Laryngeal mask airway insertion in children: comparison between rotational, lateral and standard technique

Background:  The purpose of the study was to compare the success and ease of insertion of three techniques of laryngeal mask airway (LMA) insertion; the standard Brain technique, a lateral technique with cuff partially inflated and a rotational technique with cuff partially inflated.
Methods:  One hundred and sixty-eight ASA I and II children aged 6 months to 6 years undergoing short elective surgical procedures lasting 40–60 min were included in the study. A standard anesthesia protocol was followed for all patients. Patients were randomly allocated into one of the three groups i.e. standard (S), rotational (R) and lateral (L). The primary outcome measure of the study was success rate at the first attempt using three techniques of LMA insertion. Secondary outcomes measures studied were overall success rate, time before successful LMA insertion, complications and maneuvers used to relieve airway obstruction.
Results:  Successful insertion at the first attempt was significantly higher in group R (96%) compared with group L (84%) and group S (80%) ( P  =   0.03). Overall success rate (i.e. successful insertion with two attempts) was 100% for group R, 93% for group L and 87% for group S ( P  =   0.03). Time for successful insertion was significantly lower in group R compared with group L and S ( P  <   0.001). The incidence of complications was lower in group R.
Conclusions:  A rotational technique with partially inflated cuff is associated with the highest success rate of insertion and lowest incidence of complications and could be the technique of first choice for LMA insertion in pediatric patients.     

Giant-cell tumour in the cervical spine: a case report

A forty-six-year-old man presented with a two-month history of increasing neck pain of insidious onset. He received treatment from his familty doctor and chiropractor consisting of analgesics and manipulation respectively, both of which did not offer relief. The patient presented to University Hospital where plain radiographs and CT showed a pathological fracture of the C4 vertebral body. A neoplasm was suspected and surgical excision revealed a giant-cell tumour of bone. This type of neoplasm is rare in the spine and difficult to manage in this site. This case highlights some of the problems encountered in the treatment of giant-cell tumour of the spine.     

A technique for eliminating allele specific amplification failure during DNA amplification of heterozygous cells for preimplantation diagnosis

Advances in techniques of molecular biology have made possible the amplification of specific genes from single cells. This has a major clinical application in preimplantation diagnosis of monogenic disorders. However, the incidence of allele specific amplification failure (allele drop out) in heterozygous single cells can lead to misdiagnosis and the transfer of affected embryos. Few studies have been done to investigate the actual cause of allele drop out, although some investigators have succeeded in reducing but not eliminating it. Here we report the efficiency of amplifying both alleles in heterozygous cells lysed according to two different protocols. A total of 177 heterozygous cells from carriers of cystic fibrosis (CF) and haemoglobin C (HbC) were lysed using two different lysis buffers. Interestingly none of the cells that were lysed with sodium dodecyl sulphate/proteinase K showed any example of allele specific amplification failure whereas in those lysed by KOH/dithiothreitol it was present in 17.6 and 4.7% of the CF and HbC cells respectively. Our results suggest that the phenomenon of allele specific amplification failure is at least in part dependent on the lysis buffer used.      

The Role of Graduate Medical Education in Global Health: Proceedings From the 2013 Academic Emergency Medicine Consensus Conference

The past 40 years have seen expanded development of emergency medicine (EM) postgraduate residency training programs worldwide. An important part of this educational experience is the ability of resident trainees to participate in experiences abroad. However, little is known about how these experiences shape trainees and the populations they serve. During the 2013 Academic Emergency Medicine consensus conference, a group of educators met to define and outline current trends in graduate medical education (GME) emergency care research. The authors discuss future research questions bridging the gap of GME and global health.     

