensive patients. Similar results were obtained for RA volumes and RA ejection fraction estimated by 2DE. Independent predictors of 3DE RV ejection fraction, 2DE RV and RA global longitudinal strain were left ventricular mass index and RV wall thickness. An additional independent predictor of the RV longitudinal strain was 3DE RV ejection fraction, and for RA longitudinal strain, an additional independent predictor was tricuspid E/é ratio. Two-DE speckle tracking evaluation and 3DE examination revealed that the RV and RA function and mechanics were more deteriorated in the non-dipper patients than in dipper untreated hypertensive patients.

[The effects of resveratrol on rat behaviour in the forced swim test].

INTRODUCTION: The trans-isomer of resveratrol is the active ingredient of Poligonum cuspidatum, known for its medicinal properties and traditionally used in the treatment of neuropsychiatric disorders. It is also found abundantly in the skin of red grapes and red wine. Previous studies have suggested that trans-resveratrol demonstrates a variety of pharmacological activities including antioxidant, anti-inflammatory, as well as neuroprotective properties and procognitive effects. OBJECTIVE: The goal of the present study was to examine the influence of trans-resveratrol on behavior in rats and its antidepressant properties. METHODS: Male Wistar rats were treated intraperitoneally (i.p.) with the increasing doses of trans-resveratrol (5, 10 and 20 mg/kg) or vehicle (dimethyl sulfoxide--DMSO), 30 minutes before testing of the spontaneous locomotor activity or forced swimming. For the experiments, the behavior of the animals was recorded by a digital camera, and the data were analyzed by one-way ANOVA, followed by Tukey post-hoc test. RESULTS: Testing of spontaneous locomotor activity, after the application of vehicle or increasing doses of trans-resveratrol, showed no statistically significant difference between groups (p > 0.05). In the forced swim test, one-way ANOVA indicated statistically significant effects of trans-resveratrol (p < 0.001).Tukey post-hoc test showed that resveratrol significantly decreased immobility time at the doses of 10 mg/kg and 20 mg/kg, manifesting the acute antidepressant-like effects. There were no statistically significant differences between the resveratrol treatment of 5 mg/kg and vehicle (p > 0.05). CONCLUSION: The results from our study suggest that transresveratrol produces significant effects in the central nervous system. After single application, it has acute antidepressant effects, but without influence on locomotor activity.

Does a nondipping pattern influence left ventricular and left atrial mechanics in hypertensive patients?

OBJECTIVE: The aim of this study was to determine left ventricular and left atrial function in untreated hypertensive patients with different blood pressure (BP) patterns by using two-dimensional echocardiography (2DE) and three-dimensional echocardiography (3DE) speckle tracking analyses. METHODS: This cross-sectional study included 147 recently diagnosed hypertensive patients (86 dippers and 61 nondippers). All patients underwent a 24-h ambulatory BP monitoring and complete 2DE and 3DE examination including speckle tracking analysis. RESULTS: The analysis of our results showed that 3DE left ventricular global longitudinal strain was significantly lower in the nondippers (-17.8 ±â€Š2.6 vs. -16.2 ±â€Š2.4%, P < 0.001). Similar results were obtained for 3DE left ventricular global circumferential strain (-17.4 ±â€Š2.7 vs. -16.3 ±â€Š2.6%, P = 0.015), as well for 3DE left ventricular global radial strain (45.8 ±â€Š8.5 vs. 42.1 ±â€Š8.2%, P = 0.009), and left ventricular global area strain (-29.1 ±â€Š4.7 vs. -27.4 ±â€Š4.3%, P = 0.027). The left ventricular twist was increased in the nondippers (12.7 ±â€Š2.9 vs. 14.1 ±â€Š3.4°, P = 0.008), whereas the untwisting rate was significantly decreased in this group (-43.7 ±â€Š5.7 vs. -36.9 ±â€Š5.1 °/s, P < 0.001). The left atrial longitudinal strain, as well as left atrial systolic and early diastolic strain rates, was decreased in nondippers. Independent predictors of 3DE left ventricular longitudinal, circumferential, radial, and area strain were a 24-h mean BP, (E/e')m, and 3DE left ventricular ejection fraction. An additional independent predictor of the left atrial longitudinal strain was 3DE left ventricular mass index. CONCLUSION: The 3DE speckle tracking examination demonstrated that the left ventricular and left atrial mechanics were more impaired in the nondippers than in the dippers untreated hypertensive patients.

