Hospital doors under pressure; policies and trends in the major tertiary care hospital in Albania.

OBJECTIVES: Quantification of elective and emergency hospital admissions as a resultant of patients' diagnostic and therapeutic pathways (referral system) and patients' preferences to choose the health-care provider. DESIGN: Retrospective analysis of routine hospital discharge data. Findings were analyzed with descriptive statistical methods. SETTING: University Hospital Center, "Mother Teresa", Albania, a secondary and tertiary health care provider to the capital Tirana and tertiary health care provider for the rest of Albania. SUBJECTS: 692,284 hospital admissions during eleven years period, 2006-2016. MAIN OUTCOME MEASURES: Hospital admission trends measured as Average Annual Percentage Change and standardized admissions by district per 100,000 inhabitants. RESULTS: Number of hospital admissions increased from 55,528 in the baseline year to 78,130 in the last year of our study. During eleven years ALOS changed from 7.60 to 5.80 days and BOR increased from 83.2% to 91.6%. AAPC total, Average Annual Percentage Change was 3.2% at the ending year, 2006 to 2016. Cramér's V between variables 'year of admission' and 'prefecture' was 0.024, p < 0.001 and between 'year of admission' and 'Tirana University Hospital Center administrative units' was 0.055, p < 0.001. Both relationships are weak but significant. Maps show the exaggerated flow from other districts towards Tirana. CONCLUSIONS: Patient satisfaction, as a health care quality metric, is a driving force towards the choice of health provider. The satisfied patient chooses again or tells the next patient the preferred provider. The perceived professional difference among health care providers has built a competitive environment. The referral system puts strict rules over patient pathway which in his turn finds ways to bypass it if preferences are not taken in consideration. Commitment to such rules is accepted till forces considered as expression of free choice overcome them, jeopardizing the performance of the whole system. Patient's preferences deserve to be evaluated and incorporated in the patient pathway design.

Intramural duodenal hematoma after submucosal injection of epinephrine for a bleeding ulcer: case report and review.

We present a case of intramural duodenal hematoma as a complication of endoscopic therapy for a bleeding duodenal ulcer in an adult patient with no evidence of other pathologies. A 18-year-old man was admitted in emergency room with gastrointestinal bleeding manifested by melena. Previous medical history revealed that he had endoscopic sclerotherapy for bleeding duodenal ulcer 5 months before. Endoscopy revealed a Forrest 2a ulcer in the duodenal bulb and sclerotherapy was performed by injecting 10 ml of 0.2% epinephrine and 20 ml of Na- Cl 0.9% solution. Upper occlusion's signs appeared 36 hours after the procedure. The hematoma, that was identified by endoscopy and confirmed by MRI and CT scan of the abdomen, caused transient duodenal obstruction. Combined conservative management with nasogastric tube and total parenteral nutrition resulted in reduction of obstructive symptoms within 4 weeks.

Actual status of preoperative diagnosis of thyroid cancer in Albania.

INTRODUCTION: Thyroid cancer is the most common endocrine malignancy and accounts for almost 1% of human cancer. It is well known that the majority of cases occur in women in the middle decades of life. Thyroid cancer is a relatively rare disease; on the other hand clinically apparent thyroid nodules are present in 4-7% of the adult population. Most thyroid nodules are not malignant, with reported malignancy rates from 3-12%. It is important for the surgeon to know beforehand the diagnosis of malignancy, in order to perform a more radical operation on the thyroid gland. PATIENTS AND METHODS: In our study we have analyzed the preoperative clinical data of 84 patients operated in the First Clinic of General Surgery, UHC "Mother Theresa" in Tirana; all with a positive histopathologic diagnosis of thyroid cancer. The data comprised age, sex, age distribution, blood group, time-lapse from the first endocrinologic visit, clinical examination, signs and symptoms, imaging, functional tests, preoperative FNA, admission diagnosis, associated diseases and preoperative treatment. RESULTS: From the study emerged that only 9,3% of these patients were diagnosed preoperatively as thyroid cancer. Another related problem is the low percentage of preoperative FNA - only 22%. Among the signs and symptoms related to thyroid cancer we found that 40 and 33% of these patient presented dyspnea and dysphagia, respectively. The physical examination revealed apparent nodular growth of the thyroid gland in 81% and nodular hard consistency in 79% of cases. The proper endocrinologist consultation lacked in 23% of cases. CONCLUSION: In our opinion, close collaboration between endocrinologists and surgeons in a multidisciplinary frame is the key to correct preoperative thyroid cancer diagnosis and optimal treatment.

