Comparison of Fentanyl, Ketamine, and Lidocaine Combined with Propofol Anesthesia in Patients with Crohn Disease Undergoing Colonoscopy.

BACKGROUND Colonoscopy is the predominant invasive procedure for Crohn disease (CD) patients. Opioids and propofol carry risks of respiratory and cardiovascular complications. This study aimed to evaluate whether substituting fentanyl with ketamine or lidocaine could diminish propofol usage and minimize adverse events. MATERIAL AND METHODS In total, 146 patients with CD scheduled for elective colonoscopy were assigned to anesthesia with fentanyl (n=47), ketamine (n=47), or lidocaine (n=55). Propofol was administered to achieve sufficient anesthesia. Measured outcomes in each group included propofol consumption, hypotension and desaturation incidents, adverse event types, consciousness recovery time, abdominal pain intensity, Aldrete scale, and Post Anaesthetic Discharge Scoring System (PADSS). RESULTS Patients administered fentanyl needed significantly more propofol (P=0.017) than those on ketamine, with lidocaine showing no notable difference (P=0.28). Desaturation was significantly less common in the ketamine and lidocaine groups than fentanyl group (P<0.001). The ketamine group experienced milder reductions in mean arterial (P=0.018) and systolic blood pressure (P<0.001). Recovery metrics (Aldrete and PADSS scores) were lower for fentanyl (P<0.001), although satisfaction and pain levels were consistent across all groups (P=0.797). Dizziness occurred less frequently with lidocaine than fentanyl (17.2%, P=0.018) and ketamine (15.1%, P=0.019), while metallic taste incidents were more prevalent in the lidocaine group (13.5%, P=0.04) than fentanyl group. CONCLUSIONS Using ketamine or lidocaine instead of fentanyl in anesthesia for colonoscopy in patients with CD significantly lowers propofol use, reduces desaturation events, maintains blood pressure more effectively, without increasing hypotension risk, and accelerates recovery, without negatively impacting adverse events or patient satisfaction.

Autopsy Histopathologic Lung Findings in Patients Treated With Extracorporeal Membrane Oxygenation.

CONTEXT.­: Extracorporeal membrane oxygenation (ECMO) is increasingly used in the treatment of respiratory and cardiac failure, but data describing lung histopathology in ECMO recipients are limited. OBJECTIVE.­: To examine pulmonary histopathologic findings in patients who underwent venovenous (VV) ECMO for pulmonary reasons, or venoarterial (VA) ECMO for cardiac indications shortly before death, and to determine if the pulmonary changes provided insights into therapy that may prevent complications and improve outcome. DESIGN.­: We conducted a retrospective study of lung autopsies, from VV and VA ECMO recipients and patients with acute respiratory distress syndrome (ARDS) and non-ECMO treatment, between 2008 and 2020 in Silesia Center for Heart Diseases in Zabrze, Poland. RESULTS.­: Among 83 ECMO patients (42-64 years; male, 57 [68.7%]), the most common histopathologic findings were bronchopneumonia (44 [53.0%]), interstitial edema (40 [48.2%]), diffuse alveolar damage (DAD; 32 [38.6%]), hemorrhagic infarct (28 [33.7%]), and pulmonary hemorrhage (25 [30.1%]). DAD was associated with longer ECMO treatment and longer hospital stay. The use of VV ECMO was a predictor of DAD in patients with ARDS and undergoing ECMO, but it also occurred in 21 of 65 patients (32.3%) in the VA ECMO group, even though VA ECMO was used for heart failure. CONCLUSIONS.­: Although DAD was significantly more common in lung autopsies of VV ECMO patients, one-third of VA ECMO patients had histopathologic changes characteristic of ARDS. The presence of DAD in lung autopsies of patients treated with VA ECMO indicates that in these patients, protective lung ventilation should be considered.

