ABSTRACT
An 18-year-old man with hypoxic encephalopathy was admitted because of recurrent minor bleeding a tracheal stoma, which was suspected as a tracheo-innominate artery fistula (TIF). He had undergone tracheostomy and gastrostomy 2 years prior and had mild opisthotonos and scoliosis. Although tracheal endoscopy showed no tracheal mucosal erosion, necrosis, or granulation tissue formation, contrast-enhanced computed tomography (CT) revealed a close contact between the innominate artery and the anterior wall of the trachea, and an equal height between the innominate artery and the tip of the tracheal cannula. Magnetic resonance angiography of the head showed dominant intracranial blood flow from the left internal carotid and vertebral arteries. Preventive innominate artery transection through the supra-sternal approach without sternotomy or reconstruction of the innominate artery was performed for this high-risk case of TIF. The patient's postoperative course was uneventful. Postoperative CT revealed that the innominate artery was transected and isolated from the site of tracheostomy. The preserved connection between the right common carotid and subclavian artery at the distal sutured stump helped maintain blood flow in the right internal and middle cerebral arteries. The patient was discharged on postoperative day 9 without any new neurological complications or bleeding from a tracheal stoma. TIF is a rare but fatal complication after laryngotracheal separation or tracheostomy. It is important to prevent the onset of TIF, however, there are no criteria for preventive innominate artery transection. Our preventive innominate artery transection through the supra-sternal approach is considered as one of the useful surgical treatment for high-risk cases of TIF accompanied by severe neuromuscular disorders.
ABSTRACT
Mercury is a common element found in household, industrial and medical products. Mercury waste has the potential to leak into rivers that flow to the oceans where bacteria can convert mercury into a soluble form that can allow concentrations to build up in local fish populations. Previous research performed in Anguilla in 2013 - 2014 found that the fish species Mahi mahi had the highest mercury concentration at 0.08 mg / Kg. The FDA and WHO recommend a maximum of 1 mg / Kg per year. Chronic ingestion of mercury has been linked to pregnancy complications, early childhood developmental complications, and various neurological and gastrointestinal manifestations. METHODSFish tissue samples were acquired locally on the Caribbean Island of Anguilla from 10 different fish species, documented, prepared for temporary preservation and sent to the Biodiversity Research Institute where mercury concentration processing was performed on their DMA (Direct Mercury Analyzer). RESULTSData showed that mercury concentrations have risen for certain fish species and fallen in others since samples were last taken in 2013. The mercury concentration of Mahi mahi decreased, back in 2013 the reported concentration was 0.08 mg / Kg while the 2020 result was 0.023 mg / Kg. On the other end of the spectrum, the mercury concentration of the Red Hind species in 2013 was 0.07 mg / Kg and had increased to 0.2604 mg / Kg in 2020. CONCLUSIONSOur findings support the notion that mercury concentrations within the tissues of fish around the Caribbean island of Anguilla have increased. Future mercury testing should be performed around other local Caribbean islands so as to compare the relative mercury concentrations and so that local governments can also appropriately inform the Caribbean communities of the potential risks they take with chronic ingestion of local seafood
ABSTRACT
Introduction: The applicability of the Modified Mallampatitest in supine patients is doubtful. We undertook this studyto evaluate the efficacy of acromio-axillo-suprasternal notchindex (AASI) for predicting difficult intubation and tocompare it with modified Mallampati test in supine position(MMT-S).Material and Methods: This prospective observationalstudy included 200 patients of American Society ofAnaesthesiologist (ASA) physical status I and II ofeither gender, aged 18-60 years. Patients with anatomicalabnormalities involving head and neck, pregnant, edentulousand BMI>35Kg/m2 were excluded. AASI and MMT-S wereassessed preoperatively. Direct laryngoscopy was performedby an experienced anaesthesiologist blinded to the result ofairway assessment tests. Cormack Lehane grade (CL grade)and number of attempts to successful intubation were noted.Primary objective was to assess AASI as predictor of difficultvisualisation of larynx (DVL) and secondary objective was tocompare it with MMT-S. Statistical analysis- McNamer testwas used to compare sensitivity and specificity of both themethods. Comparison of Area under Curve(AUC) of both themethods was performed.Results: AASI was 92% sensitive and 97.71% specificin predicting difficult intubation whereas sensitivity andspecificity of MMT-S was 76% and 84.57% respectively. AreaUnder Curve (AUC) of AASI was 0.97 with cut-off value>0.49 as a predictor of difficult intubation.Conclusion: AASI with cut off value >0.49 has highersensitivity and positive predictive value and is better inpredicting difficult airway in supine patients as compared toMMT-S.