Evaluation of patterns and appropriate gastro protection in Albanian primary health care users.

Our aim was to assess the prevalence of gastro protection in the Albanian population using non-steroidal anti-inflammatory drugs (NSAIDs). A cross-sectional study, conducted in November-December 2011 in Albania, included 610 NSAIDs users (236 men and 374 women) who visited pharmacies to receive their NSAID medication. A structured questionnaire was administered to all participants including information on age, sex, educational status, pathology being treated with NSAID, presence of gastrointestinal ulcer or related complications, duration of NSAIDs therapy, type of drug used, and gastro protection therapy. Almost all participants (N=599) received NSAIDs to treat rheumatic and/or musculoskeletal disorders. Of these, 475 individuals were on chronic therapy with high daily doses of NSAIDs. Concomitant gastro protective therapy was found in 184 individuals (30 percent of the overall sample). Women and the more educated individuals received more gastro protection than men and the low educated counterparts, respectively (33.4 percent in women vs 25 percent in men; 47 percent in highly educated vs 18 percent in low educated). Appropriate use of gastro protective therapy for NSAID users needs to be promptly implemented in Albania, as its inappropriate use raises ethical and economic concerns. Prescriptions should follow clear guidelines for prevention of gastrointestinal damage following NSAIDs therapy among persons at high risk.

Postoperative pain management at Tirana university hospital center -Mother Teresa-, Tirana, Albania.

There is no or little evidence on postoperative pain assessment and treatment in Albanian hospitals. This study is based on our every day work and aims to highlight our experience. We conducted a descriptive drug utilization study which implied data collection over 6 months. Evidence of the enrolled patients was kept by maintaining records and the completed structured questionnaires. Postoperative pain was assessed through a five-category verbal rating scale (VRS). Metamizole was the most prescribed and administered analgesic drug as single therapy and in combination therapy, and acetaminophen was the least prescribed drug. The compliance between the prescribed dosages and those administered was higher in patients treated with a single analgesic compared to multiple therapies. A few patients reported adverse events (4.2 percent). There is much variability in postoperative pain management methods used by medical staff within the Tirana University Hospital. In Albania to date there is no standard protocol for postoperative pain treatment. This study shows that there are no essential differences in patient outcomes in terms of efficacy of analgesic treatment. This leads to the conclusion that a postoperative protocol/guideline for pain management should be prepared, based on our local study findings and also on international experience. Moreover, the guidelines should consider use of balanced analgesia.

Cecal volvulus during pregnancy. Case report.

INTRODUCTION: Acute intestinal obstruction in pregnancy is a rare, but life-threatening complication associated with high fetal and maternal mortality. CASE REPORT: A 20-year old gravida presented with a 24 hour history of several episodes of vomiting, complete constipation and severe crampy abdominal pain. The patient was admitted with the diagnosis of acute abdomen associated with septic shock. On examination echography showed distended intestinal loops and presence of free peritoneal fluid. Abdominal X-ray with shielding of the fetus revealed colonic air-fluid levels. The obstetrician consult diagnosed dead fetus in utero and was decided to operate immediately. On laparotomy was found complete cecal volvulus with gangrene of cecum, part of ascending colon and terminal ileum. A right hemicolectomy was performed with side to side ileotransverse anastomosis. Afterwards a lower segment cesarean section was made and a stillborn fetus was delivered. The patient made an uneventful recovery and was discharged on 9th postoperative day. CONCLUSION: Cecal volvulus during pregnancy is a rare, but serious surgical problem. Correct diagnosis may be difficult until exploratory laparotomy is performed. Undue delay in diagnosis and surgical treatment can increase the maternal and fetal mortality.

