Comparação do C‐MAC convencional e C‐MAC D‐blade com laringoscópios diretos em simulação de lesão da coluna cervical–estudo em modelo

Background

CMAC videolaryngoscope has recently been introduced for videoscope guided intubation. The aim of our study was to compare and evaluate the efficacy of the conventional blade and the angulated D blade of the CMAC videolaryngoscope with the direct laryngoscopes in simulated cervical spine injury patients on the airway manikin.

Materials and methods

Following power analysis, 33 resident doctors were enrolled to perform endotracheal intubation using all the 4 different laryngoscopes namely the Macintosh laryngoscope, McCoy laryngoscope, conventional CMAC videolaryngoscope and the D blade of the CMAC videolaryngoscopes on the airway manikin in simulated cervical spine injury. The demographic variables of the resident doctors were recorded. The outcomes measured included vocal cord visualization (Cormack–Lehane grading), time taken to intubate, number of attempts for successful intubation and optimizing maneuvers required.

Results

The use of indirect videolaryngoscopes resulted in better glottic visualization in comparison to the direct laryngoscopes (CL‐I) in 20/33 (60.6%) in the Macintosh group, 24/33 (72.7%) in McCoy group, 30/33 in (90.9%) in Vlc group and 32/33 (96.9%) in Vld group. The time taken to intubate averaged to 15.54 ± 2.6 in Macintosh group, 18.90 ± 4.47 in McCoy group, 20.21 ± 7.9 in Vlc group and 27.42 ± 9.09 in Vld group. The 1st attempt intubation success rate was 84.8% (Macintosh), 72.7% (McCoy), 90.9% (Vlc) and, 78.7% (Vld).

Conclusions

The overall performance of the conventional CMAC blade proved to be the best when compared with the D‐blade CMAC, Macintosh blade and the McCoy blade for intubation in simulated cervical spine patients by anesthesia residents.     

Prevalence and outcome of fungal infection in patients with severe acute pancreatitis

Background and Aim:  To study the prevalence of risk factors and outcome of fungal infections in patients with severe acute pancreatitis.
Methods:  Fifty consecutive patients with severe acute pancreatitis were investigated for evidence of fungal infection by weekly culture of body fluids and aspirate from pancreatic/peripancreatic tissue and samples collected at necrosectomy. All patients were managed as per a standard protocol. Patients with documented fungal infection were treated with intravenous amphotericin or fluconazole. Data were analyzed using SPSS software (version 13), and risk factors for fungal infection and mortality were determined.
Results:  Fungal infection was documented in 18 (36%) of 50 patients with Candida albicans (the commonest species). The incidence of fungal infection steadily increased with increasing duration of hospital stay. Those with fungal infection more often had evidence of respiratory failure ( P  = 0.031) and hypotension ( P  = 0.031) at admission, prolonged hospital stay > 4 weeks ( P  = 0.034), longer duration of antibiotics ( P  = 0.003), received total parenteral nutrition ( P  = 0.005), and required mechanical ventilation ( P  = 0.001) in contrast to those without fungal infection. The logistic regression analysis found the independent risk factors for fungal infection to be antibiotic therapy for > 4 weeks and hypotension at hospitalization. Of the 18 patients with fungal infection, 13 were administered intravenous antifungals; eight of these patients survived, while the five who did not receive antifungals died.
Conclusion:  Fungal infection was detected in 36% of our patients. The independent risk factors associated with it were hypotension at hospitalization and prolonged antibiotic therapy. Antifungal therapy improved their chances of survival.     

Cholangiographically guided aspiration cytology in the management of malignant biliary obstruction

Fifteen patients with malignant biliary obstruction were subjected to fine needle aspiration cytology (FNAC) under fluoroscopic guidance. Fourteen (93%) of them were correctly diagnosed to have a malignancy at FNAC. Simultaneous with FNAC or at a later date, all the patients underwent percutaneous biliary drainage with a drop in serum bilirubin from a mean of 23.2 mg/dl to 8.5 mg/dl. Ten patients were subjected to exploratory laparotomy and biopsy at which the diagnosis of FNAC was confirmed in nine of them. The tenth patient with a negative yield at FNAC had a 1.0 cm cholangiocarcinoma. The usefulness of FNAC combined with biliary drainage as an alternative to surgery is highlighted.     

