早产儿呼吸暂停脑氧合及脑血流变化的研究

目的:探讨早产儿原发性呼吸暂停时脑氧合及脑血流的变化。方法:应用近红外光谱技术动态观察16例早产儿原发性呼吸暂停时脑rSO2、HbO2、Hb及CBV变化。结果:早产儿呼吸暂停时脑rSO2与外周动脉SO2的变化同步;呼吸暂停发生后SO2与rSO2逐步降低,呼吸暂停15 s,两者与基础值相比,有显著性差异(97．16±3．50 vs 89．25±3．33;59．58± 4．23 vs 50．92±4．39,P<0．001),30 s秒时为最低值;rSO2恢复较慢,60 s时与基础值相比差异仍有显著差异(P<0．05)。呼吸暂停发作后给予常规物理刺激,CBV无明显的变化,但给予呼吸皮囊加压通气治疗,CBV可明显增加;氨茶碱对早产儿脑血流改变无明显影响作用。结论:早产儿呼吸暂停对脑rSO2有明显影响,反复发作应考虑进行早期临床的干预。 NIRS技术能客观评价脑组织的氧合状况,了解脑血流动力学变化,对呼吸暂停过程及治疗可提供有效信息。     

Sensitivity of Near Infrared Spectroscopy to Cerebral and Extra-Cerebral Oxygenation Changes is Determined by Emitter-Detector Separation

Objective. To examine the effect of two emitter-detector separations (2.7 and 5.5 cm) on the detection of changes in cerebral and extra-cerebral tissue oxygenation using near infrared spectroscopy (NIRS). Methods. Two NIR detectors were placed on the scalp 2.7 and 5.5 cm from a single NIR emitter. Changes in deoxyhaemoglobin (HHb), oxyhaemoglobin (O2Hb),oxidised cytochrome C oxidase (Cyt) and total haemoglobin (tHb) were recorded from each detector during the induction of cerebral oligaemia (transition from hypercapnia to hypocapnia) and scalp hyperaemia (following release of a scalp tourniquet). Results. Cerebral oligaemia (mean decrease in middle cerebral artery blood flow velocity of 44%) induced by a mean reduction in end tidal CO2 of 18 mmHg was accompanied by a significant increase in the spectroscopic signal for HHb and a decrease in the O2Hb signal. The signal change per unit photon path length detected at 5.5 cm was significantly greater for HHb (p = 0.007) than that detected at 2.7 cm. In contrast, the increase in all chromophores detected at 5.5 cm during scalp hyperaemia was significantly less than that detected at 2.7 cm (p < 0.001). Conclusions. The differing sensitivity of the proximal and distal channels to changes in cerebral and extra-cerebral oxygenation is compatible with theoretical models of NIR light transmission in the adult head and may provide a basis for spatially resolving these changes. The optimal emitter-detector separation for adult NIRS requires further investigation and may differ between individuals.     

近红外线乳腺影像诊断在妇女乳腺疾病普查中的应用价值

目的：观察近红外线乳腺影像诊断在妇女乳腺疾病普查中的价值。材料与方法：采用DX-9000E红外线乳腺诊断仪,被普查者袒露双乳正对摄像机,双手自然下垂,收腹使双乳放松,红外探头逐象限仔细扫描观察。结果：乳痛症866例,乳腺囊性增生198例,乳腺纤维腺瘤28例,乳腺癌6例。结论：（1）红外线乳腺诊断仪使用携带方便,图像直观,诊断快,可反复多次检查并可进行图像记录,各年龄段的妇女都适用,成为当前开展乳腺疾病普查的主要手段。（2）对鉴别肿块的良、恶性有很高的准确率,可为诊断早期乳腺癌提供可靠的依据。（3）这种检查手段简便易行,便于医生操作。（4）缺陷,国内尚无统一的诊断标准,加之操作水平不一,诊断标准有待进一步探讨。     

aEEG and NIRS during transition and resuscitation after birth: Promising additional tools; an observational study

Aim of the study

During resuscitation no routine cerebral monitoring is available. We aimed at monitoring cerebral activity and oxygenation continuously during neonatal transition and resuscitation.