Surgical treatment of the adenocarcinoma of the cardia.

Adenocarcinomas of the esophagogastric junction should be classified into adenocarcinoma of the distal esophagus (Type I), true carcinoma of the cardia (Type II), and subcardial carcinoma (Type III) in a pathogenic and therapeutic point of view. During a 15-year period (1995 - 2009), 117 surgical laparotomies for adenocarcinoma of the cardia were performed in elective surgery in the First Clinic of General Surgery UHC "Mother Theresa" in Tirana. The classification was performed by summarizing the information obtained from oral contrast radiography, endoscopy, and intra-operative findings. There were 54 (46%) patients of Type I, 40 (34%) of Type II and 23 (20%) of Type III . Surgical procedures included "subtotal esophagectomy and proximal gastrectomy", "distal esophagectomy and proximal gastrectomy", "total gastrectomy and distal esophagectomy". All anastomoses performed in the above mentioned procedures were hand sewn. Thirty-seven patients (32%) resulted inoperable at the time of laparotomy and 80 (68%) patients were treated with curative intent, those resulting in an operability index of 68%. The overall morbidity and mortality rates of 29% and 4,3% respectively.

Rectal cancer surgery. A ten years experience.

Rectal cancer is one of the most common malignancies in the western world population. The management of rectal cancer has changed thoroughly in recent years owing to the rapid advances in surgical techniques, imaging and adjuvant therapy. The present study analyses extensively 152 patients operated for diagnosis of, rectal cancer in the First Clinic of General Surgery UHC "Mother Theresa" in Tirana, Albania, in a ten years period. In the medical and operative records were analysed demographic, diagnostic, clinic, operative, pathology and postoperative patient's data. M : F ratio was 1,5:1. The average age of all patients was 59,8 ± 12,2 (29 - 79) years. 48% of all patients were of the age group 61 - 70 years. The diagnosis interval was 6 ± 4,6 months. The mean distance of tumor from the anal verge was 8,3 ± 4,2 (3,7 - 16) cm. 30% of all patients resulted stage D, according to the Astler - Coller classification. Overall operability index was 97,5%. 30 % of patients were treated with palliative operative procedures. 67,5% of all patients were treated with curative intent. The most common curative operation was low anterior resection with mesorectal excision in 76 patients (51%). The mean postoperative hospital stay was 12 ± 9,7 (3 - 45) days. Overall postoperative morbidity and mortality were 30% and 2,6% respectively. The surgical treatment of rectal cancer has changed radically in recent years in Albania. Relatively new surgical techniques, like low anterior resection and use of adjuvant chemoradiotherapy have improved the outcome, quality of life and survival of our patients.

Distribution of angiographic measures of restenosis after drug-eluting stent implantation.

BACKGROUND: A bimodal distribution of measures of restenosis has been demonstrated at 6-8 months after bare metal stent implantation. Drug-eluting stent (DES) treatment has attenuated the impact of certain factors (eg, diabetes) on restenosis but its effect on the distribution of indices of restenosis is not known. OBJECTIVE: To perform a detailed analysis of the metrics of restenosis indices after DES implantation. Design, settings, PATIENTS: Prospective observational study of patients undergoing DES implantation (Cypher, sirolimus-eluting stent; or Taxus, paclitaxel-eluting stent) at two German centres, with repeat angiography scheduled at 6-8 months after coronary stenting. MAIN OUTCOME MEASURES: In-stent late luminal loss (LLL) and in-segment percentage diameter stenosis (%DS) as determined by quantitative coronary angiography at recatheterisation. RESULTS: Paired cineangiograms were available for 2057 patients. Overall mean (SD) LLL was 0.31 (0.50) mm; mean (SD) %DS was 30.3 (15.7)%. Distribution of both LLL and %DS differed significantly from normal (Kolmogorov-Smirnov test; p<0.001 for each). For both parameters a mixed distribution model better described the data (likelihood ratio test with 3df; p<0.001 for each). This consisted of two normally distributed subpopulations with means (SD) of 0.10 (0.25) mm and 0.69 (0.60) mm for LLL, and means (SD) of 22.2 (8.6)% and 40.1 (16.6)% for %DS. The results were consistent across subgroups of DES type, "on-label" versus "off-label" indication, and presence or absence of diabetes. CONCLUSIONS: LLL and %DS at follow-up angiography after DES implantation have a complex mixed distribution that may be accurately represented by a bimodal distribution model. The introduction of DES treatment has not resulted in elimination of a variable propensity to restenosis among subpopulations of patients with stented lesions.

