The aerosol box for intubation in coronavirus disease 2019 patients: an in-situ simulation crossover study.

The coronavirus disease 2019 pandemic has led to the manufacturing of novel devices to protect clinicians from the risk of transmission, including the aerosol box for use during tracheal intubation. We evaluated the impact of two aerosol boxes (an early-generation box and a latest-generation box) on intubations in patients with severe coronavirus disease 2019 with an in-situ simulation crossover study. The simulated process complied with the Safe Airway Society coronavirus disease 2019 airway management guidelines. The primary outcome was intubation time; secondary outcomes included first-pass success and breaches to personal protective equipment. All intubations were performed by specialist (consultant) anaesthetists and video recorded. Twelve anaesthetists performed 36 intubations. Intubation time with no aerosol box was significantly shorter than with the early-generation box (median (IQR [range]) 42.9 (32.9-46.9 [30.9-57.6])s vs. 82.1 (45.1-98.3 [30.8-180.0])s p = 0.002) and the latest-generation box (52.4 (43.1-70.3 [35.7-169.2])s, p = 0.008). No intubations without a box took more than 1 min, whereas 14 (58%) intubations with a box took over 1 min and 4 (17%) took over 2 min (including one failure). Without an aerosol box, all anaesthetists obtained first-pass success. With the early-generation and latest-generation boxes, 9 (75%) and 10 (83%) participants obtained first-pass success, respectively. One breach of personal protective equipment occurred using the early-generation box and seven breaches occurred using the latest-generation box. Aerosol boxes may increase intubation times and therefore expose patients to the risk of hypoxia. They may cause damage to conventional personal protective equipment and therefore place clinicians at risk of infection. Further research is required before these devices can be considered safe for clinical use.

The utility of molecular diagnostics to predict recurrence of head and neck carcinoma.

BACKGROUND: Locoregional recurrence is the major cause of treatment failure after surgery for oral squamous cell carcinoma. Molecular diagnostics have the potential to improve on clinicopathological parameters to predict this recurrence and plan adjuvant treatment. The test most frequently applied is based on detecting TP53 mutations, but alternative methodology is required for cases that harbour the wild-type gene. METHODS: One hundred and two cases with tumour-adjacent margins, considered to be clear margins by microscopy, were examined using carefully optimised molecular diagnostics based on detection of the TP53 and Ly-6D markers. The markers were also combined to provide a dual approach. RESULTS: The dual molecular diagnostic identified cases with a significant increase in the probablility of developing locoregional recurrence when tumour-adjacent positive and clear margins were compared (P=0.0001). These tests were most useful when the clearance at the resection margins was 5 mm or less. The TP53-based diagnostic was a better predictor of locoregional recurrence than established clinicopathological parameters. CONCLUSION: The optimised TP53-based diagnostic rapidly identifies an important subgroup of cases with close margins that will benefit from new treatment modalities to reduce the risk of recurrence.

Self-management in bronchiectasis: the patients' perspective.

Self-management programmes for chronic disease are a high priority for healthcare providers. The content and method of delivery of self-management should give consideration to the specific requirements of the disease population. The aims of the present study were to assess the physical and psychosocial impact of bronchiectasis, to determine whether patients with bronchiectasis are receptive to self-management and to identify any obstacles or sources of support for a disease-specific self-management programme. A total of 32 patients with a diagnosis of bronchiectasis attended four focus groups. Each focus group was videotaped and subjected to qualitative analysis using the grounded theory approach. Bronchiectasis had an impact on patients' physical and psychosocial well-being. Patients demonstrated the potential to self-manage with strategies including self-regulation of medication and airway clearance. Perceived obstacles to self-management included lack of information and confidence. Patients suggested that self-management could be promoted through disease-specific information and appropriate healthcare procedures. In summary, patients with bronchiectasis have their lives disrupted by this chronic condition, but are receptive to self-management. The present study has provided information from the patients' perspective of elements which need to be included in a successful disease-specific self-management programme.

Effects of sub-chronic exposure to naturally occurring N-terminally truncated metabolites of glucose-dependent insulinotrophic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1), GIP(3-42) and GLP-1(9-36)amide, on insulin secretion and glucose homeostasis in ob/ob mice.

