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艾司西酞普兰与喹硫平联合治疗首发抑郁症的效果分析

DOI:10.16662/ki.1674-0742.2021.33.089艾司西酞普兰与喹硫平联合治疗首发抑郁症的效果分析杨晓江泉州市第三医院精神科,福建泉州362121[摘要]目的探讨艾司西酞普兰与喹硫平联合治疗首发抑郁症的效果。

方法方便选取2018年1月—2020年12月在该院就诊的116例首发抑郁症患者为研究对象,以随机数表法将其划分为两组。

对照组58例患者应用艾司西酞普兰治疗,研究组58例在此基础上联合喹硫平治疗。

比较两组患者的临床疗效、治疗前后的神经因子水平[髓鞘间隙蛋白(MBP)与神经营养因子(BDNF)],治疗前、治疗4周与8周时的认知功能[以重复性成套神经心理状态测验(RBANS)评价]以及不良反应情况。

结果研究组治疗的总有效率为94.83%较对照组79.31%高,差异有统计学意义(χ2=6.202,P<0.05)。

治疗后,研究组MBP(4.52±0.85)ng/mL较对照组(5.79±0.69)ng/mL低,BDNF(27.52±4.03)ng/mL较对照组(24.33±5.00)ng/mL高,差异有统计学意义(t=8.834、3.783,P<0.05)。

治疗4周与8周时,研究组RBANS评分(73.52±10.00)分、(78.62±10.40)分较对照组高(68.03±8.46)分、(71.32±9.05)分,差异有统计学意义(t=3.192,4.033,P<0.05)。

研究组不良反应发生率为10.34%,对照组不良反应发生率为8.62%,差异无统计学意义(χ2=0.100,P>0.05)。

结论首发抑郁症患者应用艾司西酞普兰与喹硫平联合治疗能够提高临床疗效,改善神经因子水平与认知功能,安全性佳,具有临床推广价值。

[关键词]艾司西酞普兰;喹硫平;首发抑郁症[中图分类号]R5[文献标识码]A[文章编号]1674-0742(2021)11(c)-0089-04. All Rights Reserved.Analysis of the Effect of Escitalopram and Quetiapine in the Treatment ofFirst-episode DepressionYANG XiaojiangDepartment of Psychiatry,Quanzhou Third Hospital,Quanzhou,Fujian Province,362121China[Abstract]Objective To explore the effect of escitalopram and quetiapine in the treatment of first-episode depression.Methods Conveniently selected the116first-episode depression patients who visited the hospital from January2018toDecember2020for research.They were divided into two groups using a random number table.58patients in the controlgroup were treated with escitalopram,and58patients in the study group were treated with quetiapine on this basis.Compared the clinical efficacy of the two groups of patients,the levels of neurological factors[myelin interstitial protein(MBP)and neurotrophic factor(BDNF)]before and after treatment,and the cognitive function[in a repetitive set ofneuropsychological status test(RBANS)evaluation]before and after treatment,4weeks and8weeks of treatment,andadverse reactions.Results The total effective rate of treatment in the study group was94.83%higher than79.31%in thecontrol group,the difference was statistically significant(χ2=6.202,P<0.05).After treatment,MBP(4.52±0.85)ng/mL in thestudy group was lower than that in the control group(5.79±0.69)ng/mL,and BDNF(27.52±4.03)ng/mL was higher thanthat in the control group(24.33±5.00)ng/mL,the difference was statistically significant(t=8.834,3.783,P<0.05).In thetreatment of4weeks and8weeks,the RBANS score of the study group was(73.52±10.00)points and(78.62±10.40)pointshigher than that of the control group(68.03±8.46)points and(71.32±9.05)points,the difference was statistically significant(t=3.192,4.033,P<0.05).The incidence of adverse reactions in the study group was10.34%,and the incidence of adversereactions in the control group was8.62%,the difference was not statistically significant(χ2=0.100,P>0.05).Conclusion Thecombined treatment of escitalopram and quetiapine in patients with first-episode depression can improve the clinicalefficacy,improve the level of neurological factors and cognitive function,with good safety and clinical promotion value.[Key words]Escitalopram;Quetiapine;First episode depression[作者简介]杨晓江(1978-),男,本科,主治医师,研究方向为精神病。

学术英语医学 Unit 3

bout
• If you have a bout of an illness or of an unpleasant feeling, you have it for a short period. （疾病或不愉快情绪的）发作
• He was recovering from a severe bout of flu.
• 该公司显然处于发展的关键时刻。 • The company was clearly at a crossroads.
Unit 3 Prevention and Treatment
Text A Critical reading and thinking
of
Diseases
Topics for presentation
Task 1
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
40,000 56,300 Measures taken 13-64 82 22 African Americans Take Charge, Take the Test gained bisexual men development of a comprehensive HIV prevention plan for the united states
Causes
Treatments
Flu
Myopia Hepatitis
Unit 3 Prevention and
Lead-in
Treatment
of
Task: Work in pairs and discuss the causes and treatments you know of the following
3. What did Terry do before he self-experimented? (7-8 para.)

管理顾问

Reduce frequency of location change Reduce level of luxury
POSITIONIERUNG DER LOGIKBÄUME
Der Logikbaum kann … … das Problem strukturieren helfen
… Arbeitsschwerpunkte und den Projektfortschritt transparent machen
Source: McKinsey EFIC
6
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RANKINGS FOR MARKETING PURPOSES: ONE EXAMPLE
Source: The Economist
7
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RANKING ONE EXAMPLE: BOOKRUNNERS OF ALL INTERNATIONAL/ EUROBONDS
14
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PRINZIP DER STRUKTURIERTEN PROBLEMLÖSUNG
Vorteile der Strukturierung
• Leichtere Lösungsfindung
– Teilprobleme leichter überschaubar – Vollständigkeit gesichert – Schwerpunktthemen schneller erkennbar
How? – Type of costs How? – Quantity vs. price Reduce no. of days away Reduce hotel and food expenses Reduce costs per day away

超选择性子宫动脉栓塞治疗子宫肌瘤规范化操作探讨281例

论著·临床论坛CHINESE COMMUNITY DOCTORS 超选择性栓塞子宫动脉治疗子宫肌瘤以其创伤小，疗效好，保留子宫完整与功能，为广大子宫肌瘤患者所接受。

选取2003年5月-2016年8月经子宫动脉超选择性插管栓塞治疗的子宫肌瘤患者281例，治疗成功率达100%，为超选择性栓塞子宫动脉介入治疗子宫肌瘤积累了较丰富的经验。

根据实践，结合文献，从病例选择、术前准备、规范插管、规范栓塞、术后处理、并发症和不良反应防治等诸多方面归纳总结，以探讨超选择性栓塞子宫动脉治疗子宫肌瘤工作规范化。

术前注重选择病例(把握适应证)从如下方面把握适应证：①＜45岁、已生育、瘤体＜10cm、月经量增多是最佳适应证；②瘤体＞10cm，肌瘤位于浆膜下，临近绝经期，有生育要求的年轻患者或无症状的子宫肌瘤则需慎重；③排除子宫恶性肿瘤；④月经干净后10d 左右手术。

如下情况属于禁忌证，应予以排除：①妇科急慢性炎症未得到控制；②患有严重心、肝、肾重要脏器疾病；③凝血机制明显异常；④穿刺部位感染。

做好术前准备工作术前3d 碘伏阴道擦洗，1～2次/d，禁性生活。

血常规、胸片、心电图、盆腔B 超、肝功能等常规检查，刮宫涂片(细胞学检查)及盆腔MR 检查。

碘过敏试验。

留置导尿管和双侧腹股沟备皮。

将可能出现的各种风险、不良反应告知患者及家属并签字。

按规范化插管操作子宫肌瘤多由一侧或双侧子宫动脉供血。

经子宫动脉插管栓塞治疗子宫肌瘤一般需栓塞双侧子宫动脉，有时仅栓塞优势侧供血子宫动脉[1]。

选择拟穿刺侧股动脉：一般经对侧股动脉穿刺插管较易到达对侧子宫动脉，因此选择优势侧供血子宫动脉的对侧股动脉穿刺插管较易到达优势侧供血子宫动脉内。

根据B 超和MR 报告，大致判断优势侧子宫动脉供血，然后选择其对侧股动脉穿刺插管入路。

否则常规取右侧穿刺股动脉入路[2]。

穿刺股动脉：按Seldingers 法穿刺操作规范穿刺股动脉，上好动脉鞘，建立导管进出通道。

HarmonizingTradi...

