Acute hypoxia due to right to left blood shunting in a patient with atrial septal defect

Acute right to left blood shunt is an unusual cause of acute hypoxia. We describe a case of a patient with an atrial septal defect who developed acute hypoxia due to cardiac tamponade. Acute haemopericardium developed as a complication of temporary transvenous cardiac pacing. Bubble contrast echocardiography confirmed right to left blood shunting at the atrial level. Acute hypoxaemia and the right to left blood shunt resolved when the pericardium was drained. The case underscores the importance of evaluating the presence of an intracardial shunt in patients with otherwise inexplicable hypoxia.     

Competencies and skills for remote and rural maternity care: a review of the literature

AIM: This paper reports a review of the literature on skills, competencies and continuing professional development necessary for sustainable remote and rural maternity care. BACKGROUND: There is a general sense that maternity care providers in rural areas need specific skills and competencies. However, how these differ from generic skills and competencies is often unclear. METHODS: Approaches used to access the research studies included a comprehensive search in relevant electronic databases using relevant keywords (e.g. 'remote', 'midwifery', 'obstetrics', 'nurse-midwives', education', 'hospitals', 'skills', 'competencies', etc.). Experts were approached for (un-)published literature, and books and journals known to the authors were also used. Key journals were hand searched and references were followed up. The original search was conducted in 2004 and updated in 2006. FINDINGS: Little published literature exists on professional education, training or continuous professional development in maternity care in remote and rural settings. Although we found a large literature on competency, little was specific to competencies for rural practice or for maternity care. 'Hands-on' skills courses such as Advanced Life Support in Obstetrics and the Neonatal Resuscitation Programme increase confidence in practice, but no published evidence of effectiveness of such courses exists. CONCLUSION: Educators need to be aware of the barriers facing rural practitioners, and there is potential for increasing distant learning facilitated by videoconferencing or Internet access. They should also consider other assessment methods than portfolios. More research is needed on the levels of skills and competencies required for maternity care professionals practising in remote and rural areas.     

Macrolide-resistant Staphylococcus aureus colonization in cystic fibrosis patients: is there transmission to household contacts?

OBJECTIVES: Patients with cystic fibrosis (CF) are frequently colonized by macrolide-resistant Staphylococcus aureus, a result of maintenance macrolide therapy. As transmission of S. aureus between household contacts is common, we examined the prevalence of macrolide-resistant S. aureus colonization in CF patients on maintenance azithromycin therapy and their household contacts and compared this with the S. aureus macrolide resistance prevalence in the community. PATIENTS AND METHODS: Sixty-five CF patients on maintenance macrolide therapy and 194 household contacts were screened for S. aureus colonization by culturing sputa, cough swabs and nasal swabs. Resistance to macrolide, lincosamide and methicillin was determined by disc diffusion tests. The prevalence of macrolide-resistant S. aureus colonization in both groups was compared with figures from a nationwide study into S. aureus carriership and resistance. To assess possible transmission, genotyping of S. aureus was performed using the spa-typing method. RESULTS: Macrolide resistance among CF patients with S. aureus colonization was 69.6%; 75% of these isolates displayed lincosamide resistance too. Among household contacts, macrolide resistance prevalence did not differ significantly from resistance prevalence in the community (9.6% versus 6.3%; P = 0.358). No methicillin resistance was observed. No identical (macrolide-resistant and -susceptible) S. aureus genotypes were observed between CF patients and their household contacts except for one household, suggesting a probable transmission. CONCLUSIONS: No significant increase in macrolide-resistant S. aureus colonization was observed among household contacts of CF patients on long-term azithromycin therapy. Transmission of macrolide-resistant S. aureus could not be proved by genotyping in the majority of households.     

Serum and intraperitoneal levels of amphotericin B and flucytosine during intravenous treatment of critically ill patients with Candida peritonitis

OBJECTIVES: To study the relation between serum and peritoneal levels of amphotericin B and flucytosine during intravenous treatment in patients with abdominal sepsis due to a perforated gut. PATIENTS AND METHODS: Included were consecutive patients with abdominal sepsis due to a perforated gut, who were treated intravenously with amphotericin B and/or flucytosine after surgery if an abdominal drain was present. Amphotericin B and flucytosine were measured from simultaneously collected serum and abdominal fluid samples. RESULTS: Twenty-one consecutive patients were included. Five repeated samples were taken from three patients. The time interval between the start of the medication and the first sampling was median 4.0 days (range 2-7 days). The correlation coefficient (r(2)) between serum and peritoneal levels of amphotericin B was 0.79. In nine patients (43%) with a maximum serum level of 0.28 mg/L, amphotericin B in the peritoneal fluid was undetectable. The lowest serum level that was present with a detectable peritoneal level was 0.16 mg/L. A short duration of treatment (2 days) was associated with low serum and undetectable peritoneal levels. In seven patients, flucytosine levels were measured. Peritoneal flucytosine levels did not differ significantly from serum levels. Serum and peritoneal flucytosine levels correlated well with r(2)=0.88. Peritoneal amphotericin B level was inversely correlated with C-reactive protein level on the same day (r(2)=0.30). CONCLUSIONS: It is shown, during continuous infusion, that peritoneal levels of amphotericin B are lower than serum levels. The amphotericin B serum levels should exceed 0.5 mg/L to obtain peritoneal levels above MIC values. Flucytosine levels in the abdominal fluid are comparable to serum levels and within MIC ranges.     