Effect of wine polyphenol resveratrol on the contractions elicited electrically or by norepinephrine in the rat portal vein.

We investigated the effects of resveratrol on rat portal vein (RPV) contractility without endothelium. Contractions were produced by electrical field stimulation of perivascular nerves (EFS), norepinephrine (NE), adenosine 5'-triphosphate (ATP), high K(+) solution and by calcium chloride (CaCl2 ) in Ca(2+) -free and high K(+) , Ca(2+) -free solution. The EFS-evoked contractions were more sensitive to resveratrol and to NS1619-selective openers of big calcium-sensitive (BKCa ) channels, than NE-evoked contractions. Effects of resveratrol on the ATP-evoked contractions were weak. Blockers of BKCa channels partly inhibited the effect of resveratrol only in EFS-contracted preparations. Western blotting showed that RPV expressed KCa 1.1 protein. Inhibitors of ATP- and voltage-sensitive K(+) channels did not modify the effects of resveratrol. None of the antagonists of K(+) channels affected the resveratrol inhibition of NE-evoked contractions and effect of high concentrations of resveratrol on the EFS-evoked contractions. Resveratrol more potently inhibited CaCl2 than potassium chloride contractions of RPV. Thus, BKCa channels partly mediate the inhibitory effect of resveratrol on the neurogenic contractions of RPV. The smooth muscle Ca(2+) channels and/or Ca(2+) mobilizing through cells might be involved in the effects of resveratrol on the contractility of RPV. Our results are important for better understanding the impact of resveratrol on the portal circulation.

Clinical outcome in patients with hilar malignant strictures type II Bismuth-Corlette treated by minimally invasive unilateral versus bilateral endoscopic biliary drainage.

BACKGROUND: Stenting of malignant hilar strictures remains a standard endoscopic treatment in patients with unresectable tumors. The aim of this two-center prospective study was to compare unilateral versus bilateral drainage in hilar malignant stenosis Bismuth-Corlette type II. METHODS: During a 3-year period, a total of 49 patients with hilar tumors (Bismuth-Corlette type II) were referred for endoscopic treatment, following the criteria of unresectability. Ultrasound, computed tomography scan and magnetic resonance cholangiopancreatography (MRCP) were previously performed in all patients in order to facilitate endoscopic retrograde cholangiopancreatography (ERCP). The stricture was first passed by the hydrophilic guide-wire and then contrast medium was injected. Mechanical bile duct dilation was performed, followed by plastic stent placement only in the liver lobe which was previously opacified. The procedures were performed under conscious sedation. The patients were followed up for the next 12 months with a stent exchange every 3 months. Primary outcome was assessed by patient survival in the first 12 months after the procedure. RESULTS: All 49 patients were treated with ERCP while 39 (79.59%) had successful stent placement. Among these, 32 had hilar cholangiocarcinoma (82%) and 7 (18%) had gallbladder cancer. Two groups of patients had Bismuth II strictures: A, 21 patients (54%) with unilateral contrast injection and drainage, and B, 18 (46%) with bilateral contrast injection and drainage. A total of 57 plastic stents were used (10 Fr, 89%; 11.5 Fr, 11%). Group B showed a lower bilirubin level 7 days after the procedure (P=0.008). Early complications were cholangitis (3 patients, 2 in group A and 1 in group B) and acute pancreatitis (2 patients, 1 each in A and B) with no statistical difference between the groups. Late complications were stent migration (5 patients, 1 in A and 4 in B) and stent clogging (6 patients, 2 in A and 4 in B) showing a significant difference between the groups (P<0.01). The first stent replacement after 3 months was successful in 87% of patients (four died due to disease progression and one due to cardiopulmonary insufficiency) showing no statistical difference between the groups. At 6 months follow-up, 72% patients survived, with no statistical difference between the groups. A final follow-up (12 months) showed the survival rate of 18% (4 patients from group A and 3 from group B) (P>0.05). CONCLUSIONS: A minimally invasive approach, based on the criterion that every bile duct being opacified needs to be drained, is associated with a lower incidence of early complications. Considering that the clinical outcome measured by bilirubin level was lower in patients with bilateral drainage 7 days after the procedure, we assumed that drainage of 50% or more of the liver volume leads to sufficient drainage effectiveness.

Complications during the establishment of laparoscopic pneumoperitoneum.