Decreased segregation of brain systems across the healthy adult lifespan

Healthy aging has been associated with decreased specialization in brain function. This characterization has focused largely on describing age-accompanied differences in specialization at the level of neurons and brain areas. We expand this work to describe systems-level differences in specialization in a healthy adult lifespan sample (n = 210; 20–89 y). A graph-theoretic framework is used to guide analysis of functional MRI resting-state data and describe systems-level differences in connectivity of individual brain networks. Young adults’ brain systems exhibit a balance of within- and between-system correlations that is characteristic of segregated and specialized organization. Increasing age is accompanied by decreasing segregation of brain systems. Compared with systems involved in the processing of sensory input and motor output, systems mediating “associative” operations exhibit a distinct pattern of reductions in segregation across the adult lifespan. Of particular importance, the magnitude of association system segregation is predictive of long-term memory function, independent of an individual’s age.Healthy adult aging is characterized by a progressive degradation of brain structure and function associated with gradual changes in cognition (see reviews in refs. 1, 2). Among the age-accompanied functional changes, one prominent observation is a reduction in the specificity with which distinct neural structures mediate particular processing roles [i.e., a reduction in functional specialization, or “dedifferentiation” (3)]. A reduction in functional specificity has been observed across multiple spatial scales of brain organization, ranging from the firing patterns of single neurons (e.g., refs. 4, 5) to the evoked activity of individual brain areas (6–10). (For additional discussion see ref. 11.)Despite the compelling evidence for age-accompanied reductions in functional specialization across numerous brain areas, the relationship between neural specialization and cognition generally is weak. This likely is related to the fact that broad cognitive domains such as “long-term memory” and “executive control” are mediated by distributed and interacting brain systems, each consisting of multiple interacting brain areas. Thus, relating functional specialization in a single brain area to general measures of cognition likely will be unsuccessful. Such an argument is consistent with the view that severe impairment in cognitive function due to injury or insult typically is a consequence of damage to multiple brain locations (e.g., refs. 12, 13). Based on these considerations, it seems plausible that the cognitive decline evident even in healthy older adults may be related to decreased functional integrity at a systems level of organization. The present report approaches healthy aging from this systems-level perspective in an effort to relate systems-related functional specialization to age-accompanied differences in cognition.Before proceeding, it is important to clarify the meaning of system. The term “system” often is used in relation to brain organization when referring to any group of areas that subserve common processing roles. For example, the visual system comprises brain areas primarily defined by their role in processing visual stimuli (e.g., ref. 14), and the frontal–parietal task control system consists of brain areas involved mainly in adaptive task control (15). Identifying distinct brain systems and defining their functional roles by examining how their constituent areas are modulated by experimental testing or are impaired by brain damage is not an easy endeavor; systems of brain areas typically mediate processing roles that span multiple stimulus and task demands. This reality makes assessing changes in the functional specialization of systems across cohorts of individuals extremely challenging.An alternative formal and complementary approach to defining a brain system involves understanding how brain areas relate to one another via their patterns of shared functional or anatomical relationships in the context of a large-scale network (16, 17). Like many other complex networks, brain networks may be analyzed as a graph of connected or interacting elements. When a brain network graph represents the interaction of areas, one prominent feature is the presence of subsets of areas that are highly interactive with one another and less interactive with other subsets of areas. This pattern of organization reflects the presence of distinct “modules” or “communities” (e.g., ref. 18). Importantly, numerous connectivity-defined human brain modules have been shown to overlap closely with functional systems as defined by other methods of assessing information processing [e.g., task-evoked activity, lesion-mapping (19, 20)]. The close correspondence between differing methods of system identification provides a basis for using connectivity to understand the organization of brain systems and how they may differ with age.Modular brain networks are characterized by a fine balance of dense within-system relationships among brain areas (nodes) that have highly related processing roles, as well as sparser (but not necessarily absent) relationships between areas in systems with divergent processing roles. This pattern of system segregation facilitates communication among brain areas that may be distributed anatomically but nevertheless are in the service of related sets of processing operations, and simultaneously reinforces the functional specialization of systems that perform different sets of processing operations (21). Importantly, segregated systems can communicate with one another via the presence of the sparser connections between them. As such, any deviation in the patterns of within- and between-system connectivity may be considered evidence for a change in the system’s specialization. Furthermore, if aging is associated with changes in functional specialization at the level of brain systems, this may be revealed by examining the differences in patterns of within- and between-system areal connectivity across age.We use functional connectivity, as measured by blood oxygen-level–dependent (BOLD) functional MRI (fMRI) during rest [resting-state functional correlations (RSFCs), see ref. 22], to assess age-related differences in the organization of brain systems. Changes in RSFC patterns between sets of areas have been observed following extensive directed training (23–25), and differences in RSFC patterns also have been reported in cross-sectional comparisons spanning from childhood to older age (e.g., refs. 26–29). The extant data suggest that RSFCs are malleable and reflect sensitivity to a history of coactivation: changes in the processing roles of areas may be characterized by changes in their RSFCs with other areas (for discussion, see ref. 17). This feature makes RSFCs particularly useful in assessing differences in the organization and specialization of brain systems.In the present study, the age-accompanied differences in the functional specialization of brain systems are revealed by examining patterns of within- and between-system areal RSFCs in a large healthy adult lifespan sample (n = 210; age range, 20–89 y). The inclusion of subjects distributed across each decade of adulthood not only allows us to assess how older and younger adults differ in their organization of brain systems, but also provides insight as to whether there is a critical stage of the adult lifespan when differences in system organization may appear. Previous reports attempted to address related questions by examining end points of the adult aging spectrum, focusing on the organization within specific systems (e.g., refs. 26, 28, 30), or using area nodes that are not representative of functional areas [e.g., structural parcels (31–34)]. The latter feature likely contributes to the inconsistent findings observed in the relationship between summary network measures and age groups (e.g., refs. 31, 35 vs. refs. 30, 36). In addition to examining age-related differences in system organization developed from a biologically plausible cortical parcellation of the human brain network, we also relate systems-level differences in organization to differences in general measures of cognitive ability. To foreshadow the results that follow, we report that aging is associated with differences in patterns of connectivity within and between brain systems, that these differences are not uniform across all systems, and that the segregation of brain systems has a direct relationship to measures of cognitive ability independent of age.