The effect of activated protein C on plasma cytokine levels in a porcine model of acute endotoxemia

Objective To assess the anti-inflammatory effects of recombinant human activated protein C (rhAPC) in a porcine model of acute endotoxemia. Design and setting Animal randomized controlled study at the Laboratory of Clinical Institute, Aarhus University Hospital. Subjects Eighteen female landrace pigs (30 kg). Interventions By pairwise randomization, pigs were given either LPS or LPS and rhAPC. Both groups received a stepwise increasing LPS infusion for 30 min; whereafter the infusion continued at a lower rate (300 min LPS in both groups). The LPS+rhAPC group received rhAPC (100 μg/kg per hour) 15 min before the LPS infusion began and throughout the trial period. Results While rhAPC showed no modifying effects on peak plasma levels of pro- or anti-inflammatory cytokines (TNF-α, IL-6, IL-8, IL-10), TNF-α and IL-10 peaked significantly later in the rhAPC-treated animals. The profibrinolytic effects of rhAPC were confirmed by decreased plasminogen activator inhibitor 1 levels, while no differences were found in other coagulation markers, hemodynamic, metabolic, or leukocyte data between the two groups. Conclusions We found no significant effect of rhAPC on plasma levels of either pro- or anti-inflammatory cytokines in this porcine model of acute endotoxemia. However, TNF-α and IL-10 peaked significantly later in the rhAPC-treated animals.     

Medication safety: just a label away

IN PERIOPERATIVE SETTINGS, medications are removed from manufacturers' identifying containers; therefore, scrub personnel should label medications placed on the sterile field.COMPLIANCE WITH MEDICATION labeling practices with the use of both blank and preprinted labels was tested in the OR at a Houston, Texas, hospital.SCRUB PERSONNEL WERE more likely to label medications and medication-delivery devices when preprinted medication labels were provided.DATA OBTAINED FROM this project influenced the hospital's management team to supply preprinted labels for all procedures to improve safety for surgical patients.     

Five-year clinical effectiveness of a two-step self-etching adhesive

PURPOSE: The purpose of this prospective randomized controlled clinical study was to evaluate the clinical performance of a "mild" two-step self-etching adhesive, Clearfil SE, in Class V restorations after 5 years of clinical functioning. MATERIALS AND METHODS: Twenty-nine patients received two or four restorations following two randomly assigned experimental protocols: (1) a mild self-etching adhesive (Clearfil SE, Kuraray) was applied following manufacturer's instructions on both enamel and dentin (C-SE non-etch); (2) similar application of Clearfil SE, but including prior selective acid-etching of the enamel cavity margins with 40% phosphoric acid (C-SE etch). Clearfil AP-X (Kuraray) was used as the restorative composite for all 100 restorations. The clinical effectiveness was recorded in terms of retention, marginal integrity, marginal discoloration, caries recurrence, postoperative sensitivity, and preservation of tooth vitality after 5 years of clinical service. The hypothesis tested was that selective acid etching of enamel with phosphoric acid improved retention, marginal integrity, and clinical microleakage of Class V restorations. RESULTS: Only one restoration of the C-SE non-etch group was lost at the 5-year recall. All other restorations were clinically acceptable. Marginal integrity deteriorated with time in both groups. The number of restorations with defect-free margins was significantly lower in the C-SE non-etch group (p = 0.0043). This latter group presented significantly more small incisal marginal defects on the enamel side (p = 0.0169). Superficial marginal discoloration increased in both groups, but was more pronounced in the C-SE non-etch group and was related to the higher frequency of small incisal marginal defects. CONCLUSION: The clinical effectiveness of the two-step self-etching adhesive Clearfil SE remained excellent after 5 years of clinical service. Additional etching of the enamel cavity margins resulted in an improved marginal adaptation on the enamel side; however, this was not critical for the overall clinical performance of the restorations.     

Factors influencing the outcome of non-surgical periodontal treatment: a multilevel approach

AIM: To investigate, by means of multilevel analysis, factors that may affect the short-term clinical outcome of non-surgical periodontal treatment. MATERIALS AND METHODS: Forty-one patients randomly assigned to two protocols of non-surgical therapy were included. The impact of different covariates on the probability of "pocket closure" [i.e. probing pocket depth (PPD)相似文献   

A meta-analysis of clinical studies to estimate the 4.5-year survival rate of implants placed with the osteotome technique

PURPOSE: To estimate the survival rate of implants placed with the osteotome technique by means of a systematic review. MATERIALS AND METHODS: The literature was searched using Medline; the search was limited to the years 1953 to 2005. Inclusion criteria were: (1) clinical studies or clinical reports investigating the osteotome technique for dental implantation and (2) control or test group(s) from clinical studies or clinical reports, even if they did not fit with other criteria. By pooling the data of the included studies, overall Kaplan-Meier survival curves were constructed for the periods before and after loading. RESULTS: The initial literature search yielded 164 studies. After selection criteria were applied, 5 studies were considered suitable for inclusion. The combined data of 349 implants revealed survival probabilities of 98% (confidence interval [CI], 97.2% to 100%) until loading and 99% (CI, 94% to 100%) after 56 months of loading. At the end of the observation period 41 implants in 18 patients were still at risk. CONCLUSION: The outcome of dental implantation using the osteotome technique in terms of implant survival seems to be similar to that of implants placed by means of the conventional implantation technique.