美国新生儿重症监护室床旁即时超声检查的临床方案解读

2022年12月美国儿科学会发布了新生儿重症监护室(neonatal intensive care unit,NICU)床旁即时超声检查(point-of-care ultrasonography,POCUS)的临床方案。该方案概述了NICU中POCUS的发展和现状,并对NICU顺利开展POCUS的核心要素和实施准则进行了总结。该文对该临床方案的要点进行了解读,并对国内POCUS的开展现状进行了分析,为国内新生儿科开展POCUS提供参考。

Bacterial presence on flexible endoscopes vs time since disinfection

AIM To correlate the length of endoscope hang time and number of bacteria cultured prior to use.METHODS Prospectively, we cultured specimens from 19 gastroscopes, 24 colonoscopes and 5 side viewing duodenoscopes during the period of 2011 to 2015. A total of 164 results had complete data denoting date of cleansing, number of days stored and culture results. All scopes underwent initial cleaning in the endoscopy suite utilizing tap water, and then manually cleaned and flushed. High level disinfection was achieved with a Medivator~? DSD(Medivator Inc., United States) automated endoscope reprocessor following manufacturer instructions, with Glutacide~?(Pharmax Limited, Canada), a 2% glutaraldehyde solution. After disinfection, all scopes were stored in dust free, unfiltered commercial cabinets for up to 7 d. Prior to use, all scopes were sampled and plated on sheep blood agar for 48 h; the colony count was obtained from each plate. The length of endoscope hang time and bacterial load was analyzed utilizing unpaired t-tests. The overall percentage of positive and negative cultures for each type of endoscope was also calculated. RESULTS All culture results were within the acceptable range(less than 200 cfu/mL). One colonoscope cultured 80 cfu/mL after hanging for 1 d, which was the highest count. ERCP scopes cultured at most 10 cfu, this occurred after 2 and 7 d, and gastroscopes cultured 50 cfu/mL at most, at 1 d. Most cultures were negative for growth, irrespective of the length of hang time. Furthermore, all scopes, with the exception of one colonoscope which had two positive cultures(each of 10 cfu/mL), had at most one positive culture. There was no significant difference in the number of bacteria cultured after 1 d compared to 7 d when all scopes were combined(day 2: P = 0.515; day 3: P = identical; day 4: P = 0.071; day 5: P = 0.470; day 6: P = 0.584; day 7: P = 0.575). There was also no significant difference in the number of bacteria cultured after 1 day compared to 7 d for gastroscopes(day 2: P = 0.895; day 3: P = identical; day 4: P = identical; day 5: P = 0.893; day 6: P = identical; day 7: P = 0.756), colonoscopes(day 2: P = 0.489; day 4: P = 0.493; day 5: P = 0.324; day 6: P = 0.526; day 7: P = identical), or ERCP scopes(day 2: P = identical; day 7: P = 0.685). CONCLUSION There is no correlation between hang time and bacterial load. Endoscopes do not need to be reprocessed if reused within a period of 7 d.

Evaluation of TB elimination strategies in Canadian Inuit populations:Nunavut as a case study

Tuberculosis(TB)continues to disproportionately affect Inuit populations in Canada with some communities having over 300 times higher rate of active TB than Canadian-born,non-Indigenous people.Inuit Tuberculosis Elimination Framework has set the goal of reducing active TB incidence by at least 50%by 2025,aiming to eliminate it by 2030.Whether these goals are achievable with available resources and treatment regimens currently in practice has not been evaluated.We developed an agent-based model of TB transmission to evaluate timelines and milestones attainable in Nunavut,Canada by including case findings,contact-tracing and testing,treatment of latent TB infection(LTBI),and the government investment on housing infrastructure to reduce the average house-hold size.The model was calibrated to ten years of TB incidence data,and simulated for 20 years to project program outcomes.We found that,under a range of plausible scenarios with tracing and testing of 25%e100%of frequent contacts of detected active cases,the goal of 50%reduction in annual incidence by 2025 is not achievable.If active TB cases are identified rapidly within one week of becoming symptomatic,then the annual incidence would reduce below 100 per 100,000 population,with 50%reduction being met between 2025 and 2030.Eliminating TB from Inuit populations would require high rates of contacttracing and would extend beyond 2030.The findings indicate that time-to-identification of active TB is a critical factor determining program effectiveness,suggesting that investment in resources for rapid case detection is fundamental to controlling TB.

Using data from‘visible’populations to estimate the size and importance of‘hidden’populations in an epidemic:A modelling technique

We used reported behavioural data from cisgender men who have sex with men and transgender women(MSM/TGW)in Bangalore,mainly collected from‘hot-spot’locations that attract MSM/TGW,to illustrate a technique to deal with potential issues with the representativeness of this sample.A deterministic dynamic model of HIV transmission was developed,incorporating three subgroups of MSM/TGW,grouped according to their reported predominant sexual role(insertive,receptive or versatile).Using mathematical modelling and data triangulation for‘balancing’numbers of partners and role preferences,we compared three different approaches to determine if our technique could be useful for inferring characteristics of a more‘hidden’insertive MSM subpopulation,and explored their potential importance for the HIV epidemic.Projections for 2009 across all three approaches suggest that HIV prevalence among insertive MSM was likely to be less than half that recorded in the surveys(4.5e6.5%versus 13.1%),but that the relative size of this subgroup was over four times larger(61e69%of all MSM/TGW versus 15%).We infer that the insertive MSM accounted for 10e20%of all prevalent HIV infections among urban males aged 15e49.Mathematical modelling can be used with data on‘visible’MSM/TGW to provide insights into the characteristics of‘hidden’MSM.A greater understanding of the sexual behaviour of all MSM/TGW is important for effective HIV programming.More broadly,a hidden subgroup with a lower infectious disease prevalence than more visible subgroups,has the potential to contain more infections,if the hidden subgroup is considerably larger in size.

