The Effect of Preoperative Administration of Glucocorticoids on the Postoperative Complication Rate in Liver Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: Glucocorticoids may grant a protective effect against postoperative complications. The evidence on their efficacy, however, has been inconclusive thus far. We investigated the effects of preoperatively administered glucocorticoids on the overall postoperative complication rate, and on liver function recovery in patients undergoing major liver surgery. Methods: We performed a systematic literature search on PubMed, Embase, and CENTRAL in October 2021, and repeated the search in April 2023. Pre-study protocol was registered on PROSPERO (ID: CRD42021284559). Studies investigating patients undergoing liver resections or transplantation who were administered glucocorticoids preoperatively and reported postoperative complications were eligible. Meta-analyses were performed using META and DMETAR packages in R with a random effects model. Risk of bias was assessed using RoB2. Results: The selection yielded 11 eligible randomized controlled trials (RCTs) with 964 patients. Data from nine RCTs (n = 837) revealed a tendency toward a lower overall complication rate with glucocorticoid administration (odds ratio: 0.71; 95% confidence interval: 0.38-1.31, p = 0.23), but it was not statistically significant. Data pooled from seven RCTs showed a significant reduction in wound infections with glucocorticoid administration [odds ratio: 0.64; 95% confidence interval: 0.45-0.92 p = 0.02]. Due to limited data availability, meta-analysis of liver function recovery parameters was not possible. Conclusions: The preoperative administration of glucocorticoids did not significantly reduce the overall postoperative complication rate. Future clinical trials should investigate homogenous patient populations with a specific focus on postoperative liver recovery.

Procalcitonin-guided antibiotic therapy may shorten length of treatment and may improve survival-a systematic review and meta-analysis.

BACKGROUND: Appropriate antibiotic (AB) therapy remains a challenge in the intensive care unit (ICU). Procalcitonin (PCT)-guided AB stewardship could help optimize AB treatment and decrease AB-related adverse effects, but firm evidence is still lacking. Our aim was to compare the effects of PCT-guided AB therapy with standard of care (SOC) in critically ill patients. METHODS: We searched databases CENTRAL, Embase and Medline. We included randomized controlled trials (RCTs) comparing PCT-guided AB therapy (PCT group) with SOC reporting on length of AB therapy, mortality, recurrent and secondary infection, ICU length of stay (LOS), hospital LOS or healthcare costs. Due to recent changes in sepsis definitions, subgroup analyses were performed in studies applying the Sepsis-3 definition. In the statistical analysis, a random-effects model was used to pool effect sizes. RESULTS: We included 26 RCTs (n = 9048 patients) in the quantitative analysis. In comparison with SOC, length of AB therapy was significantly shorter in the PCT group (MD - 1.79 days, 95% CI: -2.65, - 0.92) and was associated with a significantly lower 28-day mortality (OR 0.84, 95% CI: 0.74, 0.95). In Sepsis-3 patients, mortality benefit was more pronounced (OR 0.46 95% CI: 0.27, 0.79). Odds of recurrent infection were significantly higher in the PCT group (OR 1.36, 95% CI: 1.10, 1.68), but there was no significant difference in the odds of secondary infection (OR 0.81, 95% CI: 0.54, 1.21), ICU and hospital length of stay (MD - 0.67 days 95% CI: - 1.76, 0.41 and MD - 1.23 days, 95% CI: - 3.13, 0.67, respectively). CONCLUSIONS: PCT-guided AB therapy may be associated with reduced AB use, lower 28-day mortality but higher infection recurrence, with similar ICU and hospital length of stay. Our results render the need for better designed studies investigating the role of PCT-guided AB stewardship in critically ill patients.

Hemoadsorption Therapy for Critically Ill Patients with Acute Liver Dysfunction: A Meta-Analysis and Systematic Review.

