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Available online at http://ccforum.com/content/9/4/E12 Evidence-Based Medicine Journal Club EBM Journal Club Section Editor: Eric B. Milbrandt, MD, MPH Journal club critique Early percutaneous dilatational tracheostomy leads to improved outcomes in critically ill medical patients as compared to delayed tracheostomy John C. Lee 1 and Mitchell P. Fink 2 1 Clinical Fellow, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA 2 Professor and Chair, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA Published online: 15 June 2005 This article is online at http://ccform.com/content/9/4/E12 © 2005 BioMed Central Ltd Critical Care 9: E12 (DOI: 10.1186/cc3759) Expanded Abstract Citation Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB: A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004, 32:1689-1694 [1]. Hypothesis In the critically ill medical patients who are projected to require ventilation for ≥14 days, early percutaneous tracheostomy within 48 hours of intubation offers significant survival advantage as well as decreased morbidity when compared with prolonged translaryngeal intubation (delayed tracheostomy) 14-16 days after intubation. Methods Design: Prospective, randomized trial. Setting: Closed medical intensive care units of three academic medical centers in Memphis, Tennessee and Tampa, Florida. Subjects: All patients in the three medical ICUs who were intubated and mechanically ventilated for acute respiratory failure were screened and included if they were: >18 years old, projected to need mechanical ventilation >14 days, and had an initial APACHE II score >25. Specific exclusion criteria were established to ensure the safe performance of percutaneous tracheostomy (anatomical factors, evidence of potential prolonged bleeding, and PEEP >12 cm H 2 O). Intervention: One hundred and twenty patients projected to need ventilation >14 days were prospectively randomized to either early percutaneous tracheostomy within 48 hrs of intubation (early group, n=60) or delayed tracheostomy at days 14-16 (late group, n=60). All tracheostomies were performed by the study authors under bronchoscopic surveillance. Clinical circumstances determined whether patients who were randomized to receive a delayed tracheostomy actually received one. Outcomes: Time in the intensive care unit and on mechanical ventilation and the cumulative frequency of pneumonia, mortality, and accidental extubation were documented. The airway was assessed for oral, labial, laryngeal, and tracheal damage at tracheostomy and 10 weeks post-intubation using a combination of physical examination, fiberoptic bronchoscopy, and linear radiographic tomography. Results The early group showed significantly less hospital mortality (31.7% vs. 61.7%, p<0.005), pneumonia (5% vs. 25%, p<0.005), and accidental extubation (0% vs. 10%, p=0.03) compared with the late group. The early group spent less time in the intensive care unit (4.8 vs. 16.2 days, p<0.001) and on mechanical ventilation (7.6 vs. 17.4 days, p<0001). There was significantly less damage to the mouth and larynx, but not the trachea, in the early group. Conclusion This study demonstrates that the benefits of early tracheostomy outweigh the risks of prolonged translaryngeal intubation. It gives credence to the practice of subjecting this group of critically ill medical patients to early tracheostomy rather than delayed tracheostomy. Commentary Mechanical ventilation through the cannulation of the trachea is one of the fundamental therapies of intensive care, with translaryngeal endotracheal intubation and Critical Care August Serum Albumin vs Outcomes in Critically Ill Children CONTENT Introduction Albumin in critically ill patients Discussion Benefit of albumin administration Conclusion INTRODUCTION • Serum albumin is a strong biomarker of disease severity and prognosis in adult patients • In contrast, its value as predictor of outcome in critically ill children has not been established • The question of whether to administer albumin in hypoalbuminemic patients remains largely unanswered BENEFIT OF ALBUMIN ADMINISTRATION BENEFIT OF ALBUMIN ADMINISTRATION CONCLUSION • Serum Albumin Is an Independent Predictor of Clinical Outcomes in Critically Ill Children • We suggest using albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock, when patients require substantial amounts of crystalloids Albumin infusion is safe and cost-effective in