Methods

Neonates ≥34 weeks of gestation born via cesarean section were included. Cerebral activity was continuously measured with amplitude-integrated-EEG (aEEG) and cerebral oxygenation (rSO₂) with near-infrared-spectroscopy (NIRS) during the first 10 min after birth. For quantitative analysis of aEEG every minute the mean minimum amplitude (V_min) and maximum amplitude (V_max) was determined. Uncompromised neonates were compared to neonates in need of resuscitation.

Results

Out of 224 eligible neonates 31 uncompromised and 15 in need of respiratory support were included. Uncompromised neonates showed higher values for V_min in the third minute and higher values for V_max in the third and fourth minute compared to the tenth minute post-partum. In uncompromised neonates rSO₂ values during the first 6 min after birth were lower compared to minute ten. Neonates in need of respiratory support had lower rSO₂ values over the first 8 min after birth compared to minute ten.

Conclusions

This is the first study demonstrating that monitoring of aEEG and NIRS to measure cerebral activity and oxygenation during immediate postpartum transition is feasible. During transition compromised neonates requiring resuscitation showed a different cerebral activity pattern compared to uncompromised neonates.     

Using near infrared light to manage symptoms associated with restless legs syndrome

The purpose of this study was to determine whether the application of near infrared (NIR) light could positively modulate symptoms associated with restless legs syndrome (RLS). Twenty-one subjects with RLS were treated with NIR three times weekly for four weeks. Baseline measures of: (1) international restless legs syndrome rating scale (IRLSRS) score; (2) Semmes Weinstein monofilament (SWM) test; (3) visual analog pain scale (VAS); (4) ankle-brachial index (ABI); and (5) sonographic imaging of the popliteal and posterior tibial arteries were compared to post-treatment values. NIR (850 nm) was delivered transcutaneously at 8 J/cm² to four locations on each leg and the plantar surface of each foot. A pre-test–post-test one group design was employed. Baseline and post-treatment measures were compared using either a dependent t-test when data were normal or the Wilcoxon signed rank test in the absence of normality. A significant improvement in IRLSRS scores was observed. Sensation improved from less than protective in 16.6% of sites tested at the baseline to 13.4% post-intervention. There was a significant improvement in ABI scores. VAS and sonographic imaging measures other than ABI remained unchanged. The use of NIR to modulate symptoms associated with RLS was supported by the data.     

136例危重孕产妇临床特征及其入住ICU的影响因素

目的了解危重孕产妇的流行病学特点,探讨其入住ICU的影响因素。 方法回顾性分析东南大学附属中大医院2016年1月至2019年12月136例危重孕产妇的临床资料,以是否入住ICU分为未入住ICU组（60例）和入住ICU组（76例）。收集包括年龄、学历、居住地、外院转诊、是否经产妇、是否规律产检、孕前体质量指数（BMI）、瘢痕子宫、分娩方式、分娩孕龄、24 h产后出血量、首要致病因素及主要致病因素等临床特征,并对其进行单因素及多因素Logistic回归分析。 结果危重孕产妇前3位首要致病因素为产后出血（39.0%）,妊娠期高血压疾病（19.1%）及妊娠合并心脏病（8.8%）。2组患者年龄、学历、居住地、是否经产妇、是否规律产检、瘢痕子宫、分娩孕龄、24 h产后出血量比较,差异均无统计学意义（P＞0.05）。2组患者外院转诊、孕前BMI、分娩方式、主要致病因素比较,差异均有统计学意义（χ²=4.802,P=0.028;P＜0.001;χ²=5.913,P=0.015;χ²=15.074,P＜0.001）。多因素回归分析显示孕前BMI（≥25 kg/m²）、主要致病因素（妊娠合并症）是危重孕产妇入住ICU的独立危险因素（OR=31.816,95%CI：1.767~1339.337,P=0.036;OR=31.894,95%CI：5.029~720.700,P=0.003）。 结论危重孕产妇的首要致病因素仍为产后出血、妊娠期高血压疾病及妊娠合并心脏病,孕前BMI≥25 kg/m²及具有妊娠合并症是危重孕产妇进入ICU的危险因素。     

Does red blood cell transfusion change the near infra red photoplethysmography signal in infants?