Harmonizing Traditional Chinese and Modern Western Medicine: A Perspective from the USKa Kit Hui, M.D., F.A.C.P.Professor, Department of Medicine, UCLA School of Medicine; Director, UCLA Center for East-West MedicineThe current interest in traditional and complementary medicine in the United States is attracting attention in many parts of the community - the health care industry, governmental agencies, media and the public.1 An increasing number of insurers and managed care organizations are providing benefits for traditional medicine, a majority of U.S. medical schools now offer courses covering traditional medicine,2,3 and, as Eisenberg’s national studies have revealed, more people are using complementary therapies.4,5 To facilitate research on the effectiveness of alternative therapies, the National Center for Complementary and Alternative Medicine (NCCAM) received a budget of $50 million in 1999. Recognizing the need to encourage quality and quantity of scientific information on botanicals, as well as develop a systematic evaluation of safety and efficacy of dietary supplements, two research centers were also established this year to investigate the biological effects of botanicals.6Many patients are using traditional and modern medical paradigms concurrently, creating a need for the appropriate and smooth merger of the two medicines. The theories and techniques of traditional Chinese medicine (TCM) encompass most practices classified as complementary medicine in the United States, and have become increasingly important in the health care system.7 Traditional Chinese medicine is affordable, low tech, safe and effective when used appropriately. Ongoing research around the world on acupuncture, herbs, massage8,9 and Tai-Chi10,11 have shed light on some of the theories and practices of TCM. Evidence derived from vigorous research design12 as well as patient demand are fueling the merger of TCM with modern medicine at the clinical level, while more academic researchers and institutions are becoming more interested in the potential of integrating these two healing traditions. AcupunctureBased on evidence reviewed during the 1997 NIH Consensus Conference, the NIH Consensus Development Panel conservatively recommended that acupuncture may be used as an adjunct treatment, an alternative, or part of a comprehensive management program for a number of conditions. The panel ascertained that acupuncture can be used to treat post-operative and chemotherapy induced nausea and vomiting, as well as post-operative dental pain. It was also recommended as an adjunct treatment or an acceptable alternative for addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofacial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma.13Future clinical trials that test acupuncture within the framework of traditional Chinese medicine are likely to provide a more appropriate and clinically meaningful assessment of acupuncture efficacy than the current generation of clinical trials which use a diagnosis framed primarily in biomedical terms. The scientific rigor of current research must continue; however, the NIH approach towards data analysis is too strict and limits potentially useful indications. Unlike drugs, acupuncture is more akin to surgery and physical therapy in terms of therapeuticmodalities. Hence, the evaluation of evidence for efficacy in acupuncture ought to be similar to these therapeutic interventions. For the time being, evidence based on large case series should be considered in determining recommendations for clinical practice while evidence derived from more vigorous research designs are being carried out.In elucidating the mechanisms of acupuncture and exploring its role in a variety of situations, innovative techniques such as fMRI (functional magnetic resonance imaging),14 PET (positron emission tomography), SPECT (single photon emission computer tomography), and MEG (magnetoencephalography) are beginning to be utilized. Studies on acupuncture in terms of its neuroanatomic and neurophysiological bases, bioelectrical properties, analgesia effects, and its role in regulation in areas such as gastrointestinal, immunological and cardiovascular functions are being carried out. More intense research with increased funding and scientific vigor, in an out of the US, will likely uncover additional areas where acupuncture may prove useful. This will further drive the adoption of acupuncture as a common therapeutic modality, not only in treatment, but also in prevention of disease and promotion of wellness. With technological advancement, innovative methods of acupuncture point stimulation will continue to be explored and perfected. Basic research on acupuncture will also help facilitate improved understanding of neuroscience and other aspects of human physiology and function.Because of heightened patient demand and better understanding of the role of acupuncture in health care through research and clinical experience, the biomedical establishment, health insurance industries, physicians and other health care providers are beginning to take an interest in acupuncture. In time, those who do not embrace acupuncture will be at a disadvantage. As the efficacy and cost saving potential of acupuncture is more widely recognized, there will be an even stronger push for more insurance companies, medical groups, and even Medicare to provide coverage of acupuncture treatment. We will witness acupuncture being utilized increasingly in outpatient settings, hospitals, rehabilitation units and hospices. An increasing number of physician acupuncturists as well as non-physician acupuncturists are working in different clinical settings. Some licensed acupuncturist specialists will work side by side with MDs in specialized areas.In the new millennium, the practice of acupuncture will be guided not only by traditional Chinese medicine concepts, but also by data generated through research advances in diverse fields such as neuroscience, molecular biology, chronobiology, computer and information science, energetics, integrative physiology and innovative clinical trial methodology.Herbs*Humans and animals have tested and used botanicals to relieve their suffering since ancient times. The appropriate use of Chinese herbs requires proper TCM diagnosis of the zheng (pathophysiological pattern) of the patient, correct selection of the corresponding therapeutic strategies and principles that guide the choice of herbs and herbal formulas. When appropriately prepared and used, herbs can be safe and effective. However, when used without proper guidance, a wide array of complications may result.* Modified from Hui, K.K. “Summary and Conclusions” (1999). Botanical Medicine: Efficacy, Quality Assurance, and Regulation. Eskinazi, D. (ed.) New York: Mary Ann Liebert, Inc.15Modern scientific investigations on plant-based medicine have been carried out in many parts of the world, including clinical trials of botanical combination products. Clinical research methodologists should take the theoretical construct and clinical approach of TCM into consideration when designing trials. Research designs such as randomized controlled trials have advantages and disadvantages in determining the efficacy of any therapeutic intervention, and can be carried out for botanicals, as seen by a study on herbal formulas for irritable bowel syndrome.16 Yet, we should seek approaches other than conducting a clinical trial for each product to evaluate safety and efficacy. Alternatives to RCTs include quasi-experiments, cohort studies, case-control studies, and “N = 1” trials. These methods have their advantages and limitations but may be more suited to the evaluation of herbal efficacy. The accurate measures of patient-centered outcomes both generic and disease-specific are important regardless of the design of the study. Above all, the appropriate study design depends on the research question and hypothesis being tested.Evaluating evidence is both difficult and subjective. The synthesis of evidence is completely dependent on the completeness of the literature search, which is often not available for foreign studies, as well as the accuracy of evaluation. Also, there are situations when neither RCTs nor database analyses separately can answer the question of interest due to different populations being used in the various kinds of studies. Consensus in the real world of health care often requires using information that is less stringent than so-called hard data. Realizing this, we should recognize the research and practice of herbal therapies in China, Korea and Japan when making recommendations for clinical practice. The pharmacological basis for many herbs have been determined in these studies and, as long as safety is assured, their findings should be considered when making recommendations. It is essential that researchers and practitioners be educated in both traditional and western medicines in order to perform research appropriately and treat patients effectively.Integrative East-West MedicineHarmonizing traditional medicine and modern medicine is more than utilizing modern research design or scientific technology to assess traditional medicine; it should include assessment of the intrinsic value of traditional medicine in society. Political, economic and social factors play as equally an important role as research and education in the eventual blending of the two healing traditions.On the clinical level, blending involves the integration of the concepts and techniques of the two systems -- modern medicine’s analytical, quantitative, mechanistic approach with the systemic, holistic, individualistic approach of TCM. This framework is applied through the process of diagnosis, prevention, treatment, and rehabilitation and guides the use of the appropriate techniques, allowing the strengths of TCM to compensate for the weaknesses of modern western medicine. As our graying society falls victim to an increasing number of chronic illnesses, we need a health paradigm that solves problems and provides affordable, effective health care for all. We believe that integrative East-West medicine is a candidate for such a model of medicine.References1.Workshop on Alternative Medicine, Alternative Medicine: Expanding Medical Horizons, AReport to the National Institutes of Health on Alternative Medical Systems and Practices in the United States, 1992.2.Wetzel, M.S., Eisenberg, D.M., and Kaptchuk, T.J. (1998) Courses involving complementaryand alternative medicine at U.S. medical schools. JAMA, 280, 784-787.3.Hui, K.K., Yu, J., and Zylowska L. (in press) An innovative approach to teaching integrativeEast-West medicine to medical students and clinicians.4.Eisenberg, D.M., Foster, C., Kessler, R.C., et al. (1993) Unconventional medicine in theUnited States. N Engl J Med., 328, 246-252.5.Eisenberg, D.M., Davis, R.B., Ettner, S.L., Appel, S., Wilkey, S., Van Rompay, M., andKessler, R.C. (1998) Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. The Journal of American Medical Association, 280(18), 1569-1575.6.NIH (1999) Centers for dietary supplements research: botanicals [Internet] Available from:</grants/guide/rfa-files/RFA-OD-99-007.html> [Accessed March 23, 1999].7.Hui, K.K., Yu, J., and Zylowska L. (in press) The Progress of Chinese Medicine in the USA,The Way Forward for Chinese Medicine. Chan K and Lee H (eds.), Netherlands: Harwood Academic Publishers8.Field, T., Henteleff, T., Hernandez-Reif, M., Marting, E., Mavunda, K., Kuhn, C., andSchanberg, S. (1997b) Children with asthma have improved pulmonary functions after massage therapy. Journal of Pediatrics, 132, 854-858.9.Sunshine, W., Field, T., Schanberg, S., Quintino, O., Kilmer, T., Fierro, K., Burman, I.,Hashimoto, M., McBride, C., and Henteleff, T. (1996) Massage therapy and transcutaneous electrical stimulation effects on fibromyalgia. Journal of Clinical Rheumatology, 2, 18-22. 10.Wolf, S.L., Barnhart, H.X., Kutner, N.G., McNeely, E., Coogler, C., and Xu, T. (1996)Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized balance training. Journal of the American Geriatrics Society, 44(5), 489-497.11.Young, D.R., Appel, L.J., Jee, S., and Miller, E.R. 3rd. (1999) The effects of aerobic exerciseand Tai Chi on blood pressure in older people: results of a randomized trial. Journal of the American Geriatrics Society, 47(3), 277-284.12.Spencer, J.W., Jacobs, J.J. (1999). Complementary/Alternative Medicine: An Evidence-BasedApproach. Missouri: Mary Ann Liebert, Inc.13.NIH Consensus Conference (1998) Acupuncture. JAMA, 280(17), 1518-1524.14.Cho, Z.H., Chung, S.C., Jones, J.P., Park, H.J., Wong, E.K., and Min, B.I. (1998) Newfindings of the correlation between acupoints and corresponding brain cortices using functional MRI. Proc. Natl. Acad. Sci., 95, 2670-2673.15.Hui, K.K. “Summary and Conclusions” (1999). Botanical Medicine: Efficacy, QualityAssurance, and Regulation. Eskinazi, D. (ed.) New York: Mary Ann Liebert, Inc., p. 79. 16.Bensoussan, A., Talley, N.J., Hing, M., et. al. (1998) Treatment of irritable bowel syndromewith Chinese herbal medicine: a randomized controlled trial. The Journal of American Medical Association, 280(18), 1585-1589.。

submission to first decision (median

submission to first decision (medianDear [Editor's Name],I am writing to submit the manuscript titled "Examining the Relationship Between Exercise and Mental Health: A Cross-Sectional Study" for consideration for publication in [Journal Name].In this study, we aimed to investigate the association between exercise and mental health utilizing a cross-sectional design. Our findings provide valuable insights into the potential benefits of regular physical activity on mental well-being.The study sample consisted of 500 participants aged 18-65 years, recruited from various community centers and fitness facilities. Participants completed self-report measures assessing exercise frequency, intensity, and duration, as well as mental health indicators, including stress, anxiety, and depression levels. Statistical analyses were performed to examine the correlation between exercise and mental health variables, controlling for relevant demographic factors.Our results indicated a significant negative correlation between exercise frequency and mental health symptoms, suggesting that individuals who engaged in regular physical activity experienced lower levels of stress, anxiety, and depression. Additionally, exercise intensity and duration demonstrated modest but favorable associations with mental well-being. These findings highlight the importance of incorporating exercise into mental health interventions and support the growing body of literatureadvocating for exercise as a potential adjunctive treatment for mental health conditions.Our study contributes to the existing literature by addressing the limitations of previous research within this domain. By utilizing a larger sample size and assessing various dimensions of exercise, we provide a more comprehensive understanding of the exercise-mental health relationship. Furthermore, our findings emphasize the generalizability of these associations across diverse population groups, thereby broadening the potential applications of exercise interventions for mental health improvement.We believe that our manuscript aligns well with the scope and objectives of [Journal Name], and it is of interest to the journal's readership. We strongly believe that this study's findings have important implications for clinical practice and public health policies.Thank you for considering our submission. We look forward to hearing your decision and working with you on any necessary revisions to further improve the manuscript.Sincerely,[Your Name][Your Affiliation][Contact Information]。

脑卒中后康复早期抗抑郁治疗的效果

近些年，我国心脑血管发病率比以往有所升高，而脑卒中在脑血管疾病当中尤为多见，此疾病临床症状多体现为失语、认知障碍、偏瘫等[1]。

故尽早采取及时、有效的治疗和康复措施，对降低脑卒中的致残率有着重要意义。

但是由于其治疗与康复的时间较长，大多患者都会在此期间产生情绪波动，如抑郁、焦虑等异常心理，对治疗没有信心，致使治疗依从性也相应下降[2]，对患者的康复治疗成效以及生存质量都造成了严重影响。