Effects of adding the second drainage cannula in severely hypoxemic patients supported with VV ECMO due to COVID-19-associated ARDS.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a recognized method of support in patients with severe and refractory acute respiratory distress syndrome (ARDS) caused by SARS-CoV-2 infection. While veno-venous (VV) ECMO is the most common type, some patients with severe hypoxemia may require modifications to the ECMO circuit. In this study, we aimed to investigate the effects of adding a second drainage cannula to the circuit in patients with refractory hypoxemia, on their gas exchange, mechanical ventilation, ECMO settings, and clinical outcomes. METHODS: We conducted an observational retrospective study based on a single-center institutional registry including all consecutive cases of COVID-19 patients requiring ECMO admitted to the Centre of Extracorporeal Therapies in Warsaw between March 1, 2020 and March 1, 2022. We selected patients who had an additional drainage cannula inserted. Changes in ECMO and ventilator settings, blood oxygenation, and hemodynamic parameters, as well as clinical outcomes were assessed. RESULTS: Of 138 VV ECMO patients, 12 (9%) patients met the inclusion criteria. Ten patients (83%) were men, and mean age was 42.2 ± 6.8. An addition of drainage cannula resulted in a significant raise in ECMO blood flow (4.77 ± 0.44 to 5.94 ± 0.81 [L/min]; p = 0.001), and the ratio of ECMO blood flow to ECMO pump rotations per minute (RPM), whereas the raise in ECMO RPM alone was not statistically significant (3432 ± 258 to 3673 ± 340 [1/min]; p = 0.064). We observed a significant drop in ventilator FiO2 and a raise in PaO2 to FiO2 ratio, while blood lactates did not change significantly. Nine patients died in hospital, one was referred to lung transplantation center, two were discharged uneventfully. CONCLUSIONS: The use of an additional drainage cannula in severe ARDS associated with COVID-19 allows for an increased ECMO blood flow and improved oxygenation. However, we observed no further improvement in lung-protective ventilation and poor survival.

SepsEast Registry indicates high mortality associated with COVID-19 caused acute respiratory failure in Central-Eastern European intensive care units.

The coronavirus disease (COVID-19) pandemic caused unprecedented research activity all around the world but publications from Central-Eastern European countries remain scarce. Therefore, our aim was to characterise the features of the pandemic in the intensive care units (ICUs) among members of the SepsEast (Central-Eastern European Sepsis Forum) initiative. We conducted a retrospective, international, multicentre study between March 2020 and February 2021. All adult patients admitted to the ICU with pneumonia caused by COVID-19 were enrolled. Data on baseline and treatment characteristics, organ support and mortality were collected. Eleven centres from six countries provided data from 2139 patients. Patient characteristics were: median 68, [IQR 60-75] years of age; males: 67%; body mass index: 30.1 [27.0-34.7]; and 88% comorbidities. Overall mortality was 55%, which increased from 2020 to 2021 (p = 0.004). The major causes of death were respiratory (37%), cardiovascular (26%) and sepsis with multiorgan failure (21%). 1061 patients received invasive mechanical ventilation (mortality: 66%) without extracorporeal membrane oxygenation (n = 54). The rest of the patients received non-invasive ventilation (n = 129), high flow nasal oxygen (n = 317), conventional oxygen therapy (n = 122), as the highest level of ventilatory support, with mortality of 50%, 39% and 22%, respectively. This is the largest COVID-19 dataset from Central-Eastern European ICUs to date. The high mortality observed especially in those receiving invasive mechanical ventilation renders the need of establishing national-international ICU registries and audits in the region that could provide high quality, transparent data, not only during the pandemic, but also on a regular basis.

First lung transplantation as a treatment of a patient supported with extracorporeal membrane oxygenation (ECMO) after COVID-19 in Poland.

A 44-year-old male with no history of underlying diseases was referred to academic hospital due to ARDS with confirmed SARSCoV-2 infection after 7 days of mechanical ventilation. Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) was initiated as no improvement was noted in prone position. Mechanical ventilation was continued with TV of 3-4 mL/kg. A gradual decline of static lung compliance was observed from baseline 35 mL/cm H20 to 8 mL/cm H2O. The chest CT scan revealed extensive ground-glass areas with a significant amount of traction bronchiectasis after 3 weeks since admission. When the patient was negative for SARS-CoV-2 during the 4th week of ECMO, the decision to perform an emergency lung transplantation (LTx) was made based on the ongoing degradation of lung function and irreversible damage to lung structure. The patient was transferred to the transplant center where he was extubated, awaiting the transplant on passive oxygen therapy and ECMO. Double lung transplantation was performed on the day 30th of ECMO. Currently, the patient is self-reliant. He does not need oxygen therapy and continues physiotherapy. ECMO may be life-saving in severe cases of COVID-19 ARDS but some of these patients may require LTx, especially when weaning proves impossible. VV ECMO as a bridging method is more difficult but ultimately more beneficial due to insufficient number of donors, and consequently long waiting time in Poland.

Plasma Fibrin Clot Properties as Determinants of Bleeding Time in Human Subjects: Association with Histidine-Rich Glycoprotein.

