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.     

Domain flexibility in retroviral proteases: structural implications for drug resistant mutations

Rigid body rotation of five domains and movements within their interfacial joints provide a rational context for understanding why HIV protease mutations that arise in drug resistant strains are often spatially removed from the drug or substrate binding sites. Domain motions associated with substrate binding in the retroviral HIV-1 and SIV proteases are identified and characterized. These motions are in addition to closure of the flaps and result from rotations of approximately 6-7 degrees at primarily hydrophobic interfaces. A crystal structure of unliganded SIV protease (incorporating the point mutation Ser 4 His to stabilize the protease against autolysis) was determined to 2.0 A resolution in a new space group, P3221. The structure is in the most "open" conformation of any retroviral protease so far examined, with six residues of the flaps disordered. Comparison of this and unliganded HIV structures, with their respective liganded structures by difference distance matrixes identifies five domains of the protease dimer that move as rigid bodies against one another: one terminal domain encompassing the N- and C-terminal beta sheet of the dimer, two core domains containing the catalytic aspartic acids, and two flap domains. The two core domains rotate toward each other on substrate binding, reshaping the binding pocket. We therefore show that, for enzymes, mutations at interdomain interfaces that favor the unliganded form of the target active site will increase the off-rate of the inhibitor, allowing the substrate greater access for catalysis. This offers a mechanism of resistance to competitive inhibitors, especially when the forward enzymatic reaction rate exceeds the rate of substrate dissociation.     

Laser-speckle angular-displacement sensor: theoretical and experimental study

A novel, to our knowledge, method for the measurement of angular displacement for arbitrarily shaped objects is presented in which the angular displacement is perpendicular to the optical axis. The method is based on Fourier-transforming the scattered field from a single laser beam that illuminates the target. The angular distribution of the light field at the target is linearly mapped on a linear image sensor placed in the Fourier plane. Measuring this displacement facilitates the determination of the angular displacement of the target. It is demonstrated both theoretically and experimentally that the angular-displacement sensor is insensitive to object shape and target distance if the linear image sensor is placed in the Fourier plane. A straightforward procedure for positioning the image sensor in the Fourier plane is presented. Any transverse or longitudinal movement of the target will give rise to partial speckle decorrelation, but it will not affect the angular measurement. Furthermore, any change in the illuminating wavelength will not affect the angular measurements. Theoretically and experimentally it is shown that the method has a resolution of 0.3 mdeg ( approximately 5 murad) for small angular displacements, and methods for further improvement in resolution is discussed. No special surface treatment is required for surfaces giving rise to fully developed speckle. The effect of partially developed speckle is considered both theoretically and experimentally.     

Minimizing the average cost of paging and registration: A timer-based method

Methods of balancing call registration and paging are developed in this paper. Given that the probability distribution on the user location as a function of time is either known or can be calculated, previous work shows the existence of lower bounds on the average cost of paging. Here these bounds are used in conjunction with a Poisson incoming-call arrival model to formulate the paging/registration optimization problem in terms oftimeout parameters, _m ; the maximum amount of time to wait before registering given the last known location wasm. Timer-based methods, as opposed to location-based methods, do not require the user to record and process location information during the time between location updates. This feature might be desirable for minimizing mobile transceiver use during idle periods. We then consider uniform motion processes where a spatial translation of starting location produces an identical spatial translation of the associated time-varying probability distribution. This leads to a universal timeout parameter which may be readily calculated. We study and the minimum cost of paging/registration for a simple model of user motion and compare our results to an earlier method of location-based paging/registration cost minimization.     

A survey of problems,solution techniques,and future challenges in scheduling semiconductor manufacturing operations

In this paper, we discuss scheduling problems in semiconductor manufacturing. Starting from describing the manufacturing process, we identify typical scheduling problems found in semiconductor manufacturing systems. We describe batch scheduling problems, parallel machine scheduling problems, job shop scheduling problems, scheduling problems with auxiliary resources, multiple orders per job scheduling problems, and scheduling problems related to cluster tools. We also present important solution techniques that are used to solve these scheduling problems by means of specific examples, and report on known implementations. Finally, we summarize some of the challenges in scheduling semiconductor manufacturing operations.     

Comparing measures of model selection for penalized splines in Cox models

This article presents an application and a simulation study of model fit criteria for selecting the optimal degree of smoothness for penalized splines in Cox models. The criteria considered were the Akaike information criterion, the corrected AIC, two formulations of the Bayesian information criterion, and a generalized cross-validation method. The estimated curves selected by the five methods were compared to each other in a study of rectal cancer mortality in autoworkers. In the stimulation study, we estimated the fit of the penalized spline models in six exposure-response scenarios, using the five model fit criteria. The methods were compared on the basis of a mean squared error score and the power and size of hypothesis tests for any effect and for detecting nonlinearity. All comparisons were made across a range in the total sample size and number of cases.     

Sources and nature of secondary school teachers’ education in computer-related ergonomics

Teachers’ knowledge of computer-related ergonomics in education will have an effect on the learning process and the work practices of their students. However little is known about teacher education in this area. The study aimed to investigate the sources and nature of secondary school teachers’ education about computer-related ergonomics. It also investigated the use of computers by secondary school children. The study included all secondary schools in the Republic of Ireland. The findings suggest that computers are widely available and are used frequently by students and teachers. However, there is evidence that teachers are not receiving information on computer-related ergonomics. Teachers were generally dissatisfied with this and would welcome information on the subject. The study discusses the implications of the findings and makes recommendations to meet the needs of the teachers.     

The effect of the microfluidic diodicity on the efficiency of valve-less rectification micropumps using Lattice Boltzmann Method

The efficiency of the valve-less rectification micropump depends primarily on the microfluidic diodicity (the ratio of the backward pressure drop to the forward pressure drop). In this study, different rectifying structures, including the conventional structures (nozzle/diffuser and Tesla structures), were investigated at very low Reynolds numbers (between 0.2 and 60). The rectifying structures were characterized with respect to their design, and a numerical approach was illustrated to calculate the diodicity for the rectifying structures. In this study, the microfluidic diodicity was evaluated numerically for different rectifying structures including half circle, semicircle, heart, triangle, bifurcation, nozzle/diffuser, and Tesla structures. The Lattice Boltzmann Method (LBM) was utilized as a numerical method to simulate the fluid flow in the microscale. The results suggest that at very low Reynolds number flow, rectification and multifunction micropumping may be achievable by using a number of the presented structures. The results for the conventional structures agree with the reported results.