因此，在治疗与康复期间还应做好早期抗抑郁治疗，以消除患者悲观、恐惧、消极等情绪。

资料与方法2016年4月-2017年5月收治脑卒中患者64例，随机分为对照组和试验组，各32例。

对照组男20例，女12例；年龄48～70岁，平均(54.6±6.8)岁；病程2～18d，平均(14.5±2.1)d；抑郁程度为中度27例，重度5例；脑梗死17例，脑出血15例。

试验组男19例，女13例；年龄47～71岁，平均(55.3±6.2)岁；病程1.5～17d，平均(14.7±2.5)d；抑郁程度为中度25例，重度7例；脑梗死18例，脑出血14例。

两组性别、年龄、病程、病情以及抑郁程度等基本资料比较，差异无统计学意义(P＞0.05)。

方法：两组都进行常规治疗，主要包括肌力训练、关节活动度训练、体位摆放训练、肢体平衡训练、肢体协调与行走训练等，帮助患者恢复运动功能与神经肌肉功能。

同时还给予语言交流、视觉刺激、牵引与挤压等锻炼。

试验组在上述基础上再联合药物治疗与心理治疗，应用抗抑郁药物氟西汀给予患者口服，10mg/次，2次/d。

由于突发的疾病给患者的生活与工作都带来了严重影响，患者身心疲惫，较易出现一系列的异常情绪，如恐惧、焦虑、担心、烦躁等心理。

并对治疗效果存在疑虑，出现消极逃避的心态，对治疗造成了不利影响。

因此对患者进行及时、有效的心理疏导非常重要，应主动与其交流，讲解脑卒中的患病原因、病情发展、影响因素、治疗方法以及预后，让患者对此疾病的认知得以提升；耐心倾听患者内心的想法，对其所存在的异常情绪与疑虑给予疏导和解答，对患者目前的情况表示理解与支持，多给予其安慰，获取患者的认可与信任，给其提供情感寄托；督促患者进行积极的康复锻炼，告知其对康复的重要意义，促使患者主动配合治疗与锻炼，争取早日康复。

循证医学与系统评价诊断学

Critically appraising systematic reviews
1. What are the review’s objectives? To focus on well-defined questions, stating the populations, intervention/control groups, and outcomes to be included. 2. How comprehensive was the search strategy? To search for all the literature relevant to the question. Published and unpublished literature should be sought, any restrictions regarding language of publication should be stated and justified, as should the time period covered by the search. Ideally a systematic review needs to be up to date, incorporating all the recent literature.
How to produce a Systematic Review?
How is a systematic review conducted?
First step: to specify a tight question. population (group to whom the intervention will apply), intervention (the therapy, treatment or preventive policy to be carried out), comparison (what will the intervention be compared against – it could be a common alternative intervention, a placebo or no intervention) and outcomes (what do we wish to measure at the end, what is important to us and to consumers?).

mell practice is tort

mell practice is tort Mell Practice Is Tort: A Discussion on the Detrimental Effects of Mell Practice to Patients and Healthcare ProfessionalsFor a healthcare professional, practice is not just a series of steps taken to treat a patient. Rather, it encompasses every aspect of thepatient's treatment, from the initial diagnosis to post-treatment care, ensuring that every aspect of the patient's well-being is met. As such, medical practice is an intricate and challenging process that demands expertise, skill, and attention to detail.However, not all practice techniques employed by healthcare professionals are created equal. Some practices, such as mell practice, have been noted to have detrimental effects on the patients and the healthcare professionals themselves.Mell practice, also known as "shortcuts," "workarounds," or "gaming the system," refers to the tendency of healthcare professionals to acknowledge guidelines or processes in asuperficial manner, and then bypass them to save time or effort. For example, some healthcare providers may fabricate vital signs to avoid administering certain treatments or tests, while others may alter medication doses based on personal experiences rather than best practices.These shortcuts may seem like minor adjustments to healthcare professionals, but they have a severe impact on patient care. For example, billing codes are reliant on specific documentation, sofabricated vitals could lead to incorrect coding and a loss of revenue for the hospital, while altered medication doses could cause harm or even death to the patient.Mell practice has also been noted to increase healthcare professional burnout, stress, and dissatisfaction. Healthcare professionals who rely on mell practices tend to have a lower sense of accomplishment, as they are not able to provide optimal care or treatment to their patients. Furthermore, they may be constantly worried about being caught and punished for their actions.The detrimental effects of mell practice go beyond individual healthcare professionals or patients. On a more systemic level, mell practices could lead to inefficiencies in the healthcare system. For example, the use of fabricated vitals could result in underutilized hospital resources, as patients who do not require urgent care are unnecessarily admitted.Moreover, mell practices could erode thepublic's trust in healthcare professionals and the healthcare system as a whole. Patients may become increasingly cynical of the healthcare providers and may be less likely to seek medical attention or adhere to treatment plans.In response to the detrimental effects of mell practice, some healthcare organizations have implemented strategies to reduce their prevalence. For example, some hospitals have encouraged a culture of safety and open communication, where healthcare professionals are encouraged to speak up when they notice violations of best practices.Furthermore, some organizations have mandated additional training for healthcare professionals,to ensure that they have the skills and knowledgeto provide high-quality patient care. Other organizations have implemented technology such as electronic health records (EHRs), to reduce documentation errors and provide oversight.In conclusion, mell practice is a dangerous and highly prevalent phenomenon in healthcare. It has the potential to cause significant harm and inefficiencies in the healthcare system. Therefore, it is essential that healthcare providers betrained and equipped to provide the best possible care to patients. At the same time, healthcare organizations should foster a culture of safety and open communication to reduce the prevalence of mell practices. Ultimately, the goal should be to promote the well-being of both patients and healthcare professionals, ensuring that the healthcare system as a whole functions at its best.。

