Kerge biliaarse pankreatiidi nüüdisaegne käsitlus

Äge pankreatiit on sage seedetraktihaigus, mida esineb 13–45 juhtu 100 000 inimese kohta aastas. Üheks peamiseks põhjuseks on sapikivid, millest põhjustatud pankreatiiti nimetatakse ägedaks biliaarseks pankreatiidiks (ÄBP). Enamasti on biliaarne pankreatiit kerge kuluga ning tänapäeval soovitatakse raviks varast laparoskoopilist koletsüstektoomiat. Vaatamata ravisoovituste ja tõenduspõhise info olemasolule tehakse nende haigete ravis alusetute kartuste tõttu sageli soovitusi eiravaid valikuid. Artiklis on antud ülevaade ÄBP tõenduspõhisest ravitaktikast tänapäeval. Eesti Arst 2018; 97(7):361–36

Kerge biliaarse pankreatiidi nüüdisaegne käsitlus

Äge pankreatiit on sage seedetraktihaigus, mida esineb 13–45 juhtu 100 000 inimese kohta aastas. Üheks peamiseks põhjuseks on sapikivid, millest põhjustatud pankreatiiti nimetatakse ägedaks biliaarseks pankreatiidiks (ÄBP). Enamasti on biliaarne pankreatiit kerge kuluga ning tänapäeval soovitatakse raviks varast laparoskoopilist koletsüstektoomiat. Vaatamata ravisoovituste ja tõenduspõhise info olemasolule tehakse nende haigete ravis alusetute kartuste tõttu sageli soovitusi eiravaid valikuid. Artiklis on antud ülevaade ÄBP tõenduspõhisest ravitaktikast tänapäeval. Eesti Arst 2018; 97(7):361–36

Being accountable to Aceh: gender-related lessons learned by New Zealand NGOs from the Indian Ocean tsunami of 2004

The Indian Ocean Boxing Day Tsunami of 2004 prompted a level of international disaster response that was unprecedented. In Aceh, Indonesia, the worst hit region, thousands of international non-governmental organisations (INGOs), including some New Zealand based NGOs, arrived in the area to carry out relief and reconstruction work. A common criticism of the international response is that it has resulted in the marginalisation of Acehnese women. The criticism comes despite at least fifteen years of gender mainstreaming into the policies and practices of development organisations and the widespread acceptance that attention to gender issues is essential for sustainable and equitable development. It also comes at a time when there is ever-increasing demand for NGO accountability to donors and beneficiaries and a recognition that NGOs should continuously be learning to improve future practice and ensure they are meeting their stated goals. Post-tsunami Aceh posed a number of context-specific challenges to the implementation of gender policies, including the enormous extent of the devastation, the history of violent conflict and the rule of Sharia law. This research investigates the particular challenges and experiences workers of NZ-based NGOs faced in implementing their gender policies in the aftermath of the tsunami in Aceh, and how those NGOs responded to the challenges and experiences to ensure lessons have been learned. It also investigates whether any obstacles to learning lessons exist within those organisations. Qualitative research is used including gathering primary data from semi-structured interviews with individuals from five NZ NGOs that worked in Aceh and with representatives of NGOs willing to comment on their organisational responses. Additional comments on the issues are also obtained from two NZAID (New Zealand Agency for International Development) staff. The findings show that while participants faced numerous gender-related challenges in their work in Aceh, approximately three years after the tsunami none were able to point to any specific gender-related lessons learned. The findings also reveal that participating NGOs tend to draw learning from their international affiliates and from the NZ NGO community rather than having structured learning systems within their own organisations. A number of barriers to learning within organisations are also identified. These results, while not necessarily representative of the wider NZ NGO community, reveal the difficulties of trying to implement gender policies in a particular emergency context and contribute to an understanding of how NZ NGOs are involved in a process of continuous learning to incorporate their own experiences to ensure lessons are learned and improve their accountability

