Using a laryngeal tube during cardiac arrest reduces "no flow time" in a manikin study: a comparison between laryngeal tube and endotracheal tube

In 2005 the European Resuscitation Council published new guidelines for advanced life support. One of the issues was to reduce the "no flow time", which is defined as the time without chest compression in the first period of cardiac arrest. In a manikin study, we evaluated whether using the laryngeal tube instead of endotracheal intubation for airway management during cardiac arrest could reduce the "no flow time". METHODS: The study was prospective and included 50 volunteers who performed standardized management of simulated cardiac arrest in a manikin. All participants had completed an obligatory course in emergency medicine but had not been specifically trained in endotracheal intubation; they were therefore designated as unfamiliar in using the endotracheal tube to secure the airway, in accordance with the definition of the European Resuscitation Council. We defined two groups for the study: the LT group, who used the laryngeal tube to secure the airway; and the ET group, who used the endotracheal tube and bag-mask ventilation to ventilate the manikin. The participants were initially randomly assigned to one of the groups and thereafter completed the other scenario. Study endpoints were the total "no flow time" and adherence to guidelines of the European Resuscitation Council. RESULTS: Use of the laryngeal tube during cardiac arrest in the manikin significantly reduced the "no flow time" when compared with endotracheal intubation (109.3 s vs. 190.4 s; P < 0.01). The laryngeal tube was inserted significantly faster than the endotracheal tube (13 s vs. 52 s; P < 0.01) and was correctly positioned by 98% of the participants at the first attempt, compared with 72% using the endotracheal tube. CONCLUSION: With regard to the guidelines of the European Resuscitation Council, we are convinced that during cardiac arrest supraglottic airway devices should be used by emergency personnel unfamiliar with endotracheal intubation.     

„No-flow-time“-Reduzierung durch Einsatz des Larynxtubus

Objective

In 2005 the European Resuscitation Council (ERC) published the new guidelines for Advanced Life Support (ALS). One of the aims was to reduce the no flow time (NFT), without chest compression in the first period of cardiac arrest. Furthermore the guidelines recommend that endotracheal intubation should only be carried out by personnel experienced in this procedure.

Methods

An attempt was made to evaluate whether the use of the laryngeal tube suction (LTS-D) for emergency airway management could contribute to reduce NFT compared to bag-mask ventilation (BMV). In a randomised prospective study 50 participants were asked to perform standardised simulated cardiac arrest management on a full-scale simulator following a one-day cardiac arrest training. Each participant was randomised into the LTS-D and the BMV group for airway management. At the end of each scenario an evaluation of the use of each ventilation procedure by the participants was made by means of a questionnaire.

Results

During the manikin scenario (430 s for LTS-D and 420 s for BMV) there was a significant difference in the overall NFT comparing the use of the LTS-D vs. BMV (105.8 s, range 94–124 s vs. 150.7 s, range 124–179 s; p<0.01). This corresponded during the whole scenario to a proportion of 24.6% (LTS-D) or 35.9% (BMV). Using the LTS-D all participants were able to ventilate the manikin successfully (tidal volume 500–600 ml). In a subjective evaluation of the different airway management procedures by the participants more than 90% expressed a positive opinion about the LTS-D with respect to ease of insertion and safety of ventilation.

Conclusion

The use of the LTS-D on a manikin by emergency physicians after standardised cardiac arrest training significantly reduces the NFT in comparison to BMV. Therefore the LTS-D seems to be a good alternative to BMV during a simulated cardiac arrest scenario.     

Intra-strain variability of methicillin-resistant <Emphasis Type="Italic">Staphylococcus aureus</Emphasis> strains ST228-MRSA-I and ST5-MRSA-II

Isolates belonging to two major epidemic strains of methicillin-resistant Staphylococcus aureus (MRSA) from clonal complex 5 were characterised using diagnostic microarrays in order to detect and analyse intra-strain variability. Isolates were sampled from hospitals scattered all over Germany. The study included 56 isolates of ST228-MRSA-I, which is also known as the South German Epidemic Strain, and 40 isolates of ST5-MRSA-II (UK-EMRSA-3, Rhine-Hesse Epidemic Strain, New York/Japan Clone), as well as, for comparison, some control strains and overseas isolates of ST5-MRSA-II. Both strains showed a remarkable variability. This affected plasmid-borne resistance genes (tetK, blaZ/R/I, aacA–aphD, qacA), genes from SCCmec elements (aadD, ermA, merA/B/R/T), toxin gene clusters on pathogenicity islands (sec/l, tst1) or, probably, on plasmids, (sed/j/r), the presence or absence of beta-haemolysin-converting phages (sea, sea-N315, sak, chp, scn), deletions of single chromosomal genes (bbp, clfA) or, occasionally, of rather large clusters of neighbouring genes (seg, sei, sem, sen, seo, seu, lukD/E). Both strains could be split into four major clusters each, based on the presence of a mercury resistance operon (merA/B/R/T) and lukD/E in ST228-MRSA-I or of tst1 and enterotoxin genes seD/J/R in ST5-MRSA-II. The use of this variability for typing purposes as well as its phylogenetic significance are discussed.     

Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study)

Background

Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications. The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas.