2015+腹腔内感染管理指南

GuidelinesGuidelines for management of intra-abdominal infectionsPhilippe Montravers a,*,Herve´Dupont b,Marc Leone c,Jean-Michel Constantin d,Paul-Michel Mertes e,and the Socie´te´franc¸aise d’anesthe´sie et de re´animation(Sfar),Socie´te´de re´animation de langue franc¸aise(SRLF),Pierre-Francois Laterre f,Benoit Misset g,Socie´te´de pathologie infectieuse de langue franc¸aise(SPILF),Jean-Pierre Bru h,Re´my Gauzit i,Albert Sotto j,Association franc¸aise de chirurgie(AFC),Cecile Brigand k,Antoine Hamy l,Socie´te´franc¸aise de chirurgie digestive(SFCD),Jean-Jacques Tuech ma De´partement d’anesthe´sie-re´animation,CHU Bichat–Claude-Bernard,AP–HP,universite´Paris VII Sorbonne Cite´,46,rue Henri-Huchard,75018Paris,Franceb Poˆle anesthe´sie-re´animation,CHU d’Amiens,80054Amiens,Francec De´partement d’anesthe´sie-re´animation,CHU Nord,13915Marseille,Franced Service d’anesthe´sie-re´animation,CHU Estaing,63003Clermont-Ferrand,Francee Service d’anesthe´sie-re´animation,CHU de Strasbourg,Nouvel Hopital Civil,BP426,67091Strasbourg,Francef Service de soins intensifs,cliniques universitaires Saint-Luc,Bruxelles,Belgiumg Re´animation polyvalente,hoˆpital Saint-Joseph,75014Paris,Franceh Service des maladies infectieuses,centre hospitalier de la re´gion d’Annecy,74374Pringy,Francei Re´animation thoracique Ollier,CHU Cochin,27,rue du Faubourg-Saint-Jacques,75014Paris,Francej Service des maladies infectieuses et tropicales,CHRU de Nıˆmes,Nıˆmes,Francek Service de chirurgie ge´ne´rale et digestive,hoˆpital Hautepierre,CHU de Strasbourg,Strasbourg,Francel Service de chirurgie visce´rale,CHU d’Angers,Angers,Francem Service de chirurgie ge´ne´rale et digestive,CHU Charles-Nicolle,Rouen,FranceAnaesth Crit Care Pain Med34(2015)117–130A R T I C L E I N F OArticle history:Available online24April2015A B S T R A C TIntra-abdominal infections are one of the most common gastrointestinal emergencies and a leadingcause of septic shock.A consensus conference on the management of community-acquiredperitonitis was published in2000.A new consensus as well as new guidelines for less commonsituations such as peritonitis in paediatrics and healthcare-associated infections had becomenecessary.The objectives of these Clinical Practice Guidelines(CPGs)were therefore to deﬁne themedical and surgical management of community-acquired intra-abdominal infections,deﬁne thespeciﬁcities of intra-abdominal infections in children and describe the management of healthcare-associated infections.The literature review was divided into six main themes:diagnostic approach,infection source control,microbiological data,paediatric speciﬁcities,medical treatment ofperitonitis,and management of complications.The GRADE1methodology was applied to determinethe level of evidence and the strength of recommendations.After summarising the work of theexperts and application of the GRADE1method,62recommendations were formally deﬁned by theorganisation committee.Recommendations were then submitted to and amended by a reviewcommittee.After2rounds of Delphi scoring and various amendments,a strong agreement wasobtained for44(100%)recommendations.The CPGs for peritonitis are therefore based on a consensusbetween the various disciplines involved in the management of these patients concerning a numberof themes such as:diagnostic strategy and the place of imaging;time to management;the place ofmicrobiological specimens;targets of empirical anti-infective therapy;duration of anti-infectivetherapy.The CPGs also speciﬁed the value and the place of certain practices such as:the place oflaparoscopy;the indications for image-guided percutaneous drainage;indications for the treatmentof enterococci and fungi.The CPGs also conﬁrmed the futility of certain practices such as:the use*Corresponding author.E-mail address:philippe.montravers@bch.aphp.fr(P.Montravers)./10.1016/j.accpm.2015.03.0052352-5568/ß2015Socie´te´franc¸aise d’anesthe´sie et de re´animation(Sfar).Published by Elsevier Masson SAS.All rights reserved.1.Work group leadersJ.M.Constantin,Clermont-Ferrand terre,Brussels R.Gauzit,ParisK.Asehnoune,Nantes C.Paugam,ClichyP.F.Perrigault,Montpellier2.Work groupsExperts representing their learned society are designated by the society’s acronym.Invited experts are designated by their specialty.Diagnosis of intra-abdominal infection J.M.Constantin,Clermont-Ferrand (Sfar)J.Cazejust,Paris (Radiologist)E.Gre´goire,Marseille (Surgeon)M.Leone,Marseille (Sfar)T.Lescot,Paris (Anaesthetist-Intensive Care Physician)J.Morel,Saint-E´tienne (Anaesthetist-Intensive Care Physician)A.Sotto,Nıˆmes (SPILF)J.J.Tuech,Rouen (AFCD)Infection source control terre,Brussels (SRLF)C.Brigand,Strasbourg (AFC)socki,Angers (Anaesthetist-Intensive Care Physician)G.Plantefeve,Argenteuil (Intensive Care Physician)C.Tassin,Lyon (Anaesthetist-Intensive Care Physician)Contribution of microbiology R.Gauzit,Paris (SPILF)P.Augustin,Paris (Anaesthetist-Intensive Care Physician)A.Friggeri Pierre-Be ´nite (Anaesthetist-Intensive Care Physi-cian)C.Hennequin,Paris (Mycologist)Y.Pean,Paris (Microbiologist)A.Roquilly,Nantes (Anaesthetist-Intensive Care Physician)P.Seguin,Rennes (Anaesthetist-Intensive Care Physician)Speciﬁcities of paediatric intra-abdominal infectionsK.Asehnoune,Nantes (Anaesthetist-Intensive Care Physician)C.Daurel,Caen (Microbiologist)R.Dumont,Nantes (Anaesthetist-Intensive Care Physician)C.Jeudy,Angers (Anaesthetist-Intensive Care Physician)S.Irtant,Paris (Surgeon)Medical treatment of intra-abdominal infectionsC.Paugam,Clichy (Anaesthetist-Intensive Care Physician)J.P.Bru,Annecy (SPILF)C.Dahyot,Poitiers (Anaesthetist-Intensive Care Physician)L.Dubreuil,Lille (Microbiologist)G.Dufour,Paris (Anaesthetist-Intensive Care Physician)B.Jung,Montpellier (Anaesthetist-Intensive Care Physician)J.Pottecher,Strasbourg (Anaesthetist-Intensive Care Physician)Complications of intra-abdominal infectionsP.F.Perrigault,Montpellier (Anaesthetist-Intensive Care Physi-cian)A.Hamy,Angers (AFC)N.Kermarrec,Antony (Anaesthetist-Intensive Care Physician)unay,Rennes (Anaesthetist-Intensive Care Physician)B.Misset,Paris (SRLF)L.Ribeiro Parenti,Paris (Surgeon)B.Veber,Rouen (Anaesthetist-Intensive Care Physician)T.Yzet,Amiens (Radiologist)3.Review committeeK.Asehnoune,Nantes (Anaesthetist-Intensive Care Physician),P.Augustin,Paris (Anaesthetist-Intensive Care Physician),C.Brigand,Strasbourg (AFC),J.P.Bru,Annecy (SPILF),J.M.Constantin,Clermont-Ferrand (Sfar), C.Dahyot,Poitiers (Anaesthetist-Intensive Care Physician), C.Daurel,Caen (Microbiologist),L.Dubreuil,Lille (Microbiologist),G.Dufour,Paris (Anaesthetist-Intensive Care Physician),R.Dumont,Nantes (Anaesthetist-Intensive Care Physi-cian),H.Dupont,Amiens (Sfar),A.Friggeri,Pierre-Be´nite (Anaesthe-tist-Intensive Care Physician),R.Gauzit,Paris (SPILF),A.Hamy,Angers (AFC),C.Hennequin,Paris (Mycologist),C.Jeudy,Angers (Anaesthetist-Intensive Care Physician),B.Jung,Montpellier (Anaes-thetist-Intensive Care Physician),N.Kermarrec,Antony (Anaesthe-tist-Intensive Care Physician),unay,Rennes (Anaesthetist-Intensive Care Physician),socki,Angers (Anaesthetist-Intensive Care Physician),terre,Brussels (SRLF),M.Leone,Marseille (far),T.Lescot,Paris (Anaesthetist-Intensive Care Physician),B.Misset,Paris (SRLF),P.M.Mertes,Nancy (Sfar),P.Montravers,Paris (Sfar),J.Morel,St Etienne (Anaesthetist-Intensive Care Physician),C.Paugam,Clichy (Anaesthetist-Intensive Care Physician),Y.Pean,Paris (Microbiologist),P.F.Perrigault,Montpellier (Anaesthetist-Intensive Care Physician),G.Plantefeve,Argenteuil (Intensive Care Physician),J.Pottecher,Strasbourg (Anaesthetist-Intensive Care Physician),L.Ribeiro Parenti,Paris (Surgeon),A.Roquilly,Nantes (Anaesthetist-Intensive Care Physician),P.Seguin,Rennes (Anaes-thetist-Intensive Care Physician),A.Sotto,Nimes (SPILF),J.J.Tuech,Rouen (AFCD),B.Veber,Rouen (Anaesthetist-Intensive Care Physi-cian).4.Introduction4.1.BackgroundThe ﬁrst French consensus conference on the management of community-acquired peritonitis was published in 2000.The conclusions of this consensus conference needed to be updated in the light of the abundant literature,a number of international guidelines that fail to take into account all of the factors speciﬁc to France,changing practices and surgical techniques,the growth of bacterial resistance and the availability of new molecules in the therapeutic armamentarium.Revision of these clinical practiceguidelines was therefore conducted jointly by the Socie ´te ´franc ¸aised’anesthe´sie et de re ´animation (Sfar),the learned society that initiated the ﬁrst consensus conference,the Socie´te ´de re ´animation de langue franc ¸aise (SRLF),the Socie´te ´de pathologie infectieuse de langue franc ¸aise (SPIF),the Association franc ¸aise de chirurgie and theSocie ´te ´franc ¸aise de chirurgie digestive (SFCD).These updated guidelines had to address the management of community-acquired peritonitis,one of the most common gastro-intestinal emergencies,but also had to propose guidelines for less common infections,for which prescribers often feel at a loss,which is why the present guidelines are divided into three main topics:the management of community-acquired infection,intra-abdominal infections in children and healthcare-associated infections.of diagnostic biomarkers;systematic relaparotomies;prolonged anti-infective therapy,especially in children.ß2015Socie´te ´franc ¸aise d’anesthe ´sie et de re ´animation (Sfar).Published by Elsevier Masson SAS.All rights reserved.P.Montravers et al./Anaesth Crit Care Pain Med 34(2015)117–1301184.2.Objectives of the CPGsThe objectives of these Clinical Practice Guidelines(CPGs)are to: deﬁne the medical and surgical management of community-acquired intra-abdominal infections;deﬁne the speciﬁcities of management of intra-abdominal infections in children;describe the medical and surgical management of healthcare-associated intra-abdominal infections.4.3.DeﬁnitionsThis subject is so vast that it would be impossible to comprehensively address all forms of gastrointestinal infectious disease.These updated guidelines exclusively concern peritonitis requiring surgical management and do not concern so-called primary infections complicating cirrhosis,or focal infections such as biliary tract infections,isolated hepatic abscess or sigmoid diverticulitis infections.Common sense elements constituting the basis for good quality medicine were not analysed.The experts highlighted several essential points with which all practitioners must be familiar and which do not correspond to conventional updated guidelines:the source of infection must be systematically and urgently eradicated by complete peritoneal toilet regardless of the surgical technique performed(laparotomy or laparoscopy);initiation of anti-infective therapy must never be delayed until peritonealﬂuid microbiological samples have been obtained; regardless of the situation(community-acquired or nosocomial peritonitis),samples must not be taken from close succion drains and drainage systems because their results are uninterpretable; regardless of the results of microbiological samples in commu-nity-acquired or nosocomial peritonitis,the antibiotic spectrum must cover anaerobic bacteria.In accordance with current guidelines on severe sepsis and septic shock,the experts deﬁned a serious form of peritonitis as the presence of at least two of the following clinical manifestations in the absence of another cause:hypotension attributed to sepsis;serum lactic acid higher than the laboratory’s normal values; Diuresis<0.5mL/kg/h for more than2hours despite appropri-ate IVﬂuid therapy;PaO2/FiO2ratio<250mmHg in the absence of pneumonia;serum creatinine>2mg/dL(176.8m mol/L);serum bilirubin>2mg/dL(34.2m mol/L);thrombocytopenia<100,000/mm3.Very few data are available in the literature concerning intra-abdominal infections in critically ill patients requiring intensive care management,which left the experts with the choice between two solutions:either to propose no guidelines due to the absence of evidence or to propose guidelines based on other guidelines or by extrapolation with other similar situations.The experts chose this second option in order to provide guidance for prescribing physicians.Consequently,all recommendations concerning the management of patients in shock are based on the guidelines of the SFAR consensus conference on this subject.All of the literature published since1999,the date of theﬁrst consensus conference,and that published prior to1999and considered to be relevant by the experts was analysed.Many of the topics discussed in these guidelines are based on limited scientiﬁc evidence,for example intra-abdominal infections in children for which recommendations are extrapolated from the results obtained in adults.Recommendations concerning anti-infective therapy are also based on only a limited number of studies.No study has evaluated the effects of antifungal therapy in peritonitis and only a few publications have reported the dosage of anti-infective agents and the results of pharmacokinetic studies in these infectious sites.The recommended durations of treatment are currently based on expert opinion until the results of ongoing studies have been published.These various elements,reﬂecting a low level of scientiﬁc evidence,account for the large number of cautious recommendations.Each question was addressed inde-pendently of the others,leading to the writing of recommendations validated by the GRADE1method.The reader is therefore advised to refer to the literature review tables presented as appendix on the web site(/_docs/articles/Classementdestudes RFEintraabdo-versionﬁnalise.xls).4.4.MethodologyThe GRADE1method was used to establish these guidelines. Following quantitative analysis of the literature,this method can be used to separately determine the quality of evidence,i.e. estimation of the level of conﬁdence of the analysis of the effect of a quantitative intervention,and the grade of recommendation. Quality of evidence was classiﬁed into four categories:high:future research will very probably not change the level of conﬁdence in the estimate of the effect;moderate:future research will probably change the level