Objective Transfusion practices for neonates are controversial and based on limited scientific information. We examined the use of the plethysmographic volume pulse to assess anemia.Design We used near-infrared photoplethysmography (NIRP) to investigate signal strength parameters as area under the curve (AUC) and the first derivate of the amplitude (flux) in anemic infants before and after elective transfusion.Setting Tertiary intensive care unit.Patients Thirty-four neonates on day 25±15 of life with a pretransfusion hemoglobin level of 8±0.9 g/dl. Four infants were excluded for incomplete data.Interventions Transfusion of 10 ml packed red cells per kilogram body weightMeasurements and results The volume pulse signal was obtained with a sensor attached to the sole of the foot. After transfusion we found a significant decrease in number of bradycardia episodes per hour (0.35 vs. 0.16) and episodes of pulse oximeter desaturation less than 85% per hour (1.8 vs. 1.3) and a significant increase in daily weight gain (12±7 vs. 20±18 g), but neither of the microcirculatory parameters changed significantly (AUC 102±38 vs. 101±44; flux 435±160 vs. 405±120).Conclusions Even though infants were transfused at very low levels of hemoglobin with significant clinical effects, microcirculation assessed by NIRP seemed not be affected. Infrared photoplethysmographs present flow not only in the nutritive capillaries but mainly in the subpapillary plexus at a greater depth. This thermoregulatory flow seems not be affected by blood transfusions of anemic infants.     

电脑近红外光扫描诊断乳房包块的评价

目的　评价乳房包块近红外光扫描诊断的正确性。方法　将４８９ 例乳房包块患者的术前近红外光扫描诊断与术后病理对照。结果　近红外光扫描诊断乳腺恶性病变的正确率为８５８５ ％ ,且近红外光扫描的乳腺癌图像越典型,该肿瘤越趋于高恶性度;良性病变的诊断正确率为８９７９ ％ ,误诊共４０ 例,占８１８ ％ ,其中将乳腺癌误诊为良性１１ 例,良性误诊为恶性２９ 例。结论　近红外光扫描能比较明确地将乳腺疾病分类诊断,是鉴别乳腺良性、恶性病变的有效辅助手段,且直观、简便、无创伤。     

影响三维超声容量测定准确性因素的探讨

为了评价超声的近、远场及超声深度对三维重建容量测定准确性的影响，我们对１０个球状体在超声的近场和远场进行了三维重建并对１０个椭圆体在超声的１２ｃｍ、１５ｃｍ两个不同超声深度进行三维重建、测定其容量。结果显示，近场和远场所测容量，１２ｃｍ、１５ｃｍ两种深度所测容量高度一致（Ｐ＞０．５）。作者认为，三维超声对容量所测值不受超声近场、远场及超声深度的影响。     

Cerebral oximetry and return of spontaneous circulation after cardiac arrest: A systematic review and meta-analysis

AimThe prediction of return of spontaneous circulation (ROSC) during resuscitation of patients suffering of cardiac arrest (CA) is particularly challenging. Regional cerebral oxygen saturation (rSO₂) monitoring through near-infrared spectrometry is feasible during CA and could provide guidance during resuscitation.MethodsWe conducted a systematic review and meta-analysis on the value of rSO₂ in predicting ROSC both after in-hospital (IH) or out-of-hospital (OH) CA. Our search included MEDLINE (PubMed) and EMBASE, from inception until April 4th, 2015. We included studies reporting values of rSO₂ at the beginning of and/or during resuscitation, according to the achievement of ROSC.ResultsA total of nine studies with 315 patients (119 achieving ROSC, 37.7%) were included in the meta-analysis. The majority of those patients had an OHCA (n = 225, 71.5%; IHCA: n = 90, 28.5%). There was a significant association between higher values of rSO₂ and ROSC, both in the overall calculation (standardized mean difference, SMD –1.03; 95%CI –1.39,–0.67; p < 0.001), and in the subgroups analyses (rSO₂ at the beginning of resuscitation: SMD –0.79; 95%CI –1.29,–0.30; p = 0.002; averaged rSO₂ value during resuscitation: SMD –1.28; 95%CI –1.74,–0.83; p < 0.001).ConclusionsHigher initial and average regional cerebral oxygen saturation values are both associated with greater chances of achieving ROSC in patients suffering of CA. A note of caution should be made in interpreting these results due to the small number of patients and the heterogeneity in study design: larger studies are needed to clinically validate cut-offs for guiding cardiopulmonary resuscitation.     

