Psychological factors as predictors of early postoperative pain after open nephrectomy Ana Mimic,1 Carsten Bantel,2,3 Jelena Jovicic,1 Branko Mimic,4 Darija Kisic-Tepavcevic,5 Otas Durutovic,6,7 Nebojsa Ladjevic1,7 1Department of Anaesthesia, Urology Clinic, Clinical Centre of Serbia, Belgrade, Serbia; 2Department of Anaesthetics, Klinikum Oldenburg AöR, Oldenburg, Germany; 3Section of Anaesthetics, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; 4East Midlands Congenital Heart Centre, University Hospital Leicester, Leicester, UK; 5Institute of Epidemiology, School of Medicine, University of Belgrade, Belgrade, Serbia; 6Department of Urology, Urology Clinic, Clinical Centre of Serbia, Belgrade, Serbia; 7Department of Surgery and Anaesthesiology, School of Medicine, University of Belgrade, Belgrade, Serbia Purpose: There is an increasing interest in the identification of predictors for individual responses to analgesics and surgical pain. In this study, we aimed to determine psychological factors that might contribute to this response. We hence investigated patients undergoing a standardized surgical intervention (open nephrectomy). Patients and methods: Between May 2014 and April 2015, we conducted a prospective observational cohort study. The following psychological tests were administered preoperatively: Mini-Mental State Examination, Amsterdam Preoperative Anxiety and Information Scale (APAIS), Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, and Pain Catastrophizing Scale. The primary outcome, postoperative pain intensity (11-point numerical rating scale, [NRS]), was assessed in the “immediate early” (first 8 hours), “early” (12 and 24 hours), and “late early” periods (48 and 72 hours).Results: A total of 196 patients were assessed, and 150 were finally included in the study. NRS scores improved from 4.9 (95% confidence interval [CI]: 4.7–5.1) in the “immediate early” to 3.1 (95% CI: 2.9–3.3) in the “early” and 2.3 (95% CI: 2.1–2.5) in the “late early” postoperative period. Most (87%) patients received intravenous opioids, while 13% received analgesics epidurally. Repeated measures analysis of variance indicated better pain management with epidural analgesia in the first two postoperative periods (F=15.01, p<0.00). Postoperative pain correlated strongly with analgesic strategy and preoperative psychological assessment. Multiple linear regression analysis showed “expected pain” was the only predictor in the “immediate early” phase, and “anxiety” was most important in the “early” postoperative period. In the “late early” phase, catastrophizing was the predominant predictor, alongside “preoperative analgesic usage” and “APAIS anxiety”.Conclusion: After open nephrectomy, epidural analgesia conveys a clear advantage for pain management only within the first 24 hours. Moreover, as the psychological phenotype of patients changes distinctively in the first 72 postoperative hours, psychological variables increasingly determine pain intensity, even surpassing employed analgesic strategy as its main predictor. Keywords: psychological variables, postoperative analgesia, postoperative pain, open nephrectomy, numeric rating scale

Background: Empiric antimicrobial therapy with azithromycin is highly used in patients admitted to the hospital with COVID‐19, despite prior research suggesting that azithromycin may be associated with increased risk of cardiovascular events. Methods and Results: This study was conducted using data from the ISACS‐COVID‐19 (International Survey of Acute Coronavirus Syndromes‐COVID‐19) registry. Patients with a confirmed diagnosis of SARS‐CoV‐2 infection were eligible for inclusion. The study included 793 patients exposed to azithromycin within 24 hours from hospital admission and 2141 patients who received only standard care. The primary exposure was cardiovascular disease (CVD). Main outcome measures were 30‐day mortality and acute heart failure (AHF). Among 2934 patients, 1066 (36.4%) had preexisting CVD. A total of 617 (21.0%) died, and 253 (8.6%) had AHF. Azithromycin therapy was consistently associated with an increased risk of AHF in patients with preexisting CVD (risk ratio [RR], 1.48 [95% CI, 1.06–2.06]). Receiving azithromycin versus standard care was not significantly associated with death (RR, 0.94 [95% CI, 0.69–1.28]). By contrast, we found significantly reduced odds of death (RR, 0.57 [95% CI, 0.42–0.79]) and no significant increase in AHF (RR, 1.23 [95% CI, 0.75–2.04]) in patients without prior CVD. The relative risks of death from the 2 subgroups were significantly different from each other ( P _interaction =0.01). Statistically significant association was observed between AHF and death (odds ratio, 2.28 [95% CI, 1.34–3.90]). Conclusions: These findings suggest that azithromycin use in patients with COVID‐19 and prior history of CVD is significantly associated with an increased risk of AHF and all‐cause 30‐day mortality. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT05188612.

