Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study.

BACKGROUND: Intraosseous (IO) drug infusion has been reported to have similar pharmacokinetics to intravenous (IV) infusion. In military and civilian trauma, the IO route is often used to obtain rapid and reliable parenteral access for drug administration. Only a few case reports have described the use of IO infusion to administer drugs for rapid sequence induction of anaesthesia (RSI). OBJECTIVE: We aimed to assess the feasibility of the administration of RSI drugs via an IO catheter in a prospective observational study. METHODS: A prospective observational study was undertaken at a combat hospital in Afghanistan. A validated data form was used to record the use of IO drugs for RSI by the prehospital, physician-led Medical Emergency Response Team (MERT), and by inhospital physicians. Data were captured between January and May 2012 by interview with MERT physicians and inhospital physicians directly after RSI. The primary outcome measure was the success rate of first-pass intubation with direct laryngoscopy. RESULTS: 34 trauma patients (29 MERT and 5 inhospital) underwent RSI with IO drug administration. The median age was 24 years and median injury severity score 25; all were male. The predominant mechanism of injury was blast (n=24), followed by penetrating (n=6), blunt (n=3) and burn (n=1). First-pass intubation success rate was 97% (95% CI 91% to 100%). A Cormack-Lehane grade 1 view, by direct laryngoscopy, was obtained at first look in 91% (95% CI 81% to 100%) of patients. CONCLUSIONS: In this prospective, observational study, IO drug administration was successfully used for trauma RSI, with a comparable first pass intubation success than published studies describing the IV route. TRIAL REGISTRATION NUMBER: RCDM/Res/Audit/1036/12/0162.

The effectiveness of an informal teaching programme for junior doctors identifying pleural effusions using ultrasound at the bedside.

OBJECTIVES: The use of bedside ultrasound to localise pleural effusions has gained in popularity in recent years. We investigated whether or not junior doctors could accurately identify thoracic anatomical structures and localise pleural effusions using bedside ultrasound. METHODS: Junior doctors were instructed by a consultant chest physician in the theory and practice of using ultrasound to localise pleural effusions, and then instructed in the method of inserting a Seldinger chest drain. Juniors were instructed to record a scan picture, including labelling of relevant structures. We then conducted a review of 52 images, noting indications, complications and the grade of doctor performing the scan. A consultant radiologist reviewed the scan pictures to confirm that the anatomy was correctly identified. RESULTS: Fifty out of 52 images (96%) were of diagnostic quality, with the anatomy correctly identified. The complication rate from chest drain insertion was 3.85%. CONCLUSIONS: With instruction, junior doctors can competently utilise basic chest ultrasound, obtain useful images, identify relevant thoracic anatomy and insert chest drains by the Seldinger technique with a low rate of complications. We suggest thoracic ultrasound should be more widely taught to junior doctors.

Riboswitches in eubacteria sense the second messenger cyclic di-GMP.

Cyclic di-guanosine monophosphate (di-GMP) is a circular RNA dinucleotide that functions as a second messenger in diverse species of bacteria to trigger wide-ranging physiological changes, including cell differentiation, conversion between motile and biofilm lifestyles, and virulence gene expression. However, the mechanisms by which cyclic di-GMP regulates gene expression have remained a mystery. We found that cyclic di-GMP in many bacterial species is sensed by a riboswitch class in messenger RNA that controls the expression of genes involved in numerous fundamental cellular processes. A variety of cyclic di-GMP regulons are revealed, including some riboswitches associated with virulence gene expression, pilus formation, and flagellum biosynthesis. In addition, sequences matching the consensus for cyclic di-GMP riboswitches are present in the genome of a bacteriophage.

How does cot death prevention advice influence parents' behaviour?

OBJECTIVE: To explore parents' understanding of the recommended cot death prevention strategies, and to discuss what they are doing in practice. If there is a difference between knowledge and implementation measures, possible reasons for this will be considered. STUDY DESIGN: A qualitative study using thematic analysis, aimed at finding out attitudes and opinions of parents about cot death prevention measures. Twelve participants were interviewed from two disadvantaged communities in south Birmingham. RESULTS: Parents found that much of the cot death prevention advice they were provided with was conflicting and caused confusion. As such, many parents chose to follow advice from non-healthcare sources. Some parents were carrying out preventative measures but were not aware of the reason for doing it. Many felt they did not receive enough advice relating to cot death prevention. CONCLUSION: Cot death health promotion advice appears to be inadequate among patients from a deprived socioeconomic background. Some of these issues could be resolved with increased training addressing these matters.