Current drug-eluting stents in complex patients and lesions.

Drug-eluting stents (DES) are playing an increasingly important role in the treatment of coronary artery disease. These new devices work by releasing controlled amounts of pharmacological agents with anti-restenosis properties at the implantation site. Most of them use polymer coating as a drug carrier, but concerns about long-term negative effects of a permanent polymer coating have stimulated the development of non-polymer DES or DES based on bioabsorbable polymers. Several randomized studies with DES have demonstrated their superiority over bare metal stents mostly in selected patients and lesion subsets. Accumulating evidence is showing significant differences in performance between currently used DES. These differences are more pronounced in complex, high-risk subsets of patients and lesions and should be considered during the process of DES selection for the individual patient. Interventional cardiologists have learned that patients who receive DES require a more prolonged antiplatelet therapy, but the optimal length and regimen are still unclear and further investigations are needed. Major advances in interventional cardiology have caused a dramatic shift away from aorto-coronary bypass surgery and an increase in the complexity of percutaneous coronary interventions. Observational and specifically designed randomized studies are currently addressing the issue of the role of DES in complex situations including in-stent restenosis, ostial and bifurcation lesions, chronic occlusions, small vessels, long lesions, saphenous vein grafts, multivessel disease, left main disease, acute myocardial infarction and diabetes mellitus. Although definitive answers are still to come from ongoing research, available data support the use of DES in most of these situations.

The relationship between hospital or operator volume and outcomes of coronary patients undergoing percutaneous coronary interventions.

The relationship between volume and outcome in medicine has been intensively investigated in the last few decades. The large amount of accumulated data demonstrates that for many surgical or non-surgical procedures and medical conditions, patients being treated in high-volume hospitals or by high-volume physicians have lower mortality rates and better quality of life compared to those treated by low-volume hospitals or by low-volume physicians. Although the degree of the relationship between high volume and better outcome varies, it is persistent across a wide range of procedures and conditions. Percutaneous coronary interventions (PCIs) have an important impact on public health, given the frequency of coronary heart disease for which these procedures are performed. Studies carried out before and after the advent of stents on the relationship between volume and outcome for PCIs have almost consistently reported that performance of PCIs in high-volume institutions or by high-volume operators is associated with improved outcomes for patients, regardless of the specific indication for PCI. For those procedures for which a relationship between high volume and better outcome has been clearly demonstrated, patients as well as their referring physicians should be informed that patients can benefit both in terms of reduced mortality and improved quality of life if they are treated by high-volume health care providers. Consequently, for these procedures, a health care policy aiming at their concentration in high-volume institutions should be strongly considered.

The Chievitz juxtaparotid organ.

The Chievitz juxtaparotid organ represents a macroscopic longitudinal formation, which is developed from oral cavity ectoderm in its lateral wall. As to its function, the organ probably represents a mechanosensor with different qualities of perception. The information coming from its sensors takes part in different activities of the lateral wall of oral cavity during sucking, swallowing, mastication, speech, protecting reflexes and wall tonus. The Chievitz juxtaparotid organ is not only a morphologically interesting structure, but is of great importance also for clinic and surgical pathology of the oral cavity.

[A uterine pecoma: a case report]. / Pecoma uterino: descrizione di un caso.

The authors describe the first ever reported case of a malignant pecoma of the uterus infiltrating the ovary, the tube and two bowel loops. This extremely rare tumour usually shows a benign behaviour and seems to arise from the perivascular epithelioid cells (PEC).

Thymectomy and multiple sclerosis: ultrastructural study of an experimental model.