Vastsündinu insult – haigestumus Eestis

Insult vastsündinueas on raske tüsistus, mis on senini olnud aladiagnoositud, kuid tänu radioloogiliste uurimismeetodite täiustumisele on selle diagnoosimine kõikjal sagenenud. Neonataalse insuldi kliinilisele pildile on iseloomulik fokaalsete krampide, apnoehoogude ja teadvushäirete esinemine, hiljem avalduvad lastel hemiparees, epilepsia ning kognitiivsete funktsioonide häired. Eestis tehtud epidemioloogilise uuringu senised tulemused näitavad, et vastsündinuea isheemilise insuldi esmashaigestumus oli aastatel 1998–2002 üks juht 2000 ja 2003. aastal 1 juht 1200 elussünni kohta. Artiklis on käsitletud neonataalse insuldi epidemioloogiat, tekkepõhjusi, riskitegureid ja diagnoosimist. Eesti Arst 2004; 83 (5): 296–30

Muutused aju ja siseelundite verevoolu kiiruses asfüksias sündinud vastsündinutel

Raskes asfüksias sündinud lastel teki­vad pärast sündi lisaks neuroloogiliste­le probleemidele mitmete elundite ve­revarustuse häired. Elundikahjustuse ulatust aitab hinnata verevoolukiiruste uurimine aju ja vistseraalsete organite arterites. Raske hüpoksilis-isheemilise entsefalopaatia (HIE) korral kujuneb esimesel elunädalal vasoparalüüsi tõttu oluline aju verevoolu kiiruse suurene­mine. Ülemises mesenteriaalarteris ja truncus coeliacus’es esineb kerge ning mõõduka HIE korral esimestel tundidel asfüksia järel verevoolukiiruse kompen­satoorne suurenemine, raske HIE korral verevoolukiiruse vähenemine neeruar­teris ja mesenteriaalarteris. Ühe kuu va­nuses verevoolukiirused vistseraalsetes arterites normaliseeruvad, raske HIEga lastel kujuneb väike pea ümbermõõt ja väike verevoolukiirus ajuarterites. Eesti Arst 2 008; 87(10):755−76

Development and evaluation of a gentamicin pharmacokinetic model that facilitates opportunistic gentamicin therapeutic drug monitoring in neonates and infants.

Trough gentamicin therapeutic drug monitoring (TDM) is time-consuming, disruptive to neonatal clinical care and a patient safety issue. Bayesian models could allow TDM to be performed opportunistically at the time of routine blood tests. This study aimed to develop and prospectively evaluate a new gentamicin model and a novel Bayesian computer tool (neoGent) for TDM use in neonatal intensive care. We also evaluated model performance for predicting peak concentrations and AUC(0-t). A pharmacokinetic meta-analysis was performed on pooled data from three studies (1325 concentrations from 205 patients). A 3-compartment model was used with covariates being: allometric weight scaling, postmenstrual and postnatal age, and serum creatinine. Final parameter estimates (standard error) were: clearance: 6.2 (0.3) L/h/70kg; central volume (V) 26.5 (0.6) L/70kg; inter-compartmental disposition: Q=2.2 (0.3) L/h/70kg, V2=21.2 (1.5) L/70kg, Q2=0.3 (0.05) L/h/70kg, V3=148 (52.0) L/70kg. The model's ability to predict trough concentrations from an opportunistic sample was evaluated in a prospective observational cohort study that included data from 163 patients with 483 concentrations collected in five hospitals. Unbiased trough predictions were obtained: median (95% confidence interval (CI)) prediction error was 0.0004 (-1.07, 0.84) mg/L. Results also showed peaks and AUC(0-t) could be predicted (from one randomly selected sample) with little bias but relative imprecision with median (95% CI) prediction error being 0.16 (-4.76, 5.01) mg/L and 10.8 (-24.9, 62.2) mg h/L, respectively. NeoGent was implemented in R/NONMEM, and in the freely available TDMx software

