Peak Cough Flow Fails to Detect Upper Airway Collapse During Negative Pressure Titration for Cough-Assist

ObjectiveTo study the ability of peak cough flow (PCF) and effective cough volume, defined as the volume exsufflated >3 L/s, to detect upper airway collapse during mechanical insufflation-exsufflation (MI-E) titration in neuromuscular patients.DesignProspective observational study.SettingRehabilitation hospital.ParticipantsPatients (N=27) with neuromuscular disease causing significant impairment of chest wall and/or diaphragmatic movement.InterventionsThe lowest insufflation pressure producing the highest inspiratory capacity was used. Exsufflation pressure was decreased from ?20 cm H₂O to ?60/?70 cm H₂O, in 10-cm H₂O decrements, until upper airway collapse was detected using the reference standard of flow-volume curve analysis (after PCF, abrupt flattening or flow decrease vs previous less negative exsufflation pressure).Main Outcome MeasuresPCF and effective cough volume profiles during expiration with MI-E.ResultsUpper airway collapse occurred in 10 patients during titration. Effective cough volume increased with decreasing expiratory pressure then decreased upon upper airway collapse occurrence. PCF continued to increase after upper airway collapse occurrence. In 5 other patients, upper airway collapse occurred at the initial ?20 cm H₂O exsufflation pressure, and during titration, PCF increased and effective cough volume remained unchanged at <200 mL. PCF had 0% sensitivity for upper airway collapse, whereas effective cough volume had 100% sensitivity and specificity.ConclusionOf 27 patients, 15 experienced upper airway collapse during MI-E titration. Upper airway collapse was associated with an effective cough volume decrease or plateau and with increasing PCF. Accordingly, effective cough volume, but not PCF, can detect upper airway collapse.     

Atrioventricular block with lidocaine therapy

A case is presented of complete atrioventricular (A-V) block occurring after a 50 mg bolus injection of lidocaine. Base-line studies before administration of lidocaine showed evidence of trifascicular block manifested by complete right bundle branch block, left anterior hemiblock and a markedly prolonged H-V interval. Advanced A-V block and then complete A-V block distal to the His bundle developed after administration of lidocaine. Lidocaine should be used with caution in patients with trifascicular disease; if it is administered to such patients, insertion of a temporary pacemaker catheter should be considered.     

2012年昆山市产科现状分析与对策

目的：了解全市产科服务现状,以便对各接产机构的产科服务能力与潜力做出客观评价,为卫生行政部门制定缓解产科医疗服务供需矛盾的决策提供依据。方法对全市所有助产服务机构产科资源利用和服务数量进行调查。结果2012年全市共有产科医院11家其中一级医院7家,二级医院2家,三级医院2家。分娩产妇17728人,其中在一级医院、二级医院、三级医院分娩占比分别是15.90%、20.16%、63.94%。产妇分娩与床位比44.32：1,其中一级医院、二级医院、三级医院的产妇分娩与床位比为17.29：1、53.36：1、66.68：1。产科人均助产服务率84,其中一级医院、二级医院、三级医院分别为43、80、113。全市产科人员与床位比为0.91：1。结论产科服务的供需矛盾集中凸显＂结构性＂问题,服务对象集中于三级医院,呈现＂重心上移＂,而使服务资源出现＂超负荷＂与闲置并存现象,急需以＂缓解短期矛盾和解决深层次问题＂双管齐下为原则,从供需两方考虑解决对策。     

Testing a novel pictorial medication sheet to improve adherence in veterans with heart failure and cognitive impairment

Objectives(a) To evaluate efficacy of a pictorial medication sheet to improve adherence in veterans with heart failure (HF) and cognitive impairment (CI); (b) to describe acceptance of the intervention.BackgroundCI is prevalent in HF and is associated with worsened medication adherence. The Veteran's Administration has developed a medication image library; however, use of images to improve adherence has not been tested.MethodsThirty-six veterans with HF and CI were enrolled and provided pictorial medication sheets and an optional alarmed pillbox. Adherence pre-and post-intervention was determined by 30-day pill counts. Acceptance was assessed from interviews.ResultsTwenty-seven veterans (75%) completed the study. Overall medication adherence was poor, however there was significant improvement from pre-intervention (M = 79.74, SD = ±16.98) to post-intervention (M = 84.74, SD = ±10.00) adherence (t(26) = 2.16, p < .05, Cohen's d = .42).ConclusionsThis pilot study provides preliminary evidence that medication images improve adherence with complex medication regimens. The intervention was well received by patients.