UK esthetics associations: A robust safety net or credibility accessories?

BACKGROUND: Currently, safe practice in the UK esthetics industry is largely reliant on self-regulatory bodies. If these bodies do not maintain high standards of safety guidelines and properly accredit practitioners, patient safety may be at risk. To our knowledge, no studies have addressed cosmetic self-regulatory bodies and their websites on Google, the most commonly used information source. This study aimed to map self-regulatory bodies on Google and evaluate their roles in the current UK esthetics industry. METHOD: We conducted a systematic search of Google Search results using eight search terms. The first 100 search results were screened against our eligibility criteria. We searched each website of a self-regulatory body for their requirements to join registers, membership fees, and features listed on the UK government's criteria for an effective self-regulatory body. RESULTS: We identified 22 self-regulating bodies for the UK esthetics industry. Only 15% of registers required an in-person assessment of cosmetic skills to qualify for membership. Of the self-regulatory bodies, 65% did not set clear standards and guidelines for practice. No qualifications were required by 14% of surgical and 31% of non-surgical bodies. The mean membership fee was £331. CONCLUSION: This study uncovered important information about the self-regulation of the esthetics industry in the UK. A significant majority of self-regulatory bodies did not meet best practices, potentially putting patients at risk. We recommend further studies screening a higher number of pages in a Google Search to scope all other existing self-regulatory bodies, due to the creation of Google "filter bubbles."

Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies.

Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of 'sustained exhaled carbon dioxide' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.

Project for Universal Management of Airways - part 1: concept and methods.

Multiple professional groups and societies worldwide have produced airway management guidelines. These are typically targeted at the process of tracheal intubation by a particular provider group in a restricted category of patients and reflect practice preferences in a particular geographical region. The existence of multiple distinct guidelines for some (but not other) closely related circumstances, increases complexity and may obscure the underlying principles that are common to all of them. This has the potential to increase cognitive load; promote the grouping of ideas in silos; impair teamwork; and ultimately compromise patient care. Development of a single set of airway management guidelines that can be applied across and beyond these domains may improve implementation; promote standardisation; and facilitate collaboration between airway practitioners from diverse backgrounds. A global multidisciplinary group of both airway operators and assistants was assembled. Over a 3-year period, a review of the existing airway guidelines and multiple reviews of the primary literature were combined with a structured process for determining expert consensus. Any discrepancies between these were analysed and reconciled. Where evidence in the literature was lacking, recommendations were made by expert consensus. Using the above process, a set of evidence-based airway management guidelines was developed in consultation with airway practitioners from a broad spectrum of disciplines and geographical locations. While consistent with the recommendations of the existing English language guidelines, these universal guidelines also incorporate the most recent concepts in airway management as well as statements on areas not widely addressed by the existing guidelines. The recommendations will be published in four parts that respectively address: airway evaluation; airway strategy; airway rescue and communication of airway outcomes. Together, these universal guidelines will provide a single, comprehensive approach to airway management that can be consistently applied by airway practitioners globally, independent of their clinical background or the circumstances in which airway management occurs.

Intubating laryngeal mask airway for difficult out-of-hospital airway management: a prospective evaluation.

BACKGROUND: Out-of-hospital airway management is a critical skill, demanding expert knowledge and experience. The intubating laryngeal mask airway (ILMA) is a ventilatory and intubating device which may be of value in this arena. We evaluated the ILMA for out-of-hospital management of the difficult airway. METHODS: Twenty-one anaesthesia-trained emergency physicians (EPs) completed a training programme and used the ILMA in patients with difficult-to-manage airways. Indications for use of the ILMA included patients with difficult laryngoscopy, multiple intubation attempts, limited access to the patient's head, presence of pharyngo-laryngeal trauma, and gastric fluids or bleeding obscuring the view of the vocal cords. RESULTS: During the study period, 146 of 2513 patients underwent tracheal intubation or alternate rescue airway insertion. In 135 patients, laryngoscopy was performed and Cormack-Lehane view was recorded as grade I in 72 (53.3%), II in 45 (33.3%), III in 10 (7.4%), and IV in 8 (5.9%). EPs encountered 11 patients (7.5%) with difficult-to-manage airways. ILMA insertion and ventilation was possible in 10 patients in the first and one patient in the second attempt. ILMA-guided tracheal intubation was successful in all patients, in 10 after the first and in 1 after two attempts. CONCLUSIONS: In this study, ventilation and intubation with ILMA was successful in all patients with difficult-to-manage airways. Our data support the use of the ILMA as rescue device for out-of-hospital airway management by staff who have appropriate airway skills and have received appropriate training.

The LMA CTrach in airway resuscitation: six case reports.

We report six patients with unexpected difficult airways who underwent tracheal intubation using the Laryngeal Mask Airway CTrach. All these patients had failed orotracheal intubation using direct laryngoscopy and gum elastic bougie placement. Fibreoptic bronchoscopy failed in two of these patients due to blood and secretions in the airway. This report describes the successful use of this new intubating laryngeal mask in these cases, all of whom were intubated on the first attempt with this new device.