Critically ill patients are at risk of developing acute liver dysfunction as part of multiorgan failure sequelae. Clearing the blood from toxic liver-related metabolites and cytokines could prevent further organ damage. Despite the increasing use of hemoadsorption for this purpose, evidence of its efficacy is lacking. Therefore, we conducted this systematic review and meta-analysis to assess the evidence on clinical outcomes following hemoadsorption therapy. A systematic search conducted in six electronic databases (PROSPERO registration: CRD42022286213) yielded 30 eligible publications between 2011 and 2023, reporting the use of hemoadsorption for a total of 335 patients presenting with liver dysfunction related to acute critical illness. Of those, 26 are case presentations (n = 84), 3 are observational studies (n = 142), and 1 is a registry analysis (n = 109). Analysis of data from individual cases showed a significant reduction in levels of aspartate transaminase (p = 0.03) and vasopressor need (p = 0.03) and a tendency to lower levels of total bilirubin, alanine transaminase, C-reactive protein, and creatinine. Pooled data showed a significant reduction in total bilirubin (mean difference of -4.79 mg/dL (95% CI: -6.25; -3.33), p = 0.002). The use of hemoadsorption for critically ill patients with acute liver dysfunction or failure seems to be safe and yields a trend towards improved liver function after therapy, but more high-quality evidence is crucially needed.

Early prediction of acute necrotizing pancreatitis by artificial intelligence: a prospective cohort-analysis of 2387 cases.

Pancreatic necrosis is a consistent prognostic factor in acute pancreatitis (AP). However, the clinical scores currently in use are either too complicated or require data that are unavailable on admission or lack sufficient predictive value. We therefore aimed to develop a tool to aid in necrosis prediction. The XGBoost machine learning algorithm processed data from 2387 patients with AP. The confidence of the model was estimated by a bootstrapping method and interpreted via the 10th and the 90th percentiles of the prediction scores. Shapley Additive exPlanations (SHAP) values were calculated to quantify the contribution of each variable provided. Finally, the model was implemented as an online application using the Streamlit Python-based framework. The XGBoost classifier provided an AUC value of 0.757. Glucose, C-reactive protein, alkaline phosphatase, gender and total white blood cell count have the most impact on prediction based on the SHAP values. The relationship between the size of the training dataset and model performance shows that prediction performance can be improved. This study combines necrosis prediction and artificial intelligence. The predictive potential of this model is comparable to the current clinical scoring systems and has several advantages over them.

Role of faith in strategies of healthcare professionals in intensive care units in end-of-life decision making / A vallásosság szerepe az intenzív osztályon dolgozó orvosok és ápolók véleményének kialakításában az életvégi döntések meghozatalakor.

Összefoglaló. Bevezetés: A haldoklást minden korban kulturális és vallási szabályok vették körül, melyek a mai napig hatnak a társadalomban. A 21. században számos beteg a kórházban, az intenzív osztályon fejezi be életét, ahol nem ritkán kerülhet sor életvégi döntés meghozatalára. Célkituzés: Vizsgálatunk célja annak feltárása volt, milyen hatással van az orvosok és ápolók vallásossága a kezeléskorlátozással kapcsolatos döntésekre az intenzív osztályon. Módszer: Magyarországi intenzív osztályokon dolgozó orvosok és szakdolgozók körében végeztünk kérdoíves felmérést a vallás életvégi döntésekre gyakorolt hatásáról. 189 orvos és 105 ápoló által anonim módon kitöltött kérdoívet elemeztünk. Eredmények: Az intenzív osztályra történo betegfelvételre nem volt hatással a vallásosság, azonban a szabad ágyak száma a vallásos orvosokat erosebben befolyásolta, mint az ateista és választ nem adó orvosokat (<0,0001). A vallásukat gyakorló orvosok szignifikánsan jobban figyelembe vették a hozzátartozó kérését, mint az ateisták (p = 0,0002). A vallásos ápolók gyakrabban folytatnák a beteg kezelését a hozzátartozó kérése ellenére is, ha még látnának esélyt a gyógyulásra, mint a nem vallásosak. Következtetés: Vizsgálatunk alátámasztotta, hogy a világnézet befolyásolja az orvosokat és ápolókat az élet végérol hozott döntésekben. A kezeléskorlátozásról hozott döntés összetett, elengedhetetlen megismerni hozzá a beteg és családjának haldoklással kapcsolatos vallási szokásait, mivel jó életvégi döntés a világnézeti szempontok figyelembevétele nélkül nem hozható. Orv Hetil. 2021; 162(51): 2047-2054. INTRODUCTION: Death has always been surrounded by habits in all ages, influenced by cultural and religious differences. Many patients finish their lives at intensive care units where end-of-life decisions are the part of everyday practice in the 21th century. OBJECTIVE: The goal of our study was to assess how the religious beliefs of physicians and nurses affect their decision on therapy restriction. METHOD: We have performed questionnaire-based enquiries among physicians and nurses working at intensive care units on how religion affects end-of-life decisions. We have analyzed the anonymous questionnaires filled out by 189 physicians and 105 nurses. RESULTS: Our results have confirmed the hypothesis that religion affects decision making about therapy restriction. Patients' admissions were not affected by religious beliefs, but the number of available patient beds influenced the religious physicians more than the atheists ones or the non-responders (<0.0001). Actively religious physicians complied significantly better with the relatives than atheists (p = 0.0002). Religious nurses would continue patient treatment even against the will of relatives more often than atheists if they see a chance for recovery. CONCLUSION: The study supports that religion influences physicians and nurses in their end-of-life decisions. Decisions on therapy restriction are complex; it is important to find out religious beliefs and perception of death among patients and families because good end-of-life decision cannot be made disregarding religious considerations. Orv Hetil. 2021; 162(51): 2047-2054.

Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study.

BACKGROUND: End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS: In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS: Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. INTERPRETATION: Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. FUNDING: None.

Ethical climate and intention to leave among critical care clinicians: an observational study in 68 intensive care units across Europe and the United States.

PURPOSE: Apart from organizational issues, quality of inter-professional collaboration during ethical decision-making may affect the intention to leave one's job. To determine whether ethical climate is associated with the intention to leave after adjustment for country, ICU and clinicians characteristics. METHODS: Perceptions of the ethical climate among clinicians working in 68 adult ICUs in 12 European countries and the US were measured using a self-assessment questionnaire, together with job characteristics and intent to leave as a sub-analysis of the Dispropricus study. The validated ethical decision-making climate questionnaire included seven factors: not avoiding decision-making at end-of-life (EOL), mutual respect within the interdisciplinary team, open interdisciplinary reflection, ethical awareness, self-reflective physician leadership, active decision-making at end-of-life by physicians, and involvement of nurses in EOL. Hierarchical mixed effect models were used to assess associations between these factors, and the intent to leave in clinicians within ICUs, within the different countries. RESULTS: Of 3610 nurses and 1137 physicians providing ICU bedside care, 63.1% and 62.9% participated, respectively. Of 2992 participating clinicians, 782 (26.1%) had intent to leave, of which 27% nurses, 24% junior and 22.7% senior physicians. After adjustment for country, ICU and clinicians characteristics, mutual respect OR 0.77 (95% CI 0.66- 0.90), open interdisciplinary reflection (OR 0.73 [95% CI 0.62-0.86]) and not avoiding EOL decisions (OR 0.87 [95% CI 0.77-0.98]) were all associated with a lower intent to leave. CONCLUSION: This is the first large multicenter study showing an independent association between clinicians' intent to leave and the quality of the ethical climate in the ICU. Interventions to reduce intent to leave may be most effective when they focus on improving mutual respect, interdisciplinary reflection and active decision-making at EOL.

Prevalence of Disagreement About Appropriateness of Treatment Between ICU Patients/Surrogates and Clinicians.

BACKGROUND: ICU patients/surrogates may experience adverse outcomes related to perceived inappropriate treatment. The objective was to determine the prevalence of patient/surrogate-reported perceived inappropriate treatment, its impact on adverse outcomes, and discordance with clinicians. METHODS: We conducted a multicenter, prospective, observational study of adult ICU patients. RESULTS: For 151 patients, 1,332 patient, surrogate, nurse, and physician surveys were collected. Disagreement between patients/surrogates and clinicians regarding "too much" treatment being administered occurred in 26% of patients. Disagreement regarding "too little" treatment occurred in 10% of patients. Disagreement about perceived inappropriate treatment was associated with prognostic discordance (P = .02) and lower patient/surrogate satisfaction (Likert scale 1-5 of 4 vs 5; P = .02). Patient/surrogate respondents reported "too much" treatment in 8% of patients and "too little" treatment in 6% of patients. Perceived inappropriate treatment was associated with moderate or high respondent distress for 55% of patient/surrogate respondents and 35% of physician/nurse respondents (P = .30). Patient/surrogate perception of inappropriate treatment was associated with lower satisfaction (Family Satisfaction in the ICU Questionnaire-24, 69.9 vs 86.6; P = .002) and lower trust in the clinical team (Likert scale 1-5 of 4 vs 5; P = .007), but no statistically significant differences in depression (Patient Health Questionnaire-2 of 2 vs 1; P = .06) or anxiety (Generalized Anxiety Disorder-7 Scale of 7 vs 4; P = .18). CONCLUSIONS: For approximately one-third of ICU patients, there is disagreement between clinicians and patients/surrogates about the appropriateness of treatment. Disagreement about appropriateness of treatment was associated with prognostic discordance and lower patient/surrogate satisfaction. Patients/surrogates who reported inappropriate treatment also reported lower satisfaction and trust in the ICU team.

Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool.

BACKGROUND: Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU). OBJECTIVES: To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates. METHODS: Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups. RESULTS: Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner. CONCLUSIONS: The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians' behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.

[Options for the improvement of communication and self-determination in end-of-life decisions in intensive care units]. / A kommunikáció és az önrendelkezés javításának lehetoségei az életvégi döntések meghozatalánál az intenzív osztályokon.

The end-of-life decision making process normally based on patient autonomy or substituted judgement. If the patient can express his/her wishes, one must take note of his autonomy. If he/she is unable to self-determination, the importance of advanced directives or substituted judgement increases in the field of end-of-life care. The most important target of the efforts is to improve end-of-life care at intensive care units. Based on bioethical studies of the author and international literature this paper analizes the practice of end-of-life care and presents recommendations for lawmakers. The author proposes to divide patients with organ failure into three parts (end-of-life triage). The first part includes definitely salvageable, the second part definitely unsalvageable, and the third part possibly salvageable groups. This classification depends on the development of medical science and the local options of medical treatment. The quality of the decision-making process can be improved, but all participants must participate and medio-legal regulation must be improved.

[Evaluation of the diagnostic value of bedside ultrasonography in the emergency care]. / Az ágy melletti ultrahangvizsgálat diagnosztikus lehetoségeinek vizsgálata a sürgosségi betegellátásban.

INTRODUCTION: Rapid differential diagnosis of circulatory failure (shock) with unknown etiology is a daily challenge in the field of emergency medicine. The Rapid Ultrasound in Shock (RUSH) protocol is well known since 2010. With the use of targeted steps, the 4 forms of shock (cardiogen, distributive, obstructive, hypovolemic) can be separated in a few minutes. AIM: The aim of the authors was to evaluate the usefulness of the Rapid Ultrasound in Shock protocol for the diagnosis of different forms of shock. METHOD: The retrospective study included 123 critically ill patients admitted to the Emergency Department of Markusovszky Hospital, Szombathely, Hungary. Detailed records were obtained from all patients. RESULTS: From the 123 crirically ill patients, 64 patients suffered from circulatory failure, while the remaining patients had acute severe chest or abdominal pain, or respiratory failure. CONCLUSIONS: Based on the results of the first evaluation of the Rapid Ultrasound in Shock protocol in Hungarian patients, the authors conclude that, the bedside ultrasonography has a great value in emergency medicine, and this the protocol is suitable for its integration into patient care and education of emergency medicine.

A detailed semiologic analysis of childhood psychogenic nonepileptic seizures.