AIMS: Fibrin formation and histidine-rich glycoprotein (HRG) are involved in primary hemostasis and wound healing. Little is known regarding the relationship of clot characteristics, bleeding time, and wound healing. METHODS AND RESULTS: We studied 154 patients with coronary artery disease (CAD) and 154 subjects free of CAD matched for age, obesity, and current smoking. We evaluated bleeding time (BT) using standardized skin incisions on a forearm, along with plasma clot permeability (K s), clot lysis time (CLT), and histidine-rich glycoprotein (HRG). Compared with controls, BT was 45% shorter in CAD cases. CAD patients had 32% lower K s), clot lysis time (CLT), and histidine-rich glycoprotein (HRG). Compared with controls, BT was 45% shorter in CAD cases. CAD patients had 32% lower p < 0.001). After adjusting for potential confounders, K s), clot lysis time (CLT), and histidine-rich glycoprotein (HRG). Compared with controls, BT was 45% shorter in CAD cases. CAD patients had 32% lower n = 79, 25.6%) was independently predicted by both short and prolonged BT in CAD cases (OR 21.87, 95% CI 7.41-64.55 and OR 10.17, 95% CI 2.88-35.97) and controls (OR 5.94, 95% CI 2.29-15.41 and OR 14.76, 95% CI 4.29-50.77, respectively). CONCLUSIONS: The study shows that plasma fibrin clot density and HRG may influence BT and that appropriate skin wound healing is associated with medium BT. Translational Perspective. Elucidation of the complex relationships between plasma fibrin clot phenotype and wound healing might have important practical implications.

Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery.

BACKGROUND: Perioperative fluid management is a crucial element of perioperative care and has been studied extensively recently; however, 'the right amount' remains uncertain. One concept in perioperative fluid handling is goal-directed fluid therapy (GDFT), wherein fluid administration targets various continuously measured haemodynamic variables with the aim of optimizing oxygen delivery. Another recently raised concept is that perioperative restrictive fluid therapy (RFT) may be beneficial and at least as effective as GDFT, with lower cost and less resource utilization. OBJECTIVES: To investigate whether RFT may be more beneficial than GDFT for adults undergoing major non-cardiac surgery. SEARCH METHODS: We searched the following electronic databases on 11 October 2019: Cochrane Central Register of Controlled Trials, in the Cochrane Libary; MEDLINE; and Embase. Additionally, we performed a targeted search in Google Scholar and searched trial registries (World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov) for ongoing and unpublished trials. We scanned the reference lists and citations of included trials and any relevant systematic reviews identified. SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing perioperative RFT versus GDFT for adults (aged ≥ 18 years) undergoing major non-cardiac surgery. DATA COLLECTION AND ANALYSIS: Two review authors independently screened references for eligibility, extracted data, and assessed risk of bias. We resolved discrepancies by discussion and consulted a third review author if necessary. When necessary, we contacted trial authors to request additional information. We presented pooled estimates for dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs), and for continuous outcomes as mean differences (MDs) with standard deviations (SDs). We used Review Manager 5 software to perform the meta-analyses. We used a fixed-effect model if we considered heterogeneity as not important; otherwise, we used a random-effects model. We used Poisson regression models to compare the average number of complications per person. MAIN RESULTS: From 6396 citations, we included six studies with a total of 562 participants. Five studies were performed in participants undergoing abdominal surgery (including one study in participants undergoing cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy (HIPEC)), and one study was performed in participants undergoing orthopaedic surgery. In all studies, surgeries were elective. In five studies, crystalloids were used for basal infusion and colloids for boluses, and in one study, colloid was used for both basal infusion and boluses. Five studies reported the ASA (American Society of Anesthesiologists) status of participants. Most participants were ASA II (60.4%), 22.7% were ASA I, and only 16.9% were ASA III. No study participants were ASA IV. For the GDFT group, oesophageal doppler monitoring was used in three studies, uncalibrated invasive arterial pressure analysis systems in two studies, and a non-invasive arterial pressure monitoring system in one study. In all studies, GDFT optimization was conducted only intraoperatively. Only one study was at low risk of bias in all domains. The other five studies were at unclear or high risk of bias in one to three domains. RFT may have no effect on the rate of major complications compared to GDFT, but the evidence is very uncertain (RR 1.61, 95% CI 0.78 to 3.34; 484 participants; 5 studies; very low-certainty evidence). RFT may increase the risk of all-cause mortality compared to GDFT, but the evidence on this is also very uncertain (RD 0.03, 95% CI 0.00 to 0.06; 544 participants; 6 studies; very low-certainty evidence). In a post-hoc analysis using a Peto odds ratio (OR) or a Poisson regression model, the odds of all-cause mortality were 4.81 times greater with the use of RFT compared to GDFT, but the evidence again is very uncertain (Peto OR 4.81, 95% CI 1.38 to 16.84; 544 participants; 6 studies; very low-certainty evidence). Nevertheless, sensitivity analysis shows that exclusion of a study in which the final volume of fluid received intraoperatively was higher in the RFT group than in the GDFT group revealed no differences in mortality. Based on analysis of secondary outcomes, such as length of hospital stay (464 participants; 5 studies; very low-certainty evidence), surgery-related complications (364 participants; 4 studies; very low-certainty evidence), non-surgery-related complications (74 participants; 1 study; very low-certainty evidence), renal failure (410 participants; 4 studies; very low-certainty evidence), and quality of surgical recovery (74 participants; 1 study; very low-certainty evidence), GDFT may have no effect on the risk of these outcomes compared to RFT, but the evidence is very uncertain. Included studies provided no data on administration of vasopressors or inotropes to correct haemodynamic instability nor on cost of treatment. AUTHORS' CONCLUSIONS: Based on very low-certainty evidence, we are uncertain whether RFT is inferior to GDFT in selected populations of adults undergoing major non-cardiac surgery. The evidence is based mainly on data from studies on abdominal surgery in a low-risk population. The evidence does not address higher-risk populations or other surgery types. Larger, higher-quality RCTs including a wider spectrum of surgery types and a wider spectrum of patient groups, including high-risk populations, are needed to determine effects of the intervention.