Prevalence, consequences and prevention of childhood nutritional iron deficiency: a child public health perspective.

The true extent of nutritional iron deficiency (ID) in childhood is unclear because of uncertainty over its definition and the insensitivity of markers of ID. The major cause is likely to be the excessive and early use of cow's milk. Recent neurophysiological observations support the many field studies correlating ID with cognitive developmental delays. Prevention is best sought through supplementation of essential foods.

Incidence of symptomatic vitamin D deficiency.

A survey of West Midlands paediatricians in 2001 identified 24 cases of symptomatic vitamin D deficiency in children less than 5 years of age. The overall incidence was 7.5 per 100,000 children per year with notable differences in incidence per ethnic group.

Light-emitting diode 415 nm in the treatment of inflammatory acne: an open-label, multicentric, pilot investigation.

BACKGROUND: The management of acne remains a challenge, with current therapies linked to significant side effects and patient non-compliance. Phototherapy using blue light has been proven in the treatment of acne vulgaris and offers the clinician an effective alternative. OBJECTIVE: To determine the effect of narrowband light-emitting diode (LED) blue light in the reduction of inflammatory and non-inflammatory lesions in patients with mild to moderate acne and to evaluate patient tolerance of the therapy. METHODS: Forty-five patients were treated with high-intensity pure blue light, 415 nm and 48 J/cm2, receiving two treatments of 20 minutes per week for a period of 4-8 weeks. Clinical assessment was performed at baseline, and 2, 4 and 8 weeks after treatment. A patient's therapeutic response was measured using a global improvement scoring system. RESULTS: The mean improvement score was 3.14 at 4 weeks and 2.90 at 8 weeks. Nine patients experienced complete clearing at 8 weeks. The treatment was well tolerated, with 50% of patients highly satisfied with the treatment. CONCLUSION: This open-label study suggests the therapeutic efficacy of high-intensity LED pure blue light in the treatment of acne vulgaris with no reported side effects.

Parental smoking and passive smoking in infants: fathers matter too.

This study examines mothers' and fathers' smoking patterns in different kinds of smoking households, and assesses their relative contribution to infants' exposure to environmental tobacco smoke. It uses data from a cross-sectional survey of 314 smoking households (infants: mean age 10 weeks) in Coventry and Birmingham, England, examining reported tobacco consumption and objective measures of exposure: the study infant's urinary cotinine:creatinine ratios and their mother's salivary cotinine. The study shows that both mothers' and fathers' tobacco smoke make substantial contributions to infant exposure to tobacco smoke. Households were more likely to contain a smoking father than mother, with over two-thirds of households including a smoking father. In households where both parents smoke, fathers' tobacco consumption was found to be significantly higher than in households where only the father smokes. This suggests that the interaction between parents needs to be considered rather than focusing on mothers' or fathers' smoking behaviour in isolation. The implications for health promotion programmes are discussed, particularly the need to place more emphasis on tackling fathers' smoking. Currently, fathers' smoking receives far less research or health promotion attention than mothers' smoking. Protecting infants from fathers' as well as mothers' smoking is key to reducing environmental tobacco exposure in early infancy, when the risk of Sudden Infant Death is highest.

Mohs micrographic surgery-induced pemphigus.

BACKGROUND: Pemphigus is an autoimmune blistering disease that presents with flaccid intraepidermal blisters, erosions of the skin and mucous membranes, acantholysis, and in vivo bound and circulating autoantibodies against keratinocyte antigen. Currently a handful of reports incriminate surgical trauma as an initiating factor in this disease. OBJECTIVE: To document pemphigus evolving in a wound after Mohs micrographic surgery. METHODS: Case report. RESULTS: We present a case of pemphigus that started in a Mohs surgical wound after the excision of a squamous cell carcinoma (SCC) from a 49-year-old woman. Biopsy of the preoperative lesion did not reveal pemphigus. Biopsy of the postoperative lesion revealed pemphigus with no residual SCC. CONCLUSION: We suggest that Mohs surgery, like any other skin surgery, may nonspecifically activate pemphigus. This change must be differentiated from postoperative wound infection and other causes of poor wound healing.

