Manejo anestésico de las pacientes embarazadas tetrapléjicas durante el parto: una revisión sistemática

IntroductionPregnancy in spinal cord injured patients has specific issues that must be carefully addressed. However, guidelines for their management are scarce.MethodsA systematic review of the literature regarding the anaesthetic management during delivery of pregnant patients with cervical spinal cord injury was performed on the electronic databases of PubMed (Medline) and Cochrane.ResultsA higher incidence of preterm birth and caesarean delivery were seen. Anaesthetic management was diverse, although most pregnant patients received epidural analgesia. Autonomic dysreflexia symptoms were present in 51% of pregnancies.ConclusionTimely management of these patients could possibly reduce caesarean and preterm delivery rates, avoid or minimize common complications, as well as reduce costs. An early reference to anaesthesiology consultation and a multidisciplinary approach is recommended.     

早孕期监测子宫动脉多普勒参数在预测低危人群不良妊娠结局的价值

目的 建立妊娠11~13+6周子宫动脉多普勒参数在低危人群中的正常参考值，同时评估其对不良妊娠结局的预测价值。方法 收集2019年6月至2021年6月于我院行产前超声检查的妊娠11~13+6周孕妇，根据妊娠结局分组。收集两侧子宫动脉多普勒指标，包括搏动指数（PI）、阻力指数（RI）、舒张早期是否有切迹，以及孕妇基本临床资料和胎儿出生信息，将以上相关参数进行统计学分析。结果 最终纳入800例孕妇，包括正常妊娠结局组740例和不良妊娠结局组60例。两组孕妇体质量指数（BMI）、分娩孕周和胎儿出生体质量比较，差异均有统计学意义（均P＜0.05）。随着孕周的增加，子宫动脉两侧平均搏动指数（mPI）、平均阻力指数（mRI）和两侧舒张早期切迹检出率均呈逐渐下降的趋势。ROC曲线分析显示，mPI、mRI及两侧舒张早期切迹预测妊娠结局的曲线下面积（AUC）分别为0.542、0.574、0.521，三者联合预测妊娠结局的AUC为0.648；孕妇BMI、年龄mPI、mRI及两侧舒张早期切迹预测妊娠结局的AUC为0.751。结论 建立了低危人群在妊娠11~13+6周子宫动脉多普勒参数的正常参考值范围。在妊娠11~13+6周单纯应用子宫动脉多普勒参数预测妊娠结局的价值有限，将子宫动脉参数与临床相关指标结合可提高对不良妊娠结局的预测价值。     

Diabetic foot ulcers: A devastating complication of diabetes mellitus continues non-stop in spite of new medical treatment modalities

Diabetic foot ulcer is a devastating complication of diabetes mellitus and significant cause of mortality and morbidity all over the world and can be complex and costly. The development of foot ulcer in a diabetic patient has been estimated to be 19%-34% through their lifetime. The pathophysiology of diabetic foot ulcer consist of neuropathy, trauma and, in many patients, additional peripheral arterial disease. In particular, diabetic neuropathy leads to foot deformity, callus formation, and insensitivity to trauma or pressure. The standard algorithms in diabetic foot ulcer management include assessing the ulcer grade classification, surgical debridement, dressing to facilitate wound healing, off-loading, vascular assessment (status and presence of a chance for interventional vascular correction), and infection and glycemic control. Although especially surgical procedures are sometimes inevitable, they are poor predictive factors for the prognosis of diabetic foot ulcer. Different novel treatment modalities such as nonsurgical debridement agents, oxygen therapies, and negative pressure wound therapy, topical drugs, cellular bioproducts, human growth factors, energy-based therapies, and systematic therapies have been available for patients with diabetic foot ulcer. However, it is uncertain whether they are effective in terms of promoting wound healing related with a limited number of randomized controlled trials. This review aims at evaluating diabetic foot ulcer with regard to all aspects. We will also focus on conventional and novel adjunctive therapy in diabetic foot management.     

