Cases 11, 12, and 13

Self-assessment case studies illustrating prudent selection of antimicrobial agents in recurrent urinary tract infection, urinary frequency in a diabetic, and urinary tract infection without significant bacteriuria     

Emergency Care, 11th Edition

Abstract

The National Association of EMS Physicians (NAEMSP) advocates for a strong emergency medical services (EMS) role in all phases of disaster management—preparedness, response, and recovery. Emergency medical services administrators and medical directors should play a leadership role in preparedness activities such as training and education, development of performance metrics, establishment of memoranda of understanding (MOUs), and planning for licensure and liability issues. During both the planning and response phases, EMS leadership should advocate for participation in unified command, modified scope of practice appropriate for providers and the event, and expanded roles in community and federal response efforts. To enhance recovery, EMS leadership should strongly advocate for national recognition for EMS efforts and further research into strategies that foster healthy coping techniques and resiliency in the EMS workforce. This resource document will outline the basis for the corresponding NAEMSP position statement on the role of EMS in disaster management.     

Simultaneous determination of plasma 11-deoxycorticosterone, 18-hydroxy-11-deoxycorticosterone, and aldosterone in man

A method for simultaneous measurement of 11-deoxycorticosterone (DOC), 18-hydroxy-11-deoxycorticosterone (18-OH-DOC) and aldosterone using 1.0-2.0 ml of plasma has been developed. The present method consists of extracting plasma with dichloromethane, separating the DOC, 18-OH-DOC, and aldosterone from other steroids on a Sephadex LH-20 column, and quantitating each steroid by radioimmunoassay. This method was demonstrated to be sensitive, accurate and precise. In 20 normal male subjects, the mean recumbent level of DOC was 9.1 +/- 3.1 ng/100 ml, on random diet, at 0800 h. The corresponding levels of 18-OH-DOC and aldosterone were 8.2 +/- 3.9 ng/100 ml, and 6.7 +/- 2.6 ng/100 ml, respectively. Plasma levels of these three steroids were measured in several types of adrenocortical disorders associated with hypertension and hypokalemia. Patients with Cushing's syndrome due to adrenocortical hyperplasia, and 17alpha-hydroxylase deficiency had elevated DOC and 18-OH-DOC levels, but showed normal or lower aldosterone levels. Hypersecretion of DOC and 18-OH-DOC may cause the symptoms of hypertension and hypokalemia. Patients with primary aldosteronism had elevated levels of DOC and 18-OH-DOC as well as aldosterone. The former two steroids may be hyperproduced as a precursor of aldosterone.     

彩色多普勒监测妊娠期糖代谢异常妊娠不良结局的ROC曲线及影响因素分析

目的 探讨妊娠期糖代谢异常孕妇及胎儿血流动力学参数对妊娠不良结局的预测价值,并分析妊娠不良结局的影响因素。方法 选取晚孕期妊娠期糖代谢异常孕妇109例,按照妊娠结局分为妊娠预后不良组75例和妊娠预后良好组34例。应用彩色多普勒超声分别测量两组胎儿大脑中动脉（MCA）、脐动脉（UA）及孕妇子宫动脉（Ut-A）的血流动力学参数,包括：脐动脉收缩期峰值流速（PSV）、收缩末期血流速度（EDV）、收缩期峰值流速/收缩末期血流速度（S/D） 、阻力指数（RI）及搏动指数（PI）。绘制各血流动力学参数预测妊娠糖代谢异常预后受试者工作特征（ROC）曲线,确定最佳指标及其界值。采用Logistic回归分析妊娠结局相关影响因素。结果 妊娠预后不良组的MCA-PI、MCA-RI、RI比值（MCA/UA）均低于妊娠预后良好组,Ut-A-PI高于妊娠预后良好组,差异均有统计学意义（均P＜0.05）。ROC曲线分析结果表示,当MCA-PI＜1.56,其预测预测妊娠不良结局的敏感性、特异性分别为91.18%、80.00%。Logistic回归分析表示妊娠不良结局的危险因素有：高龄[OR=1.30,95%可信区间（1.107~1.525）,P＜0.05]、体质量指数≥24.0 kg/m2[OR=49.549,95%可信区间（1.464~1286.062）,P＜0.05]及糖尿病家族史[OR=43.393,95%可信区间（1.464~1286.062）,P＜0.05]。保护因素有：有孕期运动[OR=0.068,95%可信区间（0.009~0.522）,P＜0.05]、MCA-PI≥1.56[OR=0.113,95%可信区间（0.023~0.558）,P＜0.05]、MCA-RI≥0.63[OR=0.072,95%可信区间（0.009~0.581）,P＜0.05]及RI比值（MCA/UA）≥0.84[OR=0.034,95%可信区间（0.004~0.332）,P＜0.05]。结论 彩色多普勒超声测得MCA-PI＜1.56可作为预测妊娠期糖代谢异常妊娠不良结局的界值。孕妇年龄越大、体质量指数≥24.0 kg/m2及糖尿病家族史为妊娠期糖代谢异常妊娠不良结局的危险因素;有孕期运动、MCA-PI≥1.56、MCA-RI≥0.63及RI比值（MCA/UA）≥0.84为妊娠期糖代谢异常妊娠不良结局的保护因素。