Research Progress of Assessment Tools for Peripheral Venous Access Difficulties in Children

Objective:To review the research progress of peripheral venous access difficulty assessment tools in children and to provide a reference for clinical nurses to select and develop appropriate assessment tools.Methods:Search the literature at home and abroad and summarize and analyze the existing evaluation tools.Results:There is no unified assessment tool about difficult venous access in children at home and abroad.The existing tools include the difficult venous access assessment scale and peripheral venous grading assessment tool.Conclusion:The current assessment tools for venous access difficulties in children have their own limitations,and it is necessary to develop further the assessment tools suitable for the cultural background of children's venous access difficulties.This paper summarized the current progress of research on peripheral venous access difficulty assessment tools.It also analyzed and summarized the shortcomings of existing tools to provide a reference for clinical staff to choose appropriate assessment tools.

难变形金属复杂构件电流辅助流动-分形旋压成形机理研究

针对采用传统多道次切削及插齿工艺所制备难变形金属复杂件存在的工艺流程长、强韧性不足等问题,提出采用电流辅助流动-分形旋压工艺实现此复杂件少无切削的近净成形。以具有“差异壁厚”和“差异结构”的30CrMnSiA合金结构钢复杂构件为研究对象,分析了电流辅助流动-分形旋压成形原理;基于ABAQUS软件建立了电流辅助流动-分形旋压成形有限元分析模型,并对模型精度进行了验证;分析了电流辅助流动-分形旋压成形机理并进行试验研究。结果表明:所构建的有限元模型对电流辅助流动-分形旋压成形工艺的预测精度较高,两种工艺的最大相对误差分别为6.72%和5.63%。电流辅助流动旋压的材料呈现三向压应力状态,在成形末期坯料壁部存在较大的拉应力和拉应变;电流辅助分形成形时,变形材料的应力分布则呈现齿槽材料呈现三向压应力状态,齿顶则为径向拉、其余两向压的应力状态;脉冲电流可降低了材料变形抗力,不仅缩小了流动旋压变形区的危险区,同时也可提高分形旋压时材料向径向填充的能力,进而减弱了齿形填充不满的现象。试验结果表明,电流辅助流动-分形旋压工艺可实现难变形复杂构件的高精度高强韧性制备。

左西孟旦联合膈肌电刺激对困难脱机风险患者的临床疗效

目的:观察左西孟旦联合膈肌电刺激对困难脱机风险患者的临床疗效。方法:选择2021年12月—2023年12月于赣州市人民医院就诊的困难脱机风险患者92例,采用随机数字表法将其分成常规组(n=46)与观察组(n=46)。常规组接受膈肌电刺激治疗,观察组在常规组的基础上接受左西孟旦治疗。比较两组ICU住院时间、呼吸机使用时长、脱机相关指标、炎症因子及脱机成功率。结果:观察组ICU住院时间、呼吸机使用时长均短于常规组(P<0.05)。治疗前,两组脱机相关指标比较,差异均无统计学意义(P>0.05);治疗48 h后,两组N末端B型利钠肽原(NT-proBNP)水平均降低,且观察组较常规组低,氧合指数均升高,且观察组较常规组高,差异均有统计学意义(P<0.05)。治疗前,两组白细胞介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)比较,差异均无统计学意义(P>0.05);两组治疗48 h后的IL-6、TNF-α均降低,观察组均较常规组低(P<0.05)。观察组脱机成功率高于常规组,差异有统计学意义(P<0.05)。结论:左西孟旦联合膈肌电刺激应用于困难脱机风险患者,可缩短ICU住院时间、呼吸机使用时长,减轻炎症反应,调节氧合指数、NT-proBNP水平,提高脱机成功率。

疑难病原菌案例集教学模式在临床微生物检验实习教学中的应用

目的探讨疑难病原菌案例集教学模式在临床微生物检验实习教学中的应用效果,为临床实践教学改革提供参考。方法选择2022年5月至2024年3月于检验科实习的38名学生作为研究对象,按照不同毕业年份将其分为对照组(n=18)和研究组(n=20)。对照组采用传统小讲课教学模式,研究组采用疑难病原菌案例集教学模式。比较两组的应用效果。结果研究组的作业答案完整性、知识整合和应用能力、疑难问题解决能力、临床沟通意识及认知评分高于对照组(P<0.05);两组的互相探究学习能力评分比较,差异无统计学意义(P>0.05)。研究组对教学效果及教程或案例构建合理性的满意度高于对照组,差异具有统计学意义(P<0.05)。研究组的操作技能成绩高于对照组,差异具有统计学意义(P<0.05)。结论疑难病原菌案例集教学模式既能提高实习生的综合知识应用能力和临床沟通意识,又能促进教师开拓创新思维。