Transmission electron microscopy was performed on specimens of the thymus of rats induced for acute experimental allergic encephalomyelitis (EAE). The ultrastructural alterations of the thymus were progressive and correlated with EAE development. The thymic disorganization was due to a progressive degeneration of both epithelial cells and thymocytes. These data suggest a direct involvement of the epithelial thymic cells and thymocytes in EAE pathogenesis and may suggest the intriguing therapeutic concept of thymectomy in the management of multiple sclerosis.

Interposition vein cuff in infrainguinal prosthetic bypasses.

The Authors describe the interposition vein cuff technique as an adjuvant method to infrainguinal prosthetic bypass grafts. The haemodynamic, mechanical and humoral factors thought to be involved in the beneficial effects of the vein cuff are herein discussed. The results of the main series suggest the use of this method particularly in patients without any available autologous vein conduit requiring a below-knee popliteal or crural reconstruction.

Radiolabelled monoclonal antibodies in clinical and surgical oncology: a review.

Over the past decade, the role of immunoscintigraphy using radiolabelled monoclonal antibodies has been steadily growing in clinical oncology, and in particular, in radioimmunotherapy and radioimmunoguided surgery for the treatment of primary, recurrent, and metastatic colorectal, ovarian, gastric, and prostate cancer. Herein, the authors review the requirements for successful tumour radioimmunodetection and related procedures.

[Parathyroidectomy: our school experience]. / La paratiroidectomia: esperienza di Scuola.

The Authors evaluated the results obtained in 145 patients operated on for hyperparathyroidism: 109 patients had primary hyperparathyroidism and 36 patients had secondary hyperparathyroidism. Preoperative localization by ultrasonography was assured in all cases, while only few patients were preoperatively evaluated by arteriography and selected venous sampling of the parathyroid hormone concentration. After surgical resection for primary hyperparathyroidism, transient postoperative hypoparathyroidism occurred in 30 patients (27.5%), recurrent disease occurred in 3 patients (2.7%), while 1 patient experienced persistent hypoparathyroidism (1%). In 3 patients (3%), resection of a solitary adenoma and biopsy of all parathyroid glands resulted in a permanent hypoparathyroidism which required long-term administration of vitamin D and oral calcium. Neither recurrent nor persistent hyperparathyroidism occurred in patients surgically treated for secondary hyperparathyroidism, and no postoperative hypoparathyroidism was registered. The Authors emphasize the importance of an adequate surgical strategy and accurate initial cervical exploration of the parathyroid glands as a necessary step for the correct treatment of this challenging disease.

[Surgery of differentiated cancer of the thyroid]. / La chirurgia del cancro differenziato della tiroide.

A retrospective study on patients with differentiated thyroid carcinoma operated on at the 3rd Department of General Surgery of the University "La Sapienza" of Rome from 1970 to 1996 was performed. In 709 patients total thyroidectomy was performed as the minimal procedure acceptable, while 19 patients had subtotal thyroidectomy out of necessity. A functional ipsilateral or bilateral lymphnectomy of the neck was performed in 256 cases. This wider operation is indicated in the presence of metastatic lymph nodes and on principle in patients older than forty-five years in which at least another risk factor is present. Long term follow-up (12 years) was assured in 302 patients and the survival rate was 92% independently from the histotype (papillary or follicular). The survival rate of a group of 120 patients (80 with papillary and 40 with follicular carcinoma) was analyzed in relation to the risk factors. This group analysis demonstrated a very low mortality rate in patients with low risk index and an increased rate in patients with a high risk index.

Cholera in the Mediterranean: outbreak in Albania.

In the 1990s, an epidemic of cholera caused by Vibrio cholerae 01 El Tor has spread from northern Pakistan to the Mediterranean. In 1993 sporadic cases of cholera, and epidemic foci, were recorded in many countries of the southern part of Eastern Europe.

Cholera in the Mediterranean: outbreak in Albania.

In the 1990s, an epidemic of cholera caused by Vibrio cholerae 01 El Tor has spread from northern Pakistan to the Mediterranean. In 1993 sporadic cases of cholera, and epidemic foci, were recorded in many countries of the southern part of Eastern Europe.