Haemodynamic Studies During the Management of Severe Tetanus

Detailed invasive haemodynamic studies were performed in 27of 32 patients with severe tetanus. Nineteen had severe uncomplicatedtetanus and eight had associated major complications, chieflyinfection and pulmonary complications. The results were comparedwith those obtained from 15 healthy male volunteers who servedas controls. There were two deaths in 32 patients (mortality6.25 per cent). Severe tetanus without major complications wascharacterized by a high output hyperkinetic circulatory statewith tachycardia (heart rate 131 (19.2) beats/minute), increasedstroke volume index (43.1 (10.7) ml/m²), increased cardiac index(5.48 (0.94)1/min/m²) and a normal left ventricular stroke workindex (60.5 (15.9) g/m/m²). Volume loading demonstrated a significanthaemodynamic response and increased vascular capacitance. Evenso the maximum percent rise from baseline values of these indicesafter volume load was significantly higher in controls (p <0.001). Autonomic cardiovascular disturbances affected bothsympathetic and parasympathetic activity. Hypertension and tachycardiaalternating with hypotension and bradycardia were related tosudden fluctuations in systemic vascular resistance. Our studiessuggested some degree of myocardial dysfunction in patientswith severe uncomplicated tetanus. The haemodynamics of severetetanus were masked and altered by complicating infection, pneumonia,and atelectasis.     

Double-blind study of endotracheal tobramycin in the treatment of gram-negative bacterial pneumonia. The Endotracheal Tobramycin Study Group.

A prospective, double-blind, placebo-controlled study was conducted to determine the safety and efficacy of endotracheal tobramycin (ETT) for treatment of gram-negative bacterial pneumonia. Patients were randomized to either 40 mg of tobramycin or a placebo instilled endotracheally every 8 h. Patients also received intravenous tobramycin plus either cefazolin or piperacillin. Of 85 patients enrolled, 41 were assessable. Most microbiologic diagnoses were made by endotracheal aspiration with strict grading criteria. The clinical-radiographic responses of patients and standard demographic data were recorded. Pseudomonas aeruginosa, "multiple pathogens," and Klebsiella-Enterobacter-Serratia-Citrobacter species were isolated in 41, 32, and 15% of the instances, respectively. Causative pathogens were eradicated from sputum significantly more frequently by patients who received ETT (P less than 0.05). However, no significant differences were noted in the clinical outcomes of the two study groups. No local adverse reactions attributable to the administration of this agent were observed, but four patients had supraventricular tachycardia, compared with none who received the placebo (P = 0.053). ETT may be considered as adjunctive therapy for seriously ill individuals.     

Nationwide survey of home transfusion practices

BACKGROUND: Limited information exists on home transfusion practices. STUDY DESIGN AND METHODS: In 1995, a survey requesting data for 1994 was sent to 1273 American Association of Blood Banks (AABB) institutional members and 113 non-AABB home health care agencies that provide out-of-hospital transfusions. RESULTS: Of 943 respondents, 102 provide blood to a home transfusion program, 37 provide blood and run a home transfusion program, and 13 run a home transfusion program only, for a total of 152 (16%) with some involvement in home blood transfusions. Most of the 50 respondents with a home transfusion program are licensed by their state and accredited by the Joint Commission on Accreditation of Healthcare Organizations. All respondents have written policies for home transfusion, and 90 percent require a signed informed-consent document before initiating transfusions in the home. Most have policies requiring that there be a second adult and a telephone in the home, that the home be deemed safe for transfusion, that the patient's physician be readily available, and that the patient have had prior transfusions. The most common component issued by the blood providers was red cells, followed by platelets. White cell-reduced components were always provided by 36 percent of respondents. The most common patient diagnosis was cancer. Home transfusions were provided primarily by registered nurses. Only 14 percent of respondents indicated that the medical director of the blood bank is responsible for approving a patient for home transfusion. A posttransfusion visit is performed by 46 percent of respondents. CONCLUSION: Although most facilities have policies for the administration of home transfusions, there remains marked heterogeneity among blood providers and transfusionists regarding home transfusion practices.     

Effects of colonoscopy on intracranial pressure: observation in a large animal model

BACKGROUND AND STUDY AIMS: Increased intra-abdominal pressure has been associated with increased intracranial pressure. Bowel insufflation during colonoscopy may increase the intra-abdominal pressure. It was hypothesized that colonoscopy may be associated with intracranial pressure elevation subsequent to an elevation in intra-abdominal pressure. MATERIALS AND METHODS: Colonoscopy was carried out in seven anesthetized pigs, and the colonoscope was advanced up to 60 cm from the anal verge. Insufflation was used to allow safe advancement of the colonoscope and to allow visualization of the colon, in the same way as in the procedure performed in humans. Intra-abdominal pressure was measured by determining the hydrostatic pressure in the urinary bladder. A subarachnoid screw was used to monitor intracranial pressure. The mean arterial blood pressure and intra-abdominal venous pressure were directly monitored via the femoral vessel access; all parameters were recorded before and during colonoscopy. RESULTS: A statistically significant elevation in intracranial pressure was demonstrated during colonoscopy. The average increase in intracranial pressure was 3.1 mm Hg. The intra-abdominal pressure and intra-abdominal venous pressure were also significantly elevated during the procedure. CONCLUSIONS: Colonoscopy may increase intracranial pressure due to an increase in intra-abdominal pressure. This may have clinical implications when colonoscopy is conducted in patients with brain pathology associated with high intracranial pressure.     