severe sepsis and septic shock 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 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 MANAGEMENT OF SUSPECTED VIRAL ENCEPHALITIS IN CHILDREN OVERVIEW • 1980s: dramatically improved by aciclovir HSV encephalitis in adults • Delays treatment(> 48h after hospital admission): associated with a worse prognosis OVERVIEW • Syndrome of neurological dysfunction: inflammation of the brain parenchyma • Many causes: Infectious: viruses, bacteria, parasites and fungi Non- infectious: antibody-mediated RECOMMENDATION • Which clinical features should lead to a suspicion of encephalitis in children? RECOMMENDATION • Current or recent febrile illness: altered behaviour, personality, cognition or consciousness, seizures or new focal neurological signs (A, II) • The differential diagnosis: metabolic, toxic, autoimmune causes or sepsis outside the CNS (B, III), past history is very important • Sub-acute (weeks to months) encephalitis: autoimmune, paraneoplastic, metabolic aetiologies (C, III) • Priority of the investigations: determined by clinical history and clinical presentation (C, III) RECOMMENDATION • Diagnostic features for specific aetiologies? Age  Immunocompetence  Geography Exposure HSV encephalitis RECOMMENDATION • Symptom: non – specific • Children: labial – herpes is diagnostic specific (develop encephalitis with primary HSV infection) • Acute opercular syndrome (disturbance of voluntary control of the facio-linguo-glossopharyngeal muscles leading to oro-facial palsy, dysarthria and dysphagia) • Sexual abuse RECOMMENDATION • MRI: as soon as possible on all patients with suspected encephalitis/ diagnosis is uncertain, 24 hrs – 48 hrs after hospital admission (B, II) • MRI: chosen appropriately should be interpreted by an experienced paediatric neuroradiologist • SPECT and PET are not indicated in the assessment of suspected acute viral encephalitis (B, II) • For which patients should aciclovir treatment be started empirically? RECOMMENDATIO • Initial CSF and/or imaging suspected encephalitis: start acyclovir within hours of admission if these results are awaited (A, II) • First CSF/imaging: normal, clinical suspicion of HSV or VZV encephalitis: start acyclovir within hours of admission whilst further diagnostic investigations are awaited (A, II) RECOMMENDATION • Dose? 3 months-12 years 500mg/m2 hourly  >12 years 10mg/kg hourly reduced in patients with pre-existing renal impairment (A, II) If meningitis is also suspected, should also be treated (A, II) • How long should acyclovir be continued in proven HSV encephalitis, and is there a role for oral treatment? RECOMMENDATION • Proven: continued for 14-21 days (A, II), repeat LP • CSF PCR is still positive for HSV: aciclovir should continue, with weekly CSF PCR until it is negative (B, II) • months-12 years a minimum of 21 days of aciclovir should be given before repeating the LP (B, III) • When can presumptive treatment with aciclovir be safely stopped, in patients that are HSV PCR negative? RECOMMENDATION • An alternative diagnosis has been made, or • HSV PCR in the CSF is negative on two occasions 24-48 hours apart, and MRI imaging (performed >72 hours after symptom onset), is not characteristic for HSV encephalitis, or • HSV PCR in the CSF is negative once >72 hours after neurological symptom onset, with normal level of consciousness, normal MRI, CSF white cell count of less than 106/L (B, III) • What is the role of corticosteroids in HSVB encephalitis? RECOMMENDATION • Corticosteroids should not be used routinely in patients with HSV encephalitis (B, III) • Corticosteroids may have a role in patients with HSV encephalitis under specialist supervision (study results are awaited (C, III)) • What should be the specific management of VZV encephalitis? RECOMMENDATION • No specific treatment for VZV cerebellitis (B, II) • ... OF ALBUMIN ADMINISTRATION BENEFIT OF ALBUMIN ADMINISTRATION CONCLUSION • Serum Albumin Is an Independent Predictor of Clinical Outcomes in Critically Ill Children • We suggest using albumin in. ..CONTENT Introduction Albumin in critically ill patients Discussion Benefit of albumin administration Conclusion INTRODUCTION • Serum albumin is a strong biomarker of disease severity and prognosis in. .. patients • In contrast, its value as predictor of outcome in critically ill children has not been established • The question of whether to administer albumin in hypoalbuminemic patients remains largely