Priorities for content for a short-course on postoperative care relevant for low- and middle-income countries: an e-Delphi process with training facilitators

Most surgical and anaesthetic mortality and morbidity occurs postoperatively, disproportionately affecting low- and middle-income countries. Various short courses have been developed to improve patient outcomes in low- and middle-income countries, but none specifically to address postoperative care and complications. We aimed to identify key features of a proposed short-course addressing this topic using a Delphi process with low- and middle-income country anaesthesia providers trained as short-course facilitators. An initial questionnaire was co-developed from literature review and exploratory workshops to include 108 potential course features. Features included content; teaching method; appropriate participants; and appropriate faculty. Over three Delphi rounds (panellists numbered 86, 64 and 35 in successive cycles), panellists indicated which features they considered most important. Responses were analysed by geographical regions: Africa, the Americas, south-east Asia and Western Pacific. Ultimately, panellists identified 60, 40 and 54 core features for the proposed course in each region, respectively. There were high levels of consensus within regions on what constituted core course content, but not between regions. All panellists preferred the small group workshop teaching method irrespective of region. All regions considered anaesthetists to be key facilitators, while all agreed that both anaesthetists and operating theatre nurses were key participants. The African and Americas regional panels recommended more multidisciplinary healthcare professionals for participant roles. Faculty from high-income countries were not considered high priority. Our study highlights variability between geographical regions as to which course features were perceived as most locally relevant, supporting regional adaptation of short-course design rather than a one-size-fits-all model.     

经纤支镜气道内膜下注射药物治疗对支气管内膜结核患者并发症的影响

目的探讨纤支镜气道注射药物治疗对支气管内膜结核患者并发症的影响。方法选择2018年1月—2019年1月在湖北省潜江市中心医院治疗的支气管内膜结核患者66例,分为对照组和研究组各33例。对照组给予药物雾化吸入疗法,研究组经过纤支镜气道内膜下注射药物治疗。比较两组治疗效果和症状缓解的影响。结果研究组总有效率为90.91%,对照组总有效率为84.85%,研究组的治疗效果均高于对照组(P<0.05);对照组并发症发生率为39.39%,研究组并发症发生率18.18%,研究组并发症发生率明显低于对照组(P<0.05)。结论经纤支镜气道内膜下注射药物治疗支气管内膜结核患者并发症的发生率较小。     

多巴胺或多巴胺复合去甲肾上腺素对肝移植术中患者血液动力学、氧代谢及肾功能的影响

目的评价原位肝脏移植术(OLT)中持续输注多巴胺或多巴胺复合去甲肾上腺素对血液动力学、组织氧代谢和肾功能的影响。方法拟行OLT的患者30例,ASAⅢ或Ⅳ级,随机分为2组 (n=15)。A组:术中持续输注多巴胺,初始输注速率为1-3μg·kg-1·min-1;B组:术中持续输注多巴胺复合去甲肾上腺素,初始输注速率分别为1-3μg·kg-1·min-1和0．03μg·kg-1·min-1,多巴胺输注速率不超过5μg·kg-1·min-1;术中两组均调节输注速率维持MAP 60-80 mm Hg。分别于切皮前即刻、切肝期1 h、无肝期1 h、新肝期1h和术毕测定血液动力学、组织代谢和肾功能指标。结果两组HR、 MAP均维持较平稳。无肝期两组CVP、MPAP、PAWP、CO、CI、DO2、VO2降低(P<0．05);SVR和SVRI升高(P<0．05),但均在正常范围内。术中PVR、PVRI、pH及SvO2均较平稳。乳酸浓度增高并持续到术毕。两组术中Cr和BUN均在正常范围,B组总尿量高于A组(P相似文献   

Free flap monitoring with continuous tissue oxygen tension measurement

Intraoperative and postoperative free flap monitoring by means of oxygen tension measurement was carried out in 11 patients. We used an invasive flexible microcatheter that allowed for measurement of oxygen tension in all types of free flaps. Two cases of the measured flaps were buried free flaps which do not allow monitoring by clinical assessment. All flaps monitored in this study survived. One case of displacement of the microcatheter occurred. In one patient, the tissue pO₂ monitor successfully detected early vascular thrombosis with subsequent reoperation and salvage of the free flap.     