Surgical management of the diaphragmatic defect in congenital diaphragmatic hernia:a contemporary review

Worldwide,150 children are born each day with congenital diaphragmatic hernia(CDH),a diaphragmatic defect with concomitant abnormal lung development.Patients with CDH with large defects are particularly challenging to treat,have the highest mortality,and are at significant risk of long-term complications.Advances in prenatal and neonatal treatments have improved survival in high-risk patients with CDH,but surgical treatment of large defects lacks standardization.Open repair by an abdominal approach has long been considered the traditional procedure,but the type of defect repair(patch or muscle flap)and patch material(non-absorbable,synthetic or absorbable,biological)remain subjects of debate.Increased experience and improved techniques in minimally invasive surgery(MIS)have expanded selection criteria for thoracoscopic defect repair in cardiopulmonary stable patients with small defects.However,the application of MIS to repair large defects remains controversial due to increased recurrence rates and unknown long-term effects of perioperative hypercapnia and acidosis resulting from capnothorax and reduced ventilation.Current recommendations on the surgical management rely on cohort studies of varying patient numbers and data on the long-term outcomes are sparse.Here,we discuss surgical approaches for diaphragmatic defect repair highlighting advancements,and knowledge gaps in surgical techniques(open surgery and MIS),patch materials and muscle flaps for large defects,as well as procedural adjuncts and management of CDH variants.

Respective IL-17A production by γδ T and Th17 cells and its implication in host defense against chlamydial lung infection

The role of IL-17A is important in protection against lung infection with Chlamydiae,an obligate intracellular bacterial pathogen.In this study,we explored the producers of IL-17A in chlamydial lung infection and specifically tested the role of major IL-17A producers in protective immunity.We found thatγδT cells and Th17 cells are the major producers of IL-17A at the early and later stages of chlamydial infection,respectively.Depletion ofγδT cells in vivo at the early postinfection(p.i.)stage,when mostγδT cells produce IL-17A,failed to alter Th1 responses and bacterial clearance.In contrast,the blockade of IL-17A at the time when IL-17A was mainly produced by Th17(day 7 p.i.)markedly reduced the Th1 response and increased chlamydial growth.The data suggest that theγδT cell is the highest producer of IL-17A in the very early stages of infection,but the protection conferred by IL-17A is mainly mediated by Th17 cells.In addition,we found that depletion ofγδT cells reduced IL-1αproduction by dendritic cells,which was associated with a reduced Th17 response.This finding is helpful to understand the variable role of IL-17A in different infections and to develop preventive and therapeutic approaches against infectious diseases by targeting IL-17A.

Carbon nanomaterials for cardiovascular theranostics:Promises and challenges

Cardiovascular diseases(CVDs)are the leading cause of death worldwide.Heart attack and stroke cause irreversible tissue damage.The currently available treatment options are limited to“damage-control”rather than tissue repair.The recent advances in nanomaterials have offered novel approaches to restore tissue function after injury.In particular,carbon nanomaterials(CNMs)have shown significant promise to bridge the gap in clinical translation of biomaterial based therapies.This family of carbon allotropes(including graphenes,carbon nanotubes and fullerenes)have unique physiochemical properties,including exceptional mechanical strength,electrical conductivity,chemical behaviour,thermal stability and optical properties.These intrinsic properties make CNMs ideal materials for use in cardiovascular theranostics.This review is focused on recent efforts in the diagnosis and treatment of heart diseases using graphenes and carbon nanotubes.The first section introduces currently available derivatives of graphenes and carbon nanotubes and discusses some of the key characteristics of these materials.The second section covers their application in drug delivery,biosensors,tissue engineering and immunomodulation with a focus on cardiovascular applications.The final section discusses current shortcomings and limitations of CNMs in cardiovascular applications and reviews ongoing efforts to address these concerns and to bring CNMs from bench to bedside.

Immunomodulators:still having a role?

Immunomodulators,particularly the thiopurines and to a lesser extent methotrexate,were standard of care for inflammatory bowel diseases,including Crohn’s disease and ulcerative colitis,for>40 years.While there has been a renaissance in available therapies with the advent of biologics and small molecules,an impetus remains for the ongoing use of thiopurines and methotrexate.This is particularly true for the maintenance of remission and when used in combination therapy with infliximab to suppress anti-biologic antibodies.This article summarizes the data behind immunomodulator use in Crohn’s disease,focusing on the beneficial role these drugs still have while acknowledging their clinical limitations.