Glucose-dependent insulinotrophic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) are important enteroendocrine hormones that are rapidly degraded by an ubiquitous enzyme dipeptidyl peptidase IV to yield truncated metabolites GIP(3-42) and GLP-1(9-36)amide. In this study, we investigated the effects of sub-chronic exposure to these major circulating forms of GIP and GLP-1 on blood glucose control and endocrine pancreatic function in obese diabetic (ob/ob) mice. A once daily injection of either peptide for 14 days had no effect on body weight, food intake or pancreatic insulin content or islet morphology. GLP-1(9-36)amide also had no effect on plasma glucose homeostasis or insulin secretion. Mice receiving GIP(3-42) exhibited small but significant improvements in non-fasting plasma glucose, glucose tolerance and glycaemic response to feeding. Accordingly, plasma insulin responses were unchanged suggesting that the observed enhancement of insulin sensitivity was responsible for the improvement in glycaemic control. These data indicate that sub-chronic exposure to GIP and GLP-1 metabolites does not result in physiological impairment of insulin secretion or blood glucose control. GIP(3-42) might exert an overall beneficial effect by improving insulin sensitivity through extrapancreatic action.

Transformation of a prefabricated hydroxyapatite/osteogenic protein-1 implant into a vascularised pedicled bone flap in the human chest.

We describe the intramuscular transformation of a hydroxyapatite/osteogenic protein-1 (HA/OP-1) composite implant, into a vascularised pedicled bone flap useful for reconstruction of a hemi-mandible. Extraskeletal induction of a bone flap for transplantation was achieved without the addition of harvested bone, bone marrow, or stem cells. Five months after apparent clinical success, an MRSA infection of the graft led to its failure. The background to ectopically induced bone flaps is introduced, with our experience in a human case presented. The results from this emerging biotechnology are discussed in the light of limited human clinical experience.

Sagittal split osteotomy of a vascularised iliac crest free flap to correct residual asymmetry and malocclusion in the reconstructed mandible.

Reconstruction of the mandible with a vascularised bone graft from the iliac crest based on the deep circumflex iliac artery is an established and reliable technique. We report two cases in which mandibular asymmetry followed reconstruction with such grafts and was corrected by sagittal split osteotomies.

Expression of haptoglobin mRNA in the liver and oviduct during the oestrous cycle of cows (Bos taurus).

Recent evidence supports involvement of the acute phase protein haptoglobin in numerous events of mammalian reproduction. The objective of this study was to determine whether haptoglobin mRNA was expressed in the bovine ovary and oviduct, and to evaluate whether expression of haptoglobin mRNA in reproductive tissues and liver was associated with a specific phase of the bovine oestrous cycle. Oestrus was synchronized in Holstein cows by prostaglandin injection and tissues were collected during the luteal and peri-oestrous stages of the oestrous cycle. Total RNA was isolated and reverse-transcription polymerase chain reaction (RT-PCR) was performed using primers designed against regions of similarity in human, rat and mouse haptoglobin sequences. Haptoglobin mRNA expression was detected in oviductal cells and liver, during both stages of the oestrous cycle, but not in ovarian follicular cells. The 302 bp PCR product was determined to share 82-83% identity with reported primate haptoglobin sequences. Analysis by Northern blotting revealed 1.2 and 1.4 kb haptoglobin mRNA transcripts in the oviduct and liver, and indicated that hepatic haptoglobin mRNA expression was elevated above basal levels in a greater proportion of peri-oestrous cows (4/4) than luteal cows (1/5). Haptoglobin cDNA was cloned and in vitro transcribed to generate probes for in situ hybridization. Haptoglobin mRNA was detected in the liver, but not in the ovary or oviduct. We conclude that haptoglobin mRNA expression in the bovine liver is up-regulated during the peri-oestrous phase of the oestrous cycle, and that the bovine oviduct expresses a low level of haptoglobin mRNA constitutively. This temporal pattern of haptoglobin mRNA expression would expose reproductive tissues to elevated concentrations of serum haptoglobin during the peri-oestrous stage, and suggests that haptoglobin may be important in reproductive events occurring during this time period.

Identification and immunohistochemical localization of a haptoglobin-like protein in the tissues and fluids of the bovine (Bos taurus) ovary and oviduct.