BACKGROUND: A safe establishment of the laparoscopic pneumoperitoneum is of the utmost importance, as potentially fatal complications, such as vascular or visceral injury or gas embolism, may occur during the procedure. OBJECTIVE: We used the published studies and our own experience to evaluate the advantages and disadvantages of various techniques for the establishment of the laparoscopic pneumoperitoneum, thus aiming to contribute to the reduction in the rate of fatal complications. METHODS: We performed a retrospective review of 4940 medical charts of patients without prior history of abdominal surgeries who had the laparoscopic pneumoperitoneum established by using a modified closed method (i.e., the patient is in an anti-Trendelenburg's position 20-30 degrees and a left lateral tilt of 10-15 degrees, with the Veress needle and the first trocar introduced through the umbilicus and directed toward the intersection of the anterior axial line and the right costal arc). Additionally, we searched Medline, Embase, and the Cochrane libraries with a cut-off date of December 2006, using specific key-words (i.e., trocar injury, complication, laparoscopic surgery, Veress needle, open vs. closed pneumoperitoneum, prospective study). RESULTS: There were no reports of injuries to the major blood vessels or visceral organs. However, liver capsule injury was reported in 432 (8.2%) patients, pneumo-omentum in 55 (1.1%) patients, and subfascial insufflations in 45 (0.9%) patients. CONCLUSIONS: No reliable conclusions regarding advantages or disadvantages of different techniques for the laparoscopic pneumoperitoneum can be drawn in the absence of adequately powered, prospective, comparative studies. Based on the fact that no major blood vessel or visceral organ injuries were observed in our experience, we conclude that the modified closed method deserves further multicentric prospective evaluation.

Low fresh gas flow balanced anesthesia versus target controlled intravenous infusion anesthesia in laparoscopic cholecystectomy: a cost-minimization analysis.

BACKGROUND: Laparoscopic surgery is widely recognized as a well-tolerated and effective method for cholecystectomy. It is also considered cost saving because it has been associated with a decreased hospital length of stay. Variables that might lead to increased costs in laparoscopic surgery are the technique and drugs used in anesthesia. OBJECTIVE: The goal of this study was to compare the costs of 2 anesthetic techniques used in laparoscopic cholecystectomy (LC)--balanced versus IV anesthesia--from the standpoint of an outpatient surgical department, with a time horizon of 1 year. METHODS: Patients scheduled to undergo elective LC were enrolled in this prospective case study. Patients were randomly allocated to receive balanced anesthesia, administered as low fresh gas flow (LFGF) with inhalational sevoflurane and IV sufentanil in a target controlled infusion (LFGF SS group), or IV anesthesia, administered as IV propofol/sufentanil in a target controlled infusion (TCI group). We used a microcosting procedure to measure health care resource utilization in individual patients to detect treatment differences. The costs of medications used for the induction and maintenance of anesthesia during surgery were considered for LFGF SS and TCI. Other end points included duration of anesthesia; mean times to early emergence, tracheal extubation, orientation, and postanesthesia discharge (PAD); pain intensity before first analgesia; number of analgesics required in the first 24 hours after surgery; and prevalences of nausea, vomiting, and agitation. RESULTS: A total of 60 patients were included in this analysis (male/female ratios in the LFGF SS and TCI groups: 11/19 and 12/18, respectively; mean [SD] ages, 48 [7.9] and 47 [8.6] years; and mean [SD] body mass indexes, 26 [2.0] and 26 [3.0] kg/m2). The costs of anesthetics were significantly lower with LFGF SS compared with TCI (euro17.40 [euro2.66] vs euro22.01 [euro2.50] [2006 euros]). Times to early emergence and tracheal extubation were significantly shorter with LFGF SS than TCI (5.97 [1.16] vs 7.73 [1.48] minutes and 7.57 [1.07] vs 8.87 [1.45] minutes, respectively). There were no significant between-group differences in mean duration of anesthesia; times to orientation and PAD; pain intensity before first analgesia; number of analgesics required in the first 24 hours; or prevalences of nausea, vomiting, and agitation. Because no clinically significant differences in the anesthetic results were observed, a cost-minimization analysis was conducted and found that using LFGF SS, the outpatient surgical department could realize a budget savings of euro454 per 100 patients. For the nearly 1000 expected patients per year, the savings for the department was calculated as euro4540. CONCLUSION: The results from this cost analysis in these patients who underwent elective LC suggest that the use of sevoflurane through the LFGF technique would be cost saving in this outpatient surgical department.