Acta Medica Croatica最新文献

Although survey results indicate clear connection between the physician-patient communication and health outcomes, mechanismsof their action are still insufficiently clear. The aim was to investigate the specificity of communication with patients sufferingfrom gastrointestinal diseases and the impact of good communication on measurable outcomes. We performed PubMed(Medline) search using the following key words: communication, health outcomes, and gastrointestinal diseases. Seven pathwaysthrough which communication can lead to better health include increased access to care, greater patient knowledge and sharedunderstanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency andempowerment, and better management of emotions. Although these pathways were explored with respect to cancer care, theyare certainly applicable to other health conditions as well, including the care of patients suffering from gastrointestinal diseases.Although proposing a number of pathways through which communication can lead to improved health, it should be emphasizedthat the relative importance of a particular pathway will depend on the outcome of interest, the health condition, where the patientis in the illness trajectory, and the patient’s life circumstances. Besides, research increasingly points to the importance of placeboeffect, and it is recommended that health professionals encourage placebo effect by applying precisely targeted communicationskills, as the unquestionable and successful part of many treatments. It is important that the clinician knows the possible positiveand negative effects of communication on health outcomes, and in daily work consciously maximizes therapeutic effectsof communication, reaching its proximal (understanding, satisfaction, clinician-patient agreement, trust, feeling known, rapport,motivation) and intermediate outcomes (access to care, quality medical decision, commitment to treatment, trust in the system,social support, self-care skills, emotional management) to improve the health of patients he cares for.

Colorectal cancer is a global problem worldwide because of its very high prevalence and mortality. Therefore, prevention ofcolorectal cancer and its early diagnosis is of great importance. In Croatia, the National Program for Colorectal Cancer has beencarried out since 2007; however, the rate of response was about 18 percent, depending on the region. Such a great public healthand social and economic problem requires multidisciplinary approach in which family physicians have an important role. The wellspread and developed network of primary health care and the availability of family physicians to each inhabitant have not beensufficiently exploited, especially for such preventive activities where family physicians could supervise program implementation.

Acute respiratory distress syndrome (ARDS) develops in patients with predisposing conditions that induce systemic inflammatoryresponse such as sepsis, pneumonia, acute pancreatitis, major trauma, or multiple transfusions. Sepsis is the most common causeof ARDS. Sepsis-related ARDS patients have significantly lower PaO2 /FiO2 ratios than patients with non-sepsis-related ARDS.Furthermore, their recovery from lung injury is prolonged, weaning from mechanical ventilation less successful, and extubationrate slower. Clinical outcomes in patients with sepsis-related ARDS are also worse, associated with significantly higher 28-dayand 60-day mortality rates (31.1% vs. 16.3% and 38.2% vs. 22.6%, respectively). It is extremely important to optimally adjustventilator setting to current condition of lungs, while providing all other therapeutic measures in the treatment of sepsis, severesepsis and septic shock. The pool of data on treatment possibilities for patients with ARDS grows every year, with specificallydesigned mechanical ventilation strategies. Ventilator modes and adequate positive end-expiratory pressure (PEEP) settings playa major role in these strategies. However, how can we best apply these experimental and clinical data to everyday clinical practice?This article emphasizes protective ventilation as a measure that is proven to reduce mortality in this group of patients, whensystematically and consistently applied.

The most important multiresistant bacteria causing treatment failures are extended-spectrum β-lactamase and/or plasmid-mediatedAmpC β-lactamase positive Enterobacteriaceae, carbapenemase producing Acinetobacter baumannii and Pseudomonas(P.) aeruginosa, methicillin-resistant Staphylococcus (S.) aureus, penicillin-resistant Streptococcus pneumoniae, and van-comycin-resistant Enterococcus spp. Extended-spectrum β-lactamases hydrolyze oxyimino-caphalosporins and aztreonam, aremostly produced by Enterobacteriaceae, and are encoded on transferable plasmids which often contain resistance genes tonon-􀁠-lactam antibiotics. Plasmid-mediated AmpC β-lactamases descend from the chromosomal ampC gene transferred to theplasmid. Those 􀁠-lactamases confer resistance to first, second and third generation of cephalosporins, monobactams, and to􀁠-lactam-􀁠-lactamase inhibitor combinations. Enterobacteriaceae may develop resistance to carbapenems due to the hyperproductionof ESBLs or plasmid-mediated AmpC β-lactamases in combination with porin loss or due to the production of carbapenemasesof class A (KPC, IMI, NMC, SME), B (metallo-β-lactamases from VIM, IMP or NDM series), and D (OXA-48 β-lactamase).Carbapenemases found in Acinetobacter spp. belong to molecular class A (KPC), B (metallo-β-lactamases of IMP, VIM, NDM orSIM family) and D (OXA enzymes). The most frequent mechanism of carbapenem resistance in Acinetobacter spp. is through theproduction of OXA-enzymes but other various mechanisms including decreased permeability and efflux pump overexpressioncould also be involved. Carbapenem-resistance in P. aeruginosa is usually mediated by the production of metallo-β-lactamases ofIMP, VIM, GIM, SPM or NDM series, loss of OprD outer membrane protein and/or upregulation of MexAB or MexCD efflux pumps.Methicillin-resistance in S. aureus occurs as the result of the acquisition of mecA gene that encodes novel PBP2a protein. Expressionof PBP2a renders bacteria resistant to all 􀁠-lactams including cephalosporins (with the exception of ceftaroline and ceftobiprole)and carbapenems. Most strains of penicillin resistant Streptococcus pneumoniae are often resistant to cephalosporinsand antibiotics from other classes, presenting a serious problem in treating invasive infections. The most important therapeuticproblem in enterococci is development of resistance to vancomycin.