The management of threatened hanging and near hanging: A unique feature of remote area emergency care

Hanging is one of the commonest methods of suicide. It is an expression of despair and powerlessness. Young Australian Indigenous men from remote communities are over represented in the suicide statistics and the care provided to them when they are expressing suicide ideation or have a near hanging injury in most cases is inadequate.

Discussion

The national recommendations for the management of alcohol-related problems in Indigenous primary care do not reflect the national reality. This article proposes that Australia is developing an underclass in remote Australia where the life chances of remote Indigenous people are being compromised by the lack of access to appropriate primary health care services, education and employment opportunities and that young men are communicating their despair both in life and death.

Conclusion

Improving the rates of suicide amongst young remote Indigenous men requires more than adequate resuscitation.     

豫东地区手足口病留观患者回顾研究1200例

目的探讨豫东地区手足口病留观室患者的临床特点,诊断治疗及转归。为进一步了解防治该病提供科学依据。方法回顾性分析1200例留观室手足口病患儿的临床资料。结果皮疹以手部为主者占36．1％、足部为主者占31．2％、口腔部病变为主占35．4％、以臀部为主占10．2％、以肘、膝部和胸腹部为主者占0．5％。其中手足部皮疹被误诊的占8．5％,因病情加重转入住院患者占9．6％。观察48～72h解除留观者占62．3％,发热者占80．64％。年龄以学龄前儿童为主,占80．1％,有明确接触史者,占60．6％。发病以4—7月份高发。结论手足口病发病以学龄前儿童为主,以手、足、口、臀等部位发生丘疱疹为主要临床表现,部分容易误诊。病情严重者大部分是EV71感染。留观患者病情易变,早隔离、诊断、治疗预后良好。     

Establishing rudimentary health‐care facilities in East Timor

The former Portuguese colony of East Timor was forcibly absorbed into the Republic of Indonesia in 1975. An armed East Timorese resistance movement maintained a fight for independence for the next quarter of a century. The Indonesian Government allowed a plebiscite of the population in August 1999, the result of which was strongly in favour of independence. Following the poll, there was an outbreak of extreme violence and the structure of the country was virtually destroyed. The Indonesian Government invited a multinational force to restore order. This report is of the medical work conducted while serving in a multifunction non‐government organization in East Timor in the post‐conflict environment. The work includes developing a tuberculosis clinic, conducting refugee medicine at the border crossing point and establishing a rudimentary health‐care system based on a primary‐care model. A background in emergency medicine is very useful in situations such as this, where improvisation becomes a core skill.     

Middle East respiratory syndrome: current status and future prospects for vaccine development

The outbreaks of Middle East respiratory syndrome (MERS) previously in Middle East and recently in South Korea have raised serious concerns worldwide, reinforcing the importance of developing effective and safe vaccines against MERS-coronavirus (MERS-CoV). A number of vaccine candidates have been developed on the basis of viral vectors, recombinant proteins, DNAs, nanoparticles, and recombinant MERS-CoV, and some of them have shown efficacy in laboratory animals. However, the paucity of financial support has made it difficult to transfer effective candidates from the preclinical stage to clinical trials. Here, we summarize currently available MERS vaccine candidates and illustrate strategies for future development, with the aim of provoking government agencies and Big Pharma to invest more funds for developing efficacious and safe MERS vaccines.     

