Are physician assistant and patient airway assessments reliable compared to anesthesiologist assessments in detecting difficult airways in general surgical patients?

BACKGROUND: Airway management remains one of the most important responsibilities of anesthesiologists. Prediction of difficult airway allows time for proper selection of equipment, technique, and personnel experienced in managing patients with difficult airway. Face to face preoperative anesthesia interviews are difficult to conduct as they necessitate patients traveling to the clinics, and, in practice, are usually conducted in the morning of the procedure by the anesthesiologist, when identification of predictors of difficult intubation may lead to schedule delays or case cancelations. We hypothesized that an airway assessment tool could be used by patients or physician assistants to accurately assess their airways. METHODS: We administered an airway assessment tool, which had been constructed in consultation with a psychometrician and revised after non-medical layperson feedback, to 215 patients presenting to the preoperative clinic for evaluation. Separately, patients had the airway exam performed by a physician assistant and an anesthesiologist. Agreement was compared using kappa. RESULTS: We found good agreement between observers only on "can you put three fingers in your mouth?" (three-way kappa = .733, p < 0.001) and poor agreement on Mallampati classification (three-way kappa = .195, p < 0.001) and "Can you fit three fingers between your chin and your Adam's Apple?" (three-way kappa = .216, p < 0.001). The agreements for the other questions were mostly fair. Agreements between patients and anesthesiologists were similar to those between physician assistants and anesthesiologists. CONCLUSIONS: Neither the patients' self-assessments nor the physician assistants' assessments were adequate to substitute for the anesthesiologists' airway assessments.

Bicultural Straddling Among Immigrant Adolescents: A Concept Analysis.

BACKGROUND: Increasing population diversity in the United States creates challenges for providing culturally responsive health care to immigrant adolescents. Nursing providers have few effective concepts to guide their understanding of how culturally diverse adolescents handle different cultural influences (between family and society) and how straddling two cultures may influence adolescents' decision making about health. AIM: Bicultural straddling is defined as an ongoing process of adaptation resulting from living within two different cultural influences. A concept analysis of bicultural straddling is important to nursing professionals in caring for culturally diverse adolescents. METHOD: Walker and Avant's methodology was used to guide our understanding about how immigrant adolescents straddle cultural influences between their homes and society. RESULTS: Straddling two different cultures influences adolescents' health-related beliefs, attitudes, perceptions, and behaviors as they navigate everyday struggles to make informed health decisions. Adolescents' ability to achieve active straddling will allow them to experience positive social functioning, psychological development, and health outcomes. CONCLUSIONS: By understanding the ongoing process of "bicultural straddling" as a balancing act, nurse professionals can develop effective interventions to alleviate stress derived from acculturation among immigrant families and ultimately help adolescents achieve biculturalism.

Dried blood spot analysis of donepezil in support of a GLP 3-month dose-range finding study in rats.

Donepezil hydrochloride is a reversible acetyl cholinesterase inhibitor approved for Alzheimer disease treatment. As an alternate therapy, a donepezil hydrochloride transdermal patch is in development. Recommended nonclinical safety studies include a 3-month Good Laboratory Practice (GLP) dose-range finding (DRF) study prior to conducting the 2-year dermal carcinogenicity study in rats. Demonstration of systemic exposure is necessary to interpret the in vivo data. Previous nonclinical reports supporting oral dosing have utilized liquid chromatography tandem mass spectrometry (LC/MS/MS) to quantify donepezil concentrations in plasma. Smaller species with limited blood volumes do not allow serial sampling to derive the full pharmacokinetic profile from a single animal. Therefore, the option of another analytical method requiring decreased sample volumes is desirable as it would decrease the required number of animals while obtaining the complete profile. The dried blood spot (DBS) technique allows drug level measurement from a few microliters; however, the method is still not widely utilized in GLP studies. Because donepezil plasma levels are known by the oral route, DBS was used to bridge the previous oral data and to support a 13-week GLP DRF study for repeated topical application in rats, comparing oral administration with 4 topical formulations. The DBS method was validated and demonstrated robustness and reproducibility for application to the DRF study. The assay results were comparable to a previously reported plasma LC/MS/MS assay-derived pharmacokinetic profile and provided justification for selection of the topical formulation and dose levels for the subsequent dermal carcinogenicity study.

Comparison of oral and transdermal administration of rasagiline mesylate on human melanoma tumor growth in vivo.

BACKGROUND/AIMS: Transdermal patch administration results in a locally high concentration of drug that induce local toxicity, including tumorogenicity. As a worst-case scenario for consequences of repeated application on neoplastic growth, the melanin-binding drug, rasagiline, was used in a transdermal formulation applied directly to a human-derived melanoma to determine the effects on tumor growth. MATERIALS AND METHODS: Rasagiline mesylate was administered either orally or transdermally to athymic mice implanted with human melanoma (SKMEL28) to determine the effects on tumor growth and survival. Over a 21-day period, animals were administered daily oral gavage (15 mg/kg) or one or two rasagiline mesylate transdermal patches every 3 days. After the last dose administration, blood samples were collected to confirm drug exposure. RESULTS: All animals from the untreated, vehicle and rasagiline groups survived to the end of the study; however, 7 out of the 10 cisplatin-treated animals died before the end of the study. Rasagiline mesylate dosed either via the oral or transdermal routes had comparable plasma exposure and, unexpectedly, significantly reduced absolute tumor volumes and tumor growth rates in the nude mouse SKMEL28 xenograft model. CONCLUSION: Transdermal delivery of melanin-binding rasagiline does not increase melanoma growth in the xenograft model. Because rasagiline decreases melanoma growth, it may be candidate for combination therapy for melanoma.