日美情报合作的演进、动因及影响——以日美同盟强化为框架

论述日美同盟与日美情报合作间的联系、考察日美情报合作的演进、分析当前日美强化情报合作的动因及影响,以期完善我国对日美同盟与情报合作的认识。运用系统分析法与文献分析法,以日美同盟强化为框架,将日美情报合作演进按时期划分为“强依赖”“弱依赖”“难独立”三个阶段,并着重对当前日美情报合作强化的动因及影响加以研判。日美同盟强化为日美情报合作提供空间。在以日美对华战略协调且态度趋于一致的条件下,日本对美采取追随性合作政策。在未来,日美同盟借助先进技术为战略工具赋能,持续强化日美同盟,使大国战略竞争愈加隐蔽、复杂、激烈。

高原高寒地区山岳救援的难点与对策

本文通过深入探讨近年来在高原高寒地区发生的典型人员被困雪山、失联人员搜救等案例,详细分析了高原高寒地区山岳救援的独特特点、面临的诸多难点以及存在的问题。在此基础上,文章进一步研究并提出了针对高原高寒地区山岳救援的技战术方法、专业队伍建设、救援装备配备以及专业训练等方面的对策措施,旨在为提高该地区山岳救援的效率和安全性提供参考和借鉴。

门诊处方适宜性审核的难点内容回顾性分析

目的通过对医院门诊处方适宜性审核,提高药师审核处方能力。方法对2019年~2023年门诊处方采取系统审核后药师再次审核,选取难点内容进行分析,去掉重复案例。结果难点内容233例,不合理70处,不合理处占30.04%,主要表现在用药与临床诊断(14处),剂量与给药频次(19处),重复用药(8处),剂型与给药途径(6处)和联合用药(6处)等方面,审方药师提供专业修改建议给处方医师,保障处方合理。结论药师挖掘出了很多的假阳性处方和假阴性处方,提高了审方能力和效率,保障了处方合理,保障了患者用药安全。

渭北“旱腰带”困难立地类型及生态修复技术探讨

困难立地的生态修复一直是林业技术工作中的重点和难点之一。以陕西省生态脆弱区域渭北“旱腰带”为研究范围,调查区域内主要困难立地类型(高陡边坡、干旱阳坡、石质山地、土石山地、侵蚀沟坡、采石迹地、盐碱地)及特点,阐述不同困难立地类型的生态修复技术要点,分析困难立地生态修复存在的难点,对困难立地生态空间治理提出对策与建议。

Endoscopic management of difficult common bile duct stones

Endoscopy is widely accepted as the first treatment option in the management of bile duct stones.In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones.Most biliary stones can be removed with an extraction balloon,extraction basket or mechanical lithotripsy after endoscopic sphincterotomy.Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients.Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed.Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.

ESWL for difficult bile duct stones:A 15-year single centre experience

AIM:To evaluate the efficacy of extracorporeal shock wave lithotripsy(ESWL)for the management of refractory bile duct cholelithiasis in a third level referral centre.METHODS:The clinical records of all patients treated with a second generation electromagnetic lithotripter (Lithostar Plus,SIEMENS)from October 1990 to April 2005 were evaluated.All patients were monitored during the procedure and antibiotics were administered in case of cholangitis.Theχ 2 test and logistic regression analysis were performed as appropriate.RESULTS:Two hundred and fourteen patients(102 males,112 females;mean age 74.8±0.84 years-single stone 97,multiple stones 117)underwent ESWL.The mean number of sessions and shock waves were 3.5 ±0.13 and 3477.06±66.17,respectively.The maximum stone size was 5 cm.Complete stone clearance was achieved in 192(89.7%)patients.Of the remain-ing patients 15 required surgery,2 a palliative stent and in 5 patients stone fragmentation led to effective bile drainage with clinical resolution despite incomplete clearance.Age,sex and stone characteristics were not related to treatment outcome.Major complications occurred in two patients(haemobilia and rectal bleeding) and minor complications in 25(3 vomiting,22 arrhythmias).No procedure-related deaths occurred.CONCLUSION:ESWL is a safe and effective technique for clearance of refractory bile duct stones.