The objective of this study was to establish the identity of a 40 kDa bovine oviductal fluid protein as a haptoglobin-like protein and to evaluate the association of the haptoglobin-like protein with ovarian and oviductal tissues and fluids. An oviductal fluid protein band corresponding to a molecular mass of 40 kDa was excised and electroeluted from SDS-PAGE gels. Sequence analysis revealed an N-terminal region sharing 81% identity with the beta-subunit of bovine haptoglobin. The 40 kDa oviductal fluid protein crossreacted on immunoblots with antiserum against rabbit endometrial haptoglobin and with an anti-human haptoglobin polyclonal antibody. Two-dimensional PAGE revealed four protein variants ranging in pI from 7.7 to 8.6, which appeared identical, with respect to molecular weight, number of isoforms and pI, to bovine haptoglobin in acute phase serum. The haptoglobin-like protein was localized using immunohistochemistry to the lumina of blood vessels and to the extracellular matrix of ovarian and oviductal tissues. Immunostaining for the haptoglobin-like protein was also detected in the oviductal lumen, in the mucosa of the ampullary oviduct but not the isthmic oviduct, and in intermittent ampullary epithelial cells. Within the ovary, the haptoglobin-like protein was localized to the avascular granulosa cells and follicular fluid of antral follicles, but not in the theca cells or in preantral follicles of any developmental stage. It was concluded that the haptoglobin-like protein is a normal constituent of bovine ovarian and oviductal tissues and fluids, and it was hypothesized that the haptoglobin-like protein contributes to ovarian follicular development and oviductal function.

A phase III placebo-controlled study in advanced head and neck cancer using intratumoural cisplatin/epinephrine gel.

Patients with recurrent or refractory head and neck squamous cell carcinoma received cisplatin/epinephrine injectable gel or placebo gel injected directly into the clinically dominant tumour. The double-blind phase III trial comprised of up to 6 weekly treatments over 8 weeks, 4 weekly evaluation visits, and then monthly follow-up; open-label dosing began as needed after three blinded treatments. Tumour response was defined as complete (100% regression) or partial (50-99% regression) sustained for > or =28 day, and patient benefit as attainment of palliative or preventive goals prospectively selected by investigators and patients. With cisplatin/epinephrine gel, 25% (14 out of 57) of tumours responded (16% complete regression, 9% partial regression), vs 3% (one out of 35, complete regression) with placebo (P=0.007). Patient benefit was positively associated with target tumour response in the blinded period among cisplatin/epinephrine gel recipients (P=0.024): 43% (six out of 14) of responders benefited, vs 12% (five out of 43) of non-responders. The most frequent adverse event was pain during injection and the next most frequent was local cytotoxic effects consistent with the gel's mode of action. Systemic adverse events typical of intravenous cisplatin were uncommon. Intratumoural therapy with cisplatin/epinephrine gel provided safe, well-tolerated, effective palliative treatment for patients with locally advanced head and neck squamous cell carcinoma, who lack other satisfactory treatment options.

Phacoemulsification conditions resulting in thermal wound injury.

PURPOSE: To determine and model the relationships between phacoemulsification conditions and viscoelastic agents that result in thermal wound injury. SETTING: Animal laboratory, Irvine, California, USA. METHODS: Mechanical and animal models, various wound sizes, phacoemulsification tips, and dispersive and cohesive viscoelastic agents were evaluated. Settings for phaco power, vacuum, and irrigation levels were controlled within a surgically relevant range. In the mechanical and animal models, incision temperature was assessed as a function of phacoemulsification parameters and time. In the animal model, wound damage was evaluated at the time of surgery. RESULTS: Induced time delays from the onset of phaco power to the onset of irrigation flow caused a thermal rise at the incision site. In these experiments, lack of irrigation and aspiration resulted in the greatest thermal rise and caused wound damage. Both the cohesive and dispersive viscoelastic agents were associated with a delay in the start of irrigation and aspiration, which resulted in similar maximum temperatures. Mathematical models were developed to estimate the maximum incision temperature from the phacoemulsification power, the duration (seconds) of occlusion, the tip gauge and type, and other phacoemulsification parameters. The models predict that under comparable conditions, occlusion with a viscoelastic agent will result in higher incision temperatures than occlusion with a balanced salt solution. CONCLUSION: Under comparable phacoemulsification conditions, both the cohesive and dispersive viscoelastic agents were associated with elevated temperatures that would be preventable by ensuring irrigation and aspiration flow before the onset of phacoemulsification power.

Management of Jehovah's Witness patients undergoing major head and neck surgery.

BACKGROUND: Several diverse strategies have been recommended to manage Jehovah's Witness patients undergoing surgery when significant blood loss is expected. However, many of the proposed management strategies cannot be used when the urgent nature of the disease precludes adequate preoperative preparation of the patient. We present our experience of the management of two Jehovah's Witnesses with oral carcinoma requiring extensive resection, neck dissection, and reconstruction with free tissue transfer. METHODS: Hypervolemic hemodilution, hypotensive anesthesia, meticulous surgical hemostasis, and antifibrinolytic therapy were used as an alternative to blood products or transfusion. RESULTS: Radical surgical ablation and state-of-the-art reconstruction were possible, as a single-stage procedure, even though blood transfusion or blood product replacement therapy was refused. CONCLUSION: Radical surgical ablation of oral carcinoma, with free tissue transfer reconstruction, is possible in this group of patients without the use of blood products or transfusion. There would have been no advantage in raising the red cell mass preoperatively, as the packed cell volume was ideal for free tissue transfer.

