Clinical and cost effectiveness of sacral nerve stimulation for faecal incontinence.

BACKGROUND: Sacral nerve stimulation (SNS) has better results and safety than other surgical procedures for faecal incontinence. This prospective study assessed the clinical effectiveness and costs of SNS at a single centre. METHODS: Patients who had experienced one or more episodes of faecal incontinence were studied for up to 5 years by continence diary, anorectal manometry and quality of life questionnaires. Direct medical costs were calculated and the cost-effectiveness of the treatment was analysed. RESULTS: Fifty-seven percutaneous nerve evaluations were performed in 47 patients between June 1999 and February 2006; 29 patients underwent permanent implantation. After a median follow-up of 34.7 (range 2.3-81.2) months, 25 of the 29 patients had a significant reduction in incontinence episodes; 14 patients were in complete remission. At 3-year follow-up, the mean reduction in incontinence episodes was 89 per cent. No change was observed in anal manometric values. Patients reported a significant improvement in quality of life. The introduction of SNS has an incremental cost-effectiveness ratio, below the accepted Spanish threshold. CONCLUSION: The introduction of SNS to the management of faecal incontinence within the Spanish setting is both effective and efficient.

Improved cardiac function in patients with obstructive jaundice after internal biliary drainage: hemodynamic and hormonal assessment.

OBJECTIVE: To investigate myocardial function in patients with obstructive jaundice before and after internal biliary drainage. SUMMARY BACKGROUND DATA: Increased plasma levels of atrial natriuretic peptide (ANP) have been found in patients with biliary obstruction. METHODS: Thirteen patients with newly diagnosed obstructive jaundice and no previous heart, lung, or renal disease were studied using a Swan-Ganz catheter. Hemodynamic measurements were taken before and 4 days after internal biliary drainage. Levels of ANP and brain natriuretic peptide (BNP) were obtained and liver function tests were also determined. RESULTS: Plasma levels of ANP and BNP were increased twofold to fourfold in the basal state and declined after biliary drainage. Independent variables predicting left ventricular systolic work were total bilirubin concentrations, duration of jaundice, and BNP. In addition, bilirubin concentrations correlated with pulmonary vascular resistance, mean arterial pulmonary pressure, and right ventricular systolic work. Internal biliary drainage resulted in an improvement in left ventricular systolic work. A correlation was found between decreasing ANP concentrations and increasing cardiac output. CONCLUSIONS: Increased plasma levels of natriuretic peptides in patients with obstructive jaundice may reflect a subclinical myocardial dysfunction correlating with the degree of jaundice. After internal biliary drainage, there is a measurable improvement of cardiac function.

Nutritional assessment of patients with benign and malignant obstructions of the biliary tract.

OBJECTIVES: the aim of this study was to assess the severity and type of nutritional deficiencies observed in patients with benign and malignant obstructive jaundice (OJ). METHOD: in this prospective cross-sectional study 51 patients with OJ (21 with benign and with 30 malignant obstruction) were investigated. Nutritional status was assessed by anthropometric parameters (ideal body weight, midarm muscle area and skinfold thickness), visceral proteins, creatinine height index and total lymphocyte count. Observed values in patients with OJ were normalized to the percentage value of the lower limit of normal (obtained from 17 healthy subjects matched for age and sex) and averaged to obtain a total score for protein-energy malnutrition. RESULTS: forty-two (82%) patients with OJ had protein-calorie malnutrition (PCM). Malnutrition was mild in 55%, moderate in 35% and severe in 10%. Severity of PCM was associated with intensity (p < 0.05) and duration of jaundice (p < 0.01). Kwashiorkor (74%) was the dominant type of malnutrition. PCM was common in benign (71%) as well as in malignant obstruction (90%), but the total score (92 +/- 20 vs 80 +/- 19; p < 0.05) and the proportion of mild PCM in patients with benign obstruction (80% vs 41%, p < 0.01) was significantly higher than in patients with malignant tumors. CONCLUSIONS: a high percentage of patients with OJ had PCM. The degree of nutritional alteration was associated with the intensity of jaundice. Malnutrition was equally prevalent among patients with benign obstructions and patients with malignant causes of biliary obstruction, although it was more severe in the latter. Acute malnutrition (kwashiorkor) was the dominant type of malnutrition in both groups of patients.

Preoperative assessment of body fluid disturbances in patients with obstructive jaundice.

