Reduction in Perinatal Mortality after Implementation of HBB Training at a District Hospital in Mali.

BACKGROUND: Mali has a high neonatal mortality rate of 38/1000 live births; in addition the fresh stillbirth rate (FSR) is 23/1000 births and of these one-third are caused by intrapartum events. OBJECTIVES: The aims are to evaluate the effect of helping babies breathe (HBB) on mortality rate at a district hospital in Kati district, Mali. METHODS: HBB first edition was implemented in April 2016. One year later the birth attendants were trained in HBB second edition and started frequent repetition training. This is a before and after study comparing the perinatal mortality during the period before HBB training with the period after HBB training, the period after HBB first edition and the period after HBB second edition. Perinatal mortality is defined as FSR plus neonatal deaths in the first 24 h of life. RESULTS: There was a significant reduction in perinatal mortality rate (PMR) between the period before and after HBB training, from 21.7/1000 births to 6.0/1000 live births; RR 0.27, (95% CI 0.19-0.41; p < 0.0001). Very early neonatal mortality rate (24 h) decreased significantly from 6.3/1000 to 0.8/1000 live births; RR 0.12 (95% CI 0.05-0.33; p = 0.0006). FSR decreased from 15.7/1000 to 5.3/1000, RR 0.33 (95% CI 0.22-0.52; p < 0.0001). No further reduction occurred after introducing the HBB second edition. CONCLUSION: HBB may be effective in a local first-level referral hospital in Mali.

Prehospital advanced life support provided by specially trained physicians: is there a benefit in terms of life years gained?

BACKGROUND: The benefit of prehospital advanced life support (ALS) is disputed, as is the prehospital use of specially trained, hospital-based physicians. The purpose of the study was to assess the health benefit from an anesthesiologist-manned prehospital emergency medical service (EMS), and to separate the benefit of the anesthesiologist from that of rapid transport. METHODS: The anesthesiologist-manned helicopter and rapid response car service at Rogaland Central Hospital assisted 1106 patients at the scene during the 18-month study period. Two expert panels assessed patients with a potential health benefit for life years gained (LYG) using a modified Delphi technique. The probability of survival as a result of the studied EMS was multiplied by the life expectancy of each patient. The benefit was attributed either to the anesthesiologist, the rapid transport or a combination of both. RESULTS: The expert panels estimated a benefit of 504 LYG in 74 patients (7% of the total study population), with a median age of 54 years (range 0-88). The cause of the emergency was cardiac diseases (including cardiac arrest) in 61% of the 74 patients, trauma in 19%, and cardio-respiratory failure as a result of other conditions in 20%. The LYG were equally divided between air and ground missions, and the majority (88%) were attributed solely to ALS by the anesthesiologist. CONCLUSION: The expert panels found LYG in every 14th patient assisted by this anesthesiologist-manned prehospital EMS. There was no difference in LYG between the helicopter and the rapid response car missions. The role of the anesthesiologist was crucial for health benefits.

Acute epiglottitis in a rural area: experiences with an anesthesiologist-staffed ambulance helicopter.

The majority of fatalities due to acute epiglottitis (AE) result from prehospital airway problems. We reviewed the courses of 14 patients with AE treated by an aeromedical team consisting of an anesthesiologist and a paramedic. Eight patients were transported from a physician's office or from the patient's own home. One patient was intubated at the scene, and two received ventilatory support with mask and bag en route to the hospital. Two patients suffered cardiopulmonary arrest before arrival of the aeromedical team, both resulting in severe hypoxic encephalopathy. All six patients transported from hospitals were intubated prior to the helicopter transport. Based on our own experience and a review of the literature, we discuss prehospital airway management in this group of patients.

In search of mediators of skin vasodilation induced by transcutaneous nerve stimulation: III. Increase in plasma VIP in normal subjects and in Raynaud's disease.

