Cúm A H7N9 6slide | Website Bệnh viện nhi đồng 2 - www.benhviennhi.org.vn cum AH7N9 6 slide tài liệu, giáo án, bài giảng...
Timing of default from tuberculosis treatment: a systematic review Margaret E. Kruk 1 , Nina R. Schwalbe 2 and Christine A. Aguiar 1 1 Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA 2 Global Alliance for TB Drug Development, TB Alliance, New York, NY, USA Summary objectives To provide a systematic assessment of the timing of default from tuberculosis (TB) treatment which could help to quantify the potential contribution of new shorter duration TB drugs to global TB control. methods We performed a systematic review following QUOROM guidelines. MEDLINE was searched from 1998 to the present using the terms TB and default or drop-out or compliance or adherence and therapy. A total of 840 articles were returned. A further detailed manual review selected 15 randomized trials and observational studies that reported timing of drop-out and focused on developing countries. results The selected studies comprised randomized controlled trials, retrospective record reviews, and qualitative assessments and spanned 10 countries. Both directly observed treatment (DOT) and non-DOT programs were represented. Thus results were highly heterogeneous and not statistically aggregated. Data suggest, but do not conclude, that the majority of defaulters across the studies completed the 2-month intensive phase of treatment. conclusions There is insufficient high-quality comparable information on the timing of default from TB treatment to permit any firm conclusions on trends in default. However, a substantial pro- portion of defaulters appear to leave treatment in the later stages of the current 6-month regimen, suggesting that new TB chemotherapeutic agents which can reduce the length of treatment have the potential to improve global TB treatment success rates. keywords tuberculosis therapy, directly observed treatment, default, time of default, temporal trends Introduction Tuberculosis (TB) is a global health emergency, killing nearly 1.6 million people each year, mostly in low- and middle-income countries (Stop-TB Partnership 2006). TB cases in Africa have more than quadrupled since 1990, as a result of co-infection with HIV (WHO 2005). The World Health Organization (WHO) – recommended treatment strategy, directly observed treatment or direct observation (DOT), which forms the basis of the Stop TB Strategy, is a 6- to 8-month regimen with a combination of anti-TB agents (Lienhardt & Ogden 2004). This regimen is also known as short-course chemotherapy (SCC). The first 2 months of SCC, known as the intensive phase, generally involve a combination of four drugs and the 4- to 6-month follow-up period, known as the continuation phase, involves two drugs. Both the drugs used in treatment and the duration of the intensive phase may vary within SCC programs. While cure rates with this combination under optimal conditions approach 95%, actual global treatment success in 2005 was 84% (Borgdorff et al. 2002; WHO 2007). This figure is much lower in some regions: In Africa, the overall cure rate for smear-positive TB was 74% and as low as 54% in some areas (WHO 2007.) Further, Mycobacterium tuberculosis resistant to both isoniazid and rifampicin, or multi-drug resistant TB, is now diagnosed in an estimated 4.3% of all new and previously treated TB patients (Zignol et al. 2006). A major contributor to both treatment failure and the rise of multidrug-resistant TB is inadequate and incomplete treatment (Borgdorff et al. 2002; Sharma & Mohan 2006). While structural factors such as interruptions in drug supply play a role, patient default ESPGHAN Committee on 04/03/2014 Cúm A H7N9 "avian