Severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation support: a consequence of vaping.

In the past decade, vaping has become more prevalent globally. Since mid-2019, reports have linked the use of vaping devices to lung injury (EVALI). This is the first reported adult case outside the USA to require ECMO for a severe vaping complication. https://bit.ly/39hf2ZY.

Paramedic laryngoscopy in the simulated difficult airway: comparison of the Venner A.P. Advance and GlideScope Ranger video laryngoscopes.

OBJECTIVES: This study assesses intubation times and potential trauma with two new portable video laryngoscopes, the GlideScope Ranger (GSR) and the Venner A.P. Advance (APA), in a simulated difficult prehospital airway. The GSR has a hockey stick shape and is inserted by a different (midline) technique compared with direct laryngoscopy and requires the use of a stylet. The APA has a handle similar to a direct laryngoscope, but with an angulated difficult airway blade. The APA is designed to have an intuitive insertion technique somewhat similar to that of direct laryngoscopy (lateral tongue displacement) and has a guiding mechanism that foregoes the need for a stylet. METHODS: Thirty qualified paramedics received a short demonstration of each device and were asked to intubate a modified Grade III difficult laryngoscopy mannequin in a random order (closed envelope technique). Optimal view and tracheal intubation times were recorded, and potential trauma assessed by the number of additional discrete forward advances and by visual analog scale (VAS). Direct laryngoscopy was used as a comparator. The Wilcoxon rank sum test was used for intubation times, optimal view times, percentage of glottis opening (POGO) seen, and objective trauma assessment. Student's paired t-test was used for subjective trauma assessment and a Bonferroni correction was used for the primary outcome measures. RESULTS: Participants declared a median of 60 (range 20 to 300) previous intubations. Time to achieve optimal view between APA and GSR was not different (20 seconds vs. 19 seconds; p = 0.19), but tracheal intubation was significantly faster with the APA (25 seconds vs. 46 seconds; p < 0.0001). Intubation success was ultimately 97% in both groups. Participants judged subjective trauma to be less for the APA than GSR on a VAS (1.6 cm vs. 3.3 cm; p < 0.001). More than three additional forward advances were required in 43% of GSR and 0% of APA intubations. CONCLUSIONS: Following a brief demonstration to paramedics naïve to video laryngoscopy, the APA demonstrated earlier intubation, fewer additional discrete forward advances of the tube, and less participant-judged subjective trauma when compared to the GSR in this simulation model.

Central nervous system injury triggers hepatic CC and CXC chemokine expression that is associated with leukocyte mobilization and recruitment to both the central nervous system and the liver.

The administration of interleukin-1beta to the brain induces hepatic CXC chemokine synthesis, which increases neutrophil levels in the blood, liver, and brain. We now show that such hepatic response is not restricted to the CXC chemokines. CCL-2, a CC chemokine, was released by the liver in response to a tumor necrosis factor (TNF)-alpha challenge to the brain and boosted monocyte levels. Furthermore, a clinically relevant compression injury to the spinal cord triggered hepatic chemokine expression of both types. After a spinal cord injury, elevated CCL-2 and CXCL-1 mRNA and protein were observed in the liver by TaqMan reverse transcriptase-polymerase chain reaction and enzyme-linked immunosorbent assay as early as 2 to 4 hours. Simultaneously, we observed elevated levels of these chemokines and circulating leukocyte populations in the blood. Leukocytes were recruited to the liver at this early stage, whereas at the site of challenge in the central nervous system, few were observed until 24 hours. Artificial elevation of blood CCL-2 triggered dose-dependent monocyte mobilization in the blood and enhanced monocyte recruitment to the brain after TNF-alpha challenge. Attenuation of hepatic CCL-2 production with corticosteroids resulted in reduced monocyte levels after the TNF-alpha challenge. Thus, combined production of CC and CXC hepatic chemokines appears to amplify the central nervous system response to injury.

Differential induction of interleukin-1beta and tumour necrosis factor-alpha may account for specific patterns of leukocyte recruitment in the brain.

In peripheral tissue, IL-1beta has been shown to induce TNFalpha expression and vice versa, resulting in mixed neutrophil and mononuclear cell recruitment to the site of injury. This has led to the concept of crosstalk in peripheral cytokine signalling pathways. In the brain parenchyma, however, restricted patterns of leukocyte recruitment following the focal injection of pro-inflammatory agents into the brain are observed. This study investigates the expression of the principal pro-inflammatory cytokines--IL-1beta and TNFalpha--in the brain after IL-1beta, TNFalpha, NMDA or endotoxin injection into the brain parenchyma of rats. Each of these agents gives rise to a distinct pattern of acute leukocyte recruitment at 24 h. We found that IL-1beta induces de novo synthesis of additional IL-1beta but not TNFalpha, as determined by RT-PCR and ELISA, and TNFalpha does not induce either itself or IL-1beta. Injection of NMDA results in IL-1beta, but not TNFalpha up-regulation. Injection of IL-1beta or NMDA is associated with neutrophil recruitment whereas injection of TNFalpha is associated with mononuclear cell recruitment. Following injection of endotoxin, both TNFalpha and IL-1beta levels are elevated and neutrophils and mononuclear cells are recruited to the brain. These data suggest that the signalling pathways that are present in the periphery are modified in the brain and that differential induction of TNFalpha and IL-1beta may have a role in the atypical pattern of leukocyte recruitment observed in the brain.

Altered chemokine expression in the spinal cord and brain contributes to differential interleukin-1beta-induced neutrophil recruitment.

The pattern of neutrophil recruitment that accompanies inflammation in the CNS depends on the site of injury and the stage of development. The adult brain parenchyma is refractory to neutrophil recruitment and associated damage as compared to the spinal cord or juvenile brain. Using quantitative Taqman RT-PCR and enzyme-liked immunosorbent assay (ELISA), we compared mRNA and protein expression of the rat neutrophil chemoattractant chemokines (CINC) in spinal cord and brain of adult and juvenile rats to identify possible association with the observed differences in neutrophil recruitment. Interleukin-1beta (IL-1beta) injection resulted in up-regulated chemokine expression in both brain and spinal cord. CINC-3 mRNA was elevated above CINC-1 and CINC-2alpha, with expression levels for each higher in spinal cord than in brain. By ELISA, IL-1beta induced greater CINC-1 and CINC-2alpha expression compared to CINC-3, with higher protein levels in spinal cord than in brain. In the juvenile brain, significantly higher levels of CINC-2alpha protein were observed in response to IL-1beta injection than in the adult brain following an equivalent challenge. Correspondingly, neutrophil recruitment was observed in the juvenile brain and adult spinal cord, but not in the adult brain. No expression of CINC-2beta mRNA was detected. Thus differential chemokine induction may contribute to variations in neutrophil recruitment in during development and between the different CNS compartments.