The role of mucoregulatory agents after continence-preserving urinary diversion surgery.

PURPOSE: The postsurgical use of N-acetylcysteine, octreotide, and other agents to reduce mucus accumulation after urinary diversion procedures is described. SUMMARY: Patients undergoing continence-sparing bladder resection are at risk for infection and stone formation due to mucus accumulation. In addition to N-acetylcysteine, agents studied for mucoregulatory control in such patients include aspirin, urea, ranitidine, and octreotide. N-acetylcysteine has high mucolytic activity in vitro, and positive outcomes with instillations of 20% N-acetylcysteine solution have been reported in some patients. Significant mucus reductions were reported in small numbers of patients treated with oral ranitidine 300 mg daily or instillations of 30 mL of urea 40% solution, while the benefits of aspirin are more questionable. To date, there has been only one randomized controlled trial comparing various agents for mucus reduction after reconstructive bladder surgery; the results indicated no significant benefits with the use of N-acetylcysteine, aspirin, or ranitidine. In one small study (n = 40), the use of subcutaneous octreotide immediately before and for 15 days after surgery was reported to yield significant reductions in mucus production, the need for bladder irrigation to clear blockages, and the mean duration of hospital stays. CONCLUSION: Various agents evaluated for mucus control after urinary diversion procedures (oral ranitidine or aspirin, N-acetylcysteine or urea instillations, and subcutaneous octreotide), while reportedly effective for some patients, remain of questionable benefit. More research is needed to define the optimal role of these agents for this indication.

Economic evaluation in critical care: a focus on severe sepsis in oncology.

Hospital care, physician and clinical services, and prescription drugs continue to drive healthcare expenditures across healthcare systems and nations. The critical-care setting, owing to the complexity and intensity of care, is a high user of the resources that drive healthcare spending. Information regarding the cost and effectiveness of critical-care therapies is necessary to properly guide care and policies for this unique population. Many challenges exist for conducting and comparing economic evaluation in critical care. Recently, recommendations on cost and cost-effectiveness analysis in critical care have been developed that will guide future research. A focus area, severe sepsis in oncology, is reviewed to highlight the challenges and opportunities of economic evaluation in this setting.