Surveillance of Antibiotic Prescribing in Intensive Care Units in Poland.

Antibiotic use and microbial resistance in health care-associated infections are increasing globally and causing health care problems. Intensive Care Units (ICUs) represent the heaviest antibiotic burden within hospitals, and sepsis is the second noncardiac cause of mortality in ICUs. Optimizing appropriate antibiotic treatment in the management of the critically ill in ICUs became a major challenge for intensivists. We performed a surveillance study on the antibiotic consumption in 108 Polish ICUs. We determined which classes of antibiotics were most commonly consumed and whether they affected the length of ICU stay and the size and category of the hospital. A total of 292.389 defined daily doses (DDD) and 192.167 patient-days (pd) were identified. Antibiotic consumption ranged from 620 to 3960 DDD/1000 pd. The main antibiotic classes accounted for 59.6% of the total antibiotic consumption and included carbapenems (17.8%), quinolones (14%), cephalosporins (13.7%), penicillins (11.9%), and macrolides (2.2%), respectively, whereas the other antibiotic classes accounted for the remainder (40.4%) and included antifungals (34%), imidazoles (20%), aminoglycosides (18%), glycopeptides (15%), and polymyxins (6%). The most consumed antibiotic classes in Polish ICUs were carbapenems, quinolones, and cephalosporins, respectively. There was no correlation between antibiotic consumption in DDD/1000 patient-days, mean length of ICU stay, size of the hospital, size of the ICU, or the total amount of patient-days. It is crucial that surveillance systems are in place to guide empiric antibiotic treatment and to estimate the burden of resistance. Appropriate use of antibiotics in the ICU should be an important public health care issue.

Pancreatoduodenectomy for pancreatic head tumors in the elderly - Systematic review and meta-analysis.

The age at which patients are undergoing pancreatoduodenectomy is increasing worldwide. The data on the outcome of this surgical procedure in the elderly is constantly expanding. This meta-analysis aims to assess the safety of pancreatoduodenectomy in elderly population, primarily focusing on morbidity and mortality. We searched the Medline, Embase and Cochrane databases to identify eligible studies. The most recent search was performed on 10th April 2017. Inclusion criteria were: (1) comparison of the characteristics and perioperative outcomes of older patients versus younger patients undergoing pancreatoduodenectomy; (2) objective evaluation of mortality or overall morbidity; and (3), publication in English. Exclusion criteria were: (1) a lack of comparative data; (2) a lack of primary outcomes or insufficient data to analyze; (3) a focus on procedures other than pancreatoduodenectomy; or (4), the impossibility of extraction of data specifically concerning pancreatoduodenectomy. Primary outcomes were overall morbidity and mortality. Secondary outcomes analyzed postoperative complications, R0 rate and length of hospital stay. 45 eligible studies were chosen, with a combined total of 21,295 patients. Older patients compared to younger patients had a higher risk of death (2.26% vs. 4.54%; RR: 2.23; 95% CI 1.74-2.87) and a higher complication rate (47.23% vs. 39.35%; RR: 1.17; 95% CI 1.12-1.24). There were no differences in pancreatic fistula occurrence (p = 0.27), bile leakage (p = 0.81), postoperative hemorrhage (p = 0.08), or R0 rate (p = 0.92). Our review confirms, that in the case of pancreatoduodenectomy, advanced age is a risk factor for increased non-surgical morbidity and, by extension, higher mortality.