of conﬁdence in the estimate of the effect and could modify the estimate of the effect itself;low:future research will very probably have an impact on the level of conﬁdence in the estimate of the effect and will probably modify the estimate of the effect itself;very low:the estimate of the effect is very uncertain.Analysis of the quality of evidence was performed for each study and a global level of evidence was then deﬁned for a particular question and a particular criterion.Theﬁnal formulation of the recommendations is always binary, either positive or negative and either strong or weak:strong:It must be done or must not be done(GRADE1+or1–); weak:It can be either done or not done(GRADE2+or2–).The strength of recommendation was determined according to key factors,validated by the experts after a vote,using the Delphi method:estimate of the effect;the global level of evidence:the higher the level of evidence,the more likely the recommendation will be strong;the balance between desirable and adverse effects:the more favourable this balance,the more likely the recommendation will be strong;values and preferences:the recommendation is more likely to be weak in the case of uncertainty or marked variability;these values and preferences must ideally be determined directly with the people concerned(patient,doctor,decision-maker);costs:the higher the costs or the use of resources,the more likely the recommendation will be weak.Management of intra-abdominal infections was analysed according to5themes:preoperative diagnosis,infection source control,information provided by microbiology,medical treatmentP.Montravers et al./Anaesth Crit Care Pain Med34(2015)117–130119of intra-abdominal infections,complications of intra-abdominal infections.Elements speciﬁc to community-acquired infections and postoperative infections were identiﬁed for each theme. Paediatric infections were analysed speciﬁcally.A total of 40experts participated in6work groups.Only articles published after1999were included in the analysis. When only a small number or even no articles were published during the period considered,the search period was able to be extended until1990.The methodology of the published studies on intra-abdominal infections is generally subject to criticism.The experts were therefore faced with three situations:for some questions,several methodologically satisfactory studies and/or meta-analyses were available,allowing complete appli-cation of the GRADE1method and formulation of recommenda-tions.Only several recommendations were based on a meta-analysis;when a meta-analysis was not available to allow the experts to answer the question,qualitative analysis according to the GRADE1method was possible and a systematic review was performed.A limited number of recommendations were based on quantitative analysis due to the poor quality of the published data and the limited information available;ﬁnally,in certainﬁelds,the absence of any recent studies did not allow the formulation of any recommendations.Overall,for a large part of this work,the GRADE1method did not appear to be applicable and only expert opinions could be proposed.After summarising the work of the experts and application of the GRADE1method,62recommendations were initially formu-lated by the guidelines committee.All recommendations were submitted to a review committee for Delphi scoring.The review committee was composed of 38anaesthetists-intensive care physicians,surgeons,infectious disease specialists,microbiologists,and mycologists who had already participated in a work group,as well as several other reviewers.After2rounds of Delphi scoring and various amend-ments,18recommendations were abandoned or reformulated.A strong agreement was obtained for44(100%)recommendations, corresponding to the guidelines presented below.Ten recommen-dations were considered to be strong(Grade1positive or negative) and25were considered to be weak(Grade2positive or negative), while the GRADE1method could not be applied to9recommenda-tions,which therefore correspond to expert opinions.5.Recommendations for community-acquired intra-abdominal infectionsAlthough many clinical trials have been devoted to the management of community-acquired intra-abdominal infections, they were very often purely observational and are unable to answer all of the questions raised.Clinical practices associated with a high-level of agreement of the experts are often based on common sense or usual practice and cannot be readily justiﬁed by randomized clinical trials.Only limited French and European data are available concerning the epidemiology of bacterial resistance in community-acquired intra-abdominal infections.The speciﬁcity of the epidemiology of bacterial resistance in this setting does not allow clinical practice guidelines to be extrapolated from those proposed in other settings,such as urinary tract infections.The epidemiology of bacterial resistance also differs between community-acquired infections and healthcare-associated infections,leading to speciﬁc conclusions and recommendations.First-line use of carbapenems is strongly discouraged due to the risk of emergence of resistance.No studies have been published on several topics since theﬁrst guidelines published in2000.These guidelines therefore cannot be updated.The guidelines committee consequently decided to maintain these important recommendations unchanged.An example of such a recommendation concerns the duration of anti-infective therapy for perforated gastric or duodenal ulcer operated within24hours after the diagnosis.The recommended duration of antibiotic therapy is24hours.Similarly,in penetrating abdominal wounds with opening of the gastrointestinal tract and iatrogenic perforations below transverse mesocolon,24hours of antibiotic therapy is recommended when surgery is performed within12hours after the injury.5.1.How can the diagnosis of IAI be established?Place of imaging in the diagnosis of peritonitisR1–Imaging is probably not required in the case of suspected peritonitis due to organ perforation in a critically ill patient (according to the deﬁnition indicated in the introduction)if it delays the surgical procedure.(Expert opinion)STRONG agreementRationale:Thestudies that demonstrated the valueof imaging examinations focused on appendicitis.Patients with suspected intra-abdominal infectiondue to organ perforationoften present with typical clinical features comprising rapid onset of abdomi-nal pain and gastrointestinal signs(anorexia,nausea,vomiting, constipation)with or without signs of peritoneal inﬂammation (guarding,rigidity)and systemic signs(fever,tachycardia,and/ or tachypnoea).Physical examination and clinical history are usually sufﬁcient to establish a limited number of differential diagnoses and todetermine the degreeofseverityof the disease.Theseﬁndings guide the immediate decisions concerning rehy-dration/resuscitation,complementary diagnostic procedures, and the need for curative antibiotic therapy and emergency surgery.The timing and the nature of the percutaneous or surgical procedure are deﬁned on the basis of these decisions.When the infection is poorly tolerated,an imaging examination would only be useful when it is immediately available and in order to guide the surgical procedure.R2–When peritonitis due to perforated gastroduodenal ulcer is suspected,the indication for surgery can be based on clinical history and the presence of pneumoperitoneum on a plain abdominal X-ray.(Expert opinion)STRONG agreement.Rationale:The studies that demonstrated the value of imag-ing examinations focused on appendicitis.The presence of clinical features suggestive of perforated gastroduodenal ulcer associated with the presence of pneumoperitoneum on a plain abdominal X-rayﬁlm is sufﬁcient to constitute a formal indi-cation for immediate plementary imaging exam-inations would only be useful when they are immediately available and in order to guide the surgical procedure.5.2.How can infection source control be ensured?When should the patient be treated?R3–A patient with suspected peritonitis due to organ perforation must be operated as rapidly as possible,especially in the presence of septic shock.(Grade1+)STRONG agreementP.Montravers et al./Anaesth Crit Care Pain Med34(2015)117–130 120Rationale:Most of the available guidelines emphasize the need for immediate surgery once the diagnosis has been established.No prospective study has validated this approach.Retrospective studies have demonstrated an association be-tween delayed surgery and excess mortality,including on multivariate analysis for the majority of these studies[1–5].Patients with peritonitis complicated by septic shock(about 40%of all intra-abdominal infections[IAI])present an excess mortality and morbidity compared to patients without shock [6–8].It seems reasonable to propose resuscitation prior to surgery(IVﬂuid therapy,conditioning,etc.)without delaying surgery after achieving haemodynamic stabilization of shock, as recommended by the SFAR consensus conference on the management of septic shock[9].5.3.What are the indications for laparoscopy?R4–Laparoscopy should probably not be used for the treatment of peritonitis due to perforated peptic ulcer in a patient presenting more than one of the following risk factors: state of shock on admission,ASA score III–IV,and presence of symptoms for more than24hours.(Grade2–)STRONG agreementRationale:The Boey score attributes one point to the follow-ing risk factors:shock on admission,ASA score III-IV,symp-toms present for more than24hours.In a meta-analysis combining56publications and2784patients,the authors concluded that laparoscopy was a safe procedure in patients with a Boey score of0or1[10].According to these authors, laparoscopy is contraindicated in patients with a Boey score of 2or3due to the very high morbidity and mortality[10].R5–Laparoscopy should not be performed in the case of purulent peritonitis due to diverticulosis(Hinchey IV)or generalized peritonitis.(Grade1–)STRONG agreementRationale:No randomized prospective study has compared laparoscopy and laparotomy in perforated sigmoid diverticu-litis.Eleven studies comprising a total of276cases of Hinchey II (pelvic abscess<4cm away from the colon)and Hinchey III peritonitis(purulent)treated by laparoscopic lavage and drain-age reported a morbidity rate of10.5%.Laparoscopy is not recommended in purulent peritonitis(Hinchey IV)[11]due to a 7-day reoperation rate of37%[12–15].5.4.What is the place of image-guided percutaneous drainage?R6–In the absence of haemodynamic instability(deﬁned as the need for more than0.1m g/kg/min of epinephrine or norepinephrine),the decision to performﬁrst-line image-guided percutaneous drainage for the management of intra-abdominal abscess in the absence of clinical or radiological signs of perforation and to allow microbiological examination of peritonealﬂuid samples should probably be based on a multidisciplinary discussion.(Grade2+)STRONG agreement.Rationale:The use of interventional radiology for the man-agement of IAI must be based on multidisciplinary collabora-tion(intensive care physician,surgeon and radiologist).The global efﬁcacy of drainage of intra-abdominal collections isreported to be70to90%[16,17].Few studies have compared surgery to drainage of infected intra-abdominal collections[18].Lower mortality was reported in the group treated byimage-guided percutaneous drainage vs.surgery[18].Good indications are liver abscess(high-risk of rupture),diverticular abscess,postoperative abscess or abscess complicating Crohn’s disease.Indications to be discussed case by case are superinfection of aﬂuid collection following acute pancre-atitis,appendicular and splenic abscesses,and cholecystitis.Free effusions and collections with a large gastrointestinal ﬁstula(anastomotic leak)are poor indications.The indication for image-guided percutaneous drainage may need to be revised in the presence of severe sepsis with multiple organ failure.R7–Drainage should be checked by CT scan in the presence of signs of deterioration.(Grade1+)STRONG agreementRationale:The global efﬁcacy of drainage of intra-abdominal collections is reported to be70to90%[16,17].In a series of 956cases of drainage,Gervais et al.[19]reported45abscesses requiring a second drainage procedure(4.9%of cases).These authors recommended surveillance of drainage several times a day,with CT scan on removal of the drain and in the case of an unusual course[19].Drain obstructions andﬁstulas are the most common causes of failure[19,20].5.5.What is the place of relaparotomies?R8–When surgical treatment is considered to be satisfactory (source control,lavage),relaparotomies should not be systematically planned.(Grade1–)STRONG agreementRationale:The surgical strategy of systematic(or planned) relaparotomy consists of reoperating patients every24to 48hours until the intraoperativeﬁndings conclude on the absence of persistent sepsis.Retrospective[21–23]or non-randomized studies[24]presented multiple biases and reported discordant results.A multicentre randomized pro-spective study in adults showed a prolonged intensive care and hospital stay with no survival beneﬁt and no reduction of the number of major complications with systematic relaparo-tomies[25].5.6.How should microbiology results be interpreted?When and how should microbiological samples be obtained?R9–Peritonealﬂuid samples are probably necessary in community-acquired IAI in order to identify the microorga-nisms and determine their susceptibility to anti-infective agents.(Grade2+)STRONG agreementRationale:When the patient has not received any antibiotics during the previous3months[26],the microorganisms most likely responsible can be easily predicted(Escherichia coli, Klebsiella spp.Bacteroides sp,Clostridium sp,Peptostrepto-coccus sp,Streptococcus sp).Microbiological cultures of sur-gical samples(ﬂuid or pus)and blood cultures and antibiotic susceptibility testing are optional.When the patient has re-cently received antibiotics(last3months)for at least2days, peritonealﬂuid and pus samples and blood cultures areP.Montravers et al./Anaesth Crit Care Pain Med34(2015)117–130121。

