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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 11/24/2013 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 07/09/2011 I Mục đích - Đưa thuốc vào thể qua da để tạo tác dụng nhanh chóng - Điều trò toàn thân 07/09/2011 II Chỉ đònh - BN cấp cứu - Bệnh nặng cần tác dụng cấp thời - BN suy kiệt - Tổn thương niêm mạc, không hấp thu, bò phá hủy đường tiêu hóa - Người bệnh uống : nôn ói nhiều, người bệnh chuẩn bò mổ, tâm thần không hợp tác III Chống đònh *Tuyệt đối : -Chỗ nhiễm trùng -Nơi bò *Tương đối: -Đoạn cuối chi bò tê liệt -Chỗ phù nề -Tránh khớp nối 07/09/2011 IV Vị trí tiêm Tĩnh mạch chi : lưng bàn tay, cổ tay , khuỷu tay, lưng bàn chân , cổ chân… Tĩnh mạch vùng đầu : hai bên thái dương Chọn tĩnh mạch to , rõ, di động 07/09/2011 07/09/2011 CÁC BƯỚC TIẾN HÀNH KỸ THUẬT Báo giải thích cho thân nhân, bệnh nhi Hỏi tiền sử dị ứng thuốc Mang trang, rửa tay nhanh Soạn dụng cụ: Dụng cụ vơ trùng: Kim luồn, nút đậy kim Kim rút thuốc ống tiêm 3ml: ống ống tiêm 5ml: ống Băng keo Hộp gòn Hộp gạc Dụng cụ sạch: Mâm Găng Khẩu trang Dây garơ Bút ghi 07/09/2011 Thuốc dung dịch sát trùng: + Thuốc tiêm theo y lệnh:( kiểm tra thuốc lần 1) + Nước cất dung mơi để pha thuốc + Nacl 9%o 100ml + Dung dịch sát trùng: cồn 700 + Dung dịch rửa tay nhanh ●Dụng cụ khác: + Thùng rác sinh hoạt, rác lây nhiễm + Thùng đựng vật sắc nhọn + Hộp chống sốc phản vệ Pha thuốc rút thuốc: + + + + + + + + + + + + + Kiểm tra thuốc lần trước mở nắp lọ thuốc Mở nắp lọ thuốc, sát trùng nắp cao su Sát trùng ống nước cất (hoặc dung mơi) Dùng ống tiêm 5ml gắn kim pha thuốc, rút nước cất dung mơi theo hướng dẫn Đâm kim vào lọ, bơm dung mơi vào, sau rút khí lọ với thể tích tương đương Rút kim khỏi lọ Lắc thấy thuốc tan hẳn Bơm vào lọ lượng khí với thể tích thuốc rút Rút thuốc theo y lệnh Rút kim khỏi lọ kiểm tra thuốc lần Thay kim tiêm, đặt ống tiêm vào mâm Rút ống nước muối 9%o đặt vào mâm Nếu thuốc dư phải che gạc(gòn) vơ trùng, dán băng keo ghi ngày giờ, hàm lượng thuốc 1ml, bảo quản theo qui định 07/09/2011 Mang đến giường bệnh nhi Thực Báo & giải thích lần Đặt BN tư thích hợp Chọn bộc lộ vị trí tiêm Cột garo cách vị trí tiêm 3-5 cm Sát trùng tay nhanh, mang găng Sát trùng vùng tiêm lần Sát trùng theo kiểu xoắn ốc rộng 5cm Để cồn khơ lần sát trùng & trước tiêm Tiến hành tiêm: tay phải cầm kim luồn để mặt vát hướng lên Đâm kim qua da vào tĩnh mạch góc 30-40 độ, lúc dùng ngón bàn tay trái căng da phía giữ cố định chi Thấy máu chảy chui kim , giữ cố định Luồn kim luồn: lùi nòng khoảng 1cm lúc luồn kim luồn nhẹ nhàng vào lòng mạch 07/09/2011 Tháo garo Dán băng keo cá nhân Rút bỏ nòng kim Kiểm tra kim luồn cách dùng ống tiêm 3ml có chứa nước muối 9%o rút nhẹ, thấy có máu, bơm nước muối 9%o vào thấy nhẹ tay khơng phù Bơm thuốc theo y lệnh Bơm nước muối 9%o tráng ống Gắn nút đậy kim luồn trường hợp lưu kim để tiêm thuốc Dán băng keo vải cố định Tháo găng Ghi ngày thực lên băng keo vải vùng tiêm Dặn dò TNBN điều cần thiết Trả bệnh nhân tư tiện nghi Dọn dẹp dụng cụ Rửa tay, ghi hồ sơ.( tên thuốc, liều lượng ngày tiêm, tên Đ D thực hiện) 07/09/2011 TRƯỜNG HỢP BƠM THUỐC QUA KHĨA LƯU KIM CÁC BƯỚC TIẾN HÀNH Báo giải thích cho thân nhân, bệnh nhi.( nhìn vein, kiểm tra kim luồn) Hỏi tiền sử dị ứng thuốc Mang trang, rửa tay nhanh Chuẩn bị dụng cụ.( giống tiêm TM ) Báo & giải thích lần Kiểm tra Đặt BN tư thích hợp Bộc lộ vị trí tiêm 07/09/2011 Sát trùng tay nhanh, mang găng Sát trùng khóa lưu kim Kiểm tra kim luồn cách dùng tay trái giữ khóa lưu kim, tay phải cầm ống tiêm 3ml có chứa nước muối 9%o đâm qua khóa lưu kim rút nhẹ kiểm tra thấy có máu Nếu kim luồn nằm lòng mạch, bơm nước muối 9%o vào thấy nhẹ tay khơng phù Rút kim tiến hành bơm thuốc Bơm thuốc chậm, vừa bơm thuốc vừa quan sát bệnh nhi Tráng khóa lưu kim: dùng ống tiêm 3ml có chứa nước muối 9%o bơm vào khóa lưu kim đuổi hết