Challenge in hyponatremic patients - the potential of a laboratory-based decision support system for hyponatremia to improve patient's safety.

OBJECTIVES: Hyponatremia is the most frequent electrolyte disorder in hospitalized patients with increased mortality and morbidity. In this study, we evaluated the follow-up diagnostic, the risk of inadequate fast correction and the outcome of patients with profound hyponatremia (pHN), defined as a blood sodium concentration below 120 mmol/L. The aim was to identify a promising approach for a laboratory-based clinical decision support system (CDSS). METHODS: This retrospective study included 378,980 blood sodium measurements of 83,315 cases at a German tertiary care hospital. Hospitalized cases with pHN (n=211) were categorized into two groups by the time needed for a follow-up measurement to be performed (time to control, TTC) as either <12 h (group 1: "TTC≤12 h", n=118 cases) or >12 h (group 2: "TTC>12 h", n=93 cases). Length of hospital stay, sodium level at discharge, ward transfers, correction of hyponatremia, and risk of osmotic demyelination syndrome (ODS) due to inadequate fast correction were evaluated with regard to the TTC of sodium blood concentration. RESULTS: pHN was detected in 1,050 measurements (0.3%) in 211 cases. Cases, in which follow-up diagnostics took longer (TTC>12 h), achieved a significantly lower sodium correction during their hospitalization (11.2 vs. 16.7 mmol/L, p<0.001), were discharged more frequently in hyponatremic states (<135 mmol/L; 58 (62.4%) vs. 43 (36.4%), p<0.001) and at lower sodium blood levels (131.2 vs. 135.0 mmol/L, p<0.001). Furthermore, for these patients there was a trend toward an increased length of hospital stay (13.1 vs. 8.5 days, p=0.089), as well as an increased risk of inadequate fast correction (p<0.001). CONCLUSIONS: Our study shows that less frequent follow-up sodium measurements in pHN are associated with worse outcomes. Patients with a prolonged TTC are at risk of insufficient correction of hyponatremia, reduced sodium values at discharge, and possible overcorrection. Our results suggest that a CDSS that alerts treating physicians when a control time of >12 h is exceeded could improve patient care in the long term. We are initiating a prospective study to investigate the benefits of our self-invented CDSS (www.ampel.care) for patients with pHN.

Robotic-assisted Versus Laparoscopic Versus Open Radical Cystectomy-A Systematic Review and Network Meta-analysis of Randomized Controlled Trials.

CONTEXT: Multiple randomized controlled trials (RCTs) on the three approaches of radical cystectomy (robotic assisted [RARC], laparoscopic [LRC], and open [ORC]) have been published recently. OBJECTIVE: To perform a systematic review and network meta-analysis (NMA) of RCTs comparing RARC, LRC, and ORC, with the primary outcomes being overall survival (OS) and recurrence-free survival (RFS). EVIDENCE ACQUISITION: A search of the Cochrane Central Register of Controlled Trials, MEDLINE, and Web of Science (last search: 20/05/2022) was performed. The prospectively registered protocol stated that a NMA of the primary outcomes would be performed only if there was sufficient evidence to compare all three approaches. In case of insufficient evidence, a comparison between the two most common approaches would be performed. The risk of bias and certainty of evidence (CoE) via the Grading of Recommendations Assessment, Development, and Evaluation approach was assessed for direct evidence and the most common comparison. EVIDENCE SYNTHESIS: Ten trials were identified. There was insufficient evidence for a NMA of all approaches for the primary outcomes. The meta-analysis of RARC and ORC showed no differences in OS (hazard ratio (HR) [confidence interval (CI): 0.98 [0.73-1.30]) and RFS (HR [CI]: 0.99 [0.75-1.31]) with moderate CoE. The secondary outcomes showed lower rates of transfusions (p < 0.01) and longer operating time (p < 0.01) with high CoE for RARC compared with ORC. There were no differences for quality of life, positive margins, length of hospital stay, or major complications (all p > 0.05). CONCLUSIONS: There are no differences in OS and RFS between RARC and ORC, with moderate CoE. Clinicians should likely apply the approach with which they can reach the highest case volume and in which they have the most experience. PATIENT SUMMARY: We looked at the difference between three types (robotic assisted, laparoscopic, and open) of operating techniques for radical cystectomy. The data showed no significant differences in OS between the robotic-assisted and the open technique, while enough data were not available to make a comparison with conventional laparoscopic surgery.