Farmakokineetika alustalad arstilt arstile

Medikamentoossele ravile võib läheneda kolmest vaatenurgast (vt joonis 1). 1.  Ravimi eesmärk on avaldada organismile efektiivset toimet, vältides samal ajal toksilisust nii toimekohas kui ka kogu ülejäänud organismis. Toimet, mida ravim organismile avaldab, kirjeldab farmakodünaamika. 2.  Organismi eesmärk on ravim kui sissetungija võimalikult kiiresti kahjutuks teha ning kehast kõrvaldada. Toimet, mida organism ravimile avaldab, kirjeldab farmakokineetika. 3.  Arsti eesmärk on aidata ravimil n-ö vaenlase tagalasse tungida ehk arst peaks manustama ravimit viisil, mis tagaks paratamatutest farmakokineetilistest protsessidest hoolimata ravimi jõudmise oma toimekohta (nt raku või patogeeni retseptorile) just õiges kontsentratsioonis. Osal komplitseeritud haiguskuluga patsientidel (nt enneaegsed vastsündinud, mitmete raskete kaasuvate haigustega patsiendid, intensiivravi-, onkoloogilised, põletushaiged jt) võib farmakokineetika olulisel määral keskmisest erineda (s.t et inimeste vahel esineb suur varieeruvus) ja/või sama patsiendi puhul ka ajas kiiresti muutuda. Ravimi kontsentratsiooni pisteline jälgimine annab olulist teavet individuaalse farmakokineetika kohta, kuid tulemuse tõlgendamine ning selle alusel annuse kohandamine osutub ikkagi sageli keeruliseks. Et paremini mõista, mis patsiendi organismis ravimiga toimub ning millest see võiks tingitud olla, on artikli eesmärk õpikute (1–4) toel pakkuda arstile lühikest värskenduskursust farmakokineetika põhiprintsiipidest. Ravimimonitooringuga seotud nüansid ning annuse individuaalse  kohandamise tänapäevased tehnoloogilised võimalused jäävad ootama jätkuartiklit. Artikli käsitlusalast jäävad seekord välja ka farmakodünaamilised protsessid (nt pärilikud retseptori ja/või signaaliraja iseärasused, tolerantsuse teke, ravimite koosmõjud retseptoril jms)

Clinical parameters predicting failure of empirical antibacterial therapy in early onset neonatal sepsis, identified by classification and regression tree analysis

<p>Abstract</p> <p>Background</p> <p>About 10-20% of neonates with suspected or proven early onset sepsis (EOS) fail on the empiric antibiotic regimen of ampicillin or penicillin and gentamicin. We aimed to identify clinical and laboratory markers associated with empiric antibiotic treatment failure in neonates with suspected EOS.</p> <p>Methods</p> <p>Maternal and early neonatal characteristics predicting failure of empiric antibiotic treatment were identified by univariate logistic regression analysis from a prospective database of 283 neonates admitted to neonatal intensive care unit within 72 hours of life and requiring antibiotic therapy with penicillin or ampicillin and gentamicin. Variables, identified as significant by univariate analysis, were entered into stepwise multiple logistic regression (MLR) analysis and classification and regression tree (CRT) analysis to develop a decision algorithm for clinical application. In order to ensure the earliest possible timing separate analysis for 24 and 72 hours of age was performed.</p> <p>Results</p> <p>At 24 hours of age neonates with hypoglycaemia ≤ 2.55 mmol/L together with CRP values > 1.35 mg/L or those with BW ≤ 678 g had more than 30% likelihood of treatment failure. In normoglycaemic neonates with higher BW the best predictors of treatment failure at 24 hours were GA ≤ 27 weeks and among those, with higher GA, WBC ≤ 8.25 × 10⁹L^-1together with platelet count ≤ 143 × 10⁹L^-1. The algorithm allowed capture of 75% of treatment failure cases with a specificity of 89%. By 72 hours of age minimum platelet count ≤ 94.5 × 10⁹L^-1with need for vasoactive treatment or leukopaenia ≤ 3.5 × 10⁹L^-1or leukocytosis > 39.8 × 10⁹L^-1or blood glucose ≤ 1.65 mmol/L allowed capture of 81% of treatment failure cases with the specificity of 88%. The performance of MLR and CRT models was similar, except for higher specificity of the CRT at 72 h, compared to MLR analysis.</p> <p>Conclusion</p> <p>There is an identifiable group of neonates with high risk of EOS, likely to fail on conventional antibiotic therapy.</p

Millal mõelda raputatud lapse sündroomile: kirjanduse ülevaade ning haigusjuhu kirjeldus

Eesti andmetel on laste väärkohtlemine sage: 40,5 juhtu 100 000 alla aastase lapse kohta. Lapsi väärkoheldakse sageli korduvalt. Haigusjuhu kirjeldamise eesmärk on juhtida tähelepanu õigeaegse ja täpse diangoosi vajadusele, et ära hoida korduvat väärkohtlemist. Eesti Arst 2007; 86 (6): 420–42