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Objective To evaluate the value of suprasternal long axis view in echocardiography for right pulmonary artery (RPA) lesions.Methods Echocardiography was performed in 31 patients with clinical suspicion of pulmonary vascular disease.Through suprasternal long axis view,RPA,right superior pulmonary artery and right inferior pulmonary artery were identified,and the vessel wall,intraluminal echoes,and location of the lesion were obtained.Blood flow in pulmonary artery was detected with color Doppler flow imaging.The results of echocardiography were compared with those of computer tomography of pulmonary angiography (CTPA) and clinical diagnosis.Results With suprasternal notch echocardiography,RPA lesions were identified in 27 patients.H owever,RPA could not be clearly identified in four patients.There were 22 patients with moderate or low echo mass in RPA,and five patients with intimal thickening and artery stenosis/obliteration.In the 27 patients with detected lesions,20 lesions were located in RPA,seven lesions were located in distal RPA or its branches.Among the results obtained with echocardiography,25 were in accordance with CT results,6 were not in accordance with CT results.Conclusions The suprasternal long axis view of RPA can be an important alternative imaging modality in identification of pulmonary vascular diseases.
ABSTRACT
Thyroglossal duct cyst (TGDC) is caused by the failure of the thyroglossal duct to be obliterated following descent of the thyroid during the 6th week of fetal life. TGDC can develop anywhere along the course of the thyroglossal duct remnant, from the base of the tongue to the suprasternal region. Four general locations are well-recognized: intralingual, suprahyoid, thyrohyoid and suprasternal. The typical location of a TGDC is in the midline of the anterior neck, and this is closely related to the hyoid bone. Atypical TGDC is important because of the high incidence of misdiagnosis, inadequate therapy and possible neoplastic change. We describe a recently encountered patient with a suprasternal mass that was ultimately diagnosed as a TGDC. There are only a few case reports of atypical anatomical locations, and particularly suprasternal TGDC. So, we present a case of suprasternal TGDC that was mistaken for a simple cystic tumor, along with a brief review of the related literature.
Subject(s)
Humans , Diagnostic Errors , Hyoid Bone , Incidence , Neck , Thyroglossal Cyst , Thyroid Gland , TongueABSTRACT
BACKGOUND: Correct placement of an endotacheal tube (ETT) is crucial, and an ideal test for confirmation of proper ETT placement should be simple and quick to perform, reliable, safe, inexpensive, and repeatable. Palpation of the ETT cuff at the suprasternal notch has been used by clinicians for many years, however the effectiveness of the technique has never been documented. So the author evaluated an efficacy of the pilot balloon compression technique to verify the correct location of an ETT. METHODS: After anesthetic induction and confirmation of orotracheal intubation, the patient's head is placed in a neutral position. The ETT is withdrawn or advanced while gentle, repeated pressure is applied with the fingers at the pilot balloon. Simultaneously, the suprasternal notch is palpated in the other hand. When the cuff maximally distends from the pressure applied at the pilot balloon, the ETT is secured. After securing the ETT, the distances from its tip to the upper incisor and the carina were measured by means of fiberoptic laryngoscopy. RESULTS: Endobroncheal intubation was noted in three patients (3%). Average distance from the tip of the ETT to upper incisor in men was 23.9 cm (range, 21.7~26.9) and in women 22.5 cm (range, 20.0~26.0). Average distance to the carina in men was 2.6 cm (range, -0.5~5.0) and in women 1.8 cm (range, -0.6~4.4). CONCLUSIONS: In this study, location of the ETT was not reliably confirmed by the technique. So the technique should need some modification. When maximal sensation of the ETT cuff is palpated 2.4~3.3 cm in men and 3.2~3.7 cm in women above the suprastenal notch, the location of the ETT tip is theoretically reliable. However, the technique should not be used to verify endotracheal intubation itself.