influenza A(H7N9) virus" Câu chuyện • 25/3: người ñàn ông 58 tuổi sống Thượng Hải nhập viện Fudan University (bắt ñầu bệnh từ 21/3) • sốt, ho, chán ăn, nuốt ñau, tức ngực, suy hô hấp diễn tiến nặng • hình ảnh viêm phổi lan tỏa bên • CT ngực tổn thương phổi nặng, Khoa Nhiễm BS Nguyễn Trần Nam Câu chuyện • Mẫu phết họng ñược xét nghiệm (+) với H7N9 • ðồng thời mẫu bệnh phẩm từ bệnh nhân khác chuyển ñến dương tính với H7N9 Kèm tràn dịch màng phổi Tình hình bệnh • 31/3/2013 : thức ca nhiễm H7N9 ñầu tiên • 2/4/2013: thêm ca nhiễm Giang Tô Không ghi nhận mối liên hệ người • Các bệnh nhân có / không tiếp xúc với gia cầm • 4/3/2013: ca tử vong ñầu tiên người ñàn ông 87 tuổi • Xác ñịnh thêm nhiều chim bồ câu chợ Thượng • 10/3/2013: ca tử vong thứ người ñàn ông 27 tuổi Hải nhiễm H7N9 không chết • 4/5/2013: 127 ca nhiễm – 27 ca tử vong 10 tỉnh/TP Trung Quốc ca ðài Loan 04/03/2014 Tình hình dịch bệnh cúm Tình hình dịch bệnh cúm Virus Cúm A Gắn kết protein đặc hiệu theo loài Cúm hoạt động sao? Cơ chế lây nhiễm Siêu vi xâm nhập vào đường hô hấp Sinh sôi, nhân số lượng làm viêm phù nề đường thở Tấn công vào thể thông qua hệ mạch máu 04/03/2014 Dịch cúm H5N1 Virus cúm A/H7N9 • Số ca mắc tính đến 2013 124 ca (2013: ca) • Số ca tử vong: 62 ca • Đường lây truyền từ gia cầm bị nhiễm bệnh sang người • Khả điều trị thành công với trường hợp chưa diễn tiến nặng phải thở máy • Phòng ngừa: khó khăn ổ dịch gia cầm rải rác (chim yến Phú Yên) • Vi rút cúm A (H7N9) chủng có nguồn gốc gen từ vi rút cúm Virus cúm A/H7N9 ðặc ñiểm dịch tễ gia cầm số loài chim, có khả gây nhiễm cho người dẫn ñến viêm phổi nặng tiến triển nhanh, tỉ lệ tử vong cao • ðường lây truyền vi rút cúm A (H7N9) chưa ñược hiểu rõ chưa có chứng lây truyền vi rút từ người sang người • Chưa có trường hợp cúm A/H7N9 ghi nhận Việt Nam • Nguồn lây chưa rõ, chưa có chứng bệnh lây từ người sang người • Vi rút cúm A(H7N9) người có nguồn gốc gen từ vi rút cúm gia cầm • Phương thức lây truyền: chưa rõ • Hầu hết người chưa có miễn dịch ñây chủng vi rút • Tuổi mắc bệnh, giới mắc bệnh: ñộ tuổi mắc bệnh cao nhóm >60 tuổi, chủ yếu nam giới • Hiện chưa có vaccin phòng bệnh, biện pháp phòng bệnh chủ yếu vệ sinh cá nhân,rửa tay với xà phòng, ngăn ngừa lây truyền cộng ñồng Danh pháp Theo danh pháp WHO Khuyến cáo WHO • Không hạn chế ñi lại quốc gia • Vệ sinh cá nhân biện pháp phòng bệnh Nhóm cúm Nhóm cúm Năm phân lập hiệu quả: - Rửa tay xà phòng Nguồn gốc địa lí Số phân lập - Che miệng ho 04/03/2014 Chẩn ñoán cúm Chẩn ñoán cúm Lứa tuổi thường gặp người lớn tuổi Biểu lâm sàng • Tương tự cúm H5N1 Chẩn ñoán cúm A/H7N9 (làm lại slide này) – Thời gian ủ bệnh – ngày – Mệt mỏi, chán ăn, ñau nhức người – Sốt cao, ho, khó thở – Viêm phổi nặng, diễn tiến nhanh ñến suy hô hấp Chẩn ñoán cúm A/H7N9 ðiều trị cúm • Ca bệnh xác ñịnh – Ca bệnh nghi ngờ – Khẳng ñịnh xét nghiệm • PCR/giải trình từ gen • Phân lập virus cúm A/H7N9 04/03/2014 Nguyên tắc ñiều trị ðiều trị • Các ca bệnh nghi ngờ ñều cần ñược khám cách ly bệnh viện, làm xét nghiệm chẩn ñoán • Các ca bệnh xác ñịnh phải ñược nhập viện ñiều trị • Hạ sốt tích cực • ðiều chỉnh rối loạn nước, ñiện giải, kiềm toan • Kháng sinh không loại trừ bội nhiễm cách ly hoàn toàn • Sử dụng thuốc kháng virus sớm tốt • Hồi sức hô hấp • ðiều trị suy ña tạng ðiều trị ðiều trị Thuốc ñiều trị cúm ñang lưu hành • ức chế protein M2 – Amantadine – Rimantadine • ức chế men neuramidase (NAI) – Oseltamivir – Zanamivir 04/03/2014 Oseltamivir Oseltamivir ức chế men neuraminidase cách tranh chấp phản ứng tách liên kết acid sialic Oseltamivir Zanamivir •Tác dụng trực tiếp vào phổi •Có hiệu sau 10 giây •T1/2 2.5 – 04/03/2014 ðiều trị Dịch cúm A(H7N9) có nguy xâm nhập, lan truyền bùng phát cao • Chủng vi rút cúm A(H7N9) chưa gây bệnh cho người • ðã