从中西方文化差异看中西方的护理

从中西方的文化差异分析了中西方护理在护理教育、临床护理、护理管理和护理科研四方面的不同,提出了要博采众长,补己之短来提高我国的护理质量。     

Pulmonary oedema,pneumonia and mortality in submersion victims; a retrospective study in 125 patients

Objective The identification of risk factors contributing to the development of pulmonary oedema, pneumonia and late mortality in submersion victims.Design A retrospective study of 125 submersion victims.Setting: The medical intensive care unit in a university hospital.Methods Baseline examination on admission consisted of history, physical examination, arterial blood gas analysis and a chest radiograph. Patients were then classified into four groups: class I, baseline examination negative; class II, baseline examination positive, but mechanical ventilation not needed on admission; class III, mechanical ventilation required on admission; class IV, patients suffering form cardiopulmonary arrest. All patients who were not succesfully resuscitated or who had expired with-in 24 h after admission were excluded for determination of the risk of pulmonary oedema and pneumonia.Results Class I patients did not develop pulmonary complications; neither pulmonary oedema nor pneumonia occurred in this group. In the remaining classes the incidence of pulmonary oedema was 72% and that of pneumonia, 14.7%. Stepwise logistic regression showed that pulmonary oedema was related to the type of water (seawater, ditch water, swimming pool) victims were submerged in and to the neurological state both at the time of rescue and on admission. The development of pneumonia was related to the use of mechanical ventilation (the risk was 52%). Pneumonia was not related to neurological state at the time of rescue or on admission, to body temperature on admission, to the prohylactic administration of antibiotics or to the use of corticosteroids. Mortality was high in class IV patients, but low in all other patients. Early mortality was 18.4% while late mortality was 5.6%.Conclusions There is no need to hospitalise submersion victims when there are no signs or symptoms of aspiration upon arrival in the emergency room. All other patients should be admitted to an intensive care unit. The risk of pneumonia is high when mechanical ventilation is necessary. Mortality is high in patients with circulatory arrest on admission, but low in all other patients.     

Barriers to reporting medication errors and near misses among nurses: A systematic review

ObjectiveTo explore barriers to nurses’ reporting of medication errors and near misses in hospital settings.DesignSystematic review.Data sourcesMedline, CINAHL, PubMed and Cochrane Library in addition to Google and Google Scholar and reference lists of relevant studies published in English between January 1981 and April 2015 were searched for relevant qualitative, quantitative or mixed methods empirical studies or unpublished PhD theses. Papers with a primary focus on barriers to reporting medication errors and near misses in nursing were included.Review methodsThe titles and abstracts of the search results were assessed for eligibility and relevance by one of the authors. After retrieval of the full texts, two of the authors independently made decisions concerning the final inclusion and these were validated by the third reviewer. Three authors independently assessed methodological quality of studies. Relevant data were extracted and findings were synthesised using thematic synthesis.ResultsFrom 4038 identified records, 38 studies were included in the synthesis. Findings suggest that organizational barriers such as culture, the reporting system and management behaviour in addition to personal and professional barriers such as fear, accountability and characteristics of nurses are barriers to reporting medication errors.ConclusionsTo overcome reported barriers it is necessary to develop a non-blaming, non-punitive and non-fearful learning culture at unit and organizational level. Anonymous, effective, uncomplicated and efficient reporting systems and supportive management behaviour that provides open feedback to nurses is needed. Nurses are accountable for patients’ safety, so they need to be educated and skilled in error management. Lack of research into barriers to reporting of near misses’ and low awareness of reporting suggests the need for further research and development of educational and management approaches to overcome these barriers.     

Prolonged severe hypercapnia complicating near fatal asthma in a 35-year-old woman

Objective: We describe a patient with a prolonged and severe hypercapnia occurring during an episode of status asthmaticus induced by ophthalmic instillation of carteolol. Setting: Prehospital Emergency Medical Service and Pulmonary Intensive Care Unit in a university hospital. Patient: A 35-year-old female developed an acute asthma attack while at home, which required advanced life support. Intervention: On hospital admission, arterial blood gases revealed a PaCO₂ of 208 mmHg. Hypercapnia persisted with a PaCO₂ of more than 190 mmHg for 10 h, with pH always less than 7.00. The patient was finally discharged after 26 days without sequelae. Conclusion: This case illustrates the cerebral and cardiovascular tolerance of severe and prolonged hypercapnia associated with major acidosis. Received: 20 April 1998 Accepted: 29 July 1998