Ladjevic NG, et al. Yonsei Med J. 2009 Apr;50(2):293-295. http://dx.doi.org/10.3349/ymj.2009.50.2.293

Background/Aim. The incidence of postoperative delirium (POD) after non-cardiac surgery is a problem often not recognized by many anesthesiologists. The objective of our study was to detect POD and its possible cause, in patients undergoing Radical Retropubic Prostatectomy (RRP) under general anesthesia. Methods. After Ethical Committee approval, we enrolled 80 patients, ASA status II, in a prospective study, who were scheduled to undergo RRP under general anesthesia. All patients completed MMSE tests (Folstein Mini Mental State Exam) evening before, and 48 hours after surgery. Assessment for the presence and severity of delirium was performed using CAM (Confusion assessment method), and an assessment of the degree of agitation and sedation using RASS (The Richmond Agitation and Sedation Scale). Results. The average preoperative MMSE score (28.59±1.04) significantly decreased following the surgery (27.74±1.52) (p<0.0001). The average postoperative MMSE score trend descended in comparison to intraoperative bleeding (p=0.036). Patients with higher pain scores had significant decline in MMSE after surgery (28.75 vs 26.25; p1 drink per day) preoperatively (p<0.0001). Based on RASS score, 13 patients (16.3%) were agitated or sedated, and they had statistically significantly higher intraoperative bleeding (p<0.001). Conclusion. Results of this study emphasize the importance of proper preoperative evaluation; especially regarding the alcohol consumption since all patients that developed POD reported moderate alcohol consumption. Furthermore, greater intraoperative bleeding and postoperative pain scores did not influence the occurrence of delirium, but resulted in lower postoperative MMSE scores, which highlights the importance of proper intraoperative management from both surgery and anesthesia to lower risk for developing POD.

In December 2019, a new Corona virus (SARS-CoV-2) was identified as responsible for outbreak of viral pneumonia in Wuhan, Hubei Province, China. The World Health Organization has announced a pandemic of COVID-19 (Coronavirus disease 2019) on March 2nd 2020. COVID-19 is a respiratory infection where majority of patients have mild clinical symptoms. About 14% of patients require hospitalization and oxygen therapy and 5% of patients require admission to the intensive care unit. The most severe clinical cases include ARDS, sepsis and septic shock, acute renal failure, multiorgan dysfunction, and myocardial damage. Spread of the infection so far indicates that the number of patients requiring hospital admition and intensive care treatment will significantly burden the health care system in all countries. Several intensive and critical care protocols, based on the first experiences in treatment of viral pneumonia and severe COVID-19 illness, have already been published. Here we present the first version of a suggested protocol in our country, with an attached flowchart for the initial management of the COVID-19 patients in need for mechanical ventilation. The protocol is based on the worldwide existing experience in treatment of COVID-19 patients. The intention is not to replace the clinical experience and critical judgment of the attending doctors, but to strengthen their decisions and tailor treatment according to the recourses existing in our country.

Background/Aim. Urolithiasis is one of the most common urological illnesses with a continual rise in incidence and prevalence in the population. Its pathogenesis is multifactorial; hence, its consequences are serious problems that can significantly impact the quality of life of patients. In the last years, operational modes of urolithiasis treatment had undergone evolution changes towards minimally invasive treatment techniques aimed at improving its efficacy and patients' life quality. The aim of the study was to examine and evaluate the quality of life of the patients with urolithiasis depending on the applied treatment method. Methods. This research was designed as a panel study ? a combination of a cross-sectional and cohort study. The sample included patients with urolithiasis treated with extracorporeal shock wave lithotripsy (ESWL) or ureteroscopic lithotripsy (Lithoclast). The research was carried during one year period and 100 respondents met the inclusion criteria. They were divided into two equal groups considering the applied method of the stone disintegration: the Lithoclast group (URSL) and the ESWL group. The instrument used for measuring the quality of life was Short Form (SF) 36 questionnaire. It was administrated to the patients immediately before the operation and one month after the operation. Results. The statistical analysis of the scores obtained preoperationally on the SF 36 questionnaire revealed the decrease in the quality of life of patients with urolithiasis in almost all dimensions of life. The statistically relevant difference in preoperative SF scores between the two groups of patients was not established except in the domain of the role of physical health and the domain of mental health. In the domain of the role of physical health, the Lithoclast group had a statistically significant higher score than the ESWL group, but in the domain of mental health, the ESWL group had a statistically significant higher score than the Lithoclast group. The postoperative statistical analysis of SF questionnaire and the examination of the impact of the treatment mode on the quality of life showed that the use of the Lithoclast method resulted in the much higher, statistically significant score at SF36 questionnaires regarding several life dimensions than the ESWL method. The application of the ESWL method even resulted in the decrease in the postoperational score for some life dimensions. Conclusion. The assessment of the quality of life is an adequate tool for the evaluation of treatment modes in the clinical practice. By using the SF 36 questionnaire in this study, we established that the ureteroscopic lithotripsy (the Lithoclast method) is a method that postoperatively results in much higher and statistically significant improvement of the quality of life of patients with urolithiasis in several health domains than the ESWL method.