phát vi rút cúm A(H7N9) chim bồ câu bán chợ Trung Quốc chưa có chứng việc vi rút cúm A(H7N9) lây truyền từ gia cầm sang người từ người sang người • ðặc tính vi rút cúm A dễ biến ñổi, nguy có lây nhiễm từ người sang người xảy Dịch cúm A(H7N9) có nguy xâm nhập, lan truyền bùng phát cao Xin chân thành cám ơn! • Tình hình dịch Trung Quốc liên tục gia tăng, diễn biến phức tạp,rải rác nhiều tỉnh gây khó khăn việc kiểm soát lan truyền khống chế dịch • Vấn ñề vận chuyển, nhập lậu gia cầm qua biên giới phức tạp khó có khả ngăn chặn Việc giao lưu ñi lại người dân hai quốc gia lớn, ñó cộng ñồng chưa có miễn dịch ORIGINAL RESEARCH Open AccessEmergency intraosseous access in a helicopteremergency medical service: a retrospective studyGeir A Sunde1,2*, Bård E Heradstveit1,2, Bjarne H Vikenes1,2, Jon K Heltne1,2,3AbstractBackground: Intraosseous access (IO) is a method for providing vascular access in out-of-hospital resuscitation ofcritically ill and injured patients when traditional intravenous access is difficult or impossible. Different intraosseoustechniques have been used by our Helicopter Emergency Medical Services (HEMS) since 2003. Few articlesdocument IO use by HEMS physicians. The aim of this study was to evaluate the use of intraosseous access in pre-hospital emergency situations handled by our HEMS.Methods: We reviewed all medical records from the period May 2003 to April 2010, and compared three differenttechniques: Bone Injection Gun (B.I.G® - Waismed), manual bone marrow aspiration needle (Inter V - Medical DeviceTechnologies) and EZ-IO® (Vidacare), used on both adults and paediatric patients.Results: During this seven-year period, 78 insertion attempts were made on 70 patients. Overall success rates were50% using the manual needle, 55% using the Bone Injection Gun, and 96% using the EZ-IO®. Rates of success onfirst attempt were significantly higher using the EZ-IO® compared to the manual needle/Bone Injection Gun (p <0.01/p < 0.001). Fifteen failures were due to insertion-related problems (19.2%), with four technical problems (5.1%)and three extravasations (3.8%) being the most frequent causes. Intraosseous access was primarily used inconnection with 53 patients in cardiac arrest (75.7%), including traumatic arrest, drowning and SIDS. Otherdiagnoses were seven patients with multi-trauma (10.0%), five with seizures/epilepsy (7.1%), three with respiratoryfailure (4.3%) and two others (2.9%). Nearly one third of all insertions (n = 22) were made in patients younger thantwo years. No cases of osteomyelitis or other serious complications were documented on the follow-up.Conclusions: Newer intraosseous techniques may enable faster and more reliable vascular access, and this canlower the threshold for intraosseous access on both adult and paediatric patients in critical situations. We believethat all emergency services that handle critically ill or injured paediatric and adult patients should be familiar withintraosseous techniques.BackgroundVascular access is important in the resuscitation of criti-cally ill or injured adult and paediatric patients [1,2]. Itcan be challenging to obtain vascular access, especiallyin the resuscitation of small children in emergencysituations [3-5]. The European Resuscitation Council2005 guidelines [6] and International Liaison Committeeon Resuscitation guidelines [4] recommend intraosseousaccess during resuscitation if intravenous access provesto be difficult or impossible. Despite these recommenda-tions, intraosseous techniques appear to be rarely used[7]. While numerous reports have been published aboutthe use of different intraosseous devices in emergencypatients, they are primarily from paramedic-basedambulance services [2,8]. Few comparisons