The unanticipated difficult airway with recommendations for management

PURPOSE: To review the current literature and generate recommendations on the role of newer technology in the management of the unanticipated difficult airway. METHODS: A literature search using key words and filters of English language and English abstracted publications from 1990-96 contained in the Medline, Current Contents and Biological Abstracts databases was carried out. The literature was reviewed and condensed and a series of evidence-based recommendations were evolved. CONCLUSIONS: The unanticipated difficult airway occurs with a low but consistent incidence in anaesthesia practice. Difficult direct laryngoscopy occurs in 1.5-8.5% of general anaesthetics and difficult intubation occurs with a similar incidence. Failed intubation occurs in 0.13-0.3% general anaesthetics. Current techniques for predicting difficulty with laryngoscopy and intubation are sensitive, non-specific and have a low positive predictive value. Assessment techniques which utilize multiple characteristics to derive a risk factor tend to be more accurate predictors. Devices such as the laryngeal mask, lighted stylet and rigid fibreoptic laryngoscopes, in the setting of unanticipated difficult airway, are effective in establishing a patient airway, may reduce morbidity and are occasionally lifesaving. Evidence supports their use in this setting as either alternatives to facemask and bag ventilation, when it is inadequate to support oxygenation, or to the direct laryngoscope, when tracheal intubation has failed. Specifically, the laryngeal mask and Combitube have proved to be effective in establishing and maintaining a patent airway in "cannot ventilate" situations. The lighted stylet and Bullard (rigid) fibreoptic scope are effective in many instances where the direct laryngoscope has failed to facilitate tracheal intubation. The data also support integration of these devices into strategies to manage difficult airway as the new standard of care. Training programmes should ensure graduate physicians are trained in the use of these alternatives. Continuing medical education courses should allow physicians in practice the opportunity to train with these alternative devices.     

Changes in pain sensitivity during neurosis in rats]

OBJECTIVE: Few cases of verrucous carcinoma of the penis with foci of invasive squamous cell carcinoma have been reported and denominated "hybrid tumors". The accuracy of this term is discussed in this paper. METHODS/RESULTS: A huge penile mass in a patient that had undergone three previous operations for lesions diagnosed as verrucous carcinoma is reported. Partial penectomy was performed. Histological examination showed a very well-differentiated squamous cell carcinoma. PCR (polymerase chain reaction) did not detect any type of human papillomavirus (HPV) in the tumor. CONCLUSIONS: Verrucous carcinoma is a strictly-defined lesion with a different biological behaviour from that of squamous carcinoma. Preoperative deep biopsy may miss the squamous cell carcinoma. Definitive diagnosis can only be achieved by histological examination of the surgical specimen. In future, DNA studies could possibly support preoperative diagnosis of this lesion.     

Demonstration of the feasibility of emergency department immunization against influenza and pneumococcus

STUDY OBJECTIVE: To demonstrate the feasibility of systematic immunization against influenza and pneumococcus in a public emergency department. METHODS: This was a demonstration project conducted from October 21, 1996, through December 2, 1996, at Cook County Hospital, an inner-city hospital with a 1996 adult ED census of 120,449. Seventy-eight percent of patients are uninsured; 92% are people of color; 73% deny having a primary physician. Only 15% have emergency complaints. Nurses received standing orders that all nonemergency adult patients meeting Centers for Disease Control and Prevention criteria for high risk should be offered immunization against influenza and pneumococcus at triage. Cash prizes were offered to nurses appropriately immunizing the most patients. The date of immunization was entered into the computerized patient registration system, available to all providers within the county system. From November 4 through November 18, an extra nurse was assigned to triage to test for improvement in immunization rates. A time-motion study determined the time required per immunization on the basis of a convenience sample of 8 nurses drawn from all 3 shifts. RESULTS: Only 3% of identified high-risk patients reported previous pneumococcal immunization. Despite extreme variation in nurse performance, 2,631 patients (24% of patients triaged) were screened, and 716 high-risk patients were identified (27% of patients screened). A total of 1234 patients were immunized against influenza, and 241 patients were appropriately immunized against pneumococcus. Sixty-one percent of high-risk patients with no contraindication to influenza immunization were immunized against influenza. Thirty-five percent of high-risk patients not previously immunized against pneumococcus were immunized against pneumococcus. Immunizations per shift per triage nurse varied from 0 to 24. Median time for all activities related to immunization was 4 minutes (range, 2 to 10 minutes). There was no increase in immunization rates with the addition of an extra nurse at triage (95% confidence interval for odds ratio, .929 to 1.153). CONCLUSION: Systematic immunization against influenza and pneumococcus is both needed and feasible in a public ED. "Buy-in" by nurses is variable. Increased staffing alone does not improve immunization rates.     

