Purpose Prediction of optimal timing for extubation of mechanically ventilated patients is challenging. Ultrasound measures of diaphragm thickness or diaphragm dome excursion have been used to aid in predicting extubation success or failure. The aim of this study was to determine if incorporating results of diaphragm ultrasound into usual ICU care would shorten the time to extubation. Methods We performed a prospective, randomized, controlled study at three Brown University teaching hospitals. Included subjects underwent block randomization to either usual care (Control) or usual care enhanced with ultrasound measurements of the diaphragm (Intervention). The primary outcome was the time to extubation after ultrasound, and the secondary outcome was the total days on the ventilator. Only intensivists in the Intervention group would have the ultrasound information on the likelihood of successful extubation available to incorporate with traditional clinical and physiologic measures to determine the timing of extubation. Results A total of 32 subjects were studied; 15 were randomized into the Control group and 17 into the Intervention group. The time from ultrasound to extubation was significantly reduced in the Intervention group compared to the Control group in patients with a ∆tdi% ≥ 30% (4.8 ± 8.4 vs 35.0 ± 41.0 h, p = 0.04). The time from ultrasound to extubation was shorter in subjects with a normally functioning diaphragm (∆tdi% ≥ 30%) compared to those with diaphragm dysfunction (∆tdi% < 30%) (23.2 ± 35.2 vs 57.3 ± 52.0 h p = 0.046). When combining the Intervention and Control groups, a value of ∆tdi% ≥ 30% for extubation success at 24 h provided a sensitivity, specificity, PPV and NPV of 90.9%, 86.7%, 90.9%, and 86.7%, respectively. Conclusions Diaphragm ultrasound evaluation of ∆tdi% aids in reducing time to extubation.
TB. 2 The Kenya Central Reference Laboratory, the only public laboratory with DST capacity in the country, identifi ed 82, 102, 150 and 112 MDR-TB cases in respectively 2007, 2008, 2009 and 2010. 3-5 DST is performed only on retreatment patients, with less than 69% of retreatment cases captured for testing in 2010. 3 Only 33% (50/150) and 62% (70/112) of the patients diagnosed with MDR-TB in Kenya were initiated on treatment in respectively 2009 and 2010. 3,4 This underscores the urgent need to develop more capacity to diagnose, manage and treat MDR-TB in costeffective ways.Kenya's country-wide plan for MDR-TB care was formulated in 2006, and originally emphasized an inpatient model located at the Kenyatta National Hospital in the capital city, Nairobi. However, the distance and possible long-term separation from family support limited MDR-TB referrals. Moi Teaching and Referral Hospital (Moi Hospital), located in Eldoret, 350 km northwest of Nairobi, is the second referral hospital in Kenya. It serves a network of 26 referring district hospitals and a catchment area of over 10 million people. With no isolation wards for in-patient MDR-TB treatment, Moi Hospital initiated a community-based MDR-TB treatment program with the permission of the Division of Leprosy, TB and Lung Disease (DLTLD).The objectives of this article are to describe the design and functioning of our community-based treatment program, the treatment outcomes of our initial cohort and the challenges encountered with providing and monitoring treatment in the community, with potential solutions. METHODSIn this paper, we describe the program and retrospectively review outcomes. For the purpose of publication, ethical review was obtained from both the Institutional Review and Ethics Board of Moi University School of Medicine and the Institutional Review Board of Lifespan (Providence, RI, USA). Community-based treatment program Program designAn MDR-TB team comprising a medical offi cer (MO), an administrative assistant, a data manager, a nutritionist, a pharmaceutical technician, a social worker and DLTLD regional representatives was established. Referrals to the program were called to the team by the district tuberculosis and leprosy coordinators (DTLC) or by clinicians on receipt of MDR-TB DST results. A home visit was then scheduled. Results: An MDR-TB team established a community-based program with either home-based DOT or local facilitybased DOT. Following referral, the team instituted a home visit, identified and hired a DOT worker, trained family and local health care professionals in MDR-TB care and initiated community-based MDR-TB treatment. In the first 24 months, 14 patients were referred, 5 died prior to initiation of treatment and one had extensively drug-resistant TB. Among eight patients who initiated community-based DOT, 87% underwent culture conversion by 6 months, and 75% were cured with no relapse after a median followup of 15.5 months. Multiple challenges were experienced, including system delays, stigma and limited funding. Co...
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