have beenpublished of different IO techniques used by physiciansin emergency departments [7] or in HEMS servicesmanned by physicians/nurses [9,10].Typical HEMS operating conditions make specialdemands on medical equipment such as IO devices.Rain, cold, darkness and non-sterile conditions meanthat such equipment must be durable and simple to usein all conditions. User friendliness is important for res-cuers, both on-scene and in-flight [10].Intravenous access is traditionally regarded as theoptimal route for medication and fluids, and the* Oral Ondansetron for Gastroenteritis in a Pediatric Emergency Department Background BỘ GIÁO DỤC VÀ ĐÀO TẠO TRƯỜNG ĐẠI HỌC DÂN LẬP HẢI PHÒNG ------------------------------- ISO 9001 : 2008 KHÓA LUẬN TỐT NGHIỆP NGÀNH: NGOẠI NGỮ HẢI PHÒNG - 2010 2 HAIPHONG PRIVATE UNIVESITY FOREIGN LANGUAGES DEPARTMENT ----------------------------------- GRADUATION PAPER A STUDY ON TRANSLATION OF ENGLISH - RELATED TERMS IN FINANCE AND BANKING INTO VIETNAMESE By: BUI THI THOM Class: NA 1004 Supervisor: DAO THI LAN HUONG, M.A HAI PHONG - 2010 3 BỘ GIÁO DỤC VÀ ĐÀO TẠO TRƯỜNG ĐẠI HỌC DÂN LẬP HẢI PHÒNG -------------------------------------- Nhiệm vụ đề tài tốt nghiệp Sinh viên: .Mã Số: Lớp: Ngành: Tên đề tài: . . 4 Nhiệm vụ đề tài 1. Nội dung và các yêu cầu cần giải quyết trong nhiệm vụ đề tài tốt nghiệp ( về lý luận, thực tiễn, các số liệu cần tính toán và các bản vẽ). …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… 2. Các số liệu cần thiết để thiết kế, tính toán. …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… Update on mangement of patent ductus arteriosus in preterm infants Dr Trinh Thi Thu Ha Outline Overview of PDA Timing of screening PDA? When to treat PDA? Timing of ductal closure Prenatal MgSO4, tocolytic Postnatal surfactant Early, severe pulmonary hemorrhage is associated with ductal patency at 12 to 18 hours of age, but later pulmonary hemorrhage (after the first week) is not related to persistent ductal patency (Workbook in Practical Neonatology 5th Edition 2015) Diagnosis: In most cases, the clinically silent PDA during the first few days goes undetected unless an echocardiogram is performed Signs of bounding pulses, active precordium, and systolic murmur were of reasonable specificity but very low sensitivity in the first to days of birth for diagnosis of an echocardiographically defined significant PDA Relying on clinical signs alone led to a mean diagnostic delay of days (A blinded comparison of clinical and echocardiographic evaluation of the preterm infant for patent ductus arteriosus.Skelton R1, Evans N, Smythe J JPaediatr Child Health 1994 Oct;30(5):406-11) Ibuprofen Prophylaxis No significant differences in mortality, IVH, or BPD No reduction in IVH, PAL in the treated group Increased risk of gastrointestinal bleeding Prophylactic ibuprofen exposes many infants to renal and gastrointestinal side effects without any important short-term benefits and is not recommended Pre-symptomatic Pharmacologic Treatment No effect on the rate of mortality, BPD, IVH, ROP, or length of ventilation, death, IVH, NEC,… More renal side effect Presymptomatic indomethacin or ibuprofen therapy for PDA in preterm infants is not recommended Conservative Management Fluid restriction Diuretics, avoidance of loop diuretics Maintaining a hematocrit of 35 to 40 percent Increased positive airway pressure Correction of alkalosis Avoidance of pulmonary vasodilators: oxygen or NO Asymptomatic infants with PDAs generally not require medical management or surgical ligation These infants should be monitored for evidence of CHF, failure or renal PEDIATRIC OBSTRUCTIVE SLEEP APNEA (OSA) DEFINITION OSA • Inspiratory airflow is either partly (hypopnea) or completely (apnea) occluded during sleep The combination of sleep-disordered breathing with daytime sleepiness is referred to as the OSA syndrome • Obstructive apnea occurs when there is complete cessation of airflow for ≥ 10 s PATHOPHYSIOLOGY major predisposing factors for upper airway obstruction: • Anatomic narrowing • Abnormal mechanical linkage between airway dilating muscles and airway walls • Muscle weakness • Abnormal neural regulation PATHOPHYSIOLOGY • • • • Sleep fragmentation Increased work of breathing Alveolar hypoventilation Intermittent hypoxemia COMPLICATIONS • • • • • Neurobehavioral disturbances, ADHD Diminished learning capabilities Failure to thrive Pulmonary hypertension Cor pulmonale CONDITION ASSOCIATED-CAUSES • • • • • • • • Tonsillar and adenoid hypertrophy Neuromuscular disorders Myelomeningocele Obesity Pierre Robin sequence Cerebral palsy Down syndrome Hypothyroidism EPIDEMIOLOGY • United States: Affecting 2–3% of all children (snoring: 8-27%) • 2-8 years (adenotonsillar lymphatic tissue growth) • Sex: prepubertal children: male = female, older adolescents: male > female • Races: black children > white children, high frequency of OSA / adult Asia: craniofacial structures HISTORY • Nonspecific • Interview: speciality, sensity # 50-60% • Family: snoring, allergies, exposure to tobacco smoke • History of loud snoring >=3 nights/week: increase suspicion of OSA • Breathing difficulties during sleep, unusual sleeping positions, morning headaches, daytime fatigue, irritability, poor growth, behavioral problems PHYSICAL • • • • • • • • Growth chart, height, weight, obesity Nasal passenge Palate Tonsillar hypertrophy, uvula Malformation: cleft, chin, maxilla Compression Cardiac examination Conditions in cause POLYSOMNOGRAPHY • • • • Sleep state (>2 EEG leads) Electrooculogram (right and left) Electromyelogram (EMG) Airflow at nose and mouth (thermistor, capnography, or mask and pneumotachygraph) • Chest and abdominal wall motion • Electrocardiogram (preferably with R-R interval derivation technology) POLYSOMNOGRAPHY • Pulse oximetry (including a pulse waveform channel) • End-tidal carbon dioxide (sidestream or mainstream infrared sensor) • Video camera monitor with sound montage • Transcutaneous oxygen and carbon dioxide tensions (in infants and children 10 minutes • Total sleep time (TST) > 5.5 hours • Rapid eye movement (REM) sleep >15% of TST • Percentage of stage 3-4 non-REM sleep > 25% of TST • Respiratory arousal index (number per hour of TST) < • Periodic leg movements (number per hour of TST) < • Apnea index (number per hour of TST) 95% • Desaturation index (>4% for s; number / hour of TST) < • Highest CO2 52 mm Hg • CO2 > 45 mm Hg < 20% of TST TREATMENT Medical therapy: limited value • Antihistamine or antimuscarinic: nasal congestion, benefit is uncertain • Leukotriene modifier: eliminate residual OSA following surgery, improve clinical outcomes without surgery • Budesonide for weeks: sustained improvement in mild OSA TREATMENT Positive-pressure ventilation: safe, efficient, alternative to further surgery or tracheotomy in children and infants with unresolved OSA after tonsillectomy and adenoidectomy • CPAP • BiPAP TREATMENT Surgery: • Tonsillectomy and adenoidectomy • Tracheotomy • Uvulopharyngopalatoplasty, epiglottoplasty • Bariatric surgery Pediatric obstructive sleep apnea (OSA): A potential late consequence of respiratory syncitial virus (RSV) bronchiolitis Ayelet Snow, MD,1 Ehab Dayyat, MD,1 Hawley E RETRACTILE TESTES A review of the current literature UROLOGY DEPARTMENT CHILDREN’S HOSPITAL NO.2 Definitions Normal size Intermittently resides in the groin Testes that can be brought down into their normal position in the scrotum Remains there for a period