ABSTRACT
One of the commonest complications of endotracheal intubation occurs when the tip of the endotracheal tube passes distal to the carina and enters one of the main bronchi. The perioperative practitioner may observe high airway pressures, hypoxia or even pneumothorax. The most common reason given for the high incidence of right endobronchial intubation is that the right main bronchus comes off the trachea at a more acute angle from the midline. We sought, however, to explore two other factors which may explain this phenomenon the angle of the tube's bevel and its trajectory of approach. We conducted a prospective controlled trial in which doctors from our department intubated the trachea of an adult manikin in three distinct sets using standard tube, reversed tubes and reversed laryngoscope blades. We found that the angle of the bevel and trajectory of approach determines the side of endobronchial intubation in an adult manikin.
Subject(s)
Airway Management/instrumentation , Clinical Competence/standards , Intubation, Intratracheal/instrumentation , Bronchoscopy/methods , Equipment Design/standards , Humans , Manikins , Prospective StudiesABSTRACT
It is increasingly common for patients to be scheduled for anaesthesia and surgery with a 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decision in place. Updated guidelines for the implementation and management of DNACPR decisions were published jointly by the British Medical Association (BMA), the Resuscitation Council (UK) and the Royal College of Nursing (RCN) in 2014 (BMA, RC(UK), RCN 2014). The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published specific guidelines in 2009 to guide the perioperative management of such patients (AAGBI 2009). In this article, we explain these guidelines with a focus on how DNACPR decisions are made and how they can be modified in order to permit appropriate surgery to take place.
Subject(s)
Cardiopulmonary Resuscitation/ethics , Cardiopulmonary Resuscitation/nursing , Decision Making/ethics , Perioperative Nursing/ethics , Perioperative Nursing/standards , Resuscitation Orders/ethics , Aged , Aged, 80 and over , Anesthesia/ethics , Anesthesia/standards , Cardiopulmonary Resuscitation/standards , Female , General Surgery/ethics , General Surgery/standards , Guidelines as Topic , Humans , Ireland , Male , United KingdomABSTRACT
PURPOSE: Pars plana vitrectomy (PPV) is commonly used to remove the epiretinal membrane (ERM), but the timing of surgical intervention guided by visual acuity (VA) performance at presentation is uncertain. PATIENTS AND METHODS: Prospectively entered clinical data of 237 patients on an electronic patient record from 2001 to 2011 were analysed to determine visual outcomes, in particular in relation to pre-operative VA. RESULTS: The mean age of the patients was 68.8 years and 54.4% were female. Median follow-up was 0.55 years. The median pre-operative logMAR VA was 0.60 (SD 0.48-0.78, Snellen equivalent 6/36) and post-operative VA was 0.30 (SD 0.18-0.60, 6/12, P<0.005). Pre-operative VA correlated with post-operative VA (linear R(2)=0.22, P<0.0001). In all, 69.6% of patients showed an improvement in VA, 15.2% showed no change, and the condition of 15.2% worsened. The number of patients with an improvement in logMAR VA of more than 0.3 was greatest in those who had a pre-operative VA of 1.0 (6/60) or worse, followed by those in the range of 0.6-0.9 and then those with pre-operative VA of 0.5 or better (P<0.001). The proportion of patients with visual improvement of logMAR VA of more than 0.3 increased statistically with progressing years (P=0.019). CONCLUSION: In conclusion, this study shows improvement in VA after PPV and ERM removal. Patients with better initial VA achieve higher levels of visual outcome but those with poorer pre-operative VA show a greater change in VA following ERM surgery. Results of surgery improved over the time period of the study.
Subject(s)
Epiretinal Membrane/surgery , Visual Acuity/physiology , Vitrectomy , Adult , Aged , Aged, 80 and over , Benzenesulfonates , Coloring Agents , Epiretinal Membrane/diagnosis , Epiretinal Membrane/physiopathology , Female , Follow-Up Studies , Humans , Male , Middle Aged , Prospective Studies , Treatment Outcome , Trypan BlueABSTRACT
The Hairy/Enhancer of split/Deadpan family of basic helix-loop-helix (bHLH) proteins function as transcriptional repressors. We have examined the mechanisms of repression used by the Hairy and E(SPL) proteins by assaying the antagonism between wild-type or altered Hairy/E(SPL) and Scute bHLH proteins during sex determination in Drosophila melanogaster. Domain swapping and mutagenesis of the Hairy and E(SPL) proteins show that three evolutionarily conserved domains are required for their function: the bHLH, Orange, and WRPW domains. However, the suppression of Scute activity by Hairy does not require the WRPW domain. We show that the Orange domain is an important functional domain that confers specificity among members of the Hairy/E(SPL) family. In addition, we show that a Xenopus Hairy homology conserves not only Hairy's structure but also its biological activity in our assays. We propose that transcriptional repression by the Hairy/E(SPL) family of bHLH proteins involves two separable mechanisms: repression of specific transcriptional activators, such as Scute, through the bHLH and Orange domains and repression of other activators via interaction of the C-terminal WRPW motif with corepressors, such as the Groucho protein.
Subject(s)
DNA-Binding Proteins/metabolism , Drosophila Proteins , Drosophila melanogaster/physiology , Enhancer Elements, Genetic , Gene Expression Regulation , Helix-Loop-Helix Motifs , Insect Hormones/metabolism , Insect Proteins , Repressor Proteins , Transcription Factors/metabolism , Transcription, Genetic , Amino Acid Sequence , Animals , Animals, Genetically Modified , Basic Helix-Loop-Helix Transcription Factors , Biological Evolution , Conserved Sequence , DNA-Binding Proteins/chemistry , DNA-Binding Proteins/genetics , Drosophila melanogaster/genetics , Female , Genotype , Insect Hormones/chemistry , Insect Hormones/genetics , Male , Models, Genetic , Molecular Sequence Data , Mutagenesis , Mutagenesis, Site-Directed , Point Mutation , Recombinant Fusion Proteins/chemistry , Recombinant Fusion Proteins/metabolism , Sequence Deletion , Sequence Homology, Amino Acid , Sex Determination Analysis , Substrate Specificity , Transcription Factors/chemistry , Transcription Factors/geneticsABSTRACT
We describe a radial partition enzyme immunoassay in which fully automated quantification of human thyrotropin (hTSH) takes less than 11 min. This "sandwich"-type assay involves two monoclonal antibodies, both specific for the intact hTSH molecule. The solid phase consists of tabs of glass-fiber filter paper containing a pre-immobilized monoclonal anti-hTSH antibody complexed with a goat antibody specific for the Fc region of mouse IgG. The patient's sample is first applied to the central "reaction zone" of the tab, wherein hTSH binds to the immobilized antibody. Application of a buffered solution containing enzyme-labeled Fab' fragments of the second monoclonal anti-hTSH antibody initiates "sandwich" formation. A wash buffer containing a fluorogenic substrate elutes unbound conjugate to the tab periphery. The bound enzyme conjugate is quantified by measuring the rate of increase in fluorescence in the reaction zone of the tab, then converting the rate to clinical units by comparison with a stored calibration curve. The clinical utility and performance of the present assay compare favorably with those of other sensitive assays for hTSH.