A correlation of alpha-smooth muscle actin and invasion in micronodular basal cell carcinoma.

BACKGROUND: Actin is largely responsible for cell motility and is only sparsely found in normal epithelial cells. An altered expression of actin in some malignancies may facilitate aggressive invasion. Micronodular basal cell carcinoma (BCC) has been shown to require more surgical stages, wider tissue margins, and deeper defects for extirpation during Mohs micrographic surgery relative to nodular BCC. OBJECTIVE: To provide preliminary data regarding a possible correlation between alpha-smooth muscle actin (alpha-SMA) expression within the cells or stroma of micronodular BCC and aggressive invasion. In addition, the incidence of alpha-SMA expression in micronodular, morpheaform, and nodular BCC is evaluated. METHODS: Nine micronodular basal cell carcinomas (7 primary, 2 recurrent) were evaluated for neural invasion, depth of tissue invasion, and alpha smooth muscle actin antibodies. The presence of alpha-smooth muscle actin antibodies was assessed using immunoperoxidase staining and compared with 13 morpheaform (13 primary, 0 recurrent) and 12 nodular (12 primary, 0 recurrent). RESULTS: Six of the nine micronodular (67%), eight of the 13 morpheaform (62%), and 0 of the 12 nodular (0%) BCCs stained positive for alpha-SMA. Of the six micronodular BCCs that stained positive for alpha-SMA, three invaded the fascia or muscle and three displayed neural invasion. In contrast, of the three micronodular BCCs that stained negative for alpha-SMA, none invaded the fascia or muscle and only one exhibited neural invasion. CONCLUSION: Actin was present in 66% of micronodular, 62% of morpheaform, and 0% of nodular BCC. The presence of actin in micronodular BCC may be a marker for aggressive invasion.

Rapid HMB-45 staining in Mohs micrographic surgery for melanoma in situ and invasive melanoma.

BACKGROUND: Accurate interpretation of frozen sections in the treatment of melanoma by Mohs micrographic surgery may be difficult. OBJECTIVE: Our purpose was to review the literature on the role of Mohs micrographic surgery in the treatment of melanoma and to demonstrate the added benefits of using rapid HMB-45 staining in Mohs micrographic surgery for the treatment of melanoma. METHODS: Twenty cases of melanoma were included in our study. Histologic diagnosis in each case was made by means of excisional biopsy specimens and permanent sections. Mohs micrographic surgery was performed with 3-mm margins used for each stage. Each Mohs frozen section was stained with HMB-45. In addition, routine frozen sections stained with hematoxylin-eosin were also prepared for comparison. All tissues were also sent for permanent sections. These permanent sections were cut similarly to Mohs-oriented sections because they were sectioned horizontally. Since they were serving as the standard, no staining with HMB-45 was performed on these permanent sections. Further stages with 3-mm margins were taken until tissues stained negative. Frozen sections were compared with permanent sections at each stage of resection. RESULTS: Eleven of the 20 cases stained positive with HMB-45 antibody on the first Mohs stage. These results were consistent with findings on permanent sections. Ten of the 11 cases were cleared by the first stage. One of the 11 cases required 3 stages because margins were not cleared and the specimens stained HMB-45 positive. However, permanent sections in this case revealed no tumor in the second stage. Nine of 20 cases did not stain with HMB-45 on the first layer of Mohs excision. This was consistent with findings on permanent sections. CONCLUSION: HMB-45 staining serves as a rapid technique to aid in the interpretation of frozen sections during Mohs micrographic surgery in the treatment of melanoma.

Ocular damage due to chlorhexidine versus eyeshield thermal injury.