Methods/design

Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma ≥ 3 cm, located between 1–15 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane in a piecemeal fashion, and patients will be discharged from the hospital. Residual adenoma that is visible during the first surveillance endoscopy at 3 months will be removed endoscopically in both treatment strategies and is considered as part of the primary treatment. Primary outcome measure is the proportion of patients with recurrence after 3 months. Secondary outcome measures are: 2) number of days not spent in hospital from initial treatment until 2 years afterwards; 3) major and minor morbidity; 4) disease specific and general quality of life; 5) anorectal function; 6) health care utilization and costs. A cost-effectiveness and cost-utility analysis of EMR against TEM for large rectal adenomas will be performed from a societal perspective with respectively the costs per recurrence free patient and the cost per quality adjusted life year as outcome measures. Based on comparable recurrence rates for TEM and EMR of 3.3% and considering an upper-limit of 10% for EMR to be non-inferior (beta-error 0.2 and one-sided alpha-error 0.05), 89 patients are needed per group.

Discussion

The TREND study is the first randomized trial evaluating whether TEM or EMR is more cost-effective for the treatment of large rectal adenomas.

Trial registration number

(trialregister.nl) NTR1422     

A Prospective Trial Comparing 1% Lymphazurin vs 1% Methylene Blue in Sentinel Lymph Node Mapping of Gastrointestinal Tumors

Background  Methylene blue (M), as a dye in sentinel lymph node mapping (SLNM), has been introduced as an alternative to lymphazurin (L) after the recent shortage of L. M has been evaluated in breast cancer in multiple studies with favorable results. Our study compares L with M in the SLNM of gastrointestinal (GI) tumors. Methods  Between Jan 2005 and Aug 2008, 122 consecutive patients with GI tumors were enrolled. All patients (pts) underwent SLNM with either L or M by subserosal injection of 2–5 mL of dye. Efficacy and rates of adverse reactions were compared between the two dyes. Patients were prospectively monitored for adverse reactions including anaphylaxis, development of blue hives, and tissue necrosis. Results  Of 122 pts, 60 (49.2%) underwent SLNM using L and 62 (50.8%) underwent SLNM using M. Colon cancer (CrCa) was the most common site in both groups. The success rate of L and M in SLNM was 96.6% and 96.7%, respectively, with similar numbers of total number of lymph nodes per pt, SLNs per pt (<3), nodal positivity, skip metastasis, and accuracy. The only adverse reaction in the L group was oxygen desaturation >5% in 5% (3/60) of pts, compared with none in the M group. Cost per vial of L was $210 vs $7 for M. Conclusion  The success rate, nodal positivity, average SLNs per patient, and overall accuracy were similar between L and M. Absence of anaphylaxis and lower cost make M more desirable than L in SLNM of GI tumors.     

The mental health of asylum-seeking and refugee children and adolescents attending a clinic in the Netherlands

We investigated the sociodemographic and clinical characteristics of asylum-seeking and refugee children and adolescents referred to a child and adolescent psychiatry service in the Netherlands. Children with families and unaccompanied minors were compared. Unaccompanied minors had significantly higher frequencies of symptoms and psychiatric disorders than the children with families, both considered a high-risk population for mental health problems.     

Mild cognitive impairment in general practice: age-specific prevalence and correlate results from the German study on ageing, cognition and dementia in primary care patients (AgeCoDe)

BACKGROUND: Although mild cognitive impairment (MCI) represents a high-risk factor for developing dementia, little is known about the prevalence of MCI among patients of general practitioners (GPs). AIMS: Estimation of age-specific prevalence for original and modified concepts of MCI and their association with sociodemographic, medical and genetic (apoE epsilon4 genotype) factors among patients of GPs. METHODS: A GP practice sample of 3,327 individuals aged 75+ was assessed by structured clinical interviews. Results: Prevalence was 15.4% (95% CI = 14.1-16.6) for original and 25.2% (95% CI = 23.7-26.7) for modified MCI. Rates increased significantly with older age. Positive associations were found for apoE epsilon4 allele, vascular diseases and depressive symptoms. CONCLUSION: MCI is frequent in elderly patients of GPs. GPs have a key position in secondary prevention and care of incipient cognitive deterioration up to the diagnosis of dementia.     

Event-related potential correlates of repetition priming for ignored faces

An attentional capacity limit was recently suggested for faces, such that only one face can be processed at a time. We measured interference and repetition priming caused by irrelevant distractor faces. Participants initially performed male/female judgments for central faces or symbols flanked by distractor faces. Interference (slower responses for sex-incongruent target-distractor pairs) occurred for central symbols but was absent for central faces. In subsequent fame judgements, previously presented distractor faces had no repetition priming effect on response times. Relative to new faces, event-related brain potentials revealed a right occipitotemporal negativity approximately 400-600 ms for faces previously shown as distractors flanking central symbols (but not distractors flanking faces). These findings support a face-specific attentional capacity limit, showing that event-related brain potential priming effects can reveal covert distractor processing.     

Analgetics, co-analgetics and opioid-analgetics in the elderly

There is a continuous increase in the proportion of elderly patients. Therefore physicians should be aware of specifics according to pain therapy in the elderly. This review will concentrate on selected topics related to pain therapy in the elderly patient. Furthermore specific consequences according to drug therapy are shown.