Full-face excavation of large tunnels in difficult conditions

Following a few preliminary remarks on the tunneling methods at the beginning of the 20th century, thesuccessful applications of the full-face method also in difficult conditions are underlined. The attention isposed on the use of a systematic reinforcement of the face and of the ground, by means of fiber-glasselements. A selection of tunnels where this method was used successfully is reported with the purposeof illustrating the wide spectrum of ground conditions where it has been applied. Then, following adescription of the main concepts behind the method, the attention moves from the so-called “heavymethod”, where deformations are restrained, to the “light method”, where deformations are allowedwith the intention to decrease the stresses acting on the primary and final linings. The progress in theapplication of the “light method” is underlined, up to the development of a novel technique, which relieson the use of a yielding support composed of top head steel sets with sliding joints and specialdeformable elements inserted in the primary lining. The well-known case study of the Saint Martin LaPorte access adit, along the Lyon-Turin Base Tunnel, is described. In this tunnel, a yield-control supportsystem combined with full-face excavation has been adopted successfully in order to cope with the largedeformations experienced during face advance through the Carboniferous formation. The monitoringresults obtained during excavation are illustrated, together with the modeling studies performed whenpaying attention to the rock mass time-dependent behavior.

Predictors for difficult cecal insertion in colonoscopy: The impact of obesity indices

AIM To identify the factors influencing cecal insertion time(CIT) and to evaluate the effect of obesity indices on CIT. METHODS We retrospectively reviewed the data for participants who received both colonoscopy and abdominal computed tomography(CT) from February 2008 to May 2008 as part of a comprehensive health screening program. Age, gender, obesity indices [body mass index(BMI), waist-to-hip circumference ratio(WHR), waist circumference(WC), visceral adipose tissue(VAT)volume and subcutaneous adipose tissue(SAT) volume on abdominal CT], history of prior abdominal surgery, constipation, experience of the colonoscopist, quality of bowel preparation, diverticulosis and time required to reach the cecum were analyzed. CIT was categorized as longer than 10 min(prolonged CIT) and shorter than or equal to 10 min, and then the factors that required a CIT longer than 10 min were examined.RESULTS A total of 1678 participants were enrolled. The mean age was 50.42 ± 9.931 years and 60.3% were men. The mean BMI, WHR, WC, VAT volume and SAT volume were 23.92 ± 2.964 kg/m2, 0.90 ± 0.076, 86.95 ± 8.030 cm, 905.29 ± 475.220 cm3 and 1707.72 ± 576.550 cm3, respectively. The number of patients who underwent abdominal surgery was 268(16.0%). Colonoscopy was performed by an attending physician alone in 61.9% of cases and with the involvement of a fellow in 38.1% of cases. The median CIT was 7 min(range 2-56 min, IQR 5-10 min), and mean CIT was 8.58 ± 5.291 min. Being female, BMI, VAT volume and involvement of fellow were significantly associated with a prolonged CIT in univariable analysis. In multivariable analysis, being female(OR = 1.29, P = 0.047), lower BMI(< 23 kg/m2)(OR = 1.62, P = 0.004) or higher BMI(≥ 25 kg/m2)(OR = 1.80, P < 0.001), low VAT volume(< 500 cm3)(OR = 1.50, P = 0.013) and fellow involvement(OR = 1.73, P < 0.001) were significant predictors of prolonged CIT. In subgroup analyses for gender, lower BMI or higher BMI and fellow involvement were predictors for prolonged CIT in both genders. However, low VAT volume was associated with prolonged CIT in only women(OR = 1.54, P = 0.034).CONCLUSION Being female, having a lower or higher BMI than the normal range, a low VAT volume, and fellow involvement were predictors of a longer CIT.

Difficult Intubation in a Patient with Dysphagia after Posterior Occipitocervical Fusion: A Case Report

The authors encountered a case involving difficult intubation during anesthesia for revision of cervical fixation angle in a 62-year-old woman, with a history of chronic rheumatoid arthritis, who experienced dysphagia after initial posterior occipitocervical fusion to correct atlantoaxial subluxation. Two days after initial surgery, she developed trismus with neck flexion and dysphagia, and underwent revision surgery. General anesthesia was planned;however, tracheal intubation using the McGrath laryngoscope and bronchofiberscope was difficult, which prolonged anesthesia induction. Narrowing of the oral and pharyngeal cavities associated with overcorrection of the cervical spine was believed to be the reason for difficulty in manipulating the tracheal intubation devices. In posterior occipitocervical fusion, intraoperative evaluation of the occipito-second cervical vertebra (O-C2) angle is reported to be useful in preventing postoperative dyspnea and/or dysphagia, and avoids the need for revision of fixation angle. However, when revision surgery is needed, selection of airway management methods and tracheal intubation devices are important considerations because patients are likely to have restricted mobility in the cervical spine and narrowing of the oral and pharyngeal cavities.