Motion‐related artifacts in structural brain images revealed with independent estimates of in‐scanner head motion

Motion‐contaminated T1‐weighted (T1w) magnetic resonance imaging (MRI) results in misestimates of brain structure. Because conventional T1w scans are not collected with direct measures of head motion, a practical alternative is needed to identify potential motion‐induced bias in measures of brain anatomy. Head movements during functional MRI (fMRI) scanning of 266 healthy adults (20–89 years) were analyzed to reveal stable features of in‐scanner head motion. The magnitude of head motion increased with age and exhibited within‐participant stability across different fMRI scans. fMRI head motion was then related to measurements of both quality control (QC) and brain anatomy derived from a T1w structural image from the same scan session. A procedure was adopted to “flag” individuals exhibiting excessive head movement during fMRI or poor T1w quality rating. The flagging procedure reliably reduced the influence of head motion on estimates of gray matter thickness across the cortical surface. Moreover, T1w images from flagged participants exhibited reduced estimates of gray matter thickness and volume in comparison to age‐ and gender‐matched samples, resulting in inflated effect sizes in the relationships between regional anatomical measures and age. Gray matter thickness differences were noted in numerous regions previously reported to undergo prominent atrophy with age. Recommendations are provided for mitigating this potential confound, and highlight how the procedure may lead to more accurate measurement and comparison of anatomical features. Hum Brain Mapp 38:472–492, 2017. © 2016 Wiley Periodicals, Inc.     

Potential role of CXCL10 in the induction of cell injury and mitochondrial dysfunction

Chemokines have been known to play a critical role in pathogenesis of chronic pancreatitis and acinar cell death. However, the role played by one of the CXC chemokines: CXCL10 in regulation of acinar cell death has remained unexplored. Hence, this study was designed to assess the role of CXCL10 promoting apoptosis in ex vivo cultured acinar cells. Primary human pancreatic acinar cell cultures were established and exposed to varying doses of CXCL10 for different time intervals. Apoptotic induction was evaluated by both qualitative as well as quantitative analyses. Various mediators of apoptosis were also studied by Western blotting, membrane potential (Ψm) and ATP depletion in acinar cells. Analysis of apoptosis via DNA ladder and cell death detection – ELISA demonstrated that CXCL10 induced 3.9‐fold apoptosis when administrated at an optimal dose of 0.1 μg of recombinant CXCL10 for 8 h. Quantitative analysis using FACS and dual staining by PI‐annexin showed increased apoptosis (48.98 and 53.78% respectively). The involvement of upstream apoptotic regulators like pJNK, p38 and Bax was established on the basis of their increased expression of CXCL10. The change of Ψm by 50% was observed in the presence of CXCL10 in treated acinar cells along with enhanced expression of Cytochrome C, apaf‐1 and caspase 9/3 activation. In addition, ATP depletion was also noticed in CXCL10 stimulated acinar cells. CXCL10 induces cell death in human cultured pancreatic cells leading to apoptosis and DNA fragmentation via CXCR3 signalling. These signalling mechanisms may play an important role in parenchymal cell loss and injury in pancreatitis.     

Endoscopic balloon dilatation of benign gastric outlet obstruction

BACKGROUND AND AIM: Endoscopic balloon dilatation (EBD) has been used for the treatment of gastric outlet obstruction (GOO). There are several reports on the utility and success of this non-surgical treatment option in peptic GOO, with variable results. However, there are only a few reports documenting the efficacy of this method for non-peptic GOO. The authors here report on experience with balloon dilatation in peptic and non-peptic GOO over a 3-year period. METHODS: Twenty-three patients with benign GOO underwent EBD. Dilatation was carried out with through-the-scope balloon dilators after premedication. Dilatation was repeated every week and the response was documented on the basis of symptoms and endoscopic findings and barium studies. Helicobacter pylori was eradicated in patients with peptic GOO, when present. RESULTS: The 23 patients with GOO included 11 with peptic ulcer as the etiology, eight with corrosive-induced and four with chronic pancreatitis (alcohol three, idiopathic one). Patients with peptic GOO required 1-3 sessions (mean 2.0 +/- 0.63) to achieve a diameter of 15 mm dilatation, with uniformly good response over a mean follow-up period of 14.04 +/- 9.79 months. Corrosive-induced GOO required a larger number of dilatation sessions (2-9, mean 5.63 +/- 2.88), but the response was equally good, with follow up of 12-30 months. Patients with pancreatitis-related GOO, however, failed to respond despite a mean of 5.50 (+/-0.58) dilatations, and continued to have symptoms. All these patients were subjected to surgical bypass. There were no major complications such as perforation. CONCLUSIONS: A good response can be expected in the majority of patients with peptic and corrosive-related GOO after balloon dilatation; however, poor results are noted for chronic pancreatitis-related GOO.