Once-daily long-acting beta2-agonists/inhaled corticosteroids combined inhalers versus inhaled long-acting muscarinic antagonists for people with chronic obstructive pulmonary disease.

BACKGROUND: Three classes of inhaler medication are used to manage chronic obstructive pulmonary disease (COPD): long-acting beta2-agonists (LABA); long-acting muscarinic antagonists (LAMA); and inhaled corticosteroids (ICS). To encourage patient adherence, two classes of medication are often combined in a single medication device; it seems that once-daily dosing offers greatest convenience to patients and may markedly influence adherence. OBJECTIVES: To compare a once-daily combination of inhaled corticosteroid and long-acting beta2-agonist inhalers (ICS/LABA) versus inhaled long-acting muscarinic antagonists alone (LAMA) for people with chronic obstructive pulmonary disease (COPD). SEARCH METHODS: We performed an electronic search of the Specialised Register of the Cochrane Airways Group (14 May 2018), ClinicalTrials.gov (14 May 2018), and the World Health Organization International Clinical Trials Registry Platform (20 September 2017), then a search of other resources, including reference lists of included studies and manufacturers' trial registers (10 October 2017). Two pairs of review authors screened and scrutinised selected articles. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing once-daily administered ICS/LABA and LAMA in adults with COPD. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias in each study. We analysed dichotomous data as random-effects odds ratios (ORs) and continuous data as mean differences (MDs), both with 95% confidence intervals (95% CIs), using Review Manager 5. MAIN RESULTS: We included two studies with 880 participants. We identified one ongoing trial with planned recruitment of 80 participants. Included studies enrolled participants with both partially reversible and non-reversible COPD and baseline mean per cent predicted (%pred) forced expiratory volume in one second (FEV1) of 43.4 to 49.6. Both studies lasted 12 weeks. Both studies used the same combination of inhaled ICS/LABA (fluticasone furoate and vilanterol 100/25 mcg once daily; FF/VI) versus LAMA (18 mcg tiotropium; TIO). They were published as full articles, and neither study was at low risk of bias in all domains.Compared to the TIO arm, results for pooled primary outcomes for the FF/VI arm were as follows: mortality: OR 0.20, 95% CI 0.02 to 1.73, 880 participants (deaths reported only in the TIO arm), very low-quality evidence; COPD exacerbation (requiring short-burst oral corticosteroids or antibiotics, or both): OR 0.72, 95% Cl 0.35 to 1.50, 880 participants, very low-quality evidence; pneumonia: reported in both studies only during treatment with FF/VI: OR 6.12, 95% Cl 0.73 to 51.24, 880 participants, very low-quality evidence; and total serious adverse events: OR 0.96, 95% Cl 0.50 to 1.83, 880 participants, very low-quality evidence. None of the pneumonias were fatal. Compared to the TIO arm, we found no statistically significant difference for pooled secondary outcomes, including St George's Respiratory Questionnaire (SGRQ) mean total score change; hospital admissions (all-cause); disease-specific adverse events; mean weekly rescue medication use (results available from only one of the studies); and mean weekly percentage of rescue-free days for FF/VI. We found no statistically significant differences between ICS/LABA and LAMA for improvement in symptoms measured by the COPD Assessment Test (CAT score) nor for FEV1 (change from baseline trough in 24-hour weighted mean on treatment day 84). Many pooled estimates lacked precision. Data for other endpoints such as exacerbations leading to intubation and physical activity measures were not available in included trials. AUTHORS' CONCLUSIONS: Based on analysis of primary and secondary outcomes, we are uncertain whether once-daily ICS/LABA, combined in one inhaler, has a different efficacy or adverse effect profile compared to LAMA for treatment of people with COPD. However, the current review is based on only two trials with the main focus on primary outcomes other than those considered in this review. The short follow-up period and the very low quality of evidence limit our confidence in the result and increase uncertainty. Further trials of longer duration are needed. Current evidence is not strong enough to demonstrate important differences between inhalers in terms of effects, nor to establish that once-daily fluticasone/vilanterol 100/25 mcg and tiotropium 18 mcg are equivalent.