Use of the fibreoptic intubating LMA-CTrach in two patients with difficult airways.

We report two patients with difficult airways who underwent tracheal intubation using the new fibreoptic intubating Laryngeal Mask Airway CTrach. The imaging technology of the LMA-CTrach was decisive in the management of these two patients. The first patient had lingual tonsillar hyperplasia, and an omega-shaped retroflexed epiglottis. The second patient had a C2-occipital fusion and was completely unable to extend her head. Given the anatomical difficulties encountered, it was likely that intubation would have been difficult or impossible through the LMA-Fastrach. The aim of this report is to describe the successful use of this new intubating laryngeal mask airway in these two challenging patients.

Use of the intubating LMA-Fastrach in 254 patients with difficult-to-manage airways.

BACKGROUND: The laryngeal mask airway (LMA; LMA North America, Inc., San Diego, CA) has a well-established role in the emergency and elective treatment of patients with difficult-to-manage airways (DA). In this study, the authors report their clinical experience with the intubating LMA (LMA-Fastrach; LMA North America, Inc., San Diego, CA) in 254 patients with different types of DA. METHODS: The authors reviewed the anesthetic and medical records of patients with DA in whom the LMA-Fastrach was used electively or emergently at four institutions from October 1997 through October 2000. In each case, the number of insertion and intubation attempts was recorded. Success rates for blind and fiber optically guided intubation through the LMA-Fastrach were calculated, up to a maximum of five attempts per patient. RESULTS: The LMA-Fastrach was used in 257 procedures performed in 254 patients with DA, including patients with Cormack-Lehane grade 4 views; patients with immobilized cervical spines; patients with airways distorted by tumors, surgery, or radiation therapy; and patients wearing stereotactic frames. Insertion of the LMA-Fastrach was accomplished in three attempts or fewer in all patients. The overall success rates for blind and fiber optically guided intubations through the LMA-Fastrach were 96.5% and 100.0%, respectively. CONCLUSIONS: The LMA-Fastrach was used successfully in a high percentage of patients who presented with a variety of DA. The clinical experience presented herein indicates that this device may be particularly useful in the emergency and elective treatment of patients in whom intubation with a rigid laryngoscope has failed and in the treatment of patients with immobilized cervical spines.

The intubating laryngeal mask: use of a new ventilating-intubating device in the emergency department.

The intubating laryngeal mask airway (ILM) was introduced in 1997 as a modification of the classic laryngeal mask airway. In addition to serving as an elective or emergency ventilating device, it is designed to allow blind intubation. We report 3 cases of airway management in the emergency department of Yale-New Haven Hospital where the ILM was used to establish ventilation and intubation in patients in whom direct laryngoscopy had failed. The 3 cases are representative of situations commonly seen in the ED: the obtunded and apneic ("crash airway") patient, failed rapid sequence intubation, and the recognized difficult airway/awake intubation. In all 3 cases, a clear airway was established on initial placement of the ILM, and intubation was achieved on the first attempt at blind advancement of the endotracheal tube. Although the ILM may be an important addition to the armamentarium of the emergency physician, proficiency in its use requires practice under controlled conditions. We suggest that the emergency physician seek out elective practice in either a teaching workshop or hospital operating theater.

Practice patterns in managing the difficult airway by anesthesiologists in the United States.

UNLABELLED: Despite the availability of several techniques and devices for the management of the difficult airway, little information has been published regarding the prevalence of their use by anesthesiologists in the United States. To determine current practice patterns, we surveyed clinicians using a questionnaire consisting of 14 difficult airway scenarios. Anesthesiologists were requested to indicate their likely approach to anesthetic induction (e.g., awake but sedated, general anesthesia with spontaneous ventilation, general anesthesia with apnea after assuring a patent airway, or general anesthesia with apnea) and the primary device they would use to intubate (e.g., direct laryngoscopy [DL], flexible fiberoptic bronchoscope [FOB], rigid fiberoptic device, surgical airway, retrograde intubation kit, laryngeal mask airway, gum elastic bougie, or Combitube). The availability of these devices was also determined (in room at all times, available "stat," available if arranged preoperatively, or not available). The survey was mailed to 1000 randomly chosen active members of the American Society of Anesthesiologists. Second and third surveys were mailed to non responders. Four hundred seventy-two completed surveys were returned. Responses by demographic groups were compared by using chi 2 analysis. DL and FOB-aided tracheal intubation techniques were chosen for most cases by most anesthesiologists (P < 0.05). Anesthesiologists with > 10 yr of clinical experience and those older than 55 yr of age preferred DL with apneic conditions (P < 0.05). Anesthesiologists who had attended workshops within the last 5 yr had greater availability of retrograde guidewire equipment and FOBs (P < 0.05). There was little use of newer alternative airway devices. IMPLICATIONS: Although the teaching of alternative methods of securing a difficult airway has become ubiquitous, most anesthesiologists rely on direct laryngoscopy and fiberoptic-aided intubation in most clinical circumstances. Although workshops in the management of the difficult airway may have resulted in increased use of the fiberoptic bronchoscope and the availability of retrograde guidewire intubation equipment, other devices have not enjoyed such an increase.