Previous studies have shown that the widespread and sustained cutaneous vasodilation which can be induced by low-frequency transcutaneous nerve stimulation (TNS) in humans is dependent on a central serotonergic pathway leading to peripheral sympatho-inhibition. In addition, in a bioassay study, the release of a peripheral vasodilator was suggested. However, the TNS-induced dilator response was not blocked by antagonists to a series of known endogenous vasodilators. In the present study another candidate, the vasoactive intestinal polypeptide (VIP) was monitored by means of a specific radioimmunoassay. The results showed an increase in plasma VIP from 5.6 pmol X l-1 before TNS to 7.3 pmol X l-1 after TNS (median values for 15 normal volunteers; P less than 0.05 for the 30% increase). Patients with Raynaud's disease displayed lower levels of VIP than the normal group (median 3.7 pmol X l-1 for 20 patients; P less than 0.01 for the difference from normals). TNS-induced rewarming of the extremities in Raynaud patients was paralleled by 35% increase in plasma VIP (median 5.0 pmol X l-1; P less than 0.01 for the TNS-dependent increase). The results suggest that the TNS-induced increase in plasma VIP parallels the increase in skin temperature in the extremities. However, a causal relationship between the increase in plasma VIP and cutaneous vasodilation remains to be determined. Possible origins of the TNS-dependent increase in plasma VIP are discussed.

In search of mediators of skin vasodilation induced by transcutaneous nerve stimulation: I. Failure to block the response by antagonists of endogenous vasodilators.

Low-frequency transcutaneous nerve stimulation (TNS) produces marked and widespread increases in skin temperature in ischaemic limbs of patients with Raynaud's disease and diabetic polyneuropathy. The prolonged time course of the temperature rise, which is due to increased cutaneous microcirculation, indicates the involvement of a long-lasting neurohumoral substance or metabolite. The vascular response is insensitive to conventional low doses of naloxone (Kaada, 1982a). In the present study the possible release of known endogenous vasodilators, all operating through the sympathetic nerves (Fig. 1, Nos 2-8), have been tested in patients by employing selective pharmacological antagonists or inhibitors to see if the stimulation-induced vasodilation could be blocked. The response was not antagonised either by beta-adrenergic, cholinergic, histaminergic, purinergic, or dopaminergic antagonists or by inhibitors of prostaglandins or plasma kinins.

In search of mediators of skin vasodilation induced by transcutaneous nerve stimulation: II. Serotonin implicated.

Previous studies have shown that brain serotonin is increased and noradrenaline decreased in acupuncture and transcutaneous nerve stimulation (TNS). Increases in available brain serotonin and decreases in noradrenaline enhance pain suppression. The present study tests the possibility that the widespread and prolonged cutaneous vasodilation which can be produced by low-frequency TNS in patients with peripheral circulatory insufficiency is similarly dependent on a central serotonergic pathway leading to sympatho-inhibition. The serotonin receptor antagonist cyproheptadine was given to 4 patients with either Raynaud's phenomenon or diabetic polyneuropathy, who all prior to drug administration responded to TNS with marked and prolonged cutaneous vasodilation in the ischaemic limbs. Cyproheptadine almost completely blocked the vascular response. Contrary to endorphin-serotonin mediated pain inhibition, vasoconstrictor inhibition is not antagonized by conventional, low doses of naloxone (Kaada, 1982a). However, the involvement of more naloxone-resistant opioid receptors in the vascular response cannot be excluded.

Effect of stress during labor on the concentration of cortisol and estriol in maternal plasma.

The effect of stress during labor on the plasma concentration of cortisol, unconjugated estriol, and human chorionic somatomammotropin was studied in 15 healthy primiparous women. According to the method of pain relief the parturients were divided into two groups. One group was given continuous epidural analgesia and the other group received pethidine, diazepam, and nitrous oxide/oxygen in response to pain. In the most stressed nonepidural group there was a significant rise in the cortisol level during labor and the estriol concentration fell significantly. In the epidural group no significant changes were observed with respect to the concentration of either cortisol or estriol. These results give further support to the hypothesis that severe maternal stress may lead to a reduced concentration of estriol in maternal plasma.

Dermatomyositis, suxamethonium action and atypical plasmacholinesterase.

A 19-year-old girl suffering from active dermatomyositis was given suxamethonium 60 mg during anaesthesia for termination of pregnancy. A prolonged suxamethonium action occurred which was explained by the finding of homozygous atypical plasmacholinesterase in her blood. Although no fasciculations were seen immediately after injection of the drug, a period of fasciculations progressing from the extremities to the head and trunk occurred during recovery of muscle tone. No hyperpyrexia or elevation of serum creatine phosphokinase occurred. This was ascribed to the steroid therapy she received. Plasma from four other patients suffering from dermatomyositis was also investigated and one young woman, also pregnant, was found to be heterozygous for the atypical enzyme.