BACKGROUND: Ocular damage may occur from a number of mechanisms during laser use. OBJECTIVE: To review issues relevant to ocular protection during laser resurfacing. METHODS: The authors were consulted to evaluate the thermal energy transferred from the outer to the inner (ie, corneal contact) surface of stainless steel eyeshields following direct exposure to the carbon dioxide (CO2) resurfacing laser beam. Measurements were obtained using thermocouples (attached to the inner surface of the eyeshields) and analyzed with a computer-based acquisition system. RESULTS: A maximum eyeshield temperature increase of 13 degrees C above the ambient temperature was noted following one pass with a CO2 resurfacing laser (Sharplan continuous CO2 laser with Clinicon SureScan scanner, 15 W, 950 microsec pulse duration, square spot of 9 mm). CONCLUSION: The eyeshields analyzed in this study minimized thermal transfer following a single direct hit with a CO2 resurfacing laser. An understanding of the potential mechanisms of ocular injury is essential in preventing its occurrence.

Increased glycosaminoglycans production in sclerosing basal cell carcinoma-derived fibroblasts and stimulation of normal skin fibroblast glycosaminoglycans production by a cytokine-derived from sclerosing basal cell carcinoma.

Sclerosing basal cell carcinoma (S-BCC) is characterized by an abundant stroma. There is evidence that some tumor cells secrete cytokines that are mitogenic for stromal fibroblasts (FBs). From this study we report increased glycosaminoglycan (GAG) production by cultures of S-BCC FBs in comparison to cultures of nodular BCC (N-BCC) FBs and normal skin FBs. GAG production was measured by cetylpyridinium chloride precipitation of incorporated [3H]-glucosamine. The sclerosing BCC FBs demonstrated a significant increase in production of GAG over control FBs (P <.001) and over N-BCC FBs (P<.001). Values reported as a mean percentage +/- SEM for GAG production by S-BCC over control normal skin FBs are 359+/-28 and over N-BCC FBs are 266+/-27. In additional experiments, cell extract dilutions from S-BCC tumor, normal dermis, and normal epidermis were incubated with cultures of normal skin FBs. S-BCC-conditioned media was also incubated with normal FBs and GAG production was measured. For both S-BCC extracts and conditioned media, a dose response curve was established showing increased GAG production by normal FBs in relation to increasing the concentration of S-BCC extract or conditioned media. When S-BCC extract was added to normal FBs there was increased GAG production in comparison to normal FBs incubated with dermal or epidermal extracts (P<.001) for both. Two growth factors, transforming growth factor-beta (TGF-beta) and platelet-derived growth factor (PDGF), already known to be mitogenic for FBs, were incubated with N-BCC and normal FBs in an effort to elucidate the potential cytokine(s) released by S-BCC, causing increased GAG production by surrounding FBs. Neither of these cytokines proved to be effective in promoting a significant increase in GAG production. Our findings support the hypothesis that BCCs release factors that alter stromal FB production of GAG.

Effect of perilesional injections of PEG-interleukin-2 on basal cell carcinoma.

BACKGROUND: Multiple modalities are available for the treatment of basal cell carcinoma (BCC). The most commonly used modalities include simple excision, Mohs micrographic surgery, curettage and electrodessication, cryosurgery, and irradiation therapy. Interleukin-2 (IL-2) is a cytokine produced chiefly by activated T lymphocytes and has effects on various components of the immune system. Until now the primary clinical use of IL-2 has been in advanced stages of metastatic melanoma and renal cell carcinoma. Systemic administration of IL-2 is known to cause significant toxicity. OBJECTIVE: The objective of this study was to evaluate the therapeutic efficacy and safety of perilesional PEG-IL-2 injections in patients with BCC in an open label, uncontrolled pilot study. METHODS: Patients with histologically confirmed primary BCC over 18 years of age were included in the study. Lesions were treated by injecting a total volume of 0.5 cc of IL-2 in a radial fashion in the subcutaneous tissue. Injection dosages ranged from 3000 to 1,200, 000 IU in one to four weekly dosages. A total of 12 tumors were treated in eight patients. RESULTS: Overall response rates were as follows: complete response in 8 of 12 treated tumors (66.6% cure rate), partial response in 3 of 12 injected tumors (25% partial response rate), stable disease with no improvement in 1 treatment site (8.4%). Side effects included local pain, swelling, and erythema, and in one patient flulike symptoms. There were no significant changes of blood tests as compared to baseline levels. CONCLUSIONS: The therapeutic response induced by perilesional PEG-IL-2 injections was found to be an encouraging, safe, and well-tolerated treatment of BCC. Further studies including a larger patient population and long-term follow-up are necessary in order to substantiate these findings.