PURPOSE: Psychogenic nonepileptic seizure (PNES) is an important differential diagnostic problem in patients with or without epilepsy. There are many studies that have analyzed PNES in adults; currently, however, there is no systematic assessment of purely childhood PNES semiology. Our study based on a large pediatric video-electroencephalography (EEG) monitoring (VEM) cohort, provides a detailed analysis of childhood PNES and assesses the usability of the current classification system described in adults. METHODS: Medical and video-EEG records of 568 consecutive children (younger than 18 years) who underwent video-EEG monitoring (VEM) at our hospital were reviewed. Aura, type of movement, anatomic distribution, synchrony, symmetry, eye movement, responsiveness, vocalization, hyperventilation, vegetative and emotional signs, presence of eyewitness, and duration of the event were recorded among children with the diagnosis of PNES. We also compared our data with those of earlier adult studies. KEY FINDINGS: Seventy-five archived PNES of 27 children (21 girls; age 8-18 years) were reanalyzed. Nine children (33%) had the diagnosis of epilepsy currently or in the past. Mean age at the time of PNES onset was 11.6 (standard deviation 3.2) years. Mean duration of PNES was longer (269 s) compared to seizures of the epileptic group (83 s; p = 0.002). Eyewitnesses (mostly parents) were present in 89% of cases. Eighty percent of PNES had an abrupt start, with 68% also ending abruptly. In only 15% of events were the patients eyes closed at the beginning of the attack. Patients were unresponsive in 34%. The most frequent motor sign was tremor (25%) with the upper, rather than lower limbs more frequently involved. Pelvic thrusting was seen in only two attacks. Emotional-mostly negative-signs were observed during 32 PNES (43%). Based on Seneviratne et al.'s classification, 18 events (24%) were classified as rhythmic motor PNES, only half the frequency of that previously described in adults. No hypermotor PNES was found. The frequency of complex motor PNES (13%) and mixed PNES (4%) showed similar frequency in children as in adults. Dialeptic PNES was found more frequently among younger children. All PNES belonged to the same semiologic type in 23 patients (85%). SIGNIFICANCE: Because homogeneity of PNES within a patient was high in the pediatric population, we found it useful to classify PNES into different semiologic categories. Dialeptic PNES seems to be more frequent among younger children. Tremor is the most frequent motor sign and usually accompanied by preserved responsiveness in childhood. Negative emotion is commonly seen in pediatric PNES, but pelvic thrusting is a rare phenomenon. We, therefore, suggest a modification of the present classification system in which PNES with motor activity is divided into minor and major motor PNES, and the latter group is subdivided into synchron rhythmic motor and asynchron motor PNES. We believe that our study, a detailed analysis on the semiology and classification of purely childhood PNES might assist the early and precise diagnosis of nonepileptic paroxysmal events.

Prevention of tracheal cartilage injury with modified Griggs technique during percutaneous tracheostomy - Randomized controlled cadaver study.

INTRODUCTION: Tracheal stenosis is the most common severe late complication of percutaneous tracheostomy causing significant decrease in quality of life. Applying modified Griggs technique reduced the number of late tracheal stenoses observed in our clinical study. The aim of this study was to investigate the mechanism of this relationship. MATERIALS AND METHODS: Forty-six cadavers were randomized into two groups according to the mode of intervention during 2006-2008. Traditional versus modified Griggs technique was applied in the two groups consequently. Wider incision, surgical preparation, and bidirectional forceps dilation of tracheal wall were applied in modified technique. Injured cartilages were inspected by sight and touch consequently. Age, gender, level of intervention, and number of injured tracheal cartilages were registered. RESULTS: Significantly less frequent tracheal cartilage injury was observed after modified (9%) than original (91%) Griggs technique (p < 0.001). A moderate association between cartilage injury and increasing age was observed, whereas the level of intervention (p = 0.445) and to gender (p = 0.35) was not related to injury. Risk of cartilage injury decreased significantly (OR: 0.0264, 95%, CI: 0.005-0.153) with modified Griggs technique as determined in adjusted logistic regression model. DISCUSSION: Modified Griggs technique decreased the risk of tracheal cartilage injury significantly in our cadaver study. This observation may explain the decreased number of late tracheal stenosis after application of the modified Griggs method.

[General anesthesia during double balloon enteroscopy--Hungarian experiences]. / Kettosballon-enteroszkópiás vizsgálatoknál végzett altatások során szerzett hazai tapasztalatok. Beteg-autonómia az anesztéziában.

UNLABELLED: Double balloon enteroscopy needs sufficient sedation technique, because the examination is uncomfortable and lengthy. The most prevalent sedation method is conscious sedation world-wide. AIM: To demonstrate that double balloon enteroscopy examination can also be safely performed in general anesthesia with intubation and that this method can be an option in patients with severe multiple morbidities. METHODS: A retrospective evaluation of intubation narcosis in patients undergoing double balloon enteroscopy was performed at the 1st Department of Internal Medicine, Semmelweis University. Patients were grouped based on gender, age and physical state. Anesthesia records included the duration of anesthesia, the quantities of medications used and anesthesia-related complications. RESULTS: Data obtained from 108 general anesthesia cases were analyzed. There were no permanent anesthesia-related complications in the period examined. The most frequent side effects of anesthesia were hypotension (30.55%), desaturation (21.29%), and apnea (17.59%). These complications were significantly more frequent among patients with multiple morbidities; however, their incidence was not proportional with the quantity of the medications used or the duration of anesthesia. CONCLUSION: The findings confirm that the most important advantage of general anesthesia over other methods is that it ensures stable airways, which makes it easy to counter-act frequent complications such as desaturation, apnea and aspiration. The number of complications of anesthesia was higher among patients with multiple morbidities, but these complications could be easily overcome in all patient groups. Therefore, this method is highly recommended for patients with multiple morbidities. Intubation narcosis can be also a viable option of conscious sedation for patients without co-morbidities.