The palm print as a sensitive predictor of difficult laryngoscopy in diabetics.

BACKGROUND: Grading of the ink impression made by the palm of the hand has been proposed as a means of screening diabetic patients in whom tracheal intubation may be difficult because of glycosylation of both metacarpal and cervical joints. The current study was designed to test the predictability of the palm print and other airway evaluation indices in a diabetic population. METHOD: 83 adult, diabetic patients scheduled for surgery under general anesthesia were evaluated preoperatively using 4 physical examination indices predictive of difficult laryngoscopy and intubation: Mallampati classification, thyromental distance, head extension, and palm print. Following induction of anesthesia and neuromuscular relaxation, laryngoscopy was performed and the laryngoscopic view scored. The sensitivity, specificity and positive predictive value of each airway evaluation index was calculated. RESULTS: The palm print had the highest sensitivity of all indices (100%). The other 3 indices failed to detect 9 to 13 difficult laryngoscopies. CONCLUSION: We believe that in the diabetic population, the palm print index may be a sensitive marker of difficult intubation. It is possible that other airway evaluation indices would prove more sensitive, and have greater utility, in distinct populations as compared to when they are applied to all patients.

Assessment of the economic impact of an overage reduction program in the operating room.

STUDY OBJECTIVES: To delineate excessive supply preparation in the operating rooms (ORs) of Yale-New Haven Hospital, and to measure the reduction in such overage as a result of nursing and administration cost-containment efforts. DESIGN: Before and after trial. SETTING: Inpatient ORs of Yale-New Haven Hospital. INTERVENTIONS: After the initial documentation of overage, several cost-containment measures were instituted, including nursing education, review of overage data, and updating of surgical request lists. MEASUREMENTS AND MAIN RESULTS: The hospital cost of case-specific overage generated by all surgical procedures performed during two 2.5-month periods in 1992 and 1994 (before and after the interventions) were compared. One-thousand three hundred eighteen cases in 1992 were compared with 1,367 cases in 1994. A 45% reduction in mean per case overage occurred between the two assessment periods. Extrapolation of the data to the incidence of similar cases throughout the United States projected a comparable savings. CONCLUSIONS: Efforts to increase the efficiency of OR supply management can be measured, in part, by overage evaluation, which can serve as a resource for focusing efforts at cost-containment.

Recovery of unused operating room supplies for overseas orthopedic surgery.

Recovery of surplus operating room (OR) materials may contribute needed supplies to volunteer overseas surgical efforts. However, recovery often generates supplies that are highly heterogeneous in nature. In order to evaluate the nature and quantity of supplies useful to orthopedic surgical missions, the present investigation evaluated the material generated from 381 consecutive orthopedic cases performed during three 3-month assessment periods over 3 years. The amount of recovered material varied markedly within and among procedure types as well as surgeons. Nevertheless, the long-term, OR-wide recovery program at Yale-New Haven Hospital has provided a highly reliable source of usable materials over the 4-year life of the program.

Single photon emission computerized tomography imaging of amphetamine-induced dopamine release in drug-free schizophrenic subjects.

The dopamine hypothesis of schizophrenia proposes that hyperactivity of dopaminergic transmission is associated with this illness, but direct observation of abnormalities of dopamine function in schizophrenia has remained elusive. We used a newly developed single photon emission computerized tomography method to measure amphetamine-induced dopamine release in the striatum of fifteen patients with schizophrenia and fifteen healthy controls. Amphetamine-induced dopamine release was estimated by the amphetamine-induced reduction in dopamine D2 receptor availability, measured as the binding potential of the specific D2 receptor radiotracer [123I] (S)-(-)-3-iodo-2-hydroxy-6-methoxy-N-[(1-ethyl-2-pyrrolidinyl) methyl]benzamide ([123I]IBZM). The amphetamine-induced decrease in [123I]IBZM binding potential was significantly greater in the schizophrenic group (-19.5 +/- 4.1%) compared with the control group (-7.6 +/- 2.1%). In the schizophrenic group, elevated amphetamine effect on [123I]IBZM binding potential was associated with emergence or worsening of positive psychotic symptoms. This result suggests that psychotic symptoms elicited in this experimental setting in schizophrenic patients are associated with exaggerated stimulation of dopaminergic transmission. Such an observation would be compatible with an abnormal responsiveness of dopaminergic neurons in schizophrenia.

Focused versus operating room-wide recovery of unused supplies for overseas reconstructive surgery.

Proliferation of programs that recover surplus operating room supplies may effectively address the needs of volunteer overseas surgical efforts. However, these programs tend to garner supplies highly heterogeneous in nature. In order to evaluate the nature and quantity of supplies generated by plastic and reconstructive procedures, we extrapolated the inventory of 71 consecutive cases from our 33,000-case database. Additionally, we examined the recovery of 7 specific supplies from all cases performed at Yale-New Haven Hospital over a 3-year period. Though consistency is unlikely when only plastic and reconstructive surgical cases are examined, operating room-wide recovery may be a reliable source of usable materials.