The Cochrane collaboration ­ the role in the evolution of evidence-based medicine and development of cooperation in Poland

Evidence-based medicine (EBM) is an approach to decision making on the basis of the reliable and up to date best evidence. EBM is regarded as the gold standard all over the world. Cochrane Collaboration is one of the institutions, which promote EBM among physicians, policy makers and other health care workers. Cochrane Collaboration is international non-profit organization bringing together people from all over the world, the aim of which is to create and disseminate reliable scientific information. The Cochrane Collaboration develops and publishes systematic reviews on medical and diagnostic procedures. The article presents the history of the Cochrane Collaboration, the Cochrane Library and the first Cochrane Branch in Poland. Cochrane Branch in Poland is hosted by the Systematic Reviews Centre created in 2015 within the Faculty of Medicine at the Jagiellonian University Medical College in Krakow. The authors presented the activities of the Cochrane Collaboration, the scope of activities of Polish Branch and briefly principles for the development of Cochrane systematic reviews.

Cardiovascular risk management in type 2 diabetes of more than 10-year duration: Results of Polish ARETAEUS2-Grupa Study.

BACKGROUND: ARETAEUS 1 study showed that a great majority of patients with type 2 diabetes mellitus (T2DM) of short duration did not meet all of the treatment goals. Since then the treatment goals in T2DM have been changed. The aim of the ARETAEUS 2-Grupa Study was to assess cardiovascular (CV) risk management and meeting treatment goals in the population of T2DM of more than 10-year duration. METHODS: ARETAEUS2-Grupa was a cross-sectional questionnaire-based study conducted in Poland in 2012. Randomly selected physicians recruited 1,740 patients with T2DM diagnosed more than 10 years before the study. RESULTS: Lipid treatment goals were met respectively: for total cholesterol in 34.5% of all patients, triglycerides in 53.8%, low density lipoprotein cholesterol (LDL-C) in 26.5% and high density lipoprotein cholesterol (HDL-C) in 38.2%. Most of patients with and without coronary artery disease were receiving aspirin (90.3% and 60%, respectively) and statins (84.4% and 67.7%, respectively). The current blood pressure (BP) goal (140/90 mm Hg) was met in 43.5% of patients and the previous goal (< 130/80 mm Hg) in 12.4%. The patients were mainly treated with ≥ 3 antihypertensive drugs. All treatment goals (for HbA1c, BP and LDL-C) were reached only by 8.2% of patients, any two goals by 26.3% of patients, one goal by 39.8% of patients, none by 25.6% of patients. CONCLUSIONS: The new less restrictive treatment goals are reached more frequently but still much is to be done in the field of clinical practice guidelines implementation and CV prevention in T2DM population.

Continuous renal replacement therapy during extracorporeal membrane oxygenation in patients treated in medical intensive care unit: technical considerations.

Extracorporeal membrane oxygenation (ECMO) is used as a salvage therapy in refractory acute respiratory distress syndrome (ARDS). Although technological progress in the ECMO systems improved the survival rate, prognosis is still significantly worsened by acute kidney injury (AKI), particularly if renal replacement therapy (RRT) is required. There are no exact guidelines recommending which techniques of ECMO and continuous RRT (CRRT) should be used for management of AKI coexisting with respiratory or circulatory failure, and how to combine them. The aim of this review is to describe methods of CRRT and ECMO simultaneous application, and to present advantages of various technical approaches versus possible complications.

Management and treatment goals in Polish patients with type 2 diabetes of more than ten years' duration - results of ARETAEUS2-Grupa Study.

INTRODUCTION: Previous studies have shown insufficient diabetes control in patients with type 2 diabetes (T2DM). Diabetes Poland changed the target HbA1c and blood pressure (BP) values in diabetic patients in their practice guidelines in 2011, that were further sustained. To assess the management and treatment choices in T2DM of more than ten years' duration and the degree to which diabetic control criteria recommended by the Diabetes Poland clinical practice guidelines 2012 are being met. MATERIAL AND METHODS: ARETAEUS2-Grupa was a cross-sectional questionnaire-based study conducted in Poland in 2012 (April-June). It involved 1,740 patients of any age and both genders, with T2DM diagnosed more than ten years before the study, and recruited by randomly selected physicians. RESULTS: All patients received pharmacological treatment, most of them combination therapy or insulin in monotherapy. 40% of patients met the goal for HbA1c control (≤ 7%) and the median value of HbA1c was above the recommended threshold (7.2%). Only 8% of thetotal population met all three goals (HbA1c, BP and lipid levels), 26% - two goals, and 40% - only one goal. Over 25% of patients did not meet any of the treatment goals. CONCLUSIONS: We observed considerable deviations from treatment targets recommended by current clinical practice guidelines for patients with T2DM of more than ten years' duration. The frequency of cardiovascular risk factors and late diabetes complications was high, while a relatively high percentage of patients was not examined for late diabetes complications.