专业英语文章

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The other group, the autotrophs, fix carbon dioxide to make their own food source; this may be fueled by light energy (photoautotrophic), or by oxidation of nitrogen, sulfur, or other elements (chemoautotrophic). While chemoautotrophs are uncommon, photoautotrophs are common and quite diverse. They include the cyanobacteria, green sulfur bacteria, purple sulfur bacteria, and purple nonsulfur bacteria. The sulfur bacteria are particularly interesting, since they use hydrogen sulfide as hydrogen donor, instead of water like most other photosynthetic organisms, including cyanobacteria.
• Bacteria grow in a wide variety of habitats and conditions.
• When most people think of bacteria, they think of disease-causing organisms, like the Streptococcus bacteria growing in culture, which were isolated from a man with strep throat. While pathogenic bacteria are notorious for such diseases as cholera, tuberculosis, and gonorrhea, such disease-causing species are a comparatively tiny fraction of the bacteria as a whole. • Bacteria are so widespread that it is possible only to make the most general statements about their life history and ecology. They may be found on the tops of mountains, the bottom of the deepest oceans, in the guts of animals, and even in the frozen rocks and ice of Antarctica. One feature that has enabled them to spread so far, and last so long is their ability to go dormant for an extended period.

DECATHLON 20 WP 商品说明书

DECATHLON® 20 WP EPA Registration Number: 59807-171. IDENTIFICATION OF THE SU BSTANCE/MIXTU REAND OF THE COMPANY/UNDERTAKINGProduct identifierTrade name . . . . . . . . . . . . .: DECATH LON® 20 WPEPA Registration No. . . . . .: 59807-17Relevant identified uses of the substance or mixture and uses advised againstUse . . . . . . . . . . . . . . . . . . .: InsecticideRestrictions on use . . . . . .: See product label for restrictions .Company information . . . .: OHP, Inc .PO Box 51230Mainland, PA 19451(800) 659-6745Emergency telephone numberTRANSPORTATION EMERGENCY(24 hours a day) call . . . .: Chemtrec: 1-800-424-9300MEDICAL EMERGENCY (24 hours a day) and ProductInformation call . . . . . . . .: 1-800-356-4647SDS Information orRequest . . . . . . . . . . . . . . . .: ohp .com2. HAZARDS IDENTIFICATIONClassification in accordance with regulationHCS 29CFR §1910.1200Acute toxicity (Oral) . . . . . .: Category 4Signal word . . . . . . . . . . . . .: WarningHazard statementsHarmful if swallowed .Precautionary statementsWash thoroughly after handling .Do not eat, drink or smoke when using this product .IF SWALLOWED: Call a POISON CENTER/doctor/physician if you feel unwell .Rinse mouth .Dispose of contents/container in accordance with lo-cal regulation .Other hazards . . . . . . . . . . .: No other hazards known .3. COMPOSITION/INFORMATION ON INGREDIENTS HazardousComponent Concentration Name CAS No. % by weightCyfluthrin 68359-37-5 20.0C rystalline quartz (respirable) 14808-60-7 3.34. FIRST AID MEASURESDescription of first aid measuresGeneral advice . . . . . . . . . .: When possible, have the product container or label with you when calling apoison control center or doctor or going for treatment .Inhalation . . . . . . . . . . . . . .: Move to fresh air . If per-son is not breathing, call 911 or an ambulance, thengive artificial respiration, preferably mouth-to-mouthif possible . Call a physician or poison control centerimmediately .Skin contact . . . . . . . . . . . .: Take off contaminated clothing and shoes immediately . Wash off immedi-ately with plenty of water for at least 15 minutes . Calla physician or poison control center immediately .Eye contact . . . . . . . . . . . . .: Hold eye open and rinse slowly and gently with water for 15-20 minutes .Remove contact lenses, if present, after the first 5minutes, then continue rinsing eye . Call a physicianor poison control center immediately .Ingestion . . . . . . . . . . . . . . .: Call a physician or poison control center immediately . Rinse out mouth andgive water in small sips to drink . DO NOT inducevomiting unless directed to do so by a physician orpoison control center . Never give anything by mouthto an unconscious person . Do not leave victim unat-tended .Most important symptoms and effects, both acute and delayedSymptoms . . . . . . . . . . . . .: To date no symptoms are known .Indication of any immediate medical attention and special treatment neededTreatment . . . . . . . . . . . . . .: Appropriate supportive and symptomatic treatment as indicated by the pa-tient’s condition is recommended . There is no spe-cific antidote .DECATHLON® 20 WP EPA Registration Number: 59807-175. FIREFIGHTING MEASURESExtinguishing mediaSuitable . . . . . . . . . . . . . . . .: Water, Dry chemicalUnsuitable . . . . . . . . . . . . .: None known .Special hazards arising from thesubstance or mixture . . . .: Dangerous gases areevolved in the event of a fire .Advice for firefightersSpecial protective equipment forfire-fighters . . . . . . . . . . . .: Firefighters should wearNIOSH approved self-contained breathing apparatusand full protective clothing .Further information . . . . . .: Fight fire from upwind po-sition . Evacuate personnel to safe areas . Do not al-low run-off from fire fighting to enter drains or watercourses .Flash point . . . . . . . . . . . . .: not applicableAutoignition temperature .: no data availableLower explosion limit . . . .: not applicableUpper explosion limit . . . .: not applicableExplosivity . . . . . . . . . . . . .: no data available6. ACCIDENTAL RELEASE MEASURESPersonal precautions, protective equipment andemergency proceduresPrecautions . . . . . . . . . . . .: Keep unauthorized peo-ple away . Isolate hazard area . Avoid contact withspilled product or contaminated surfaces . Do notenter confined spaces unless adequately ventilated .Use personal protective equipment .Methods and materials for containment and cleaning upMethods for cleaning up . . .: Sweep up or vacuum up spillage and collect in suitable container for dispos-al . Clean contaminated floors and objects thorough-ly, observing environmental regulations . Decontami-nate tools and equipment following cleanup .Additional advice . . . . . . . .: Use personal protective equipment . Do not allow to enter soil, waterways orwaste water canal .Reference to othersections . . . . . . . . . . . . . .: Information regardingpersonal protective equipment, see section 8 .Information regarding safe handling, see section 7 .Information regarding waste disposal, see section 13 .7. HANDLING AND STORAGEPrecautions for safe handlingAdvice on safe handling . .: Use only in area provided with appropriate exhaust ventilation .Advice on protection against fireand explosion . . . . . . . . . .: Keep away from heat andsources of ignition .Hygiene measures . . . . . . .: Wash hands thoroughly with soap and water after handling and before eat-ing, drinking, chewing gum, using tobacco, using thetoilet or applying cosmetics . Remove Personal Pro-tective Equipment (PPE) immediately after handlingthis product . Remove soiled clothing immediatelyand clean thoroughly before using again . Wash thor-oughly and put on clean clothing .Conditions for safe storage, including any incompat-ibilitiesRequirements for storage areas andcontainers . . . . . . . . . . . . .: Store in a cool, dry placeand in such a manner as to prevent cross contami-nation with other crop protection products, fertilizers,food, and feed . Keep containers tightly closed in adry, cool and well-ventilated place .Advice on commonstorage . . . . . . . . . . . . . . .: Keep away from food,drink and animal feedingstuffs .8. EXPOSURE CONTROLS / PERSONALPROTECTIONControl parameters continuedComponents CAS-No.Controlparameters Update Basis Cyfluthrin(Particulate.)68359-37-55ug/m3(AN ESL)02 2013TX ESLCyfluthrin(Particulate.)68359-37-550ug/m3(ST ESL)02 2013TX ESLCyfluthrin68359-37-50.01 mg/m3(TWA)OES BCS*Crystalline quartz(respirable)(Respirable fraction.)14808-60-70.025 mg/m3(TWA)02 2012ACGIHCrystalline quartz(respirable)(Respirable dust.)14808-60-70.05 mg/m3(REL)2010NIOSHControl parameters continued next columnDECATHLON® 20 WPEPA Registration Number: 59807-17 Control parameters continuedComponents CAS-No.Controlparameters Update BasisCrystalline quartz (respirable) (Respirable dust.)14808-60-70.1 mg/m3(TWA)1989OSHA Z1ACrystalline quartz (respirable) (Respirable dust.)14808-60-70.1 mg/m3(TWA)06 2008TN OELCrystalline quartz (respirable) (Particulate.)14808-60-70.27ug/m3(AN ESL)02 2013TX ESLCrystalline quartz (respirable) (Particulate.)14808-60-714ug/m3(ST ESL)02 2013TX ESLCrystalline quartz (respirable) (Respirable dust.)14808-60-70.1 mg/m3(TWA PEL)08 2010US CA OELCrystalline quartz (respirable) (Total dust.)14808-60-70.3 mg/m3(TWA PEL)08 2010US CA OELCrystalline quartz (respirable) (Total dust.)14808-60-70.3 mg/m3(TWA)2000Z3Crystalline quartz (respirable) (Respirable.)14808-60-7 2.4 millions ofparticles percubic foot of air(TWA)2000Z3Crystalline quartz (respirable) (Respirable.)14808-60-70.1 mg/m3(TWA)2000Z3*OES BCS: Internal Bayer CropScience “Occupational Exposure Standard”Exposure controlsPersonal protective equipmentIn normal use and handling conditions please refer tothe label and/or leaflet . In all other cases the follow-ing recommendations would apply .Respiratory protection . . .: When respirators are re-quired, select NIOSH approved equipment based onactual or potential airborne concentrations and in ac-cordance with the appropriate regulatory standardsand/or industry recommendations .Hand protection . . . . . . . . .: Chemical resistant nitrilerubber glovesEye protection . . . . . . . . . .: Tightly fitting safetygogglesSkin and bodyprotection . . . . . . . . . . . . .: Wear long-sleeved shirtand long pants and shoes plus socks .General protectivemeasures . . . . . . . . . . . . .: Follow manufacturer’s in-structions for cleaning/maintaining PPE . If no suchinstructions for washables, use detergent and warm/tepid water .Keep and wash PPE separately from other laundry .9. PHYSICAL AND CHEMICAL PROPERTIESAppearance . . . . . . . . . . . . .: tanPhysical State . . . . . . . . . . .: powderOdor . . . . . . . . . . . . . . . . . . .: aromaticOdour Threshold . . . . . . . . .: no data availablepH . . . . . . . . . . . . . . . . . . . . .: 9 .2 (as aqueous solution)Vapor Pressure . . . . . . . . . .: < 0 .0000001 hPa at 20 °CVapor Density (Air = 1) . . . .: no data availableBulk density . . . . . . . . . . . . .: 18 .0 - 26 lb/ft³Evapouration rate . . . . . . . .: not applicableBoiling Point . . . . . . . . . . . .: not applicableMelting / Freezing Point . . .: not applicableWater solubility . . . . . . . . . .: dispersibleMinimum Ignition Energy . .: not applicableDecompositiontemperature . . . . . . . . . . . .: no data availablePartition coefficient:n-octanol/water . . . . . . . . .: not applicableViscosity . . . . . . . . . . . . . . . .: not applicableFlash point . . . . . . . . . . . . . .: not applicableAutoignition temperature . .: no data availableLower explosion limit . . . . .: not applicableUpper explosion limit . . . . .: not applicableExplosivity . . . . . . . . . . . . . .: no data available10. STABILITY AND REACTIVITYReactivityThermal decomposition . .: no data availableChemical stability . . . . . . .: Stable under recom-mended storage conditions .Possibility of hazardousreactions . . . . . . . . . . . . . .: No dangerous reactionknown under conditions of normal use .Conditions to avoid . . . . . . .: Heat, flames and sparks .Exposure to moisture .DECATHLON® 20 WP EPA Registration Number: 59807-17Incompatible materials . . . .: Methanol, Alkali metals, Alkaline earth metals, Bases, Light metalsHazardous decompositionproducts . . . . . . . . . . . . . . .: No decomposition prod-ucts expected under normal conditions of use .11. TOXICOLOGICAL INFORMATIONExposure routes . . . . . . . . .: Inhalation, Skin Absorp-tion, Eye contact, Skin contactImmediate EffectsEye . . . . . . . . . . . . . . . . . . .: Mild eye irritation .Skin . . . . . . . . . . . . . . . . . . .: Mild skin irritant . May cause a transient, localized paresthesia, character-ized by tingling, burning or numbness sensation insome individuals .Ingestion . . . . . . . . . . . . . . .: Harmful if swallowed .Inhalation . . . . . . . . . . . . . .: Mist may cause irritation involving the nose, throat and upper respiratory tractduring the end use of the product such as during aspray application .Information on toxicological effectsAcute oral toxicity . . . . . . .: LD50 (male rat)3,084 mg/kgLD50 (female rat)1,733 mg/kgAcute inhalation toxicity . .: LC50 (male/femalecombined rat) > 1 .18 mg/lExposure time: 4 hDetermined in theform of dust .Highest attainableconcentration . (actual)LC50 (male/femalecombined rat) > 4 .72 mg/lExposure time: 1 hDetermined in theform of dust .Highest attainable concentration .Extrapolated from the4 hr LC50 . (actual)Acute dermal toxicity . . . .: LD50 (male/femalecombined rabbit)> 2,000 mg/kgSkin irritation . . . . . . . . . . .: Slight irritation (rabbit)Eye irritation . . . . . . . . . . . .: Mild eye irritation . (rabbit)Sensitisation . . . . . . . . . . .: Non-sensitizing .(guinea pig)Assessment repeated dose toxicityThe toxic effects of Cyfluthrin are related to transienthyperactivity typical for pyrethroid neurotoxicity .Assessment mutagenicityCyfluthrin was not mutagenic or genotoxic in a bat-tery of in vitro and in vivo tests .Assessment carcinogenicityCyfluthrin was not carcinogenic in lifetime feedingstudies in rats and mice .ACGIHCrystalline quartz (respirable) 14808-60-7 Group A2 NTPCrystalline quartz (respirable) 14808-60-7 2000IARCCrystalline quartz (respirable) 14808-60-7 Overall evaluation: 1 OSHANone.Assessment toxicity to reproductionCyfluthrin caused reproduction toxicity in a two-gen-eration study in rats only at dose levels also toxic tothe parent animals . The reproduction toxicity seenwith Cyfluthrin is related to parental toxicity .Assessment developmental toxicityCyfluthrin caused developmental toxicity only at doselevels toxic to the dams . The developmental effectsseen with Cyfluthrin are related to maternal toxicity .Further informationOnly acute toxicity studies have been performed onthe formulated product .The non-acute information pertains to the activeingredient(s) .12. ECOLOGICAL INFORMATIONToxicity to fish . . . . . . . . . .: LC50 (Oncorhynchusmykiss (rainbow trout))0 .00047 mg/lExposure time: 96 hThe value mentioned relates to the active ingredientcyfluthrin .Toxicity to aquatic . . . . . . .: EC50 (Daphnia magnainvertebrates(Water flea)) 0 .00016 mg/lExposure time: 48 hThe value mentioned relates to the active ingredientcyfluthrin .Toxicity to aquatic plants .: IC50 (DesmodesmusDECATHLON® 20 WP EPA Registration Number: 59807-17subspicatus) > 10 mg/lGrowth rate;Exposure time: 72 hThe value mentioned relates to the active ingredientcyfluthrin .Biodegradability . . . . . . . . .: Cyfluthrin: ; not rapidly biodegradableKoc . . . . . . . . . . . . . . . . . . .: Cyfluthrin: Koc: 64300Bioaccumulation . . . . . . . .: Cyfluthrin: Bioconcentra-tion factor (BCF) 506; Does not bioaccumulate .Mobility in soil . . . . . . . . . .: Cyfluthrin: Immobile in soilEnvironmentalprecautions . . . . . . . . . . . .: Drift and runoff from treat-ed areas may be hazardous to aquatic organisms inadjacent sites .Do not contaminate surface or ground water bycleaning equipment or disposal of wastes, includingequipment wash water .Apply this product as specified on the label .Do not allow to get into surface water, drains andground water .Do not apply directly to water, to areas where surfacewater is present or to intertidal areas below the meanhigh water mark .Do not apply this product or allow it to drift to bloom-ing crops or weeds if bees are visiting the treatmentarea .13. DISPOSAL CONSIDERATIONSWaste treatment methodsProduct . . . . . . . . . . . . . . . .: Do not contaminate water, food, or feed by disposal .Dispose of contents/container in accordance with lo-cal regulation .Contaminated packaging . .: Do not re-use emptycontainers .Rinsed packaging may be acceptable for landfill,otherwise incineration will be required in accordancewith local regulations .If burned, stay out of smoke .RCRA Information . . . . . . . .: Characterization andproper disposal of this material as a special or haz-ardous waste is dependent upon Federal, State andlocal laws and are the user’s responsibility . RCRAclassification may apply .14. TRANSPORTATION INFORMATION49CFR . . . . . . . . . . . . . . . . . .: Not dangerous goods /not hazardous material IMDGUN number . . . . . . . . . . . . .: 3077Class . . . . . . . . . . . . . . . . . .: 9Packaging group . . . . . . . .: IIIMarine pollutant . . . . . . . . .: YESProper shipping name . . . .: ENVIRONMENTALLYHAZARDOUS SUBSTANCE, SOLID, N .O .S .(CYFLUTHRIN MIXTURE)IATAUN number . . . . . . . . . . . . .: 3077Class . . . . . . . . . . . . . . . . . .: 9Packaging group . . . . . . . .: IIIEnvironm. HazardousMark . . . . . . . . . . . . . . . . . .: YESProper shipping name . . . .: ENVIRONMENTALLYHAZARDOUS SUBSTANCE, SOLID, N .O .S .(CYFLUTHRIN MIXTURE )This transportation information is not intended toconvey all specific regulatory information relating tothis product . It does not address regulatory varia-tions due to package size or special transportationrequirements .Freight Classification . . . .: INSECTICIDES ORFUNGICIDES, N .O .I ., OTHER THAN POISON15. REGULATORY INFORMATIONEPA Registration No. . . . . .: 59807-17US Federal RegulationsTSCA listCrystalline quartz (respirable) 14808-60-7US. Toxic Substances Control Act (TSCA) Section 12(b) Export Notification(40 CFR 707, Subpt D) . . . .: None .SARA Title III - Section 302 - Notification andInformation . . . . . . . . . . . . .: None .SARA Title III - Section 313 - Toxic Chemical Release ReportingCyfluthrin 68359-37-5 25,000 lbs US States Regulatory ReportingDECATHLON® 20 WP EPA Registration Number: 59807-17CA Prop65This product contains a chemical known to the Stateof California to cause cancer .Crystalline quartz (respirable) 14808-60-7US State Right-To-Know IngredientsCyfluthrin 68359-37-5 NJ, RICrystalline quartz (respirable) 14808-60-7 MNCanadian RegulationsCanadian Domestic Substance ListCrystalline quartz (respirable) 14808-60-7EnvironmentalCERCLA . . . . . . . . . . . . . . .: None .Clean Water Section 307Priority Pollutants . . . . . .: None .Safe Drinking Water Act MaximumContaminant Levels . . . . .: None .International RegulationsEuropean Inventory of Existing Commercial Sub-stances (EINECS)Crystalline quartz (respirable) 14808-60-7EPA/FIFRA Information:This chemical is a pesticide product registered bythe Environmental Protection Agency and is subjectto certain labeling requirements under federal pes-ticide law . These requirements differ from the clas-sification criteria and hazard information requiredfor safety data sheets, and for workplace labels ofnon-pesticide chemicals . Following is the hazard in-formation required on the pesticide label:Signal word . . . . . . . . . . . .: Caution!Hazard statements . . . . . . .: Moderate eye irritation .H armful if swallowed, inhaled or absorbed throughthe skin .Do not get in eyes, on skin, or on clothing .Avoid breathing dust or spray mist .Wash hands thoroughly with soap and water after han-dling and before eating, drinking, chewing gum, usingtobacco, using the toilet or applying cosmetics .Remove and wash contaminated clothing before reuse . OHP981780 12/16 (03/06/2015)16. OTHER INFORMATIONNFPA 704 (National Fire Protection Association):Health - 2 Flammability - 1 Instability - 1 Others - noneHMIS (Hazardous Materials Identification System, based on the Third Edition Ratings Guide)Health - 2 Flammability - 0 Physical Hazard - 0 PPE -0 = minimal hazard, 1 = slight hazard, 2 = moderate haz-ard, 3 = severe hazard, 4 = extreme hazardReason for Revision . . . . . .: Revised according to the current OSHA Hazard Communication Standard(29CFR1910 .1200)Revision Date . . . . . . . . . . . .: 12/12/2016This information is provided in good faith but without express or implied warranty . The customer assumes all responsibility for safety and use not in accordance with label instructions .Decathlon is registered trademark of OHP, Inc .。

