Systemic barriers to optimal hemodialysis access.

Arteriovenous fistulas (AVFs) are considered the gold standard for hemodialysis vascular access based on their superior patency, low complication rates, improved adequacy, lower costs to the health care system, and decreased risk of patient mortality. The goals of the Fistula First Breakthrough Initiative are to achieve a prevalent AVF use rate of at least 66% nationally, to decrease central venous catheter use, and to reduce overall vascular access complication rates among patients on hemodialysis. Achieving optimal vascular access is a complex process and, unlike other dialysis outcomes, requires patient involvement as well as collaboration among nephrologists, surgeons, interventionalists, dialysis facilities, primary care physicians, and hospital systems. In 2009, the Fistula First Breakthrough Initiative assembled a team from varied backgrounds and perspectives to discover the systemic root causes as to why the AVF use rate in the United States is significantly lower than that in other industrialized countries. Ultimately, the 139 latent root causes identified by the root cause analysis team fall into the categories of patient, physician, and system. This article summarizes the current controversies in regard to improving AVF placement and reducing central venous catheter use, related to each of these three categories.

Simultaneous resection of the primary colorectal tumor and liver metastases--a safe and effective operation.

BACKGROUND: The aim of this retrospective study was to compare the results achieved by simultaneous resection (SR) vs. delayed resection (DR) in patients with synchronous colorectal liver metastases (SCRLM). METHODS: In "Dan Setlacec" Center of General Surgery and Liver Transplantation from Fundeni Clinical Institute, between 1995 and 2010, 117 patients underwent SR and 25 patients underwent DR. It was compared the outcome of the patients in the two groups. It was also assessed if certain subgroups of patients present a better outcome after DR than after SR. RESULTS: The location of the primary tumor, the number and diameter of liver metastases, and the proportion of major hepatectomies were similar in the two groups (p value > 0.05). For all patients, the morbidity, mortality, disease-free and overall surrvival rates were not statistically significant different between the two groups (p value > 0.05). In subgroups of patients with rectal tumors, with multiple liver metastases, and undergoing major hepatectomies, the morbidity, mortality and survival rates achieved by SR were similar to those achieved by DR. CONCLUSION: Simultaneous resection of SCRLM is similarly safe and efficient as the delayed resection, even in patients with rectal tumors, with multiple liver metastases, or undergoing major hepatectomies.