Management and treatment goals in Polish patients with type 2 diabetes of short duration: results of the ARETAEUS2-Grupa study.

INTRODUCTION:  In 2011, the Diabetes Poland updated its recommended goals in diabetes treatment, including hemoglobin A1c (HbA1c) and blood pressure (BP) levels. Adherence to the updated guidelines has not been systematically assessed so far. OBJECTIVES:  The aim of the study was to assess which methods are most commonly used in the treatment of recently diagnosed type 2 diabetes and to what extent the new criteria for diabetes control are met in these patients. PATIENTS AND METHODS:  The ARETAEUS2­Grupa study was a cross­sectional questionnaire­based study conducted in Poland in 2012 (April-June). It involved 1636 patients of any age and sex, with type 2 diabetes diagnosed within the previous 2 years, recruited by randomly selected physicians. RESULTS:  Of all patients, 37.5% met the goal of an HbA1c level of ≤6.5% (recommended in type 2 diabetes of short duration), while 62% met the goal of an HbA1c level of ≤7% (general recommendation). Only 6.7% of the patients met all 3 goals (HbA1c ≤6.5%, BP <140/90 mmHg, and low­density lipoprotein cholesterol <100 mg/dl or <70 mg/dl in coronary heart disease), 29.7% met 2 goals, 36.8% met only 1 goal, while 26.7% did not meet any of the treatment goals. With the use of the HbA1c level recommended for the overall population, the proportions of patients meeting 3, 2, and 1 goals increased to 11%, 34.5%, and 35.5%, respectively, while the percentage of the patients not meeting any goals decreased to 18%. Metformin in monotherapy or in combination was the most commonly used drug in the study population (80%).  CONCLUSIONS:  The majority of the patients with type 2 diabetes of short duration did not meet any of the treatment goals as recommended in the current practice guidelines. When the treatment goals were used for the overall population (HbA1c ≤7%), a slightly higher, but still unsatisfactory, proportion of the patients met all the treatment goals. Metformin alone or in combination was the most commonly used drug in the study population.

Risk prediction models for mortality in ambulatory patients with heart failure: a systematic review.

BACKGROUND: Optimal management of heart failure requires accurate assessment of prognosis. Many prognostic models are available. Our objective was to identify studies that evaluate the use of risk prediction models for mortality in ambulatory patients with heart failure and describe their performance and clinical applicability. METHODS AND RESULTS: We searched for studies in Medline, Embase, and CINAHL in May 2012. Two reviewers selected citations including patients with heart failure and reporting on model performance in derivation or validation cohorts. We abstracted data related to population, outcomes, study quality, model discrimination, and calibration. Of the 9952 studies reviewed, we included 34 studies testing 20 models. Only 5 models were validated in independent cohorts: the Heart Failure Survival Score, the Seattle Heart Failure Model, the PACE (incorporating peripheral vascular disease, age, creatinine, and ejection fraction) risk score, a model by Frankenstein et al, and the SHOCKED predictors. The Heart Failure Survival Score was validated in 8 cohorts (2240 patients), showing poor-to-modest discrimination (c-statistic, 0.56-0.79), being lower in more recent cohorts. The Seattle Heart Failure Model was validated in 14 cohorts (16 057 patients), describing poor-to-acceptable discrimination (0.63-0.81), remaining relatively stable over time. Both models reported adequate calibration, although overestimating survival in specific populations. The other 3 models were validated in a cohort each, reporting poor-to-modest discrimination (0.66-0.74). Among the remaining 15 models, 6 were validated by bootstrapping (c-statistic, 0.74-0.85); the rest were not validated. CONCLUSIONS: Externally validated heart failure models showed inconsistent performance. The Heart Failure Survival Score and Seattle Heart Failure Model demonstrated modest discrimination and questionable calibration. A new model derived from contemporary patient cohorts may be required for improved prognostic performance.

Systematic review and network meta-analysis of interventions for fibromyalgia: a protocol.