[Practice of treatment restriction in Hungarian intensive care units]. / A kezeléskorlátozás gyakorlata a hazai intenzív osztályokon.

UNLABELLED: End of life decisions affect most of patients in intensive care units, thus, it is important to know both local and international practice in accordance with law and ethical principles for intensive care physicians. AIM: To search for local customs of end of life decisions (withholding or withdrawing the therapy, shortening of the dying process), and to compare the data with the international literature. METHODS: In 2007-2008 the first Hungarian survey was performed with the purpose to learn more about local practice of end of life decisions. Questionnaires were sent out electronically to 743 registered members of Hungarian Society of Anesthesiology and Intensive Care. Respecting anonymity, 103 replies were statistically evaluated (response rate was 13.8%) and compared with data from other European countries. RESULTS: As expected, it turned out from replies that the practice of domestic intensive care physicians is very paternal and this is promoted by legal regulations that share a similar character. Intensive care physicians generally make their decisions alone (3.75/5 point) without respecting the opinion of the patient (2.57/5 point) the relatives (2.14/5 point) or other medical personnel (2.37/5 point). Furthermore, they prefer not to start a therapy rather than withdraw an ongoing treatment. Nevertheless, the frequency of end of life decisions (3-9% of ICU patients) is smaller than other European countries. CONCLUSIONS: There is a need for the expansion of patients' right in our country. For end of life decisions, self determinations must be supported and a dialogue must be established between lawmakers and physicians, in order to improve the legal support of this medical practice.

Double balloon enteroscopy examinations in general anesthesia.

AIM: To demonstrate that the double balloon enteroscopy (DBE) can be safely performed in general anesthesia with intubation. METHODS: We performed a retrospective examination between August 2005 and November 2008 among patients receiving intubation narcosis due to DBE examination. The patients were grouped based on sex, age and physical status. Anesthesia records included duration of anesthesia, quantity of medication used and anesthesia-related complications. We determined the frequency of complications in the different groups and their relation with the quantity of medication used and the duration of anesthesia. RESULTS: We compiled data for 108 cases of general anesthesia with intubation. We did not observe any permanent anesthesia-related complications; the most frequent side effects of anesthesia were hypotension (30.55%), desaturation (21.29%), and apnea (17.59%). These complications were significantly more frequent among patients with multiple additional diseases [hypotension (23.1% vs 76.9%, P = 0.005), de-saturation (12.3% vs 69.2%, P < 0.001) and apnea (7.7% vs 53.8%, P = 0.001)], however, their incidence was not proportional to the quantity of medication used or the duration of anesthesia. CONCLUSION: General anesthesia with intubation is definitely a viable option among DBE methods. It is highly recommended in patients with multiple additional diseases.

Double-balloon endoscopy for small intestinal disease: a single-center experience in Hungary.

BACKGROUND: We report on our experience with the Fujinon EN-450 T5 therapeutic double-balloon endoscope (DBE) and compare our findings with the results of earlier capsule endoscopy. MATERIAL/METHODS: Between August 2005 and July 2009, 150 DBE procedures were conducted in 139 consecutive patients (M/F: 67/72, age: 51.1 years, SD: 18.6 years) who presented at our tertiary referral hospital. The results of previous capsule endoscopy (CE) examinations were available in 27 patients. The indications for DBE included obscure gastrointestinal bleeding (OGIB) in 83 patients, suspected/known IBD in 25, and polyposis/suspected neoplasia in 29 patients. All of the examinations were performed at our outpatient clinic. RESULTS: In OGIB, abnormal small-bowel findings were noted in 50 patients (60.2%) including angiodysplasias, erosions, and small ulcers. Malignancy was found in 6 patients (7.2%), while an intervention was carried out in 24 patients. In suspected IBD cases, IBD was diagnosed in 5/13 cases. In known IBD patients, assessment of the extent as well as disease behavior and activity was the indication. In polyposis/suspected malignancy, polyps were removed by snare polypectomy in 8 Peutz-Jeghers patients, while primary adenocarcinoma was diagnosed in 4. The concordance of CE and DBE findings was 51.8% (14/27), while in 2 cases DBE provided significantly new information, including 1 malignancy. The average insertion length was app. 213 cm (range: 70-480 cm). CONCLUSIONS: Based on our experience, DBE is a safe and useful method for evaluating and treating small-bowel disease in selected patients with obscure bleeding, IBD or polyposis syndromes. The concordance of DBE and CE in this real-life setting was only fair.

