Mistaken Endobronchial Placement of a Nasogastric Tube During Mandibular Fracture Surgery

A 64-year-old male had an awake right nasal fiber-optic intubation with an endotracheal tube for open reduction and internal fixation of bilateral displaced mandibular fractures. After induction of anesthesia, an 18 Fr nasogastric tube (NGT) was inserted through the left nostril and was secured. The patient required high flow rates to deliver adequate tidal volumes with the ventilator. A chest x-ray done in the postanesthesia care unit revealed a malpositioned NGT in the left lower lobe bronchus, which was immediately removed. The patient was extubated on postoperative day 2. Various traditional methods, such as aspiration of gastric contents, auscultation of gastric insufflations, and chest x-ray are in use to detect or prevent the misplacement of an NGT. These methods can be unreliable or impractical. Use of capnography to detect an improperly placed NGT should be considered in the operating room as a simple, cost-effective method with high sensitivity to prevent possibly serious sequelae of an NGT placed within the bronchial tree.Key words: Nasogastric tube, Misplacement, Oral surgeryPlacement of a nasogastric tube (NGT) preoperatively for decompression of the stomach is common practice to allow drainage of gastrointestinal contents in the case of bowel obstruction, or in other cases when the patient is at risk of aspiration for some other reason. This case report involves a patient who required aspiration precautions via NGT placement for mandibular surgery due to facial trauma; the NGT was later found to be misplaced in the left main stem bronchus as the misplacement was unrecognized intraoperatively. We discuss the necessity of preventing the possible intraoperative and postoperative complications of a misplaced NGT and simple measures to recognize misplacement in patients presenting for similar surgeries.     

Enhancing ecosystem restoration efficiency through spatial and temporal coordination