Aetiology Variant of normal Strong scremasteric reflex Taut spermatic cord in a testis which is in the process of ascending Clinical examination Supine Manipulate the testis to the base of the scrotum Release to observe whether it remains there or moves back up into the groin OUTCOME OF RETRACTILE TESTES Acquired undescended testes Acute torsion Reduced fertility Tumour risk Acquired undescended testes La Scala & Ein reviewed 150 boys with 205 retractile testes with a 7year follow-up period 23% of retractile testes eventually becoming an acquired UDT [1] Agarwal et al a cohort of 122 boys with 204 retractile testes over years of follow-up: 32% of retractile testes eventually becoming acquired UDT [2] cord tautness as a risk for ascent Stec et al looked at the outcome of 172 boys with 274 retractile testes over a follow-up period of 26 months 7% acquired UDT [3] Limited: definition, indication of orchidopexy, short follow-up periods Acute torsion Only an isolated case report of this within the literature (Charles JC The fate of the retractile testis J Urol 2004;171:1237) [4] Retractile testes are no increased risk for acute torsion over normal testes Tumour risk Congenital UDT have an increased relative risk of germ cell malignancy that may be approximately 5-10 times [5] Acquired UDT not have an increased risk of malignancy [6] retractile testis per se is not at an increased relative risk of developing a cancer Reduced fertility Caucci et al sperm counts in semen of 38 young male adults treated for retractile testes before puberty and adults with retractile testes normal semen analysis: 21% in young adults with previously treated retractile testes, 29% in adults with retractile testes retractile testes with reduced size are a risk factor for male infertility [9] Other epidemiological studies of infertile adult males have identified retractile testes as being associated with lower sperm counts and hypospermatogenesis on biopsy[10-12] increase in testicular temperature resulting in impaired spermatogenesis [12] Reduced fertility Puri and Nixon assessed paternity rates in 43 adult males who as children had bilateral retractile testes: 74% of the subjects had fathered children and that testicular volumes were normal retractile testes develop normally with no harmful effects on fertility [13] Dadfar MR performed orchidopexies on 22 adult males with idiopathic infertility and bilateral retractile testes, and measured their testicular volumes and sperm parameters after year: no change in testicular volume and sperm density, but improved sperm motility [14] Limited: not established paternity, not performed semen analysis Conclusion Retractile testis may become an ascended testis: Level evidence Acute torsion: no evidence Tumour risk: no evidence Reduced fertility: poor evidence Not enough evidence to warrant orchidopexy on a retractile testis But recommend annual clinical surveillance of retractile testes until beyond puberty And reserve orchidopexy for testes which can no longer be brought down into the scrotum (ascended testes) Thank for your attention! References [1] La Scala GC, Ein SH ... thể thông qua hệ mạch máu 04/03 /20 14 Dịch cúm H5N1 Virus cúm A/ H7N9 • Số ca mắc tính đến 20 13 124 ca (20 13: ca) • Số ca tử vong: 62 ca • Đường lây truyền từ gia cầm bị nhi m bệnh sang người •... a tạng ðiều trị ðiều trị Thuốc ñiều trị cúm ñang lưu hành • ức chế protein M2 – Amantadine – Rimantadine • ức chế men neuramidase (NAI) – Oseltamivir – Zanamivir 04/03 /20 14 Oseltamivir Oseltamivir... men neuraminidase cách tranh chấp phản ứng tách liên kết acid sialic Oseltamivir Zanamivir •Tác dụng trực tiếp vào phổi •Có hiệu sau 10 giây •T1 /2 2.5 – 04/03 /20 14 ðiều trị Dịch cúm A( H7N9) có