[Wilkie's syndrome]. / A Wilkie-syndromáról.

Loss of retroperitoneal fatty tissue as a result of a variety of debilitating conditions and noxa is believed to be the etiologic factor of superior mesenteric artery syndrome. A case of a 35 years old female patient with severe malnutrition and weight loss is presented, who developed superior mesenteric artery syndrome. Various theories of etiology, clinical course and treatment options of this uncommon disease are discussed. In our case, conservative management was inefficient, while surgical treatment aiming to bypass the obstruction by an anastomosis between the jejunum and the proximal duodenum (duodenojejunostomy) was successful. An interdisciplinary teamwork provides the most beneficial diagnostic and therapeutic result in this often underestimated disease.

Double-balloon enteroscopy for the diagnosis and treatment of obscure bleeding, inflammatory bowel diseases and polyposis syndromes: we see more but do we know more?

BACKGROUND/AIMS: Our aim was to report our experience with the Fujinon EN-450 T5 therapeutic double-balloon endoscope (DBE) in the diagnosis of small bowel diseases. METHODOLOGY: Between August 2005 and October 2006, 52 DBE procedures were conducted on 47 consecutive patients (M/F: 22/25, age: 51.6 SD 19.5 years) presenting at our tertiary referral hospital (35 and 7 patients from oral and anal route, respectively; 5 patients from both). All procedures were performed using i.v. anesthesia, at our outpatient clinic. RESULTS: Indication suspected small-bowel bleeding in 28 patients, suspected/known inflammatory bowel syndrome (IBD) in 12 and polyposis/suspected neoplasia in 7. In obscure bleeding small-bowel abnormality was found in 18 patients (64.3%) including angiodysplasias/erosions and one polypoid lesion. In suspected IBD, IBD was diagnosed in 2 out of 8 cases. In patients with polyposis syndromes, polyps were in two Peutz-Jeghers patients, while a further patient with suspected stenosis was diagnosed with primary adenocarcinoma. The average insertion length was app. 213cm. No severe complications were observed. CONCLUSIONS: Based on our experience DBE is a safe and useful method for evaluating and treating small bowel disease in selected patients with obscure bleeding, IBD or polyposis syndromes, however the clinical importance of minute lesions still needs to be determined.

[Ethical and legal problems of informed consent]. / A tájékozott beleegyezés jogi és etikai problémái.

INTRODUCTION: The previously accepted paternalistic relationship between patients and doctors has changed in last century. The expectation for patients to be involved in medical decisions is growing, but this involvement cannot be imagined without informed consent, hence it became one of the most important elements of a physician's responsibilities. Although informed consent is broadly regulated legally in Hungary, experiences show that practical realization is insufficient. This is also represented in the large number of lawsuits in connection with the inadequate or wrong use of informed consent. The aim of this study was to survey for the first time in Hungary the state of informed consent by the analysis of written consents to anaesthesia. METHODS: The authors collected and studied written consents to anesthesia from 36 hospitals and clinics in Budapest. They studied among others the presence of the following formal elements: individual consent forms for anesthesia, signatures on forms etc. They also examined whether the consents contained all of the conventional elements of informed consent. RESULTS: 61% of hospitals had individual forms for consent to anesthesia. Every consent form required a signature by the patient and almost every form (except two) by the doctor as well. 39% of forms describe the medical treatment in detail and only 25% mention its advantages and disadvantages. 28% of them specify definite risks, but only 19% mention their probability. 67% of the documents refer to the possible need to extend intervention. Patients have to declare whether they permit urgent blood transfusion in 25 institutions (69%). In only two hospitals are patients informed of their rights to revoke consent or to resign from being informed of medical treatment. CONCLUSION: Although all institutions have written consent forms that adhere to legal regulations, in terms of their format and matter they leave much to be desired. It is especially conspicuous that possible risks are named in less than a fourth of all forms, thus they have to be mentioned verbally and this obviously is a source of later arguments. The authors believe that all invasive medical procedures require templates for consent forms put together by professional panels. These forms could then be adapted to all specific medical procedures of the hospital in question.