Postoperative renal dysfunction in obstructive jaundice (OJ) patients has been associated with hypovolemia and depletion of the extracellular water compartment (ECW). The aim of the study was to evaluate the preoperative status of body compartments in OJ patients measured by two methods. In a prospective study 39 OJ patients (11 benign and 28 malignant obstructions) were investigated, with 15 healthy subjects used as a control group (CG). Bioelectrical impedance analysis (BIA) determinations and values derived from anthropometric measurements were used to assess body compartment status. The coefficient of variation of BIA was below 4% in both OJ and CG subjects. No differences were found in intracellular water. However total body water (TBW) and ECW were reduced in OJ patients (50.5 +/- 4.6 vs. 56 +/- 8% body weight, p = 0.05; and 21 +/- 4.5 vs. 23.8 +/- 2.5% body weight, p < 0.05, respectively). There were no differences between benign and malignant obstructions. Seventy four percent of OJ patients had an ECW volume below the mean +/- 2 SD in the CG subjects. Anthropometric and BIA determinations correlated closely for TBW measurements in both CG (r = 0.92, p < 0.001) and OJ patients (r = 0.91, p < 0.001). Bland-Altman analysis also showed that for TBW the BIA was in agreement with anthropometry. In the present study, BIA offered a good correlation with anthropometric determinations and was a reliable method for body fluid disturbances assessment in jaundiced patients.

Candidemia in non-neutropenic critically ill patients: analysis of prognostic factors and assessment of systemic antifungal therapy. Study Group of Fungal Infection in the ICU.

OBJECTIVE: To determine the incidence and prognosis of candidemia in non-neutropenic critically ill patients, to define mortality-related factors, and to evaluate the results of systemic antifungal therapy. DESIGN: A prospective multicenter survey in which medical and/or surgical intensive care units (ICUs) in 28 hospitals in Spain participated. PATIENTS: All critically ill patients with positive blood cultures for Candida species admitted to the participating ICUs over a 15-month period were included. INTERVENTIONS: Candidemia was defined as the presence of at least one positive blood culture containing Candida species. The follow-up period was defined as the time elapsed from the first positive blood culture for Candida species to discharge or death during hospitalization. Antifungal therapy was considered to be "early" when it was administered within 48 h of the date when the first positive blood culture was obtained and "late" when it was administered more than 48 h after the first positive blood culture. MEASUREMENTS AND MAIN RESULTS: Candidemia was diagnosed in 46 patients (mean age 59 years), with an incidence of 1 critically ill patient per 500 ICU admissions. The species most frequently isolated were Candida albicans (60%) and C. parapsilosis (17%). Fluconazole alone was given to 27 patients, amphotericin B alone to 10, and sequential therapy to 6. Three patients did not receive antifungal therapy. The overall mortality was 56% and the attributable mortality 21.7%. In the univariate analysis, mortality was significantly associated with a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score at the onset of candidemia (p = 0.04) and with the time elapsed between the episode of candidemia and the start of antifungal therapy 48 h or more later (p < 0.02). Patients with an APACHE II score lower than 21 at the onset of candidemia had a higher probability of survival than patients who were more seriously ill (p = 0.04). Patients with "early" antifungal therapy (< or = 48 h between the onset of candidemia and the start of antifungal therapy) had a higher probability of survival compared with patients with late therapy (p = 0.06). No significant differences were noted between the two groups on different antifungal therapy. CONCLUSIONS: The incidence of candidemia in ICU patients was very low. An APACHE II score > 20 at the time of candidemia was associated with a higher mortality. Further studies with a large number of patients are needed to assess the effect of early antifungal therapy on the decrease in mortality associated with candidemia and to determine the appropriate dosage of fluconazole and duration of treatment.

Assessment of a new hub design and the semiquantitative catheter culture method using an in vivo experimental model of catheter sepsis.

An in vivo model of hub-related catheter sepsis in rabbits is reported. The model was used to investigate the protection offered by a new hub design against external contamination by Pseudomonas aeruginosa or Staphylococcus epidermidis and to reassess the diagnostic value of the semiquantitative culture method in bacteremia of endoluminal origin. Contamination of conventional Luer-Lock connectors was followed by clinical sepsis, positive catheter segment cultures, or both, whereas contamination of the new hub was followed by complete protection. Clinical and bacteriological discrepancies observed between contamination with P. aeruginosa and S. epidermidis suggest that the virulence of microorganisms may account for differences in the natural history of hub-originated catheter sepsis. The semiquantitative extraluminal method for catheter culture yielded less than 15 CFU in three animals with proven bacteremia and should not be used as the "gold standard" to define catheter-related bacteremia.