Aneurysmaattiseen lukinkalvonalaiseen verenvuotoon sairastuneen potilaan tehohoito

Teema : neuroanestesiologi

Comparing socioeconomic inequalities between early neonatal mortality and facility delivery: Cross-sectional data from 72 low- and middle-income countries

Facility delivery should reduce early neonatal mortality. We used the Slope Index of Inequality and logistic regression to quantify absolute and relative socioeconomic inequalities in early neonatal mortality (0 to 6 days) and facility delivery among 679,818 live births from 72 countries with Demographic and Health Surveys. The inequalities in early neonatal mortality were compared with inequalities in postneonatal infant mortality (28 days to 1 year), which is not related to childbirth. Newborns of the richest mothers had a small survival advantage over the poorest in unadjusted analyses (−2.9 deaths/1,000; OR 0.86) and the most educated had a small survival advantage over the least educated (−3.9 deaths/1,000; OR 0.77), while inequalities in postneonatal infant mortality were more than double that in absolute terms. The proportion of births in health facilities was an absolute 43% higher among the richest and 37% higher among the most educated compared to the poorest and least educated mothers. A higher proportion of facility delivery in the sampling cluster (e.g. village) was only associated with a small  decrease in early neonatal mortality. In conclusion, while socioeconomically advantaged mothers had much higher use of a health facility at birth, this did not appear to convey a comparable survival advantage

Glymfaattinen järjestelmä avaa aivojen padot

Peer reviewe

Rifampin Reduces the Plasma Concentrations of Oral and Intravenous Hydromorphone in Healthy Volunteers

Peer reviewe

Could dexmedetomidine be repurposed as a glymphatic enhancer?

Cerebrospinal fluid (CSF) flows through the central nervous system (CNS) via the glymphatic pathway to clear the interstitium of metabolic waste. In preclinical studies, glymphatic fluid flow rate increases with low central noradrenergic tone and slow-wave activity during natural sleep and general anesthesia. By contrast, sleep deprivation reduces glymphatic clearance and leads to intracerebral accumulation of metabolic waste, suggesting an underlying mechanism linking sleep disturbances with neurodegenerative diseases. The selective alpha(2)-adrenergic agonist dexmedetomidine is a sedative drug that induces slow waves in the electroencephalogram, suppresses central noradrenergic tone, and preserves glymphatic outflow. As recently developed dexmedetomidine formulations enable self-administration, we suggest that dexmedetomidine could serve as a sedative-hypnotic drug to enhance clearance of harmful waste from the brain of those vulnerable to neurodegeneration

Impact of results-based financing on effective obstetric care coverage : evidence from a quasi-experimental study in Malawi

Background: Results-based financing (RBF) describes health system approaches addressing both service quality and use. Effective coverage is a metric measuring progress towards universal health coverage (UHC). Although considered a means towards achieving UHC in settings with weak health financing modalities, the impact of RBF on effective coverage has not been explicitly studied. Methods: Malawi introduced the Results-Based Financing For Maternal and Neonatal Health (RBF4MNH) Initiative in 2013 to improve quality of maternal and newborn health services at emergency obstetric care facilities. Using a quasi-experimental design, we examined the impact of the RBF4MNH on both crude and effective coverage of pregnant women across four districts during the two years following implementation. Results: There was no effect on crude coverage. With a larger proportion of women in intervention areas receiving more effective care over time, the overall net increase in effective coverage was 7.1%-points (p = 0.07). The strongest impact on effective coverage (31.0%-point increase, p = 0.02) occurred only at lower cut-off level (60% of maximum score) of obstetric care effectiveness. Design-specific and wider health system factors likely limited the program's potential to produce stronger effects. Conclusion: The RBF4MNH improved effective coverage of pregnant women and seems to be a promising reform approach towards reaching UHC. Given the short study period, the full potential of the current RBF scheme has likely not yet been reached.Peer reviewe

Glymphatic-assisted perivascular brain delivery of intrathecal small gold nanoparticles

Nanoparticles are ultrafine particulate matter having considerable potential for treatment of central nervous system (CNS) disorders. Despite their tiny size, the blood-brain barrier (BBB) restricts their access to the CNS. Their direct cerebrospinal fluid (CSF) administration bypasses the BBB endothelium, but still fails to give adequate brain uptake. We present a novel approach for efficient CNS delivery of 111In-radiolabelled gold nanoparticles (AuNPs; 10-15 nm) via intra-cisterna magna administration, with tracking by SPECT imaging. To accelerate CSF brain influx, we administered AuNPs intracisternally in conjunction with systemic hypertonic saline, which dramatically increased the parenchymal AuNP uptake, especially in deep brain regions. AuNPs entered the CNS along periarterial spaces as visualized by MRI of gadolinium-labelled AuNPs and were cleared from brain within 24 h and excreted through the kidneys. Thus, the glymphatic-assisted perivascular network augment by systemic hypertonic saline is a pathway for highly efficient brain-wide distribution of small AuNPs.Peer reviewe