Dental extractions in patients on warfarin: is alteration of anticoagulant regime necessary?

Various clinical protocols for the management of warfarinised patients needing dental extractions have been suggested. This study was designed to compare two approaches in the management of these patients. A control group of 32 patients had their warfarin treatment stopped for 2-3 days prior to having dental extractions, resulting in a reduction in the average preoperative international normalised ratio (INR) from 2.6 to 1.6. The study group of 33 patients did not have their anticoagulant treatment altered before extractions, and had an average preoperative INR of 2.7. All patients were treated under local analgesia on an outpatient basis, and local measures-consisting of Surgicel pack and sutures-were used in all cases to control postoperative bleeding from extraction sockets. None of the patients had any immediate postoperative bleeding, and only 1 patient from each group had mild delayed haemorrhage, which was easily controlled with local measures. It is proposed that, provided the INR is within the therapeutic range of 2.0 to 4.0 and local measures are used to control postoperative bleeding, there is no justification in altering warfarin treatment prior to dental extractions in these patients, and thereby exposing them to the risk of thromboembolism.

Is there a difference in incision healing based on location?

PURPOSE: To determine whether there is a difference in the healing process between incisions that begin in avascular region and those that begin in vascular region. SETTING: Wills Eye Hospital, Philadelphia, Pennsylvania, and Kresge Eye Institute, Detroit, Michigan USA. METHODS/MATERIALS: Feline evaluations were conducted at two sites (one evaluation at each site). Eyes in both evaluations were grouped by incision location: avascular (clear corneal) incisions or vascular (limbal) incisions. A series of postoperative examinations were conducted in each group of both evaluations that included slitlamp examination, measurements of external pressure and incision stability, and histological analysis. RESULTS: All limbal incisions were stable 7 days after surgery. Histological analyses in both evaluations showed a difference in tissue response between clear corneal and limbal incisions; the limbal incisions had an early fibroblastic response and the clear corneal, a delayed response. CONCLUSION: The predominant factors in incision healing and stability were incision geometry, architecture, and location. Endothelial pump action was effective in removing fluid but was not effective in incision stability. Histological analyses confirmed that starting incisions in the vascular region (limbus) resulted in a fibroblastic response that enhanced incision stability and allowed rapid incision healing within 7 days postoperatively compared with the 60 days healing time required for incisions started in the avascular region (cornea).

Occurrence of pigment precipitates after small incision cataract surgery.

PURPOSE: To assess the incidence of pigment precipitates and potential association with glaucoma, diabetes, and/or intraocular lens (IOL) optic center thickness in patients having small incision cataract surgery and foldable IOL implantation. SETTING: Eye Care Physicians of Michigan, Jackson, Michigan, USA. METHODS: A retrospective data analysis was conducted of patients with a preoperative diagnosis of glaucoma or diabetes or in whom pigment precipitates had been reported after cataract surgery. Group 1 consisted of 23 patients in whom pigment precipitates had been reported and Group 2, 92 patients in whom no precipitates were reported. Two statistical models were used to analyze preoperative, demographic, surgical, and postoperative variables and determine potential correlations. An overall incidence of the occurrence of pigment precipitates was calculated based on the total number of patients with foldable IOLs. RESULTS: The incidence of pigment precipitates was 0.35% (n = 23/6519). Mean time to occurrence was 5.5 months. No between-group differences were found in pathologies or other demographics or postoperative variables. Intraocular lens size and implantation correlated with the occurrence of pigment precipitates. CONCLUSION: The development of pigment precipitates after foldable IOL implantation did not appear to be affected by the presence of glaucoma or diabetes. Newer, slimmer IOL styles and refined insertion techniques were associated with a lower occurrence of precipitates.

Combined radial forearm and pharyngeal flap for soft palate reconstruction.

The use of a free vascularised fascio-cutaneous radial forearm flap in combination with a cranially based pharyngeal flap for soft palate reconstruction has not been previously reported. We present the technique and illustrate its use in two cases of total and one case of subtotal soft palate reconstruction. The functional outcome is discussed with particular reference to nasal airway patency, speech and swallowing.

Apocrine hidrocystoma: report of a case.

A case of apocrine hidrocystoma, mimicking a naso-labial cyst of the maxilla is reported. The histopathological features and treatment of these rare lesions is discussed.