In many large ecosystems, conservation projects are selected by a diverse set of actors operating independently at spatial scales ranging from local to international. Although small-scale decision making can leverage local expert knowledge, it also may be an inefficient means of achieving large-scale objectives if piecemeal efforts are poorly coordinated. Here, we assess the value of coordinating efforts in both space and time to maximize the restoration of aquatic ecosystem connectivity. Habitat fragmentation is a leading driver of declining biodiversity and ecosystem services in rivers worldwide, and we simultaneously evaluate optimal barrier removal strategies for 661 tributary rivers of the Laurentian Great Lakes, which are fragmented by at least 6,692 dams and 232,068 road crossings. We find that coordinating barrier removals across the entire basin is nine times more efficient at reconnecting fish to headwater breeding grounds than optimizing independently for each watershed. Similarly, a one-time pulse of restoration investment is up to 10 times more efficient than annual allocations totaling the same amount. Despite widespread emphasis on dams as key barriers in river networks, improving road culvert passability is also essential for efficiently restoring connectivity to the Great Lakes. Our results highlight the dramatic economic and ecological advantages of coordinating efforts in both space and time during restoration of large ecosystems.Habitat loss and fragmentation are leading drivers of declining biodiversity and ecosystem services worldwide (1–3). Landscape corridors and dam removals are popular and effective strategies for mitigating fragmentation (4, 5). To implement these projects efficiently, societies around the world are developing regional and even continental-scale plans for restoring ecosystem connectivity (6). These plans set ecosystem-level conservation objectives and identify priority regions for investment, but individual project selection (e.g., a specific dam removal or habitat corridor) is generally dictated by opportunism and politics. When poorly coordinated, these piecemeal mitigation efforts may be an inefficient means of achieving ecosystem-level objectives. Transboundary coordination is known to increase the cost-effectiveness of nature reserve networks (7–9), but the benefits of coordination are likely to be even greater for connectivity efforts in rivers because the dendritic nature of drainage basins makes them highly susceptible to fragmentation (10–12). Migratory fishes, which support major fisheries and ecosystem processes, are particularly vulnerable to life cycle disruption by the millions of dams and road crossings that fragment the world’s rivers (13, 14).Here, we investigate the value of coordinating restoration efforts in space and time to maximize ecological connectivity between the Laurentian Great Lakes and their tributaries. The Great Lakes Basin (GLB) contains 21% of the world’s surface freshwater and is home to more than 33.5 million people (15). High societal dependence on lake-derived ecosystem services includes US$7 billion annually in economic activity related to recreational fishing (16). Historically, breeding migrations of dozens of native fish species formed an important ecological link between the Great Lakes and their tributaries (17). Today, hundreds of thousands of dams and road culverts partially or fully block historical fish migration routes (18). There is growing investment in removing or modifying these structures, but project selection has been largely opportunistic and driven by local priorities.Barrier removal projects to restore tributary connectivity are selected and funded by a diverse set of actors operating independently at different spatial scales across the GLB. Most road crossings are managed by counties or states, whereas impacts of dams are addressed at the watershed, state, federal, or even international level. Funding to restore connectivity is often disbursed as small, one-time investments, but large pulses of public investment are occasionally available, as within the $1.2 billion Great Lakes Restoration Initiative (19). Although connectivity restoration efforts have been piecemeal, the GLB has a long history of collaborative management of shared resources, including binational treaties regarding fisheries, invasive species, and water quality (20). The success of these initiatives demonstrates that large-scale coordination is feasible and that large pulses of spending can be arranged when justified.We used a return-on-investment framework to analyze potential efficiency gains from coordinating barrier removals at a range of spatial scales (county, tributary, state, lake, nation, or GLB-wide) and temporal scales (a single “pulse” of investment vs. the same amount allocated as a series of 2, 5, or 10 “trickle” investments). Return-on-investment approaches are known to outperform alternative strategies such as purely minimizing cost, and maximizing benefit irrespective of cost (21). Our mathematical optimization model identifies the portfolio of barrier removal projects that provides the greatest increase in total tributary channel length (hereafter “habitat”) accessible to migratory fishes for a given budget. Channel length serves as a surrogate for gains in spawning habitat across the entire fish community and is widely used in restoration planning in lieu of high-resolution spawning habitat maps for individual species.We applied this model to a comprehensive barrier inventory for the GLB, encompassing 6,692 dams and 232,068 road crossings georeferenced within the 661 largest tributary watersheds (18). For each of these structures, we estimated the direct economic cost of restoring full passability (removal of dams or retrofitting road culverts) and the net upstream habitat that would become available, and we used estimates of the current passability of each culvert (22). Barrier passability is defined as the proportion of fish able to pass through or over a barrier to migrate upstream. Because dozens of partially passable structures often separate headwater spawning grounds from the Great Lakes, we calculated the net probability that a migratory fish could reach the area upstream of a particular barrier as the product of that barrier’s passability and the passability of all downstream barriers (hereafter, the “cumulative passability” of a barrier). Similarly, the net benefit of any barrier removal includes not only full access to the unobstructed area immediately upstream but also partial access to areas above successive upstream barriers until cumulative passability declines to zero.     

Randomized Controlled Trial of Individualized Dialysate Cooling for Cardiac Protection in Hemodialysis Patients

Background and objectives

Cardiovascular disease is the most common cause of death in patients on hemodialysis (HD). HD-associated cardiomyopathy is appreciated to be driven by exposure to recurrent and cumulative ischemic insults resulting from hemodynamic instability of conventionally performed intermittent HD treatment itself. Cooled dialysate reduces HD-induced recurrent ischemic injury, but whether this confers long-term protection of the heart in terms of cardiac structure and function is not known.

Design, setting, participants, & measurements

Between September 2009 and January 2013, 73 incident HD patients were randomly assigned to a dialysate temperature of 37°C (control) or individualized cooling at 0.5°C below body temperature (intervention) for 12 months. Cardiac structure, function, and aortic distensibility were assessed by cardiac magnetic resonance imaging. Mean between-group difference in delivered dialysate temperature was 1.2°C±0.3°C. Treatment effects were determined by the interaction of treatment group with time in linear mixed models.