Evaluation of the influence of the aqueous phase bioconstituent environment on the F-19 T1 of perfluorocarbon blood substitute emulsions

Oxygen-sensitive F-19 magnetic resonance imaging of perfluorocarbon compounds requires that fluorocarbon T1 changes correlate with the local Po₂ and not with the composition of the surrounding aqueous phase. The influence of various bioconstituents and paramagnetic ions within the aqueous phase on the F-19 fluorocarbon phase T1 for PFC emulsions was evaluated at 0.14 and 0.66 T. T1 was measured for FC-43, perflubron, and a fluorinated surfactant. Controlled variables introduced in the aqueous phase included annex solution constituents, blood, pH changes, and Gd-DTPA. For a constant Po₂, the F-19 T1s were independent of the emulsion constituents, blood concentration, and pH. For FC-43 and perflubron, F-19 T1 was independent of the Gd-DTPA concentration, while the aqueous phase T1 decreased by more than an order of magnitude. XMO-10 (smallest emulsion particle size) showed a slight decrease in F-19 T1 with increasing Gd-DTPA concentration at 0.66 T.     

17β-雌二醇对子宫内膜异位症患者在位子宫内膜间质细胞β-catenin mRNA和蛋白表达的影响

目的研究17β-雌二醇(17β-E2)对子宫内膜异位症(内异症)患者在位子宫内膜间质细胞β-catenin mRNA和蛋白表达的影响,探讨Wnt/β-catenin信号通路在介导雌激素促进内异症发生发展的作用。方法体外分离培养内异症患者在位子宫内膜间质细胞。用不同浓度17β-E2处理子宫内膜间质细胞48 h;此后选用10-10mol/L 17β-E2处理子宫内膜间质细胞12、24和48 h,逆转录聚合酶链反应(RT-PCR)和免疫印迹法(Western blotting)检测17β-E2处理前后子宫内膜间质细胞β-catenin mRNA和蛋白的表达水平。同法分析雌激素受体拮抗剂ICI182,780(10-6mol/L)对17β-E2促进β-catenin mRNA和蛋白表达的影响。免疫组织化学染色观察17β-E2作用后β-catenin在子宫内膜间质细胞中的定位。结果17β-E2能明显促进内异症患者在位子宫内膜间质细胞β-catenin mRNA和蛋白的表达,并呈剂量和时间依赖性,于10-10mol/L作用48 h最明显。雌激素受体拮抗剂ICI182,780能明显抑制17β-E2对子宫内膜间质细胞β-catenin mRNA和蛋白的表达。免疫组织化学染色发现17β-E2能促进β-catenin在子宫内膜间质细胞核内的表达。结论雌激素可能通过激活Wnt/β-catenin信号通路促进内异症在位子宫内膜的异位种植。     

Inhibition of GABA-gated chloride channel function by arachidonic acid

The effects of arachidonic acid and its metabolites on gamma-aminobutyric acid (GABAA) receptor function were determined in rat cerebral cortical synaptoneurosomes. Incubation of synaptoneurosomes with phospholipase A2 decreased muscimol-induced 36Cl- uptake. Arachidonic acid, the major unsaturated fatty acid released by phospholipase A2, also inhibited muscimol-induced 36Cl uptake. Similar inhibition was obtained with other unsaturated fatty acids (docosahexaenoic, oleic) but not with saturated fatty acids (stearic, palmitic). The effect of arachidonic acid on muscimol responses was inhibited by bovine serum albumin (BSA), and BSA enhanced muscimol responses directly, indicating the generation of endogenous arachidonic acid in the synaptoneurosome preparation. The generation of endogenous arachidonic acid was also indicated by the ability of 2 inhibitors of arachidonic acid metabolism, indomethacin and nordihydroguaiaretic acid (NDGA), to inhibit muscimol-induced 36Cl uptake. We conclude that arachidonic acid probably has both direct and indirect actions on muscimol responses since both enzyme inhibitors inhibited muscimol responses but did not prevent the effect of exogenously added arachidonic acid. In additional experiments, arachidonic acid metabolites generated by cyclooxygenase, prostaglandins D2, E2 and F2 alpha, each decreased muscimol responses; prostaglandins F2 alpha was the most potent inhibitor. Since the unsaturated fatty acids and their metabolites are most susceptible to peroxidation, a generating system of superoxide radicals was tested on muscimol responses. A combination of xanthine and xanthine oxidase inhibited muscimol-induced 36Cl uptake in a concentration-dependent manner. We propose that the inhibition of GABAA neurotransmission by arachidonic acid and its metabolites can lead to increased neuronal excitability. This mechanism may play an important role in the development of neuronal damage following seizures or cerebral ischemia.     