Wound Management Tetanus Prophylaxis

A&E Clinical Guideline No. 2Wound Management and Tetanus Prophylaxis(Revised Feb 2002, last reviewed Nov 2004)Dr K H Chan, Dr C C LauI. IntroductionA. The A&E Triage Nurse should be capable of initiating Tetanus Prophylaxis Scheduleaccording to the given guidelines based on her/his professional judgement. However, in case of doubt, medical advice should be sought.B. Remember even the most trivial wound can cause Tetanus. Antibiotic prophylaxis is notuseful in wound management and cannot replace proper wound cleaning, debridement and proper immunisation.C. Take every opportunity to immunise the general population. Only rarely have cases ofTetanus occurred among persons with a documented primary series of toxoid injections.Immune pregnant women transfer temporary protection against Tetanus to their infants through transplacental maternal antibody.D. Tetanus-prone Wound“Tetanus-prone wound” is not a well-defined term. Tetanus-prone wound may include wound complicated by delay in treatment (for over 6 hours), deep puncture wounds, avulsions, heavily contaminated wounds (especially with agricultural, horticultural materials or soil) and wounds resulting from missiles, crushing, burns and frostbite.Special attention should be given to excision and exploration as necessary, and local antisepsis merits special consideration. Prompt and thorough surgical wound toilet is of key importance.Foreign materials and devitalised tissues must be removed if possible. Such wounds should not be sutured as a routine. Alternatively, packing with delayed primary closure should be considered with follow-up wound inspection after 48 to 72 hours.E. In Hong Kong, the high risk group of persons for Tetanus are drug addicts and elderlypeople with neglected wounds.II. Active ImmunisationA. Evidence indicates that a complete course of primary vaccination with Tetanus Toxoid(TT) provides long lasting protection greater than or equal to 10 years for most recipients. Boosters are recommended at 10-year intervals.Immunisation Programme3 doses of 0.5 ml Tetanus Toxoid (TT) by intramuscular route for all ages1st – on the day of attendance2nd – 1 to 2 months after 1st dose3rd – 6 to 12 months after 2nd doseB. Individuals born in Hong Kong after 1965 should have received immunisation as apre-school child with boosters at Primary 1 and Primary 6.C. For patient who had completed primary vaccination, and the injury incurred within10 years, no booster dose is required except for tetanus prone wound.If the patient is uncertain or unable to indicate about previous active immunisation for Tetanus, start a full course of TT and consider simultaneous passive immunisation. D. The purpose of multiple dosing is to maximise the booster effect. With the best resultbeing achieved by spreading out the vaccination interval one month or more between doses.Persons who have received at least 2 doses of TT rapidly develop antitoxin antibodies.TT booster is advised as part of wound management.E. Ensure that the patient understands the contents of the Tetanus Advice Form and advisethe patient to complete the course in government or private clinics.F. ComplicationsUsually, there is no major complication except fever and/or painful local erythematous or nodular reactions at injection site.Unnecessary TT injections should be avoided. A severe local reaction occurring 2-8 hours after TT is probably an Arthus-type reaction. In that case further TT dose may be administered only if the last dose was greater than 10 years previously irrespective of the nature of the wound.In exceptional cases (anticoagulation, haemorrhagic diasthesis), the toxoid can also be administered by deep subcutaneous route.II. Active Immunisation (Continued)G. ContraindicationsPrevious history of anaphylactic reaction is a contraindication to further use of the vaccine. Acute respiratory infection or other active infections are reasons for deferring administration of routine primary immunising or booster dose, but not booster dose for emergency wound.H. PregnancyThere is no convincing evidence of risk to the foetus from tetanus immunisation of pregnant women.III. Passive ImmunisationA. Human Tetanus Immune Globulin (HTIG) should be reserved for protectingnon-immunised patients or patients having existing immune deficient conditions with wounds that are considered to be Tetanus-prone. Advice from senior medical staff should be sought when in doubt.HTIG is safe and indicated for patients with a contraindication to TT (such as anaphylaxis) and have a Tetanus-prone wound.B. DosageThe prophylactic dose of HTIG is 250 units IMI and TT can safely be given at the same time but at different sites. Different syringes should be used.500-unit dose is recommended if :(a) there is gross contamination of wound;(b) wound is older than 12 hours; or(c) patient’s body weight exceeds 90 kg.C. The HTIG will not guarantee that a non-immunised patient will not develop Tetanusafter injury.IV. Clinical Guidelines for Tetanus ProphylaxisSimple Wounds (non-Tetanus prone) Complicated Wounds (Tetanus-prone)History ofFull TT CourseorTT Booster TT HTIG TT HTIGNo orUnknownFull Course No Full Course ConsiderFull TT course< 5 yearsNo No No NoFull TT coursebetween5 - 10 yearsNo No Booster NoFull TT course> 10 yearsBooster No Booster Consider * * There were reports of delay anti-toxin response in old aged patients.V. References1. Update on Adult Immunisation Recommendations of the Immunisation PracticesAdvisory Committee. MMWR 1991; 40: 1-52.2. ACEP. Tetanus Immunisation Recommendations for Persons Seven Years of Age andOlder. Ann Emer Med 1986;15: 1111-1112.3. ACEP. Tetanus Immunisation Recommendations for Persons Less than Seven YearsOld. Ann Emer Med 1987; 16: 1181-1183.4. Plotkins & Mortimer. Vaccines, 2nd Edition, P.705. McCarroll JR, Abrahams I, Skudder PA. Antibody response to tetanus toxoid 15 yearsafter initial immunisation. AM J Public Health 52:1669-1675, 1962HOSPITALNameAge Sex Male / FemaleAE No.¹w¨¾¯}¶Ë-·¯gª`®g¬ö¿ýAnti-Tetanus Immunisation Record½Ð±a¦P¦¹¬ö¿ý¡A©ó¤U¦C¤é´Á¨ìªþªñ¤½¥ßªù¶E³¡¡A±µ¨ü¹w¨¾¯}¶Ë-·¬Ì-]ª`®g¡GPlease bring along this record to a near-by public Out-Patient Departmentfor Anti-Tetanus Toxoid Injections on the following dates :ª`®g¤é´ÁDate of InjectionÅ@¤hÃ±¸p Nurse Signature²Ä¤@¦¸1st/ /²Ä¤G¦¸2nd/ /(²Ä¤@¦¸ª`®g«á¤@¦Ü¤G-Ó¤ë¤º) (1-2 months after 1st injection)²Ä¤T¦¸ 3rd/ /(²Ä¤G¦¸ª`®g«á¤»¦Ü¤Q¤G-Ó¤ë¤º) (6-12 months after 2nd injection)»Õ¤U-Y·N¥~¨ü¶Ë¡A½Ð³qª¾ÂåÅ@¤H-û´¿±µ¨ü¹w¨¾¯}¶Ë-·¬Ì-]ª`®g¡C If you are injured again, please inform your doctor or nurses that you have received ATT injections.½Ðª`·N ¡G»Õ¤U¥²¶·§¹¦¨¤T¦¸¬Ì-]ª`®g¡A¤~¥i¨É¦³¤Q¦~§K¬Ì¡C Note¡G You MUST complete all 3 injections in order to have10 years immunisation.ª`®g¬ÌÐt«á¥i¯à·|¤Þ°_µu¼Èªºµo¿N, ©Îª`®g³¡¦ì¥X²{§½³¡¬õ¸~¤Î¯kµh¡CYou may have transient fever, localised painful red swellingat the injection site.AppendixPROGRAMME OF IMMUNISATION, DEPARTMENT OF HEALTHPublic Health and Epidemiology Bulletin. Special Edition: Recommendations of the Advisory Committee on Immunisation (Dec 2002).AGE IMMUNISATION RECOMMENDEDB.C.G. VaccineNew bornPolio Type IHepatitis B Vaccine - First dose1 month Hepatitis B Vaccine - Second doseDPT Vaccine (Diphtheria, Pertussis & Tetanus) - First Dose2-4 monthsPolio Trivalent - First Dose3-5 months DPT Vaccine (Diphtheria, Pertussis & Tetanus) - Second DoseDPT Vaccine (Diphtheria, Pertussis & Tetanus) - Third Dose4-6 monthsPolio Trivalent - Second Dose6 months Hepatitis B Vaccine - Third Dose1 year MMR Vaccine (Measles, Mumps & Rubella) - First DoseDPT Vaccine (Diphtheria, Pertussis & Tetanus) - Booster Dose1 1/2 yearPolio Trivalent - Booster DoseDT Vaccine (Diphtheria & Tetanus) - Booster DosePrimary 1Polio Trivalent - Booster DoseMMR Vaccine (Measles, Mumps & Rubella) - Second DoseDT Vaccine (Diphtheria & Tetanus) - Booster DosePrimary 6Polio Trivalent - Booster DoseNote:Hepatitis B vaccination was introduced in 1988.MMR was introduced in 1990 and booster dose is recommended at Primary since 1997.。

瘢痕子宫妊娠结局：胎盘植入、瘢痕处妊娠

“cesarean scar pregnancy” “cesarean scar ectopic” “previous cesarean section scar” “first-trimester accreta” “spontaneous uterine rupture” “pathologically adherent placenta” 751 ……
Treatment
Rescue Uterine artery embolization First-line treatment Local MET injection (ultrasound-directed) +intramuscular Met administration +surgical excision(hysteroscopic guidance) Something should be avoided

Slow

Ilan E. Timor-Tritsch, MD; Ana Monteagudo, MD.Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. American Journal of Obstetrics & Gynecology 2012(7):14-29
What’s the primary treatment
>31 modalities
Complication：
Need > 2 treatment （short of major surgical / embolization)

高二英语科技词汇单选题80题

高二英语科技词汇单选题80题1. When we communicate online, we often use a ______ to connect with others.A. laptopB. routerC. serverD. keyboard答案：B。

本题考查常见网络设备词汇。

选项A“laptop”指笔记本电脑；选项B“router”意为路由器，用于连接网络；选项C“server”是服务器；选项D“keyboard”是键盘。

在网络通信中，连接他人需要路由器，所以选B。

2. To store a large amount of data, we usually need a ______.A. hard diskB. mouseC. monitorD. speaker答案：A。

此题考查科技存储设备词汇。

选项A“hard disk”为硬盘，可大量存储数据；选项B“mouse”是鼠标；选项C“monitor”是显示器；选项D“speaker”指扬声器。

存储大量数据用硬盘，故选A。

3. If you want to take photos with high quality, you should choose a ______.A. smartwatchB. digital cameraC. tabletD. scanner答案：B。

这道题涉及科技摄影设备词汇。

选项A“smartwatch”是智能手表；选项B“digital camera”为数码相机，能拍摄高质量照片；选项C“tablet”是平板电脑；选项D“scanner”是扫描仪。

想要高质量拍照应选数码相机，即B。

4. In a modern office, ______ can help us print documents quickly.A. printersB. projectorsC. headphonesD. webcams答案：A。

糖尿病基础知识-英文

This form of diabetes usually strikes children and young adults, although disease onset can occur at any age.
Type 1 diabetes may account for 5% ts.
In most Western societies, the overall prevalence has reached 4-6%, and is as high as 10-12% among 6070-year-old people.
The annual health costs caused by diabetes and its complications account for around 6-12% of all health-care expenditure.
Risk factors for type 1 diabetes may include autoimmune, genetic, and environmental factors.
Was previously called non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes.
The effects of diabetes mellitus include long–term damage, dysfunction and failure of various organs.
Diabetes mellitus may present with characteristic symptoms such as thirst, polyuria, blurring of vision, and weight loss.