Nasal cannula technique for ventilating during the administration of general anesthesia in neonates and pediatric patients.

Objective: Minor surgeries on the oral cavity, e.g., frenulectomies, are often performed under general mask anesthesia. The objective is to present the nasal cannula technique for ventilating step-by-step method for ventilating during general anesthesia for minor surgeries in neonates and pediatric patients. Technique: The nasal cannula technique for ventilating has been used in over 20 pediatric cases (neonates and toddlers), without the need to re-mask during the procedure and without complications or oxygen desaturations. After induction of general mask anesthesia, propofol with or without adjunctive ketamine is administered. The anesthesia mask is exchanged with a nasal cannula, using the largest sized prongs that accommodate the nares, and the nasal cannula is connected to the anesthesia circuit. This permits administration of inspired fractions of oxygen. Conclusion: The nasal cannula technique for ventilating provides a safe method for delivering general anesthesia and ventilating during minor surgeries for neonates and pediatric patients.

Diagnosis of human bovine tuberculosis aided by PET/CT scanning and EBUS-TBNA.

Human bovine tuberculosis is a rare zoonotic infection in developed countries which has been achieved predominantly by effective eradication programmes in cattle. The principal modes of transmission are consumption of unpasteurised dairy products and close contact with infected cattle. The clinical and radiological presentation is indistinguishable from tuberculosis caused by Mycobacterium tuberculosis The diagnosis should be considered in individuals with relevant risk factors who present with intra/extrathoracic pathology. We describe and discuss a case of bovine tuberculosis with a synchronous primary bronchus carcinoma in an immunocompetent individual who presented with a solitary pulmonary nodule and contralateral mediastinal lymphadenopathy on CT imaging. The diagnosis of M. bovis infectionwas aided by 18F-fluorodeoxyglucose positron emission tomography/CT imaging and endobronchial ultrasound-guided mediastinal lymph node sampling.

Could an increase in vigilance for spinal tuberculosis at primary health care level, enable earlier diagnosis at district level in a tuberculosis endemic country?

BACKGROUND: Expert clinicians and researchers in the field of spinal tuberculosis (STB) advocate for early identification and diagnosis as a key to reducing disability, severity of disease, expensive surgery and death, especially in tuberculosis (TB) endemic countries like South Africa. South Africa has the highest incidence per capita of tuberculosis in the world, and a conservative estimate of the incidence of STB in South Africa is 8-16:100 000. People living with STB may initially present to primary health care (PHC) centres, where the opportunity exists for early identification. Spinal pain is the most common presentation of STB, but even this symptom may not be present. Occasionally the only symptoms are neurological injury, dysphagia or referred pain. Computerised tomography-guided biopsy remains the diagnostic gold standard for STB. AIM: A narrative review was undertaken to investigate the evidence available that could assist with the early diagnosis of STB. METHOD: Articles were searched for and retrieved from three databases and assessed for quality and relevance to primary settings in a TB endemic country. RESULTS: The following evidence-based, affordable and available tools could facilitate early diagnosis of STB at PHC and district hospital levels: (1) back pain screening questions, undressed spinal physical examination, HIV and antiretroviral therapy history, (2) erythrocyte sedimentation rate, C-reactive protein, platelets, haemoglobin, white cell count (WCC), sputum for GeneXpert and accurate weight measurement, (3) physiotherapy and/or medical and/or speech therapy assessment, (4) full spinal radiograph, chest radiograph, abdominal ultrasound, urine lipoarabinomannan (LAM) if CD4 < 200 and ultrasound-guided biopsy of superficial abscesses, (5) clear referral guidelines at all levels, (6) a positive response to treatment to confirm the diagnosis. CONCLUSION: These affordable and simple actions at PHC and district levels could facilitate earlier diagnosis of STB.

Precordial Doppler evaluation of simple bone cyst injection.

BACKGROUND: A randomized prospective trial of marrow-versus-steroids treatment of solitary bone cyst was ongoing. Protocol required contrast injection of the cyst. A subpopulation was noted to have large, rapid venous outflow of contrast material (omnipaque). Central embolization and resultant acute respiratory distress syndrome has been reported with bone marrow transplant. Particulate injection can result in bradycardia, low exhaled CO2, decreased SaO2 and voltage changes on electrocardiogram. METHODS: Precordial Doppler can measure flow and turbulence centrally after a peripheral cyst injection. Our cases were monitored with precordial Doppler as well as heart rate, ETCO2, blood pressure, electrocardiogram, and pulse oximetry. RESULTS: Five patients/7 injections were noted to have large and rapid outflow veins from solitary bone cyst. The Doppler showed increased signal in all 7 particulate injections (2 steroid injections, 5 bone marrow aspirates and cyst injections.) One marrow injection resulted in transient bradycardia and decreased blood pressure with no sequelae. One developed transient decrease in exhaled CO2. CONCLUSIONS: Rapid outflow has been reported in the past but precordial Doppler monitoring of injection into peripheral cysts is not reported. The potential for embolization with serious physiologic effects is a concern. Others have advocated injection of more particulate substances, such as calcium, sulfate, and demineralized bone matrix. This Doppler technique may be valuable for monitoring the potential harmful effects of these injections and lead to a better understanding of failure of cyst healing due to rapid outflow of material. LEVEL OF EVIDENCE: Level IV case series with poor reference standard.