Infliximab in the treatment of severe, steroid-refractory ulcerative colitis: a pilot study

We report the experience of 11 patients (of 60 planned patients) enrolled in a double-blind, placebo-controlled clinical trial of infliximab in patients with severe, active steroid-refractory ulcerative colitis. The study was terminated prematurely because of slow enrollment. Patients having active disease for at least 2 weeks and receiving at least 5 days of intravenous corticosteroids were eligible to receive a single intravenous infusion of infliximab at 5, 10, or 20 mg/kg body weight. The primary endpoint used in this study was treatment failure at 2 weeks after infusion. Treatment failure was defined as 1) unachieved clinical response as defined by a modified Truelove and Witts severity score, 2) increase in corticosteroid dosage, 3) addition of immunosuppressants, 4) colectomy, or 5) death. Safety evaluations included physical examination, clinical chemistry and hematology laboratory tests, and occurrence of adverse experiences. Four of 8 patients (50%) who received infliximab were considered treatment successes at 2 weeks, compared with none of 3 patients who received placebo. Improvement in erythrocyte sedimentation rates and serum concentrations of C-reactive protein and interleukin-6 correlated with the clinical response observed in patients receiving infliximab. Infusion with infliximab produced no significant adverse events. Infliximab was well tolerated and may provide clinical benefit for some patients with steroid-refractory ulcerative colitis.     

Quality of Care for Maternal and Newborn Health in Health Facilities in Nepal

Introduction

Nepal has pledged to substantially reduce maternal and newborn death by 2030. Improving quality of intrapartum health services will be vital to reduce these deaths. This paper examines quality of delivery and newborn services in health facilities of Nepal.

Methods

Data were sourced from the Nepal Health Facility Survey 2015, which covered a national representative sample of health facilities. The datasets were analysed to assess service readiness, availability and quality of delivery and newborn care in a sample of 992 health facilities.

Results

Of the 992 facilities in the sample, 623 provided delivery and newborn care services. Of the 623 facilities offering delivery and newborn care services, 13.3% offered comprehensive emergency obstetric care (CEmONC), 19.6% provided basic emergency obstetric care (BEmONC) and 53.9% provided basic delivery and newborn service. The availability of essential equipment for delivery and newborn care was more than 80% in health facilities. Except for the coverage of vitamin K injection, the coverage of immediate newborn care was more than 85% in all health facilities. The coverage of use of chlorhexidine ointment to all newborns was more than 70% in government hospitals and primary health care centers (PHCCs) and only 32.3% in private hospitals.

Conclusions

These findings show gaps in equipment and drugs, especially in PHCCs and private health facilities. Improving readiness and availability of equipment and drugs in PHCCs and private health facility will help improve the quality of care to further reduce maternal and newborn mortality in Nepal.

     

Stunting Among Under 5-Year-Olds in Nepal: Trends and Risk Factors

Maternal and Child Health Journal - Objectives Encouraging key parenting behaviors in early infancy may help decrease income-related developmental disparities. In this study we assessed whether a...     

Perceptions of crisis care in populations who self‐referred to a telephone‐based mental health triage service

Although psychiatric crises are very common in people with mental illness, little is known about consumer perceptions of mental health crisis care. Given the current emphasis on recovery‐oriented approaches, shared decision‐making, and partnering with consumers in planning and delivering care, this knowledge gap is significant. Since the late 1990s, access to Australian mental health services has been facilitated by 24/7 telephone‐based mental health triage systems, which provide initial psychiatric assessment, referral, support, and advice. A significant proportion of consumers access telephone‐based mental health triage services in a state of crisis, but to date, there has been no published studies that specifically report on consumer perceptions on the quality and effectiveness of the care provided by these services. This article reports on a study that investigated consumer perceptions of accessing telephone‐based mental health triage services. Seventy‐five mental health consumers participated in a telephone interview about their triage service use experience. An eight‐item survey designed to measure the responsiveness of mental health services was used for data collection. The findings reported here focus on the qualitative data produced in the study. Consumer participants shared a range of perspectives on telephone‐based mental health triage that provide invaluable insights into the needs, expectations, and service use experiences of consumers seeking assistance with a mental health problem. Consumer perceptions of crisis care have important implications for practice. Approaches and interventions identified as important to quality care can be used to inform educational and practice initiatives that promote person‐centred, collaborative crisis care.