Results

There was no between-group difference in the primary outcome of left ventricular ejection fraction (1.5%; 95% confidence interval, –4.3% to 7.3%). However, left ventricular function assessed by peak systolic strain was preserved by the intervention (–3.3%; 95% confidence interval, –6.5% to –0.2%) as was diastolic function (measured as peak diastolic strain rate, 0.18 s⁻¹; 95% confidence interval, 0.02 to 0.34 s⁻¹). Reduction of left ventricular dilation was demonstrated by significant reduction in left ventricular end-diastolic volume (–23.8 ml; 95% confidence interval, –44.7 to –2.9 ml). The intervention was associated with reduced left ventricular mass (–15.6 g; 95% confidence interval, –29.4 to –1.9 g). Aortic distensibility was preserved in the intervention group (1.8 mmHg⁻¹×10⁻³; 95% confidence interval, 0.1 to 3.6 mmHg⁻¹×10⁻³). There were no intervention-related withdrawals or adverse events.

Conclusions

In patients new to HD, individualized cooled dialysate did not alter the primary outcome but was well tolerated and slowed the progression of HD-associated cardiomyopathy. Because cooler dialysate is universally applicable at no cost, the intervention warrants wider adoption or confirmation of these findings in a larger trial.     

Teething troubles?

The relationship between the eruption of the deciduous teeth and the general health of infants has been documented for over 5,000 years. A variety of physical disturbances (anything from minor upsets to potentially fatal illnesses) have historically been attributed to teething, however a number of recent publications have alluded to a clarification of some of the disputed features of teething. It is now accepted that the localised symptoms of teething vary between individuals, however, 'teething' continues to be an inappropriate diagnosis proffered by both healthcare professionals and lay people. Severe systemic upsets are unrelated to teething and, if present, the infant should be promptly referred to a physician for an accurate diagnosis and appropriate treatment. The treatment modalities used in teething have been diverse throughout the ages, frequently depending on the tenets of the medical profession and lay people, but now principally involve pain relief. This article examines the signs and symptoms frequently attributed to teething and their possible alternative causes. The contemporary principles of the management of teething are discussed, including supportive measures, the diverse range of available topical and systemic pharmacological preparations and the 'alternative' holistic therapies.     

The inability of Streptococcus mutans and Lactobacillus acidophilus to form a biofilm in vitro on dentine pretreated with ozone

Background: The use of ozone therapy in the treatment of dental caries is equivocal. The aim of this study was to use an in vitro model to determine the effects of prior ozone application to dentine on biofilm formation and to measure any associated reduction in bacteria viability. Methods: Twenty dentine discs were bonded to the bases of 5 mL polycarbonate screw top vials. Ten dentine discs were infused with ozone for 40 seconds, 10 samples remained untreated as a control. The vials were filled with nutrient medium, sterilized and placed into the outflow from a continuous chemostat culture of Streptococcus mutans and Lactobacillus acidophilus for four weeks. At the conclusion of the experiment bacterial growth was monitored by taking optical density readings of the growth medium in each vial and the outer surface of the dentine specimens were examined by scanning electron microscopy as shown by SEM analysis. Results: Ozone infusion prevented biofilm formation on all the treated samples while there was substantial biofilm present on the control specimens. While the average optical density of the control specimens was almost twice that of the ozone infused dentine (0.710 for the control with a SD of 0.288 and 0.446 for the ozonated samples with a SD of 0.371), the results were not significant (p > 0.05). Conclusions: This preliminary study has shown that the infusion of ozone into non‐carious dentine prevented biofilm formation in vitro from S. mutans and L. acidophilus over a four‐week period. The possibility exists that ozone treatment may alter the surface wettability of dentine through reaction with organic constituents.     