Neutrophil Oxygen Radical Production by Dialysis Membranes

The ability of different dialysis membranes to activate polymorphonuclearneutrophil oxygen radical production was investigated with chemiluminescence.All the six membranes, namely cuprophan, cellulose acetate,polycarbonate, polysulphone, polyacrilonitrile and polymethylmethacrylatewere able to interact with neutrophils and stimulate their oxygenradical production, the highest responses being seen with polyacrilonitrile,polymethylmethacrylate and polycarbonate. To analyse the roleof complement in this interaction, fresh plasma, heat inactivatedand zymosan-activated plasma were added: with fresh plasma oxygenradical production was stimulated on cuprophan, cellulose acetateand polysulphone, not modified on polycarbonate, and decreasedon polyacrilonitrile and polymethylmethacrylate. With heat-inactivatedplasma, the responses were decreased or abrogated on all themembranes except polycarbonate and polymethylmethacrylate, whereaswith zymosanactivated plasma similar responses to fresh plasmawere observed. In addition, when plasma was used to precoatthe membrane, cuprophan, cellulose acetate and polysulphonedisclosed an enhanced neutrophil oxidative burst, while precoatedpolyacrilonitrile and polymethylmethacrylate were less stimulatorythan uncoated membranes. In contrast the precoating of polycarbonatedid not modify oxygen radical production. These data suggestthat neutrophil activation occurs by direct membrane neutrophilinteraction. Plasmatic factors modulate this interaction butcomplement seems involved on cellulosic and polysulphone membranesonly. Therefore, it appears that oxygen radicals produced fromcontact of neutrophils with the dialysis membrane might playan initial and/or additional role in the events occurring atthe initiation of haemodialysis.     

Moving beyond empiric continuous positive airway pressure (CPAP) trials for central sleep apnea: a multi-modality titration study

There is no universally accepted method to determine effective therapy for central sleep apnea (CSA). Continuous positive airway pressure (CPAP) applied acutely most often does not eliminate apneas and hypopneas. We hypothesized that the application of two or more therapeutic modalities after the diagnostic phase of polysomnography, a multi-modality titration study (MMTS), would identify a successful CSA treatment more often than a standard split-night study (SNS) and obviate the need for additional polysomnograms to determine a successful therapy. We retrospectively analyzed polysomnograms of patients diagnosed with CSA at our Sleep Disorders Center. We defined a therapy trial that resulted in an apnea–hypopnea index < 10 with at least one treatment modality as a therapeutic success. One hundred fifteen patients with CSA were studied. Sixty-six patients (57.4%) underwent a SNS, and 49 patients (42.6%) underwent a MMTS. SNS yielded only 8/66 (12.1%) successes on the first night, whereas a MMTS yielded 19/49 (38.8%) successes (p = 0.001, two-tailed Fishers exact). Patients who underwent a SNS eventually had similar rate of success as patients studied with MMTS (60.6 vs 63.3%, NS), but required more testing. Adaptive servo-ventilation was the most successful modality tested, yielding 36/46 (78.3%) successes. Trials of additional modalities following a failed trial of CPAP often produce a successful option that may guide therapy in patients with CSA. This approach may lead to establishing the diagnosis and treatment plans faster, while reducing unnecessary testing.