BACKGROUND: Fibromyalgia is associated with substantial socioeconomic loss and, despite considerable research including numerous randomized controlled trials (RCTs) and systematic reviews, there exists uncertainty regarding what treatments are effective. No review has evaluated all interventional studies for fibromyalgia, which limits attempts to make inferences regarding the relative effectiveness of treatments. METHODS/DESIGN: We will conduct a network meta-analysis of all RCTs evaluating therapies for fibromyalgia to determine which therapies show evidence of effectiveness, and the relative effectiveness of these treatments. We will acquire eligible studies through a systematic search of CINAHL, EMBASE, MEDLINE, AMED, HealthSTAR, PsychINFO, PapersFirst, ProceedingsFirst, and the Cochrane Central Registry of Controlled Trials. Eligible studies will randomly allocate patients presenting with fibromyalgia or a related condition to an intervention or a control. Teams of reviewers will, independently and in duplicate, screen titles and abstracts and complete full text reviews to determine eligibility, and subsequently perform data abstraction and assess risk of bias of eligible trials. We will conduct meta-analyses to establish the effect of all reported therapies on patient-important outcomes when possible. To assess relative effects of treatments, we will construct a random effects model within the Bayesian framework using Markov chain Monte Carlo methods. DISCUSSION: Our review will be the first to evaluate all treatments for fibromyalgia, provide relative effectiveness of treatments, and prioritize patient-important outcomes with a focus on functional gains. Our review will facilitate evidence-based management of patients with fibromyalgia, identify key areas for future research, and provide a framework for conducting large systematic reviews involving indirect comparisons.

Patient values and preferences in decision making for antithrombotic therapy: a systematic review: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.

BACKGROUND: Development of clinical practice guidelines involves making trade-offs between desirable and undesirable consequences of alternative management strategies. Although the relative value of health states to patients should provide the basis for these trade-offs, few guidelines have systematically summarized the relevant evidence. We conducted a systematic review relating to values and preferences of patients considering antithrombotic therapy. METHODS: We included studies examining patient preferences for alternative approaches to antithrombotic prophylaxis and studies that examined, in the context of antithrombotic prophylaxis or treatment, how patients value alternative health states and experiences with treatment. We conducted a systematic search and compiled structured summaries of the results. Steps in the process that involved judgment were conducted in duplicate. RESULTS: We identified 48 eligible studies. Sixteen dealt with atrial fibrillation, five with VTE, four with stroke or myocardial infarction prophylaxis, six with thrombolysis in acute stroke or myocardial infarction, and 17 with burden of antithrombotic treatment. CONCLUSION: Patient values and preferences regarding thromboprophylaxis treatment appear to be highly variable. Participant responses may depend on their prior experience with the treatments or health outcomes considered as well as on the methods used for preference elicitation. It should be standard for clinical practice guidelines to conduct systematic reviews of patient values and preferences in the specific content area.

Specialty outpatient care of diabetic patients in Poland--are we far from treatment targets? Rationale, design, and preliminary results of the OPTIMO study.

INTRODUCTION: While clinical practice guidelines reflect the best known evidence-based approach to patient care, it is individual clinicians and patients who make decisions and treatment choices, and individual patients who actually achieve (or not) the treatment goals. OBJECTIVES: The aim of the study was to describe the population of diabetic patients attending specialty outpatient clinics, to characterize the management of patients with different types of diabetes, and to assess the accordance of management with the recommendations developed by Diabetes Poland. PATIENTS AND METHODS: The OPTIMO observational study was conducted from 2006 to 2009 and included patients with diabetes diagnosed according to the 1999 World Health Organization criteria who were observed for 1 to 3 years, with control visits at least every 6 months. Participating physicians used pocket PCs equipped with specially developed software to collect patients' data and to provide educational reminders to clinicians. RESULTS: The final analysis involved 9600 patients for whom valid baseline questionnaires were available. Type 2 diabetes was observed in 92% and type 1 diabetes in 6% of the patients. Mean age was 60.5 years. Women constituted 54% of the population. Coronary heart disease was observed in 32% and arterial hypertension in 76% of the patients. At baseline, 23% of the patients had hemoglobin A1c level below 6.5% and 44% below 7.0. Total cholesterol and triglycerides treatment goals were met at baseline by slightly more than half of the patients, while low-density lipoprotein cholesterol treatment goal was met only by 33% of the patients. Baseline blood pressure below 130/80 mmHg was reported for 11% of the patients. CONCLUSIONS: At the beginning of the OPTIMO study, we have observed considerable deviations from treatment targets recommended by current clinical practice guidelines for diabetic patients, which leaves significant room for improvement in the care of diabetic patients.