Utilizing a Sedation Decision Aid in Ambulatory Venous Access Device Placement: Effects on Patient Choice,Workup, and Recovery Time

This study was undertaken to determine the influence of using a sedation decision aid when selecting a sedation option for totally implantable vascular access device placement on patient choice, workup, and recovery time. An institutional review board-approved, Health Insurance Portability and Accountability Act-compliant, retrospective study of 76 patients (aged 23-89 years, 58% female) presenting to a vascular interventional radiology department between January 2, 2017, and May 5, 2017. Patients were given a decision aid that inquired about personal values and goals, and provided information about expectations; benefits; and risks of the options, including undergoing the procedure with no sedation (local anesthetic), minimal sedation (anxiolysis with a benzodiazepine), or moderate sedation (benzodiazepine and opiate). No sedation was selected by 15 out of 76 patients (19.7%), minimal sedation was selected by 26 out of 76 patients (34.2%), and moderate sedation was selected by 34 out of 76 patients (44.7%). Postprocedure recovery time differences were significant (P?<?.001) with a mean of 17.4 minutes for no sedation, 49.3 minutes for minimal sedation, and 70.8 minutes for moderate sedation. The use of a decision aid did not slow down the process because workup times were not significantly different: 15.9 minutes for no sedation, 22.1 minutes for minimal sedation, and 18.4 minutes for moderate sedation. Patient sedation preference for totally implantable vascular access device is variable, signifying there is a role for utilizing a decision aid because it empowers a patient to select the option most aligned with his or her goals. Influence on departmental flow is notable because this does not slow down the workup and a majority of patients choose no or minimal sedation, resulting in a decreased postprocedure recovery time burden.     

Co-occurrence of heterozygous CREB3L3 and APOA5 nonsense variants and polygenic risk in a patient with severe hypertriglyceridemia exacerbated by estrogen administration

We describe a case of a 36-year-old woman with severe hypertriglyceridemia likely caused by double heterozygosity of a known pathogenic APOA5 nonsense variant (p.Q275X) and a novel CREB3L3 nonsense variant (p.C296X) on a background of very strong polygenic susceptibility. Her clinical course worsened with development of eruptive xanthomata after oral administration of 2 mg estradiol twice daily for 2 weeks as part of a medical protocol for intrauterine embryo transfer following in vitro fertilization. Her triglyceride levels decreased to baseline and xanthomata resolved without treatment after discontinuation of hormonal therapy, which also resulted in termination of pregnancy. Before undergoing a second embryo transfer using her natural cycle and no exogenous hormones, the patient started combination therapy with eicosapentaenoic acid ethyl ester and gemfibrozil, leading to an ～80% decrease in triglyceride levels. She continued treatment throughout pregnancy, which progressed to term with the delivery of healthy twins.     

IGF1R signalling in testicular germ cell tumour cells impacts on cell survival and acquired cisplatin resistance

Testicular germ cell tumours (TGCTs) are the most frequent malignancy and cause of death from solid tumours in the 20‐ to 40‐year age group. Although most cases show sensitivity to cis‐platinum‐based chemotherapy, this is associated with long‐term toxicities and chemo‐resistance. Roles for receptor tyrosine kinases other than KIT are largely unknown in TGCT. We therefore conducted a phosphoproteomic screen and identified the insulin growth factor receptor‐1 (IGF1R) as both highly expressed and activated in TGCT cell lines representing the nonseminomatous subtype. IGF1R was also frequently expressed in tumour samples from patients with nonseminomas. Functional analysis of cell line models showed that long‐term shRNA‐mediated IGF1R silencing leads to apoptosis and complete ablation of nonseminoma cells with active IGF1R signalling. Cell lines with high levels of IGF1R activity also showed reduced AKT signalling in response to decreased IGF1R expression as well as sensitivity to the small‐molecule IGF1R inhibitor NVP‐AEW541. These results were in contrast to those in the seminoma cell line TCAM2 that lacked IGF1R signalling via AKT and was one of the two cell lines least sensitive to the IGF1R inhibitor. The dependence on IGF1R activity in the majority of nonseminomas parallels the known role of IGF signalling in the proliferation, migration, and survival of primordial germ cells, the putative cell of origin for TGCT. Upregulation of IGF1R expression and signalling was also found to contribute to acquired cisplatin resistance in an in vitro nonseminoma model, providing a rationale for targeting IGF1R in cisplatin‐resistant disease. © 2017 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.