Evidence-based strategies to reduce the incidence of postoperative delirium: a narrative review

Delirium is one of the most commonly occurring postoperative complications in older adults. It occurs due to the vulnerability of cerebral functioning to pathophysiological stressors. Identification of those at increased risk of developing delirium early in the surgical pathway provides an opportunity for modification of predisposing and precipitating risk factors and effective shared decision-making. No single delirium prediction tool is used widely in surgical settings. Multi-component interventions to prevent delirium involve structured risk factor modification supported by geriatrician input; these are clinically efficacious and cost effective. Barriers to the widespread implementation of such complex interventions exist, resulting in an ‘implementation gap’. There is a lack of evidence for pharmacological prophylaxis for the prevention of delirium. Current evidence suggests that avoidance of peri-operative benzodiazepines, careful titration of anaesthetic depth guided by processed electroencephalogram monitoring and treatment of pain are the most effective strategies to minimise the risk of delirium. Addressing postoperative delirium requires a collaborative, whole pathway approach, beginning with the early identification of those patients who are at risk. The research agenda should continue to examine the potential for pharmacological prophylaxis to prevent delirium while also addressing how successful models of delirium prevention can be translated from one setting to another, underpinned by implementation science methodology.     

滋肾育胎丸加减方预防ACA阳性者不良妊娠结局的效果及机制研究＊

目的 探讨滋肾育胎丸加减方预防抗磷脂抗体（ACA）阳性者不良妊娠结局的效果及机制研究。方法 选取2016年2月至2019年2月我院收治的89例ACA阳性，先兆性流产或有习惯性流产（RSA）史患者，将采用西医治疗的40例作为对照组，将采用西医联合滋肾育胎丸加减方治疗的49例作为观察组，比较两组中医证候疗效、中医证候积分、ACA-IgA、ACA-IgM、ACA-IgG、凝血指标［血小板聚集功能（PAF）、活化蛋白C（PC）、抗凝血酶（AT）、纤溶酶原激活抑制物-1（PAI-1）］、Th1/Th2细胞因子［干扰素γ（IFN-γ）、白介素-2（IL-2）、白介素-4（IL-4）、白介素-10（IL-10）］、妊娠结局、安全性。结果 治疗2周后检测ACA，观察组2例未降低，对照组11例未降低，观察组未降低患者占比低于对照组（P<0.05）；观察组总有效率100.00%高于对照组85.00%（P<0.05）；观察组治疗4周、7周后中医证候积分低于对照组（P<0.05）；观察组治疗4周、7周后ACA-IgA、ACA-IgM、ACA-IgG低于对照组（P<0.05）；观察组治疗4周、7周后PAF、PAI-1低于对照组，PC、AT高于对照组（P<0.05）；观察组治疗4周、7周后IFN-γ、IL-2低于对照组，IL-4、IL-10高于对照组（P<0.05）；观察组活产率95.92%高于对照组80.00%（P<0.05）；组间不良反应总发生率比较，差异无统计学意义（P>0.05）。结论 动态监测ACA对滋肾育胎丸加减方精准应用具有指导意义，指导滋肾育胎丸加减方通过调理脏腑、气血、经络功能，改善先兆性流产或有RSA史患者临床症状及凝血因子指标，降低ACA水平，并可改善患者免疫耐受功能，提高胎儿活产率，且安全性高。     

中毒性表皮坏死松解症导致眼部远期并发症1例

中毒性表皮坏死松解症与Stevens-Johnson综合征是一种由药物反应引起的严重的表皮及黏膜的不良反应。最常发生于成人,与服用磺胺类、巴比妥类、非类固醇抗炎药、苯妥英纳、醋甲唑胺、别嘌呤醇和青霉素等药物有关。约有1/5的患者否认有服药史,约在1/3病例中由于同时患有严重疾病及用药物治疗而病因不明。中毒性表皮坏死松解症为皮肤科少数病情危重的疾病之一,其死亡率达30%~35%。20%~40%的存活者有眼睛受累。少数患者由于泪管阻塞可出现泪眼,多数患者表现为睫毛、眼睑上皮增生,伴鳞状化生、结膜和角膜新生血管形成,引起一种中毒性表皮坏死松解症眼综合征。经及时治疗中毒性表皮坏死松解症可好转。但是部分患者眼部情况可继续发展,可引起畏光、灼痛、视力下降甚至失明。现汇报1例中毒性表皮坏死松解症眼综合征患者眼部远期并发症。