Utility of single and double balloon endoscopy in patients with difficult colonoscopy: A randomized controlled trial

AIM: To compare the utility of single-balloon colonoscopy (SBC) or double-balloon colonoscopy (DBC) for difficult colonoscopies. METHODS: Between August 2008 and June 2010, patients in whom total colonoscopy failed within 30 min of insertion were assigned randomly to undergo either SBC or DBC. No sedatives were used. After the endoscopy, all patients were asked to evaluate pain during the procedure on a 10-point analog scale (1 = no pain; 10 = worst imaginable pain) with a questionnaire. The study outcomes were the cecal intubation rate and time, endoscopic findings, complications, and pain score. RESULTS: The SBC and DBC groups included 11 and 10 patients, respectively. All but one SBC patient achieved total colonoscopy successfully. The cecal intubation times were 18 min (range: 10-85 min) and 12.8 min (range: 9.5-42 min) in the SBC and DBC groups, respectively (P= 0.17). No difference was observed in the prevalence of colon polyps between the SBC and DBC groups (45% vs 30%, P = 0.66). SBC showed advanced colon cancer in the ascending colon, which was inaccessible using conventional colonoscopy. The respective pain scores were 5 (1-10) [median (range)] and 5 (1-6) in the SBC and DBC groups (P = 0.64). No complications were noted in any patient. CONCLUSION: The utility of singleand double-balloon endoscopy for colonoscopy seems comparable in patients with incomplete colonoscopy using a conventional colonoscope.

Management of difficult intravenous access:a qualitative revie

BACKGROUND:A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic,difficult intravenous access(DIVA)adversely impacts patient outcomes by causing significant downstream delays with many aspects of diagnoses and therapy.As most published DIVA strategies are limited to various point-of-care ultrasound techniques while other“tricks-of-the-trade”and pearls for overcoming DIVA are mostly relegated to informal nonpublished material,this article seeks to provide a narrative qualitative review of the iterature on DIVA and consolidate these strategies into a practical algorithm.METHODS:We conducted a literature search on PubMed using the keywords“difficult intravenous access”,“peripheral vascular access”and“peripheral venous access”and searched emergency medicine and anaesthesiology resources for relevant material.These strategies were then categorized and incorporated into a DIVA algorithm.RESULTS:We propose a Vortex approach to DIVA that is modelled after the Difficult Airway Vortex concept:starting off with standard peripheral intravenous cannulation(PIVC)techniques,progressing sequentially on to ultrasound-guided cannulation and central venous cannulation and finally escalating to the most invasive intraosseous access should the patient be in extremis or should best efforts with the other lifelines fail.CONCLUSION:DIVA is a perennial problem that healthcare providers across various disciplines will be increasingly challenged with.It is crucial to have a systematic stepwise approach such as the DIVA Vortex when managing such patients and have at hand a wide repertoire of techniques to draw upon.

Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is a valuable therapeutic technique for pancreatobiliary diseases,and its application in the elderly is no longer limited.However,a higher incidence of procedure difficulty and periprocedural adverse events might be expected in elderly patients due to the presence of other medical disorders and the poor general condition of this population.AIM To evaluate the incidence,causes,and management of difficult biliary cannulation during ERCP in elderly patients and the role of difficult cannulation as a risk factor for adverse events.METHODS A total of 614 patients who underwent ERCP during the study period were prospectively studied and divided into two groups based on their age.One hundred and forty-six patients were aged 80 years or older and 468 patients were aged less than 80 years.The primary outcome measurements were cannulation difficulty,cannulation success rate,ERCP procedure time,and related adverse events.RESULTS There was no difference in the incidence of difficult cannulation among the two groups(32.9%vs 34.4%,P=0.765),as well as in the cannulation success rate(96.6%vs 96.8%,P=0.54).The cannulation techniques were shown to be safe and efficient in achieving successful cannulation.Logistic regression analysis showed that patients aged 80 years or older were not associated with increased adverse events;however,difficult cannulation cases[adjusted odds ratio(AOR)=3.478;95%confidence interval(CI):1.877-6.442;P<0.001]and patients with Charlson Comorbidity Index≥2(AOR=1.824;95%CI:0.993-3.349;P=0.045)were more likely to develop adverse events.In contrast,other factors including age≤65(AOR=3.460;95%CI:1.511-7.922;P=0.003),female gender(AOR=2.362;95%CI=1.089-5.124;P=0.030),difficult cannulation(AOR=4.527;95%CI:2.078-9.860;P<0.001),and patients with cholangitis(AOR=3.261;95%CI:1.204-8.832;P=0.020)were strongly associated with a higher rate of post-ERCP pancreatitis.CONCLUSION Advanced age has not been proved to be a risk factor for difficult cannulation,and secondary cannulation techniques can be safely and efficaciously utilized in this group.Patients with a Charlson Comorbidity Index≥2 and difficult cannulation are associated with an increased overall adverse events rate,while age≥80 years is not.

Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery

Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.

Use of Laryngeal Mask Airway in the Management of a Difficult Airway: A Case Report

Background: Difficulty in management of the airway occurs most frequently in patients who have Mallampati grade III and IV, and other unfavourable airway findings like short neck, restriction in range of motion of the temporoman-dibular joints and inadequate neck flexion and extension. Because of unavailability of fibreoptic bronchoscopes or inexperience in their use, laryngeal mask airway (LMA) has become a common and acceptable airway management option. This is a case report of a postmenopausal woman who had her airway managed with LMA following initial failed intubation necessitating a rescheduling of the operation. Result: The patient had a successful surgery and postoperative recovery was uneventful. Conclusion: The LMA is a useful option in the management of an anticipated or unexpected difficult airway, especially in resource-poor settings where fibreoptic bronchoscopes may not be readily available.

Immediate balloon deflation method in endoscopic papillary large balloon dilation for extraction of difficult bile duct stones

Background/Aims: Recently, endoscopic papillary large balloon dilation (EPLBD) using a large balloon (12 - 20 mm) for extraction of difficult common bile duct (CBD) stones has been widely accepted with favorable outcomes. However, there is no consensus with regard to the ballooning time. The aim of our study was to evaluate the efficacy and safety of immediate balloon deflation in EPLBD for the treatment of difficult bile duct stone. Methods: This was a retrospective study of 80 consecutive patients with bile duct stones who were treated with an immediate balloon deflation method in EPLBD combined with endoscopic sphincterotomy (EST) between January 2010 and December 2012. Overall success rate, success rate at first ERCP, and the frequency of mechanical lithotripsy for complete stone removal were assessed for efficacy and safety was evaluated by assessing major complications. Results: Overall success rate for complete stone removal was high (78/80, 97.5%) and success rate for complete stone removal at first ERCP was 86.3% (69/80). The use of mechanical lithotripsy was 0% (0/80). The overall complication rate was favorable (5/80, 6.3%). PostERCP pancreatitis was observed in 3 patients (two: mild, one: moderate). In subgroup analysis, the presence of periampullary diverticulum was the only factor affecting the success rate at first ERCP. Conclusion: This study demonstrated the favorable outcome of immediate balloon deflation for treatment of difficult CBD stones and can be considered for clinical application.

Change in management of predicted difficult airways following introduction of video laryngoscopes

AIM To determine if video laryngoscopy(VL) has significantly impacted management of difficult airways by decreasing the rate of awake fiberoptic intubation(FOI). METHODS Anesthetic records of 3723 patients who underwent general anesthesia at Rush University Medical Center were reviewed over a 2-mo period prior to the introduction of VLs in 2009("pre-VL" group) and over the same 2-mo period after the introduction of VLs in 2012("postVL" group). Patient records with predicted difficult air-ways based on pre-operative airway examination were analyzed. The primary outcome was rate of awake FOI.RESULTS To control for possible factors that may influence the FOI rate, a logistic regression was performed with these factors included as covariates. The rate of awake FOI was 13.1% in pre-VL group compared to 9.0% in post-VL group. Although this decrease was not statistically significant individually(P = 0.1768), it showed a trend toward significance when covariates were accounted for(P = 0.0910). Several factors predicting a higherlikelihood of awake FOI were found to be statistically significant: Morbid obesity(larger BMI P = 0.0154, OR = 1.5 per 10 point BMI increase), male gender(P = 0.0026, OR = 3.0) and a higher el-Ganzouri airway score(P = 0.0007, OR = 1.5). Although VLs were seen to be used to intubate 51% of predicted difficult airways, the rate of awake FOI has not significantly changed.CONCLUSION Although VL may continue to grow in popularity, the most difficult airways are still managed using awake FOI.