3He in 99.5% Porous Aerogel at the Normal-Superfluid Transition

We have used a torsional oscillator to measure the superfluid density and dissipation near the superfluid transition of ³ He in aerogel of 99.5% porosity. We used a new cell (constructed at Penn State) for which the aerogel was grown in the pores of a 100 m silver sinter. The cell was tested with ⁴ He and showed no signs of the second-sound resonances that have interfered with previous torsional oscillator measurements. The measurements with ³ He, presented here, were taken at pressures of 1.34 and 4.13 bars. We observed values of _s / in the T 0 limit of 0.05 and 0.14 respectively. Our measurements show an increase in the dissipation on warming through T _c . This series of measurements is ongoing and temperature sweeps at various pressures are planned.     

3He in Aerogel – an Inhomogeneously Disordered Unconventional Superfluid

We have examined the superfluidity of ³ He in 98.2% porous silica aerogel with up to 34% ⁴ He at 21.6 bar. The mixture is phase-separated for ⁴ He fractions between 11% and 34%. The ⁴ He-rich, phase preferentially occupies the regions of highest silica density in the aerogel, thus modifying the distribution of the correlated disorder seen by superftuid ³ He. The ³ He T _c increases slightly with ⁴ He content while the superfluid fraction decreases rapidly. This behavior is inconsistent with that of ³ He in a homogeneously scattering medium and is analogous to that of a granular superconductor.     

Impedance cardiography used to assess patterns of cardiovascular response to behavioral stressors

This paper presents two examples of how impedance cardiography may be used to interpret the hemodynamic influences on blood pressures measured during behavioral stress. In Study 1, blood pressure changes which were similar during two tasks were shown to have important differences in their cardiac output and vascular resistance components. During work on a reaction time task having aversive incentives compared with a neutral task, the blood pressure changes were seen to be associated with lowered vascular resistance and raised cardiac activity, a "fight-flight" pattern. In Study 2, blood pressure response differences between two subject groups working on an identical task were found to have blood pressure changes differing in their underlying cardiac and vascular components as measured by impedance. Such uses impedance cardiography have widespread potential application in psychophysiological research with humans.     

Influence of heat-treatment environment on Ni-ferrite nanoparticle formation from coconut water precursor

The kinetics of formation of NiFe₂O₄ nanoparticles were investigated where the nanoparticles were produced by the proteic-sol–gel method using coconut water followed by annealing in (i) air, (ii) air in the presence of boron nitride (BN), or (iii) nitrogen. The sample dried at 473 K for 5.5 h was composed of small disordered NiFe₂O₄ nanoparticles in a superparamagnetic state as determined from Mössbauer spectroscopy. In general, heat treatment at high temperature leads to a nanocomposite rich in NiFe₂O₄. In air, annealing at 1173 K for 8 h favored the formation of the magnetically ordered NiFe₂O₄ inverse spinel structure, with bulk characteristics and average crystal sizes of approximately 66 nm. In a nitrogen atmosphere and in compacted BN powder under air atmosphere, the NiFe₂O₄ spinel structure stabilized for temperatures up to 873 and 773 K, respectively, however, decomposition of the NiFe₂O₄ phase into other undesired structures was observed above 873 K.     

The current and residual value of superphosphate,Christmas Island C-grade ore,and Calciphos as fertilizers for a subterranean clover pasture

The effectiveness in the year of application of three phosphorus fertilizers, superphosphate, Christmas Island C-grade ore, and 500°C calcined Christmas Island C-grade ore (Calciphos), was measured for 5 consecutive years in a field experiment on a lateritic soil. The residual value of the phosphorus fertilizers was also measured for 6 years. Dry matter production of subterranean clover-based pasture and bicarbonate extractable soil phosphorus were used as indicators of fertilizer effectiveness.Despite the use of very large amounts of C-grade ore and Calciphos, the plateau of the pasture yield versus fertilizer applied curve for these fertilizers did not reach the yield plateau achieved with superphosphate in either the short or long term.C-grade ore and Calciphos were 3% and 8% as effective as superphosphate for dry matter production in the year of application. Relative to superphosphate applied in the current year the effectiveness of superphosphate decreased by about 70% between the first and second year after application and decreased by a further 14% from year 3 to year 6. C-grade ore and Calciphos remained about 2% and 9% as effective as currently applied superphosphate each year.The residual value of superphosphate as measured by bicarbonate-extracted soil phosphorus decreased by about 60% from year 2 to year 7. The residual value of Calciphos was very low for year 2, doubled from year 2–4 and thereafter decreased gradually to its original value by year 7. The residual value of C-grade ore was extremely low throughout the experiment. Thus after year 2, compared to pasture yield, bicarbonate extracted soil phosphorus overestimated the residual value of superphosphate and calciphos.It follows that neither C-grade ore or Calciphos are suitable replacement fertilizers for superphosphate for use on pastures growing on lateritic soils in south-western Australia.