Early identification of sepsis is crucial to improve patient outcomes. Yet, sepsis can be difficult to differentiate in Emergency Unit.Sepsis treatment includes fluid resuscitation as soon as possible, starting with >1000 mL of crystalloids or 500 mL of colloids for30 min. Acute kidney injury is a serious complication of sepsis, associated with increased mortality, prolonged hospital stay andincreased cost of care. In patients with sepsis, it would be useful to have some biomarkers of early organ damage, to improve thecapacity for early recognition and diagnosis of acute kidney injury.

Sepsis is a growing global problem with high health care costs. Therefore, it is important to start treatment on time. Nutritionsupport is the main element of modern therapy for sepsis. Enteral nutrition has some advantage to parenteral nutrition because itprevents bacterial translocation into systemic circulation, thus reducing the number of infections. Appropriate nutritional supporthas a direct impact on the patient clinical outcome.

Febrile neutropenia is a common and potentially fatal complication of intense cytotoxic therapy, which makes it the main causeof non-relapse mortality in patients with hematologic malignancies. Some of the patients are at risk of specific infections due tounderlying disease of previous treatment regimens. Considering that most febrile neutropenic patients can be diagnosed withsepsis, diagnosis and treatment should be treated as septic. It is important to recognize patients at high risk since the incidenceof sepsis in neutropenic patients can be significantly reduced using antimicrobial prophylaxis and granulocyte growth factors.Once sepsis occurs, prompt treatment according to guidelines, individualized based on the specific problems of each patient,and microbiological situation can significantly reduce mortality and morbidity.

Septic cardiomyopathy is a reversible myocardial dysfunction in patients with sepsis. Depression in myocardial contractility isdetected in more than 40% of patients with severe sepsis or septic shock. Sepsis-induced myocardial dysfunction (SIMD) is oneof the main predictors of poor outcome in patients with sepsis. Mortality rate in patients with sepsis and SIMD is 70%-90%, whileit is only 20% in patients without SIMD. SIMD is characterized by ventricular dilatation, decreased ejection fraction, less responseto fluid replacement and catecholamines. It is reversible within 7-10 days. Many extracellular and intracellular mechanisms andmediators included in the regulation of the heart muscle cell contraction may contribute to septic cardiomyopathy. The underlyingcause is disorder in communication between the intracellular contractile apparatus and extracellular matrix, resulting in attenuationof the myocardial contraction. Hemodynamic monitoring, ECG, transthoracic and transesophageal echocardiography, andvarious laboratory tests are used in the diagnostic work-up. There are several therapeutic interventions such as infection control,optimization of hemodynamic parameters, adequate volume resuscitation, inotropic drugs, transfusion of blood derivatives, andstatins. However, for now, there is no efficient therapy for septic cardiomyopathy. The management of SIMD includes cardio-protectivetherapy, etiologic treatment of sepsis and septic shock, and supportive measures.

Epidemiological studies indicate a large incidence of sepsis in the general population. Despite advances in surgery, surgicalpatients with sepsis make almost one-third of all cases of sepsis. Sepsis is the leading cause of morbidity and mortality amongsurgical patients, with intra-abdominal infection as the main source of sepsis. According to some authors, sepsis in surgicalpatients is different from those in non-surgical patients because of the immune function modulation that occurs as a result ofsurgery and anesthesia applied; therefore, these two groups should be monitored separately. In the treatment of sepsis, the keysteps are early recognition of sepsis, rapid diagnosis, and aggressive treatment that includes the choice of intervention with theleast physiological insult to control the sources of infection. Emphasis should be placed on the prevention of sepsis throughoutthe perioperative period. In surgical septic patients, treatment is complex and requires a multidisciplinary approach.

The incidence of healthcare-associated infections and sepsis (HAIs) is 5-10 times higher in patients in intensive care units (ICUs)than in those at other hospital departments. Predisposition for these lies in many intrinsic (disease severity, loss of immunity) andextrinsic factors (frequent use of broad-spectrum antibiotics with consequent presence of antibiotic-resistant pathogens). Themajority of HAIs in ICUs are associated with the use of invasive devices (DA-HAIs; device-associated healthcare-associated infections)(19%). Their incidence differs among specific types of ICUs (2%-49%). The most frequent DA-HAI are central line-associatedbloodstream infections (CLA-BSI), ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection(CAUTI) and surgical site infections (SSI). SSI is most often described as a distinct and separate entity of HAIs in ICUs. Recently,gram-negative bacilli (Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter spp.) are more frequently isolated inDA-HAIs than gram-positive ones (Staphylococcus aureus, Enterococcus spp.), often present as resistant strains. On the otherhand, urinary or/and systemic infections tend to increase. DA-HAIs endanger and slow down patient recovery, prolong hospitalstay, and generally increase the mortality rate. DA-HAIs are of special interest of the Hospital Committee Center for Infective Diseasein order to improve patient safety and reduce total cost allocated for prevention of DA-HAIs. DA-HAI rate is the most usefulintra- and inter-hospital measure to compare surveillance and effectiveness of preventive procedures among different ICU types.