The influence of distance and quality of care on place of delivery in rural Ghana

Facility delivery is an important aspect of the strategy to reduce maternal and newborn mortality. Geographic access to care is a strong determinant of facility delivery, but few studies have simultaneously considered the influence of facility quality, with inconsistent findings. In rural Brong Ahafo region in Ghana, we combined surveillance data on 11,274 deliveries with quality of care data from all 64 delivery facilities in the study area. We used multivariable multilevel logistic regression to assess the influence of distance and several quality dimensions on place of delivery. Women lived a median of 3.3 km from the closest delivery facility, and 58% delivered in a facility. The probability of facility delivery ranged from 68% among women living 1 km from their closest facility to 22% among those living 25 km away, adjusted for confounders. Measured quality of care at the closest facility was not associated with use, except that facility delivery was lower when the closest facility provided substandard care on the EmOC dimension. These results do not imply, however, that we should increase geographic accessibility of care without improving facility quality. While this may be successful in increasing facility deliveries, such care cannot be expected to reduce maternal and neonatal mortality.Peer reviewe

Comparing socioeconomic inequalities between early neonatal mortality and facility delivery : Cross-sectional data from 72 low-and middle-income countries

Facility delivery should reduce early neonatal mortality. We used the Slope Index of Inequality and logistic regression to quantify absolute and relative socioeconomic inequalities in early neonatal mortality (0 to 6 days) and facility delivery among 679,818 live births from 72 countries with Demographic and Health Surveys. The inequalities in early neonatal mortality were compared with inequalities in postneonatal infant mortality (28 days to 1 year), which is not related to childbirth. Newborns of the richest mothers had a small survival advantage over the poorest in unadjusted analyses (-2.9 deaths/1,000; OR 0.86) and the most educated had a small survival advantage over the least educated (-3.9 deaths/1,000; OR 0.77), while inequalities in postneonatal infant mortality were more than double that in absolute terms. The proportion of births in health facilities was an absolute 43% higher among the richest and 37% higher among the most educated compared to the poorest and least educated mothers. A higher proportion of facility delivery in the sampling cluster (e.g. village) was only associated with a small decrease in early neonatal mortality. In conclusion, while socioeconomically advantaged mothers had much higher use of a health facility at birth, this did not appear to convey a comparable survival advantage.Peer reviewe

Glymfaattinen järjestelmä avaa aivojen padot

Tiivistelmä Glymfaattinen (glia-lymfaattinen) järjestelmä eli glianestekierto on aivojen perivaskulaarinen puhdistusjärjestelmä, joka toimii syvän unen ja anestesian aikana ja mahdollistaa aivo-selkäydinnesteen virtauksen aivokudokseen huuhtomaan valveen aikana kertyneitä aineenvaihduntatuotteita. Aivo-selkäydinneste sukeltaa aivoihin valtimoita ympäröivissä perivaskulaaritiloissa ja pääsee aivokudokseen perivaskulaaritiloja ympäröivien astrosyyttien akvaporiini 4 (AQP4) -vesikanavien avustamana. Aivokudoksessa solunulkoinen neste ja sen sisältämät aineenvaihduntatuotteet, kuten beeta-amyloidi, sekoittuvat aivo-selkäydinnesteeseen. Tämä neste poistuu aivojen soluvälitilasta laskimoiden perivaskulaaritilojen kautta käyttämällä useita ulosvirtausreittejä, muun muassa aivokalvojen imusuonia. Glymfaattisen järjestelmän puutteellisen toiminnan arvellaan altistavan aivojen rappeumasairauksille sekä heikentävän toipumista aivoverenkiertohäiriöstä tai aivovammasta. Järjestelmän toimintaa tehostamalla voitaisiin puolestaan ehkäistä aivojen rappeumasairauksia tai edesauttaa esimerkiksi lääkkeiden pääsyä keskushermostoon. Glymfaattinen järjestelmä kuvattiin ensin koe-eläintutkimuksissa, ja ihmisen vastaavasta järjestelmästä tarvitaan vielä lisää tutkimusnäyttöä.Abstract The glymphatic (glial-lymphatic) system is mainly active during deep sleep and anesthesia, and allows the passage of cerebrospinal fluid into the brain parenchyma to wash the brain of harmful endogenous metabolic waste. Cerebrospinal fluid flows from the subarachnoid space to the periarterial spaces, and enters the brain parenchyma facilitated by astrocytic aquaporin 4 (AQP4) water channels. In the brain parenchyma, metabolic waste products in the interstitial fluid mix with the cerebrospinal fluid. This solute-containing fluid then flows to the perivenous spaces and is drained from the brain through several efflux routes, including the meningeal lymphatic vessels. Impaired glymphatic flow may contribute to the pathogenesis of several chronic neurodegenerative diseases and poor recovery from traumatic brain injury and ischemic stroke. On the other hand, enhancing glymphatic flow might help to prevent neurodegenerative diseases or facilitate drug delivery to the central nervous system. Although the glymphatic system was first described in rodents, recent studies suggest that a similar system functions in the human brain